Download Bioterrorism for Nevada Nurses

Bioterrorism for Nevada Nurses
This course has been awarded four
(4.0) contact hours.
This course expires on October 30, 2019.
Copyright © 2005 by RN.com.
All Rights Reserved. Reproduction and distribution of
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First Published: January 3, 2005
Revised: January 3, 2007
Revised: January 3, 2009
Revised January 18, 2013
Revised January 17, 2016
Acknowledgements
RN.com acknowledges the valuable contributions of…
…The Centers for Disease Control (CDC) (www.cdc.gov), the key government agency responsible
for disseminating knowledge about various biological agents.
…U.S. Army Medical Research Institute of Infectious Diseases (USAMRRID). USAMRRID
spearheads efforts to protect service members from biological threats. Its efforts are well known and
utilized by the civilian population. USAMRRID is located at Fort Detrick, Maryland.
….
Suzan Miller-Hoover, DNP, RN, CCNS, CCRN
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Note: All dosages given are for adults unless otherwise stated. The information on medications
contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to
consult with physicians and pharmacists about all medication issues for your patients.
Purpose and Objectives
The purpose of this course is to provide the learner with information regarding preparation for and
response to bioterrorism. Although this course is designed to meet the Nevada state requirements,
healthcare workers everywhere may benefit from the information provided in this module.
For the purposes of this course, bioterrorism will include more than just biological agents. Discussion
will include biological, chemical, radiological, and nuclear weapons.
After successful completion of this course, you will be able to:
1. Define terrorism
2. Define bioterrorism
3. Delineate the categories of bioterrorism agents
4. Delineate the categories of personal protective equipment
5. Define Syndromic Surveillance and reporting procedures for acts of terrorism that involve
biological agents
6. Delineate information available on the Health Alert Network
Introduction
The field of bioterrorism in the United States came to the forefront in the months following September
11th 2001. Bioterrorism is a unique threat that combines the fields of public health and national
security. Bioterrorism is a national security issue. Numerous state and federal agencies are dedicated
to prevention, reporting, and management of any potential terrorist act (Porter, 2012).
After the 911 attack in 2011, several anthrax letters were sent across the nation, infecting 22 people
and killing 5. This incident became “the worst biological attack in U.S. history” resulting in bioterrorism
preparedness becoming a top security priority of the Bush administration. The U.S. Government
Civilian Biodefense Funding was subsequently increased from $414 million,2001 to $3.65 billion,
2002 (Porter, 2012).
Did you know?
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Bioterrorism, biodefense, biological warfare can be traced back to the Assyrians before
600BC?
Modern day biological warfare began in World War I when the German’s attempted to infect
livestock being transported to France
The US started a bioweapons program in 1943 and discontinued it in 1969
The Biological and Toxin Weapons Convention (BTWC) was signed in Washington, London,
and Moscow in 1972 and entered into force in 1975?
The first case of U.S. bioterrorism occurred in 1984 when a religious sect in Oregon
contaminated food with salmonella?
What is Terrorism
The Federal Emergency Management Agency (FEMA) defines terrorism as the use of force or
violence against persons or property in violation of the criminal laws of the United States for purposes
of intimidation, coercion, or ransom. Terrorists often use threats to create fear among the public, to try
to convince citizens that their government is powerless to prevent terrorism, and to obtain immediate
publicity for their causes.
Terrorists usually select targets that will produce large numbers of casualties, so most acts of
terrorism will also be Mass Casualty Incidents (MCI). This means that healthcare providers and
facilities will have to change the way they normally practice to appropriately respond to an act of
terrorism.
What is Bioterrorism
The Centers for Disease Control and Prevention (CDC) defines bioterrorism as “intentional release of
viruses, bacteria, or other germs that can sicken or kill people, livestock, or crops” (Centers for
Disease Control (CDC), 2016).
The White House adds another sentence to this definition, “the act is intended to create fear and/or
intimidate governments or societies in the pursuit of political, religious, or ideological goals” (Porter,
2012).
The CDC focuses on the physical and medical damage while the White House focuses on the
intention to commit an act of terrorism.
Weapons of Mass Destruction
Weapons of Mass Destruction (WMD) encompass a broad number of weapons, including:
• Conventional weapons
• Biological weapons
• Chemical weapons
• Nuclear weapons
• Other advanced weapons
These weapons are characterized by their broad-sweeping intended effects, such as inflicting mass
casualties and/or physical destruction (Virginia Tech office of the Vice President for Research, 2005).
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Biological and Chemical Weapons
Biological agents are infectious microbes or toxins used to produce illness or death in people,
animals, or plants. Biological agents can be dispersed as aerosols or airborne particles. Terrorists
may use biological agents to contaminate food or water because they are extremely difficult to detect.
Chemical agents kill or incapacitate people, destroy livestock, or ravage crops. They can have an
immediate effect (a few seconds to a few minutes) or a delayed effect (several hours to several days).
Test your Knowledge:
Terrorists may use biological agents to contaminate food or water because they are extremely difficult
to detect.
A. True
B. False
Rationale: Biological agents can be dispersed as aerosols or airborne particles. Terrorists may use
biological agents to contaminate food or water because they are extremely difficult to detect.
Indications of Biologic Warfare or Terrorist Attack
There can be epidemiologic indications to a bioterrorist attack. The U.S Army Medical Research
Institute of Infectious Diseases (USAMRIID) located at Fort Derick, Maryland lists the following as
possible indications of a biologic related terrorist attack:
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The presence of a large epidemic with a similar disease or syndrome, especially in a discrete
population
Many cases of unexplained diseases or deaths
More severe disease than is usually expected for a specific pathogen, or failure to respond to
standard therapy
Unusual routes of exposure for a pathogen, such as the inhalational route for diseases that
normally occur through other exposures
A disease that is unusual for a given geographic area or transmission season
Disease normally transmitted by a vector that is not present in the local area
Multiple simultaneous or serial epidemics of different diseases in the same population
A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers)
A disease that is unusual for an age group
Unusual strains or variants of organisms or antimicrobial resistance patterns different from
those circulating
Similar genetic type among agents isolated from distinct sources at different times or locations
Higher disease rates in those exposed in certain areas, such as inside a building if released
indoors, or lower rates in those inside a sealed building if released outside
Disease outbreaks of the same illness occurring in noncontiguous areas
A disease outbreak with zoonotic (animal diseases that are transmitted to humans, e.g. rabies,
Ebola) impact
Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery
of munitions or tampering (USAMRIID, 2005)
Test Your Knowledge:
Which of the following may be an epidemiologic indication?
A. A disease that is usual for a specific gender
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B. Common routes of exposure for the pathogen
C. Many cases of unexplained diseases and deaths
D. Less severe disease than is usually expected for a specific pathogen
Rationale:
• The presence of a large epidemic with a similar disease or syndrome, especially in a discrete
population
• Many cases of unexplained diseases or deaths
• More severe disease than is usually expected for a specific pathogen, or failure to respond to
standard therapy
• Unusual routes of exposure for a pathogen, such as the inhalational route for diseases that
normally occur through other exposures
• A disease that is unusual for a given geographic area or transmission season
• Disease normally transmitted by a vector that is not present in the local area
• Multiple simultaneous or serial epidemics of different diseases in the same population
• A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers)
• A disease that is unusual for an age group
• Unusual strains or variants of organisms or antimicrobial resistance patterns different from
those circulating
• Similar genetic type among agents isolated from distinct sources at different times or locations
• Higher disease rates in those exposed in certain areas, such as inside a building if released
indoors, or lower rates in those inside a sealed building if released outside
• Disease outbreaks of the same illness occurring in noncontiguous areas
• A disease outbreak with zoonotic (animal diseases that are transmitted to humans, e.g. rabies,
Ebola) impact
• Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery
of munitions or tampering (USAMRIID, 2005)
Syndromic Surveillance
Syndromic surveillance is used for early detection of outbreaks; tracking the size, spread, and tempo
of outbreaks, monitoring disease trends, and providing reassurance that an outbreak has not
occurred. Syndromic surveillance systems seek to use existing health data in real time to provide
immediate analysis and feedback to those charged with investigation and follow-up of potential
outbreaks. Optimal syndrome definitions for continuous monitoring and specific data sources best
suited to outbreak surveillance for specific diseases have not been determined. Broadly applicable
signal-detection methodologies and response protocols that would maximize detection while
preserving scant resources are being sought.
There are advantages and disadvantages to syndromic surveillance systems. Syndromic surveillance
systems might enhance collaboration among public health agencies, healthcare providers,
information-system professionals, academic investigators, and industry. However, syndromic
surveillance does not replace traditional public health surveillance, nor does it substitute for direct
physician reporting of unusual or suspect cases of public health importance.
Categories of Biological Agents
Potential agents of bioterrorism are classified into 3 categories, depending on how easily they can be
spread and the severity of illness or death they cause:
Category A agents:
• Pathogens, organisms/biologic agents that pose the highest risk because they:
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o Can be easily disseminated or transmitted from person to person
o Result in high mortality rates and have the potential for major public health impact
o Might cause public panic and social disruption
o Require special action for public health preparedness
• Category A Priority Pathogens
o Bacillus anthracis (anthrax)
o Clostridium botulinum toxin (botulism)
o Yersinia pestis (plague)
o Variola major (smallpox) and other related pox viruses
o Francisella tularensis (tularemia)
o Viral hemorrhagic fevers
▪ Arenaviruses
 Junin, Machupo, Guanarito, Chapare (new in fiscal year (FY) 14), Lassa,
Lujo (new in FY 14)
▪ Bunyaviruses
 Hantaviruses causing Hanta Pulmonary syndrome, Rift Valley Fever,
Crimean Congo Hemorrhagic Fever
▪ Flaviruses
 Dengue
▪ Filoviruses
 Ebola
 Marburg
Category B agents:
• Pathogens, organisms/biologic agents that pose the second highest risk because they:
o Are moderately easy to disseminate
o Result in moderate morbidity rates and low mortality rates
o Require specific enhancements for diagnostic capacity and enhanced disease
surveillance
• Category B Priority Pathogens
o Urkholderia pseudomallei (melioidosis)
o Coxiella burnetii (Q fever)
o Brucella species (brucellosis)
o Burkholderia mallei (glanders)
o Chlamydia psittaci (Psittacosis)
o Ricin toxin (Ricinus communis)
o Epsilon toxin (Clostridium perfringens)
o Staphylococcus enterotoxin B (SEB)
o Typhus fever (Rickettsia prowazekii)
o Food- and waterborne pathogens
o Bacteria
▪ Diarrheagenic E. coli
▪ Pathogenic Vibrios
▪ Shigella species
▪ Salmonella
▪ Listeria monocytogenes
▪ Campylobacter jejuni
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▪ Yersinia enterocolitica
o Viruses
▪ Caliciviruses
▪ Hepatitis A
o Protozoa
▪ Cryptosporidium parvum
▪ Cyclospora cayatanensis
▪ Giardia lamblia
▪ Entamoeba histolytica
▪ Toxoplasma gondii
▪ Naegleria fowleri (new in FY 14)
▪ Balamuthia mandrillaris (new in FY 14)
o Fungi
 Microsporidia
o Mosquito-borne encephalitis viruses
 West Nile virus (WNV)
 LaCrosse encephalitis (LACV)
 California encephalitis
 Venezuelan equine encephalitis (VEE)
 Eastern equine encephalitis (EEE)
 Western equine encephalitis (WEE)
 Japanese encephalitis virus (JE)
 St. Louis encephalitis virus (SLEV)
Category C agents:
• Pathogens, organisms/biologic agents that pose the third highest risk because they:
o Are emerging pathogens that could be engineered for mass dissemination
▪ Availability
▪ Ease of production and dissemination
▪ Potential for high morbidity and mortality rates and major health impact
• Category C Priority Pathogens
o ipah and Hendra viruses
o Additional hantaviruses
o Tickborne hemorrhagic fever viruses
o Bunyaviruses
o Severe Fever with Thrombocytopenia Syndrome virus (SFTSV), Heartland virus
o Flaviruses
o Omsk Hemorrhagic Fever virus, Alkhurma virus, Kyasanur Forest virus
o Tickborne encephalitis complex flaviviruses
o Tickborne encephalitis viruses
o European subtype
o Far Eastern subtype
o Siberian subtype
o Powassan/Deer Tick virus
o Yellow fever virus
o Tuberculosis, including drug-resistant TB
o Influenza virus
o Other Rickettsias
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Rabies virus
Prions
Chikungunya virus
Coccidioides spp
Severe acute respiratory syndrome associated coronavirus (SARS-CoV), MERS-CoV,
and other highly pathogenic human coronaviruses (new in FY 14)
The above list of biological agents is not meant to be inclusive.
Healthcare providers must be prepared to address various biological agents.
The following link will enable the learner to access the most up-to-date information regarding
biological agents, exposure, symptoms, and treatment.
https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx
Category A Biological Agents
For each agent in Category A described in this course, we present an overview, symptoms,
treatments, vaccines, and decontamination issues. At the end of this section there is a discussion on
decontamination in general.
U.S Army Medical Research Institute of Infectious Diseases (USAMRIID)
(www.usamriid.army.mil/education/), located at Fort Derick, MD is the source of the critical
information on the various Category A potential agents of bioterrorism.
This course details those diseases in Category A and includes the following Category A bioterrorism
agents:
• Anthrax
• Botulism
• Pneumonic Plague
• Smallpox
• Tularemia
• Viral Hemorrhagic Fevers (VHF)
Bacterial Agents: Anthrax
Bacillus anthracis, the causative agent of Anthrax, is a gram-positive, sporulation rod. The spores are
the usual infective form. Anthrax is primarily a zoonotic disease of herbivores, with cattle, sheep,
goats, and horses being the usual domesticated animal hosts, but other animals may be infected.
Humans generally contract the disease when handling contaminated hair, wool, hides, flesh, blood,
and excreta of infected animals, and from manufactured products such as bone meal.
Infection is introduced through scratches or abrasions of the skin, wounds, inhalation of spores,
eating insufficiently cooked infected meat, or by being bitten by fleas.
The primary concern for intentional infection by this organism is through inhalation after aerosol
dissemination of spores. All human populations are susceptible. The spores are very stable and may
remain viable for many years in soil and water. They resist sunlight for varying periods.
Test Your Knowledge:
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Many biologic agents are zoonotic diseases (animal sources), Anthrax is a zoonotic disease primarily
from (choose all that apply)
A. Herbivores such as cattle and sheep
B. Carnivores such as dogs and cats
C. Domesticated animals
D. Undomesticated animals
Rationale: Anthrax is primarily a zoonotic disease of herbivores, with cattle, sheep, goats, and horses
being the usual domesticated animal hosts, but other animals may be infected. Humans generally
contract the disease when handling contaminated hair, wool, hides, flesh, blood, and excreta of
infected animals, and from manufactured products such as bone meal.
Presentation of Anthrax
Signs and Symptoms
Incubation period is generally 1–6 days, although longer periods have been noted. Fever, malaise,
fatigue, cough, and mild chest discomfort progresses to severe respiratory distress with dyspnea,
diaphoresis, stridor, cyanosis, and shock. Death typically occurs within 24–36 hours after onset of
severe symptoms.
Diagnosis
Physical findings are non-specific. A widened mediastinum may be seen on CXR in later stages of
illness. The organism is detectable by Gram stain of the blood and by blood culture late in the course
of illness.
Treatment
Although effectiveness may be limited after symptoms are present, high dose antibiotic treatment with
penicillin, ciprofloxacin, or doxycycline should be undertaken. Supportive therapy may be necessary.
Decontamination of clothing with antimicrobial soap and water is also recommended.
Bacterial Agents: Anthrax
Prophylaxis
Oral ciprofloxacin (Cipro) or doxycycline (Vibramycin) for known or imminent exposure. An FDA
licensed vaccine is available. Vaccine schedule is 0.5 ml SC at 0, 4 weeks, then 6, 12, and 18 months
(primary series), followed by annual boosters.
Isolation and Decontamination
Standard precautions for healthcare workers. After an invasive procedure or autopsy is performed,
the instruments and area used should be thoroughly disinfected with a sporicidal agent (hypochlorite).
Contagious?
NO!
Biological Toxins: Botulism
Botulinum
The botulinum toxins are a group of seven related neurotoxins produced by the spore-forming bacillus
Clostridium botulinum and two other Clostridia species. These toxins, types A through G, are the
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most potent neurotoxins known; paradoxically, they have been used therapeutically to treat spastic
conditions (such as strabismus, torticollis & tetanus) and cosmetically to treat wrinkles.
The spores are ubiquitous; they germinate into vegetative bacteria that produce toxins during
anaerobic incubation. Industrial-scale fermentation can produce large quantities of toxin for use as a
BW agent. There are three epidemiologic forms of naturally occurring botulism—food borne, infantile,
and wound. Botulinum could be delivered by aerosol or used to contaminate food or water supplies.
When inhaled, these toxins produce a clinical picture very similar to food borne intoxication, although
the time to onset of paralytic symptoms after inhalation may actually be longer than for food borne
cases, and may vary by type and dose of toxin. The clinical syndrome produced by these toxins is
known as "botulism."
Test Your Knowledge:
Which of the following are epidemiologic forms of naturally occurring botulism?
A. Food borne
B. Infantile
C. Wound
D. All of the above
Rationale: There are three epidemiologic forms of naturally occurring botulism—food borne, infantile,
and wound.
Biological Toxins: Botulism
Signs and Symptoms
Usually begins with cranial nerve palsies, including ptosis, blurred vision, diplopia, dry mouth and
throat, dysphagia, and dysphonia. This is followed by symmetrical descending flaccid paralysis, with
generalized weakness and progression to respiratory failure. Symptoms begin as early as 12–36
hours after inhalation, but may take several days after exposure to low doses of toxin.
Diagnosis
Diagnosis is primarily a clinical one. Biowarfare attack should be suspected if multiple casualties
simultaneously present with progressive descending flaccid paralysis. Lab confirmation can be
obtained by bioassay (mouse neutralization) of the patient’s serum. Other helpful labs include: ELISA
or ECL for antigen in environmental samples, PCR for bacterial DNA in environmental samples, or
nerve conduction studies and electromyography.
Treatment
Early administration of trivalent licensed antitoxin or heptavalent antitoxin (IND product) may prevent
or decrease progression to respiratory failure and hasten recovery. Intubation and ventilatory
assistance for respiratory failure. Tracheostomy may be required.
Prophylaxis
Pentavalent toxoid vaccine (types A, B, C, D, and E) is available for those at high risk of exposure.
Isolation and Decontamination
Standard Precautions for healthcare workers. Toxin is not dermally active and secondary aerosols are
not a hazard from patients. Decontaminate with soap and water. Botulinum toxin is inactivated by
sunlight within 1–3 hours. Heat (80OC for 30 min., 100OC for several minutes) and chlorine (>99.7%
inactivation by 3 mg/L FAC in 20 min.) also destroy the toxin.
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Contagious?
NO!
Bacterial Agents: Plague
Yersinia pestis is a rod-shaped, non-motile, non-sporulating, gram-negative bacterium of the family
Enterobacteraceae. It causes plague, a zoonotic disease of rodents. Fleas that live on the rodents
can transmit the bacteria to humans, who then suffer from the bubonic form of plague. The bubonic
form may progress to the septicemic and/or pneumonic forms. Pneumonic plague would be the
predominant form after a purposeful aerosol dissemination. All human populations are susceptible.
Recovery from the disease is followed by temporary immunity. The organism remains viable in water,
moist soil, and grains for several weeks. The bacterium can remain alive from months to years, but
are killed by 15 minutes of exposure to 55°C. It also remains viable for some time in dry sputum, flea
feces, and buried bodies but is killed within several hours of exposure to sunlight.
Signs and Symptoms
Pneumonic plague begins after an incubation period of 1–6 days, with high fever, chills, headache,
malaise, followed by cough (often with hemoptysis), progressing rapidly to dyspnea, stridor, cyanosis,
and death. Gastrointestinal symptoms are often present. Death results from respiratory failure,
circulatory collapse, and a bleeding diathesis. Bubonic plague, featuring high fever, malaise, and
painful lymph nodes (buboes) may progress spontaneously to the septicemic form (septic shock,
thrombosis, DIC) or to the pneumonic form.
Bacterial Agents
Plague
Diagnosis
Suspect plague if large numbers of previously healthy individuals develop fulminant Gram negative
pneumonia, especially if hemoptysis is present. Presumptive diagnosis can be made by Gram,
Wright, Giemsa, or Wayson stain of blood, sputum, CSF, or lymph node aspirates. Definitive
diagnosis requires culture of the organism from those sites. Immunodiagnostic is also helpful.
Treatment
Early administration of antibiotics is critical; as pneumonic plague is invariably fatal if antibiotic
therapy is delayed more than 1 day after the onset of symptoms. Choose one of the following:
streptomycin, gentamicin (Garamycin), ciprofloxacin (Cipro), or doxycycline (Vibramycin) for 10–14
days. Chloramphenicol (Chloromycetin) is the drug of choice for plague meningitis.
Prophylaxis
For asymptomatic persons exposed to a plague aerosol or to a patient with suspected pneumonic
plague, give doxycycline (Vibramycin) 100 mg orally twice daily for seven days or the duration of risk
of exposure plus one week. Alternative antibiotics include ciprofloxacin (Cipro), tetracycline, or
chloramphenicol (Chloromycetin). No vaccine is currently available for plague prophylaxis. The
previously available licensed, killed vaccine was effective against bubonic plague, but not against
aerosol exposure.
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Isolation and Decontamination
Use Standard Precautions for bubonic plague and Respiratory Droplet Precautions for suspected
pneumonic plague. Y. pestis can survive in the environment for varying periods, but is susceptible to
heat, disinfectants, and exposure to sunlight. Soap and water are effective if decontamination is
needed. Take measures to prevent local disease cycles if vectors (fleas) and reservoirs (rodents) are
present.
Contagious?
YES!
Viral Agents: Smallpox
Smallpox is caused by the Orthopox virus, variola, which occurs in at least two strains, variola major
and the milder disease, variola minor. Despite the global eradication of smallpox and continued
availability of a vaccine, the potential weaponization of variola continues to pose a military threat. This
threat can be attributed to the aerosol infectivity of the virus, the relative ease of large-scale
production, and an increasingly Orthopoxvirus-naive populace. Although the fully developed
cutaneous eruption of smallpox is unique, earlier stages of the rash could be mistaken for varicella.
Secondary spread of infection constitutes a nosocomial hazard from the time of onset of a smallpox
patient's exanthem until scabs have separated. Quarantine with respiratory isolation should be
applied to secondary contacts for 17 days post-exposure. Vaccinia vaccination and vaccinia immune
globulin each possess some efficacy in post-exposure prophylaxis.
Signs and Symptoms
Clinical manifestations begin acutely with malaise, fever, rigors, vomiting, headache, and backache.
2–3 days later lesions appear which quickly progress from macules to papules, and eventually to
pustular vesicles. They are more abundant on the extremities and face, and develop synchronously.
Test Your Knowledge:
Which of the following are NOT true about smallpox?
A. Smallpox has been eradicated worldwide, but is a potential biological warfare agent
B. Smallpox may be mistaken for varicella in the early stages
C. Respiratory isolation should be applied for 17 days to exposed contacts
D. Smallpox lesions are more abundant on the trunk
Rationale:
Despite the global eradication of smallpox and continued availability of a vaccine, the potential
weaponization of variola continues to pose a military threat.
Although the fully developed cutaneous eruption of smallpox is unique, earlier stages of the rash
could be mistaken for varicella. Secondary spread of infection constitutes a nosocomial hazard from
the time of onset of a smallpox patient's exanthem until scabs have separated. Quarantine with
respiratory isolation should be applied to secondary contacts for 17 days post-exposure.
Two to three days later lesions appear which quickly progress from macules to papules, and
eventually to pustular vesicles. They are more abundant on the extremities and face, and develop
synchronously.
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Viral Agents: Smallpox
Diagnosis
Neither electron nor light microscopy are capable of discriminating variola from vaccinia, monkeypox,
or cowpox. The new PCR diagnostic techniques may be more accurate in discriminating between
variola and other Orthopoxviruses.
Treatment
At present there is no effective drug therapy, and treatment of a clinical case remains supportive.
Prophylaxis
Immediate vaccination or re-vaccination should be undertaken for all personnel exposed.
Isolation and Decontamination
Droplet and Airborne Precautions for a minimum of 17 days following exposure for all contacts.
Patients should be considered infectious until all scabs separate and quarantined during this period.
In the civilian setting strict quarantine of asymptomatic contacts may prove to be impractical and
impossible to enforce. A reasonable alternative would be to require contacts to check their
temperatures daily. Any fever above 38° C (101° F) during the 17-day period following exposure to a
confirmed case would suggest the development of smallpox. The contact should then be isolated
immediately, preferably at home, until smallpox is either confirmed or ruled out and remain in isolation
until all scabs separate. (Scabbing is complete and falls off; skin underneath is intact.)
Contagious?
YES!
Bacterial Agents: Tularemia
Francisella tularensis is a small, aerobic non-motile, gram-negative cocco-bacillus. Tularemia (also
known as rabbit fever and deer fly fever) is a zoonotic disease that humans typically acquire after skin
or mucous membrane contact with tissues or body fluids of infected animals, or from bites of infected
ticks, deerflies, or mosquitoes. Less commonly, inhalation of contaminated dusts or ingestion of
contaminated foods or water may produce clinical disease. Respiratory exposure by aerosol would
typically cause typhoidal or pneumonic tularemia. F. tularensis can remain viable for weeks in water,
soil, carcasses, hides, and for years in frozen rabbit meat. It is resistant for months to temperatures of
freezing and below. It is easily killed by heat and disinfectants.
Signs and Symptoms
Ulceroglandular tularemia presents with a local ulcer and regional lymphadenopathy, fever, chills,
headache, and malaise. Typhoidal tularemia presents with fever, headache, malaise, substernal
discomfort, prostration, weight loss, and a non-productive cough.
Bacterial Agents: Tularemia
Diagnosis
Clinical diagnosis. Physical findings are usually non-specific. Chest x-ray may reveal a pneumonic
process, mediastinal lymphadenopathy, or pleural effusion. Routine culture is possible but difficult.
The diagnosis can be established retrospectively by serology.
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Treatment
Administration of antibiotics (streptomycin or gentamicin [Garamycin]) with early treatment is very
effective.
Prophylaxis
A live, attenuated vaccine is recommended for prophylaxis. It is administered once by scarification. A
two-week course of tetracycline is also effective as prophylaxis when given after exposure.
Isolation and Decontamination
Standard Precautions for healthcare workers. Organisms are relatively easy to render harmless by
mild heat (55 degrees Celsius for 10 minutes) and standard disinfectants.
Contagious?
NO!
Viral Agents: Hemorrhagic Fever-Ebola
Viral hemorrhagic fevers (VHFs) refer to a diverse group of illnesses that are caused by distinct
families of RNA viruses from four viral families. In general, the term VHF is used to describe a severe
multi-system syndrome. One of the newest viral agent added to this category is Ebola. Ebola was
brought to the fore-front due to the Ebola epidemic in 2015.
While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these
viruses cause severe, life-threatening disease.
Examples of VHFs include Ebola, dengue and yellow fever. These viruses are spread in a variety of
ways; some may be transmitted to humans through a respiratory portal of entry.
Although evidence for weaponization does not exist for many of these viruses, they are included in
this course because of their potential for aerosol dissemination or weaponization.
Signs and Symptoms
VHFs present as febrile illnesses which can feature flushing of the face and chest, petechiae,
bleeding, edema, hypotension, and shock. Malaise, myalgia, headache, vomiting, and diarrhea may
occur in any of the hemorrhagic fevers.
Characteristically, the overall vascular system is damaged, and the body's ability to regulate itself is
impaired. These symptoms are often accompanied by hemorrhage; however, the bleeding is itself
rarely life-threatening.
Viral Agents: Hemorrhagic Fevers
Diagnosis
Definitive diagnosis rests on specific virologic techniques. Significant numbers of military personnel
with a hemorrhagic fever syndrome should suggest the diagnosis of a viral hemorrhagic fever.
Treatment
Intensive supportive care may be required. Antiviral therapy with ribavirin (Virazole) may be useful in
several of these infections. Convalescent plasma may be effective in Argentine hemorrhagic fever.
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Prophylaxis
The only licensed VHF vaccine is yellow fever vaccine. Prophylactic ribavirin (Virazole) may be
effective for Lassa fever, Rift Valley fever, and possibly HFRS (Hemorrhagic Fever with Renal
Syndrome).
Isolation and Decontamination
Contact isolation, with the addition of a surgical mask and eye protection for those coming within
three feet of the patient, is indicated for suspected or proven VHFs. Respiratory protection should be
upgraded to airborne isolation, including the use of a fit-tested HEPA filtered respirator, a battery
powered air purifying respirator, or a positive pressure supplied air respirator, if patients with the
above conditions have prominent cough, vomiting, diarrhea, or hemorrhage. Decontamination is
accomplished with hypochlorite or phenolic disinfectants.
Contagious?
YES!
(But not always)
Chemical Agents
•
Chemical agents that might be used by terrorists range from warfare agents to toxic chemicals
commonly used in industry. Criteria for determining priority chemical agents include:
o Chemical agents already known to be used as weaponry
o Availability of chemical agents to potential terrorists
o Chemical agents likely to cause major morbidity or mortality
o Potential of agents for causing public panic and social disruption
o Agents that require special action for public health preparedness
The CDC generally groups chemical agents into a number of categories. Not all categories or agents
will be discussed within the scope of this course. Five Specific agents/types of agents will be
discussed in detail later in this course.
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Common categories and agents.
Biotoxins
Abrin
Ricin
Strychnine
Blood Agents
Arsine (SA)
Cyanide
Cyanogen chloride (CK)
Hydrogen cyanide (AC)
Potassium cyanide (KCN)
Sodium cyanide (NaCN)
Ammonia
Bromine (CA)
Chlorine (CL)
Hydrogen chloride
Osmium Tetroxide
Phosgene
Diphosgene (DP)
Phosgene (CG)
Phosphine
Phosphorus, elemental, white or yellow
Super warfarin
Choking/Lung/Pulmonary Agents
Long-Acting Anticoagulants
Nerve Agents
Blister Agents/Vesicants
Caustics (Acids)
Incapacitating Agents
Metals
Organic Solvents
Riot Control Agents/Tear Gas
Toxic Alcohols
Vomiting Agents
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G agents Sarin (GB)
Soman (GD)
Tabun (GA)
V agents VX
Mustards
Distilled mustard (HD)
Mustard gas (H) (sulfur mustard)
Mustard/lewisite (HL)
Mustard/T
Nitrogen mustard (HN-1, HN-2, HN-3)
Sesqui mustard
Sulfur mustard (H) (mustard gas)
Lewisites/chloroarsine agents
Lewisite (L, L-1, L-2, L-3)
Mustard/lewisite (HL)
Phosgene oxime (CX)
Hydrofluoric acid (hydrogen fluoride) Hydrogen fluoride
(hydrofluoric acid)
BZ
Fentanyl and other opioids
Arsenic Mercury
Thallium
Benzene
Various agents and combinations of agents
Bromobenzylcyanide (CA)
Chloroacetophenone (CN)
Chlorobenzylidenemalononitrile (CS)
Chloropicrin (PS)
Dibenzoxazepine (CR)
Ethylene glycol
Adamsite (DM)
Emergency Room Procedures in Chemical Hazard Emergencies
The following information and information for medical management of other toxic chemical agents is
provided by The Agency for Toxic Substances and Disease Registry Division of Toxicology, part of
the CDC (http://www.atsdr.cdc.gov), and from the Environmental Public Health Readiness Branch,
Chemical Weapons Elimination team.
This course contains emergency guidelines from these agencies for 5 common agents: Nerve Agent,
Phosgene, Lewisite, Mustard, and Chlorine.
Agent identification is the #1 step in preparing to receive patients from a chemical emergency.
Emergency Room Procedures in Chemical Hazard Emergencies
Preparations
1. Try to determine agent identity.
2. Break out personal protection equipment, decontamination supplies, antidotes, etc.
3. Is chemical hazard certain or very likely? YES:
• Don personal protective equipment
• Set up hot line
4. Clear and secure all areas that could become contaminated
5. Prepare to or secure hospital entrances and grounds
6. Notify local emergency management authorities if needed
7. If chemical is a military agent and Army has not been informed, call them
8. If an organophosphate is involved, notify hospital pharmacy that large amounts of atropine and
2PAM may be needed
When victim arrives
(Note: A contaminated patient may present at an emergency room without prior warning.)
9. Does chemical hazard exist?
* Known release/exposure (including late notification)
* Liquid on victim's skin or clothing
* Symptoms in victim, EMTs, others
* Odor (H, L, phosgene, chlorine)
* M-8 paper, if appropriate
YES: Go to 10
NO: Handle victim routinely
10. Hold victim outside until preparations are completed (don personal protective equipment to assist
EMT’s as necessary)
11. If patient is grossly contaminated (liquid on skin, positive M-8 paper) OR if there is any suspicion
of contamination, decontaminate patient before entry into building
M-8 paper tape provides a simple way to check exposed surfaces for the presence of chemical
agent contamination. The papers are treated with agent-sensitive dyes that change color in
the presence of liquid chemical agents. They can be placed on a person’s skin or clothing and
change color depending on the agent that the paper detects. M-8 will change to four possible
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colors: red, yellow, green or blue. If the paper changes to red, it indicates possible blister
agent. A yellow, green or blue change indicates possible nerve agent.
Emergency Room Procedures in Chemical Hazard Emergencies
1. Establish airway if necessary.
2. Give artificial respiration if not breathing.
3. Control bleeding if hemorrhaging. 4. Symptoms of cholinesterase poisoning?
* Pinpoint pupils
* Difficulty breathing (wheezing, gasping, etc.)
* Local or generalized sweating
* Fasciculation (uncontrollable muscle twitching)
* Copious secretions
* Nausea, vomiting, diarrhea
* Convulsions
* Coma
YES: Go to NERVE AGENT PROTOCOL (on the following pages)
5. History of chlorine poisoning?
YES: Go to CHLORINE PROTOCOL. (on the following pages)
6. Burns that began within minutes of poisoning?
YES: Go to 7.
NO: Go to 8.
7. Thermal burn?
YES: Go to 9.
NO: Go to LEWISITE PROTOCOL (on the following pages)
8. Burns or eye irritation beginning 2-12 hours after exposure? YES: Go to MUSTARD PROTOCOL
(on the following pages) NO: Go to 9. 9. Is phosgene exposure possible?
* Known exposure to phosgene
* Known exposure to hot chlorinated hydrocarbons
* Respiratory discomfort beginning a few hours after exposure
YES: Go to PHOSGENE PROTOCOL (on the following pages) 10.
Check other possible chemical exposures:
* Known exposure
* Decreased level of consciousness without head trauma.
* Odor on clothes or breath
* Specific signs or symptoms
Facts About Phosgene
What is phosgene?
•
•
•
•
Phosgene is a major industrial chemical used to make plastics and pesticides.
At room temperature (70°F), phosgene is a poisonous gas.
With cooling and pressure, phosgene gas is converted into a liquid that can be shipped and
stored. When liquid phosgene is released, it quickly turns into a gas that stays close to the
ground and spreads rapidly.
Phosgene gas may appear colorless or a white to pale yellow cloud. At low concentrations, it
has a pleasant odor of newly mown hay or green corn, but its odor may not be noticed by all
people exposed. At high concentrations, the odor may be strong and unpleasant.
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•
•
Phosgene itself is nonflammable but it can cause flammable substances around it to burn.
Phosgene is also known by its military designation, “CG.”
Where phosgene is found and how it is used
•
•
•
•
Phosgene was used extensively during World War I as a choking (pulmonary) agent.
Phosgene is not found naturally in the environment; it is used in industry to produce many
other chemicals such as pesticides.
Phosgene can be formed when certain compounds are exposed to heat, such as some types
of plastics.
Phosgene gas is heavier than air, so it would be more likely found in low-lying areas.
Exposure to Phosgene
The risk for exposure depends on how close an individual is to the place where the phosgene was
released. If phosgene gas is released into the air, people may be exposed through skin contact or
eye contact. They may also be exposed by breathing air that contains phosgene.
If phosgene liquid is released into water, people may be exposed by touching or drinking water that
contains phosgene.
If phosgene liquid comes into contact with food, people may be exposed by eating the contaminated
food.
Phosgene gas and liquid are irritants that can damage the skin, eyes, nose, throat, and lungs. The
extent of damage caused by phosgene poisoning depends on the amount of phosgene to which a
person is exposed, the route of exposure, and the length of time that a person is exposed.
Immediate Signs and Symptoms of Phosgene Exposure
During or immediately after exposure to dangerous concentrations of phosgene, the following signs
and symptoms may develop:
• Coughing
• Burning sensation in the throat and eyes
• Watery eyes
• Blurred vision
• Difficulty breathing or shortness of breath
• Nausea and vomiting
• Skin contact can result in lesions similar to those from frostbite or burns
• Following exposure to high concentrations of phosgene, a person may develop pulmonary edema
within 2 to 6 hours
Later Signs and Symptoms of Phosgene Exposure
Exposure to phosgene may cause delayed effects that may not be apparent for up to 48 hours after
exposure, even if the person feels better or appears well following removal from exposure. Therefore,
people who have been exposed to phosgene should be monitored for 48 hours afterward. Delayed
effects that can appear for up to 48 hours include the following:
• Difficulty breathing
• Coughing up white to pink-tinged fluid
• Low blood pressure
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•
Heart failure
Management of Phosgene Exposure
Most people exposed to phosgene make a complete recovery. However, chronic bronchitis and
emphysema have been reported as a result of phosgene exposure.
If exposed to phosgene:
• Leave the area where the phosgene was released and get to fresh air. If outdoors, go to the
highest ground possible, because phosgene is heavier than air and will sink to low-lying areas.
• Remove all clothing, rapidly wash the entire body with large amounts of soap and water, and
provide medical care as quickly as possible. Avoid pulling any contaminated clothing over the
head. Seal all clothing in double plastic bags.
• Inform the local or state health department or emergency personnel upon their arrival. Do not
handle the plastic bags.
• If a person experiences burning eyes or blurred vision, rinse the eyes with plain water for 10 to 15
minutes.
• If phosgene is ingested, do not induce vomiting or drink fluids.
Treatment for phosgene exposure consists of removing phosgene from the body as soon as possible
and providing supportive medical care in a hospital setting. No antidote exists for phosgene. Exposed
people should be observed for up to 48 hours, because it may take that long for symptoms to develop
or reoccur.
Phosgene Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post phosgene exposure:
If there is known phosphate poisoning, restrict fluids, perform chest x-ray and draw blood gases
ASAP. If results are consistent with phosgene poisoning, admit immediately and provide oxygen
under positive end-expiratory pressure and restrict fluids. Observe closely for at least 6 hours.
Facts About Sulfur Mustard
What is sulfur mustard?
• Sulfur mustard is a type of chemical warfare agent. These kinds of agents are called vesicants
or blistering agents, because they cause blistering of the skin and mucous membranes on
contact.
• Sulfur mustard is also known as “mustard gas or mustard agent,” or by the military
designations H, HD, and HT.
• Sulfur mustard sometimes smells like garlic, onions, or mustard and sometimes has no odor. It
can be a vapor, an oily-textured liquid, or a solid.
• Sulfur mustard can be clear to yellow or brown when it is in liquid or solid form.
Where sulfur mustard is found and how it is used
• Sulfur mustard is not found naturally in the environment.
• Sulfur mustard was introduced in World War I as a chemical warfare agent. Until recently, it
was available for use in the treatment of a skin condition called psoriasis. Currently, it has no
medical use.
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Exposure to Sulfur Mustard
If sulfur mustard is released into the air as a vapor, people can be exposed through skin contact, eye
contact, or breathing. Sulfur mustard vapor can be carried long distances by wind.
If sulfur mustard is released into water, people can be exposed by drinking the contaminated water or
getting it on their skin.
People can be exposed by coming in contact with liquid sulfur mustard.
Sulfur mustard can last from 1 to 2 days in the environment under average weather conditions and
from weeks to months under very cold conditions.
Sulfur mustard breaks down slowly in the body, so repeated exposure may have a cumulative effect.
The adverse health effects caused by sulfur mustard depend on the amount people are exposed to,
the route of exposure, and the length of time that people are exposed.
Sulfur mustard is a powerful irritant and blistering agent that damages the skin, eyes, and respiratory
tract. It damages DNA, a vital component of cells in the body.
Sulfur mustard vapor is heavier than air, so it will settle in low-lying areas
Management of Sulfur Mustard Exposure
Exposure to sulfur mustard liquid is more likely to produce second- and third- degree burns and later
scarring than is exposure to sulfur mustard vapor.
Extensive breathing in of the vapors can cause chronic respiratory disease, repeated respiratory
infections, or death. Extensive eye exposure can cause permanent blindness.
Exposure to sulfur mustard may increase a person’s risk for lung and respiratory cancer.
If exposed to sulfur mustard:
• Immediately leave the area where the sulfur mustard was released. Try to find higher ground,
because sulfur mustard is heavier than air and will settle in low-lying areas.
• Rapidly remove the sulfur mustard from the body and any contaminated clothing as soon as
possible after exposure, as this is the only effective way to prevent or decrease tissue damage
to the body. Seal clothing in a plastic bag, and then seal that bag inside a second plastic bag.
• Immediately wash any exposed part of the body (eyes, skin, etc.) thoroughly with plain, clean
water. Eyes need to be flushed with water for 5 to 10 minutes. Do NOT cover eyes with
bandages, but do protect them with dark glasses or goggles.
The most important factor is removing sulfur mustard from the body. Exposure to sulfur mustard is
treated by giving the victim supportive medical care to minimize the effects of the exposure. Though
no antidote exists for sulfur mustard, exposure is usually not fatal.
If someone has ingested sulfur mustard, do NOT induce vomiting. Give the person milk to
drink.
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Mustard Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post sulfur mustard exposure:
If there is known sulfur mustard poisoning, check for airway obstruction. If present, a tracheostomy
may need to be performed ASAP.
Assess for skin burns. If large burns are present, establish IV lines, but do not push fluids as for
thermal burns. Drain vesicles by unroofing large blisters and irrigating the area with topical antibiotics.
Treat other symptoms appropriately. This may include the application of antibiotic eye ointment, the
use of sterile precautions prn and the administration of morphine prn for pain (generally not needed in
emergency treatment; might be appropriate for in-patient treatment).
Where lewisite is found and how it is used
Lewisite was produced in 1918 to be used in World War I, but its production was too late for it to be
used in the war. It has been used only as a chemical warfare agent. It has no medical or other
practical use. Lewisite is not found naturally in the environment.
Facts About Lewisite
What is lewisite?
Lewisite is a type of chemical warfare agent. This kind of agent is called a vesicant or blistering agent,
because it causes blistering of the skin and mucous membranes on contact.
Lewisite is an oily, colorless liquid in its pure form and can appear amber to black in its impure form. It
has an odor like geraniums, and contains arsenic, a poisonous element.
Lewisite is also known by its military designation, “L.”
Exposure to Lewisite
Risk for exposure depends on how close an individual is to the site where the lewisite is released. If
lewisite gas is released into the air, people may be exposed through skin contact or eye contact.
Lewisite is a powerful irritant and blistering agent that immediately damages the skin, eyes, and
respiratory tract.
Exposure can also occur by inhaling air that contains lewisite.
If lewisite liquid is released into water, people may be exposed by drinking water that contains lewisite
or by getting the water on their bodies. If lewisite liquid comes into contact with food, people may be
exposed by eating the contaminated food.
Lewisite vapor is heavier than air, so it will settle in low-lying areas and will remain a liquid under a
wide range of environmental conditions. Thus, it can last for a long time in the environment.
Adverse health effects caused by lewisite depend on the amount people are exposed to, the route of
exposure, and the length of time that people are exposed.
Because it contains arsenic, lewisite has some effects that are similar to arsenic poisoning, including
stomach ailments and low blood pressure.
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Signs & Symptoms of Lewisite Exposure
Most information on the health effects of lewisite is based on animal studies. Signs and symptoms
occur immediately following a lewisite exposure, and may include:
• Skin changes: Pain and irritation within seconds to minutes, redness within 15 to 30 minutes
followed by blister formation within several hours. The blister begins as a small blister in the
middle of the red areas and then expands to cover the entire reddened area of skin. The
lesions (sores) from lewisite heal much faster than lesions caused by the other blistering
agents, sulfur mustard and nitrogen mustards, and the discoloring of the skin that occurs later
is much less noticeable.
• Eye irritation: Pain, swelling, and tearing may occur on contact. Blindness may result.
• Respiratory tract changes: Runny nose, sneezing, hoarseness, bloody nose, sinus pain,
shortness of breath, and cough.
• Digestive tract: diarrhea, nausea, and vomiting.
• Cardiovascular: “Lewisite shock” or low blood pressure may occur.
Showing these signs and symptoms does not necessarily mean that a person has been exposed to
lewisite. Lewisite does not suppress the immune system.
Management of Lewisite Exposure
If exposure to lewisite occurs, the area should be evacuated as quickly as possible. Moving quickly to
an area where fresh air is available is highly effective in reducing the possibility of death from
exposure to lewisite. People should move to the highest ground possible, because lewisite is heavier
than air and will sink to low-lying areas. If the lewisite release is indoors, get out of the building.
If you think you may have been exposed, remove your clothing as quickly as possible. Any clothing
that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This
will help protect against further exposure to any chemicals remaining on the clothing.
The entire body should be rapidly washed with soap and water, and medical attention sought as soon
as possible.
Treatment for lewisite exposure consists of removing lewisite from the body as soon as possible and
providing supportive medical care in a hospital setting.
An antidote for lewisite is available and is most useful if given as soon as possible after
exposure.
Lewisite Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post lewisite exposure:
•
•
•
•
Survey the extent of injury, and treat affected skin with British Anti-Lewisite (BAL, also known as
dimercaprol) ointment (if available).
Treat affected eyes with BAL ophthalmic ointment (if available).
Treat pulmonary effects using BAL in oil, 0.5 ml/25 lbs. body wt. deep IM to max of 4.0 ml. Repeat
q 4 h x 3 (at 4, 8, and 12 hours). Morphine may be given prn for pain.
For severe pulmonary reactions to lewisite, shorten the time interval for BAL injections to q 2 h.
Facts about Chlorine
What Is Chlorine?
Chlorine is an element used in industry and in some household products, but can also be found in the
form of a poisonous gas. It can be pressurized and cooled to change into a liquid for shipping and
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storage. When liquid chlorine is released, it turns into a gas that stays close to the ground and
spreads rapidly.
Chlorine gas can be recognized by its pungent, irritating odor, which is like the odor of bleach. The
strong smell may provide a warning to people that they have been exposed. Chlorine gas appears to
be yellow-green in color.
Chlorine itself is not flammable, but it can react explosively or form explosive compounds with other
chemicals such as turpentine and ammonia.
Test Your Knowledge:
Chlorine is a liquid and when released changes into a flammable gas that stays close to the ground
and spreads rapidly.
A. True
B. False
Rationale: When liquid chlorine is released, it turns into a gas that stays close to the ground and
spreads rapidly.
Chlorine itself is not flammable, but it can react explosively or form explosive compounds with other
chemicals such as turpentine and ammonia.
Where chlorine is found and how it is used
Chlorine was used during World War I as a choking (pulmonary) agent, and is one of the most
commonly manufactured chemicals in the United States. Its most important use is as a bleach in the
manufacture of paper and cloth, but it is also used to make pesticides, rubber, and solvents.
Chlorine is used in drinking water and swimming pool water to kill harmful bacteria. It is also as used
as part of the sanitation process for industrial waste and sewage.
Household chlorine bleach can release chlorine gas if it is mixed with other cleaning agents.
Exposure to Chlorine
People’s risk for exposure depends on how close they are to the place where the chlorine was
released. If chlorine gas is released into the air, people may be exposed through skin contact or eye
contact. They may also be exposed by breathing air that contains chlorine.
If chlorine liquid is released into water, people may be exposed by touching or drinking water that
contains chlorine.
If chlorine liquid comes into contact with food, people may be exposed by eating the contaminated
food.
Chlorine gas is heavier than air, so it would settle in low-lying areas.
The extent of poisoning caused by chlorine depends on the amount of chlorine a person is exposed
to, how the person was exposed, and the length of time of the exposure.
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When chlorine gas comes into contact with moist tissues such as the eyes, throat, and lungs, an acid
is produced that can damage these tissues.
Signs & Symptoms of Chlorine Exposure
During or immediately after exposure to dangerous concentrations of chlorine, the following signs and
symptoms may develop:
• Coughing
• Chest tightness
• Burning sensation in the nose, throat, and eyes
• Watery eyes
• Blurred vision
• Nausea and vomiting
• Burning pain, redness, and blisters on the skin if exposed to gas, skin injury similar to frostbite if
exposed to liquid chlorine
• Difficulty breathing or shortness of breath (may appear immediately if high concentrations of
chlorine gas are inhaled, or may be delayed if low concentrations of chlorine gas are inhaled)
• Pulmonary edema within 2 to 4 hours
Exhibition of these signs or symptoms does not necessarily mean that a person has been exposed to
chlorine.
Long-term complications from chlorine exposure are not found in people who survive a sudden
exposure unless they suffer complications such as pneumonia during therapy. Chronic bronchitis may
develop in people who develop pneumonia during therapy.
Test Your Knowledge:
Patients exposed to chlorine may exhibit which of the following signs or symptoms? (choose all that
apply)
A. Chest tightness
B. Blurred vision
C. Nausea
D. Difficulty breathing
Rationale:
During or immediately after exposure to dangerous concentrations of chlorine, the following signs and
symptoms may develop:
• Coughing
• Chest tightness
• Burning sensation in the nose, throat, and eyes
• Watery eyes
• Blurred vision
• Nausea and vomiting
• Burning pain, redness, and blisters on the skin if exposed to gas, skin injury similar to frostbite if
exposed to liquid chlorine
• Difficulty breathing or shortness of breath (may appear immediately if high concentrations of
chlorine gas are inhaled, or may be delayed if low concentrations of chlorine gas are inhaled)
• Pulmonary edema within 2 to 4 hours
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Exhibition of these signs or symptoms does not necessarily mean that a person has been exposed to
chlorine
Management of Chlorine Exposure
If exposure to chlorine occurs, the area should be vacated immediately. Quickly moving to an area
where fresh air is available is highly effective in reducing exposure to chlorine. If the chlorine release
was outdoors, move away from the area where the chlorine was released. Go to the highest ground
possible, because chlorine is heavier than air and will sink to low-lying areas.
If the chlorine release was indoors, get out of the building.
If you think you may have been exposed, remove your clothing as quickly as possible. Any clothing
that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This
will help protect against further exposure to any chemicals remaining on the clothing.
The entire body should be rapidly washed with soap and water, and medical attention sought as soon
as possible. Flush eyes with cold water and discard contact lenses with clothing. If chlorine is
ingested, do not induce vomiting or drink fluids. Inform either the local or state health department or
emergency personnel upon their arrival. Do not handle the plastic bags.
If you are helping other people remove their clothing, try to avoid touching any contaminated areas,
and remove the clothing as quickly as possible.
No antidote exists for chlorine exposure. Treatment consists of removing the chlorine from
the body as soon as possible and providing supportive medical care in a hospital setting.
Chlorine Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post chlorine exposure:
•
•
•
If dyspnea is present, administer oxygen by mask as well as bronchodilators. Admit to hospital for
chest X-ray and further evaluation, as soon as possible.
Treat other problems and reevaluate.
If the respiratory system is stable, provide supportive therapy; treat other problems or discharge.
Facts About Sarin (Nerve Agent)
What Is Sarin?
Sarin is a human-made chemical warfare agent classified as a nerve agent. Nerve agents are the
most toxic and rapidly acting of the known chemical warfare agents. They are similar to certain kinds
of pesticides called organophosphates in terms of how they work and what kind of harmful effects
they cause. However, nerve agents are much more potent than organophosphate pesticides.
Sarin originally was developed in 1938 in Germany as a pesticide, and is a clear, colorless, and
tasteless liquid that has no odor in its pure form. However, sarin can evaporate into a vapor and
spread into the environment. Sarin is also known as GB.
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Where Sarin is Found and How It Is Used
Sarin is not found naturally in the environment. It is man-made and was used in chemical warfare
during the Iran-Iraq War in the 1980s, and in two terrorist attacks in Japan in 1994 and 1995. Sarin is
the most volatile of the nerve agents, which means that it can easily and quickly evaporate from a
liquid into a vapor and spread into the environment. People can be exposed to the vapor even if they
do not come in contact with the liquid form of sarin. Since sarin evaporates so quickly, it presents an
immediate but short-lived threat.
Exposure to Sarin
Following the release of sarin into the air, people can be exposed through skin contact or eye contact.
They can also be exposed by breathing air that contains sarin. Sarin mixes easily with water, so it
could be used to poison water. Following release of sarin into water, people can be exposed by
touching or drinking water that contains sarin.
Following contamination of food with sarin, people can be exposed by eating the contaminated food.
A person’s clothing can release sarin for about 30 minutes after it has come in contact with sarin
vapor, which can lead to exposure of other people.
Because sarin breaks down slowly in the body, people who are repeatedly exposed to sarin may
suffer more harmful health effects. Sarin vapor is heavier than air and will sink to low-lying areas and
create a greater exposure hazard there.
Signs & Symptoms of Sarin Exposure
The extent of poisoning caused by sarin depends on the amount of which a person was exposed,
how the exposure occurred, and the length of time of the exposure.
People may not know that they were exposed because sarin has no odor. People exposed to a low or
moderate dose of sarin by breathing contaminated air, eating contaminated food, drinking
contaminated water, or touching contaminated surfaces may experience some or all of the following
symptoms within seconds to hours of exposure:
• Runny nose
• Increased urination
• Watery eyes
• Confusion
• Small, pinpoint pupils
• Drowsiness
• Eye pain
• Weakness
• Blurred vision
• Headache
• Drooling and excessive sweating
• Nausea, vomiting, and/or abdominal
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•
•
•
•
•
•
•
Cough
Pain
Chest tightness
Slow or fast heart rate
Rapid breathing
Low or high blood pressure
Diarrhea
Exposure to large doses of sarin by any route may result in the following harmful health effects:
• Loss of consciousness
• Convulsions
• Paralysis
• Respiratory failure possibly leading to death
Note! Even a small drop of sarin on the skin can cause sweating and muscle twitching where sarin
touched the skin.
Nerve agents inhibit the function of chemical that acts as the body’s “off switch” for glands
and muscles. Without an “off switch,” the glands and muscles are constantly being
stimulated. They may tire and no longer be able to sustain breathing function.
Management of Sarin Exposure
Recovery from sarin exposure is possible with treatment, but the antidotes available must be used
quickly to be effective. Therefore, the best thing to do is avoid exposure.
Evacuate the area where the sarin was released and get to fresh air. Quickly moving to an area
where fresh air is available is highly effective in reducing the possibility of death from exposure to
sarin vapor. If the sarin release was outdoors, move away from the area where the sarin was
released. Go to the highest ground possible, because sarin is heavier than air and will sink to low
lying areas.
If the sarin release was indoors, get out of the building.
If exposure occurs, remove all clothing, rapidly wash the entire body with soap and water, and get
medical care as quickly as possible. Any clothing that has to be pulled over the head should be cut off
the body and sealed in double plastic bags. This will help protect against further exposure to any
chemicals remaining on the clothing.
Flush eyes with cold water and discard contact lenses with clothing. If sarin is ingested, do not induce
vomiting or drink fluids. Inform either the local or state health department or emergency personnel
upon their arrival. Do not handle the plastic bags.
If you are helping other people remove their clothing, try to avoid touching any contaminated areas,
and remove the clothing as quickly as possible. Antidotes are available for sarin, and are most useful
if given as soon as possible after exposure.
Mild or moderate exposure usually results in a full recovery. Severe exposure results in death.
Unlike some organophosphate pesticides, nerve agents have not been associated with
neurological problems lasting more than 1 to 2 weeks after exposure.
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Nerve Agent Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post nerve agent exposure:
• If severe respiratory distress is present: * Intubate and ventilate
o Administer Atropine:
 Adults: 6 mg IM or IV
 Infants/pediatrics: 0.05 mg/kg IV
o Administer 2-PAM C1
▪ Adults: 600-1000 mg IM or slow IV
▪ Infants/pediatrics: 15 mg/kg slow IV
• If major secondary symptoms are present:
o Administer Atropine:
▪ Adults: 4 mg IM or IV
▪ Infants/pediatrics: 0.02 - 0.05 mg/kg IV
o Administer 2-PAM C1:
▪ Adults: 600-1000 mg IM or slow IV
▪ Infants/pediatrics: 15 mg/kg
• OPEN IV LINE
• Repeat atropine as needed until secretions decrease and breathing easier
o Adults: 2 mg IV or IM
o Infants/pediatrics: 0.02 - 0.05 mg/kg IV
• Repeat 2-PAM C1 as needed:
o Adults: 1.0 gm IV over 20-30 min and repeat hourly x 3 prn
o Infants/pediatrics: 15 mg/kg slow IV
• If convulsions present:
o Administer Diazepam
• Adults: 10 mg slow IV
• Infants/pediatrics: 0.2 mg/kg IV
• Reevaluate q 3-5 min. If signs worsen, repeat atropine as directed.
Note!
NOTIFY the hospital pharmacy that unusual amounts of atropine and 2-PAM may be needed.
CDC Resources
It is more than possible that an unidentified chemical agent may bring patients to your facility. The
CDC has extensive guidelines for the treatment of patients with an unidentified chemical exposure.
These are too extensive to address in this course, but can be found at http://www.atsdr.cdc.gov/, the
website for the Agency for Toxic Substances and Disease Registry, which is part of the CDC.
This registry has a wealth of knowledge and management guidelines for a variety of toxic substances.
How
•
•
•
•
•
people can get more information about these agents
Regional poison control center (1-800-222-1222)
Centers for Disease Control and Prevention
Public Response Hotline (CDC)
English (888) 246-2675
Español (888) 246-2857
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•
•
•
•
•
TTY (866) 874-2646
Emergency Preparedness and Response Web site (http://www.bt.cdc.gov/)
E-mail inquiries: [email protected]
Agency for Toxic Substances and Disease Registry (ATSDR) (1-770-488-7100; 24 hours a
day)
E-mail inquiries: [email protected]
Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and
Health (NIOSH), Pocket Guide to Chemical Hazards (www.cdc.gov/niosh/npg/npgd0504.html)
Case Study #1
Your emergency department has been notified of an external disaster. There has been an increase in
the number of GI disturbances, severe cramping, vomiting, and diarrhea over the past few days and
an acute rise in symptomology in the past few hours since lunch time. You are told to prepare for the
arrival of 30 adults from the outlying town of Idyllwild.
Based on this information, can you determine if this is bioterrorism or if this might be related to
something within the town?
There is not enough information.
Who would you notify? The Centers for Disease Control, your Public Health Department would be a
great starting point.
As the patients begin to arrive, you become aware that all of these patients work for the same
company and they all attended a company sponsored and catered event for lunch.
Where would you continue to look for clues to this GI outbreak?
1. The lunch room
2. The caterers
3. The food source company
4. Food preparation surfaces
As you are researching this GI outbreak, you remember that you recently attended an in-service on
bioterrorism and the example that was discussed was a similar case. In the discussed case, the
President of company #1 was in the midst of a stock dispute with company #2 and a member of the
company #2 work force decided to “poison” the food being served at a company #1 event in order to
influence the shareholder’s vote.
Could this be the case here? Or is your imagination on overload???
You won’t know unless you investigate further.
Fortunately, you discover that the caterers had purchased salad greens which had been
contaminated with e. coli. All of the patients had consumed this salad.
However, bioterrorism was not out of the question. It is better to have a heighten awareness than to
miss an overt attempt to harm others.
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Nuclear and Radiologic Weapons
This module is primarily focused on biologic agents. However, to be thorough, it is prudent to discuss
nuclear and radiologic weapons as well.
Radiation is a form of energy that is present all around us. Different types of radiation exist, some of
which have more energy than others. Radiation released into the environment is measured in units
called curies. However, the dose of radiation that a person receives is measured in units called rem.
Possible terrorist events could involve introducing radioactive material into the food or water supply,
using explosives to scatter radioactive materials, bombing or destroying a nuclear facility, or
exploding a small nuclear device.
Nuclear and Radiologic Weapons
Nuclear explosion (bomb, nuclear reactor explosion, etc.): radioactive fallout would extend over
a large region far from the point of impact, potentially increasing people's risk of developing
cancer over time.
“Dirty bomb” (an explosive device containing radioactive material): large scale contamination is
possible.
The CDC has outlined for physicians and other healthcare workers the following protocol to follow in
the event of radiation exposure.
Acute Radiation Syndrome
Acute Radiation Syndrome (ARS), also known as radiation toxicity or radiation sickness, is an acute
illness caused by irradiation of the body by a high dose of penetrating radiation in a very short period
of time (usually a matter of minutes).
The major cause of this syndrome is depletion of immature parenchymal stem cells in specific tissues.
This can occur when the radiation exposure is greater than 0.7 Gray (Gy), or 70 rads. Mild symptoms
may be observed as low as 0.3 Gy or 30 rads. The dose is usually external, and is penetrating (i.e.,
able to reach the internal organs).
The entire body (or a significant portion of it) must have received the dose.
Most radiation injuries are local, frequently involving the hands, and these local injuries seldom cause
classical signs of ARS. The dose must have been delivered in a short time (usually a matter of
minutes).
Fractionated doses are often used in radiation therapy. These are large total doses delivered in small
daily amounts over a period of time. Fractionated doses are less effective at inducing ARS than a
single dose of the same magnitude.
The Emergency Management Pocket Guide for Clinicians, a product of the CDC, offers a quick
review of information related to radiation exposure:
http://www.bt.cdc.gov/radiation/pdf/clinicianpocketguide.pdf
Classis Radiation Syndromes
There are three classic ARS Syndromes that occur:
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Bone Marrow Syndrome (Hematopoietic Syndrome)
• The full syndrome will usually occur with a dose between 0.7 and 10 Gy (70 – 1000 rads)
though mild symptoms may occur as low as 0.3 Gy or 30 rads.
• The survival rate of patients with this syndrome decreases with increasing dose.
• The primary cause of death is the destruction of the bone marrow, resulting in infection and
hemorrhage.
Gastrointestinal (GI) syndrome
• The full syndrome will usually occur with a dose between 10 and 100 Gy (1000 – 10,000 rads)
though some symptoms may occur as low as 6 Gy or 600 rads.
• Survival is extremely unlikely with this syndrome. Destructive and irreparable changes in the
GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance.
• Death usually occurs within 2 weeks.
Cardiovascular (CV)/ Central Nervous System (CNS) Syndrome
• The full syndrome will usually occur with a dose greater than 50 Gy (5000 rads) though some
symptoms may occur as low as 20 Gy or 2000 rads.
• Death occurs within 3 days. Death is likely due to collapse of the circulatory system as well as
increased pressure in the confining cranial vault as the result of increased fluid content caused
by edema, vasculitis, and meningitis.
Stages of Acute Radiation Syndrome
With any of the three above named syndromes, there are four stages of ARS that occur:
• Prodromal stage (N-V-D stage): The classic symptoms for this stage are nausea, vomiting, and
possibly diarrhea (depending on dose) that occur from minutes to days following exposure.
The symptoms may last (episodically) for minutes up to several days.
• Latent stage: The patient looks and feels generally healthy for a few hours or even up to a few
weeks.
• Manifest illness stage: The symptoms depend on the specific syndrome (see Table 1) and last
from hours up to several months.
• Recovery or death: Most patients who do not recover will die within several months of
exposure. The recovery process lasts from several weeks up to two years.
Acute Radiation Syndromes
Syndrome
Dose
Prodromal Stage
Latent Stage
Hematopoietic
(Bone Marrow)
>0.7 GY or
> 70 rads
Anorexia
Nausea
Vomiting
Stem cells in
bone marrow die
Mild
symptoms
may occur
with as low as
0.3 GY or 30
rads
Onset: 1 hour to 2
days post exposure
Duration: minutes to
days
Patient may look
and feel well
Duration: 1-6
weeks
Manifest Illness
stage
Anorexia
Fever
Malaise
Drop in blood cell
counts for several
weeks
Cause of death:
infection/bleeding
Survival
decreases with
increasing dose
Death occurs
within a few
months of
exposure
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Recovery
Bone marrow
regenerates
Full recovery for
high percentage
of patients within
weeks to 2 years
Death can occur
at very low GY
doses
The LD50/60+ is
about 2.5 to 5 GY
or 250 to 500
rads
Gastrointestinal
>10 GY or
>1000 rads
Some
symptoms
may occur
with as low as
6 GY or 600
rads
Anorexia
Severe nausea
Vomiting
Cramping
Diarrhea
Onset: within a few
hours
Duration: about 2
days
Stem cells in
bone marrow and
lining the GI tract
die
Patient may look
and feel well
Malaise
Anorexia
Severe diarrhea
Fever
Dehydration
Electrolyte
imbalance
Duration: less
than 1 week
Cause of death:
infection/bleeding
The LD100+ is
about 10 GY or
1000 rads
Survival
decreases with
increasing dose
Cardiovascular
Central Nervous
System
>50 GY or
>5000 rads
Some
symptoms
may occur
with as low as
20 GY or 2000
rads
Extreme
nervousness and
confusion
Severe nausea
Vomiting
Watery diarrhea
Loss of
consciousness
Burning sensations
on skin
Patient may
return to partial
functionality
Duration: hours
or less
Death occurs
within a few
months of
exposure
Return of watery
diarrhea
Convulsions
Coma
No recovery is
expected
Onset: 5-6 hours
after exposure
Death occurs
within 3 days of
exposure
Onset: within a few
minutes
Duration: minutes to
hours
The absorbed doses quoted here are “gamma equivalent” values. Neutrons or protons generally produce the same
effects as gamma, beta, or X-rays but at lower doses. If the patient has been exposed to neutrons or protons, consult
radiation experts on how to interpret the dose.
The LD50/60+ is the dose necessary to kill 50% of the exposed population in 60 days
The LD100+ is the dose necessary to kill 100% of the exposed population
Test Your Knowledge:
The LD50/60 radiation dose is the dose necessary to kill 100% of the exposed population.
A. True
B. False
Rationale: The LD50/60+ is the dose necessary to kill 50% of the exposed population in 60 days
The LD100+ is the dose necessary to kill 100% of the exposed population
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Cutaneous Radiation Syndrome (CRS)
The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the
complex pathological syndrome resulting from acute radiation exposure to the skin.
ARS will usually be accompanied by some skin damage. It is also possible to receive a damaging
dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or xrays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes.
When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or
moist desquamation can occur. Also, hair follicles may be damaged causing epilation. Within a few
hours after irradiation a transient and inconsistent erythema (associated with itching) can occur.
Then, there may be a latent phase that lasts from a few days up to several weeks, when intense
reddening, blistering and ulceration of the irradiated site is visible.
Patient Management of Radiation Exposure
If radiation exposure is suspected:
• Secure ABCs (airway, breathing, circulation) and physiologic monitoring (blood pressure, blood
gases, electrolyte and urine output) as appropriate.
• Treat major trauma, burns and respiratory injury if evident.
• In addition to the blood samples required to address the trauma, obtain blood samples for
CBC, with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to
any initial transfusion and at periodic intervals following transfusion.
• Treat contamination as needed.
• If exposure occurred within 8 to 12 hours, repeat CBC, with attention to lymphocyte count, 2 or
3 more times (approximately every 2 to 3 hours) to assess lymphocyte depletion.
Diagnosis
The diagnosis of ARS can be difficult to make because it causes no unique disease. Also; depending
on dose, the prodromal stage may not occur for hours or days after exposure, or, the patient may
already be in the latent stage by the time they receive treatment, in which case the patient may
appear and feel well when first assessed.
If a patient received more than 0.05 Gy (5 rads) and 3 or 4 CBCs are taken within 8–12 hours of the
exposure, a quick estimate of the dose can be made. If these initial blood counts are not taken, the
dose can still be estimated using CBC results over the first few days. It would be best to have
radiation dosimetrists conduct the dose assessment, if possible.
If a patient is known or suspected of having been exposed to a large radiation dose draw blood for
CBC analysis with special attention to the lymphocyte count every 2–3 hours for the first 8 hours
following exposure (and every 4–6 hours for the following 2 days). Observe the patient during this
time for symptoms and consult with radiation experts before ruling out ARS.
If no radiation exposure is initially suspected, you may consider ARS in the differential diagnosis if
there is a history of nausea and vomiting that is unexplained by other causes. Other indications are
bleeding or epilation or WBC (white blood count) and platelet counts abnormally low a few days or
weeks following unexplained nausea and vomiting. Again, consider CBC and chromosome analysis
and consultation with radiation experts to confirm diagnosis.
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Initial Treatment and Diagnostic Evaluation
Treat vomiting, and repeat CBC analysis, with special attention to the lymphocyte count, every 2–3
hours for the first 8–12 hours following exposure (and every 4–6 hours for the following 2 or 3 days).
Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening
or blistering of the skin. (Be sure to include time of onset.)
Note and record areas of erythema. If possible, take color photographs of suspected radiation skin
damage. Consider tissue, blood typing, and initiating viral prophylaxis. Promptly consult with
radiation, hematology, and radiotherapy experts in regards to dosimetry, prognosis, and treatment
options.
Call the Radiation Emergency Assistance Center/Training Site (REAC/TS) at (865) 576-3131
(MF, 8 am to 4:30 am EST) or (865) 576-1005 (after hours) to record the incident in the Radiation
Accident Registry System.
For More Help
Note that the Radiation Emergency Assistance Center/Training Site (REAC/TS) can also be reached
online at http://www.orau.gov/reacts/, and the Medical Radiobiology Advisory Team (MRAT) at (301)
295-0316.
Also, more information can be obtained from the CDC Health Alert Network at http://www.bt.cdc.gov.
Initial Treatment and Diagnostic Evaluation
After consultation, begin the following (as indicated):
• Supportive care in a clean environment (if available, the use of a burn unit may be quite
effective).
• Prevention and treatment of infections.
• Stimulation of hematopoiesis by use of growth factors.
• Stem cell transfusions or platelet transfusions (if platelet count is too low).
• Psychological support.
• Careful observation for erythema (document locations), hair loss, skin injury, mucositis,
parotitis, weight loss, or fever.
• Confirmation of initial dose estimate using chromosome aberration cytogenetic bioassay when
possible. Though resource intensive, this is the “gold standard” for dose assessment following
acute exposures.
• Consultation with experts in radiation accident management (Ricks, et al., 2002).
Personal Protective Equipment (PPE)
The development and use of proven PPE is essential to the health and safety of workers. PPE
(equipment designed to protect persons from the risk of injury by creating a barrier against workplace
hazards) is of particular importance to terrorism preparedness and response to ensure worker health
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and safety. PPE has always played an important role in public health and must continue to be
customized to mitigate the risks associated with chemical, biological, radiological/ nuclear and mass
trauma hazards.
Of equal importance is training to ensure workers can properly assess an environment’s hazards and
select the appropriate PPE.
The type of PPE used varies with each situation. The following discussion of types of PPE is general
in nature. If an act of terrorism occurs the type of PPE needed will be determined and action should
be taken to follow guidelines that are issued.
Levels of Personal Protective Equipment (PPE)
There are basically four levels of personal protective equipment:
• Level A protection is required when the greatest potential for exposure to hazards exists, and
when the greatest level of skin, respiratory, and eye protection is required. Examples of Level
A clothing and equipment include positive-pressure, full face-piece self-contained breathing
apparatus (SCBA) or positive pressure supplied air respirator with escape SCBA, totally
encapsulated chemical- and vapor-protective suit, inner and outer chemical-resistant gloves,
and disposable protective suit, gloves, and boots.
• Level B protection is required under circumstances requiring the highest level of respiratory
protection, with lesser level of skin protection. Examples of Level B protection include positive
pressure, full face-piece self-contained breathing apparatus (SCBA) or positive pressure
supplied air respirator with escape SCBA, inner and outer chemical-resistant gloves, face
shield, hooded chemical resistant clothing, coveralls, and outer chemical-resistant boots.
• Level C protection is required when the concentration and type of airborne substances is
known and the criterion for using air purifying respirators is met. Typical Level C equipment
includes full-face air purifying respirators, inner and outer chemical-resistant gloves, hard hat,
escape mask, and disposable chemical-resistant outer boots. The difference between Level C
and Level B protection is the type of equipment used to protect the respiratory system,
assuming the same type of chemical-resistant clothing is used. The main criterion for Level C
is that atmospheric concentrations and other selection criteria permit wearing an air-purifying
respirator.
• Level D protection is the minimum protection required. Level D protection may be sufficient
when no contaminants are present or work operations preclude splashes, immersion, or the
potential for unexpected inhalation or contact with hazardous levels of chemicals. Appropriate
Level D protective equipment may include gloves, coveralls, safety glasses, face shield, and
chemical-resistant, steel-toe boots or shoes.
While these are general guidelines for typical equipment to be used in certain circumstances, other
combinations of protective equipment may be more appropriate, depending upon specific site
characteristics.
One of the lessons learned from the Ebola incident in 2015 was that healthcare facilities must be
prepared to safely care for patients of all types. It was very evident that we were NOT adequately
prepared to deal with a disease such as Ebola. Many facilities did not have units that could be used
for caring for highly contagious diseases, there was no plan in place to safely transport body fluids to
the laboratory, how would you meet the needs of the family without placing them at unnecessary
risk/exposure? What about the healthcare workers themselves? How would we protect their families?
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One gap that was acknowledged was healthcare workers in general are not adept at donning and
removing PPE without contaminating themselves. Ongoing training and practice is needed to help
ensure the safety of our healthcare workforce.
Does your facility have ongoing training for donning and removing PPE? This might just be our
greatest defense against bioterrorism.
Health Alert Network
The Health Alert Network (HAN) is a nationwide communications system that was established by the
Centers for Disease Control and Prevention, and is implemented by each state.
It is designed to enable a two-way, 24/7 flow of critical health information among the Nevada State
Health Division and local and rural health care professionals throughout the state, including
physicians, nurses, hospitals, laboratories, clinicians, public health workers, emergency management
and others.
The Nevada Health Alert Network has the ability to:
• Provide ongoing surveillance activities to quickly identify potential health threats
• Offer laboratory capabilities to perform testing to determine the threat agent
• Conduct disease investigations
• Effectively report incidents and share information
• Efficiently transmit emergency communications among all involved parties
(Nevada State Health Division, 2012)
Contact Information for HAN
The Nevada Health Alert Network (HAN) contains up to date information and links to “Hot Topics” in
Disaster Preparedness. Since these are constantly changing, the reader can obtain current
information on key health topics through one resource. Relief agencies are outlined and links
provided, so that in the case of an emergency, they can be easily accessed. Additionally, the HAN
contains links to county specific emergency management and public health departments and Federal
contacts.
The CDC Bioterrorism Hotline Phone Number is the best contact to use when concerned about any
types of suspected terrorism activities that could affect the public health. By using this number, you
will be connected with one of the key government agencies with information about bioterrorism, and
they can provide you with appropriate information and direction.
24 Hour CDC Bioterrorism Hotline – 770.488.7100
Federal Links
Ready.gov (www.ready.gov)
This website provides information for individuals, families and businesses, to take action to prepare
themselves for all types of emergencies, including chemical and bioterrorism.
U.S. Department of Health and Human Services (www.dhhs.gov)
HHS is the U.S. government's principal agency for protecting the health of all Americans and
providing essential human services, especially for those who are least able to help themselves.
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Centers for Disease Control (www.cdc.gov)
The CDC is the principal agency in the United States government for protecting the health and safety
of all Americans and for providing essential human services, especially for those people who are least
able to help themselves.
CDC and American Red Cross: Readiness Today
(http://www.redcross.org/preparedness/cdc_english/CDC.asp)
The CDC and the American Red Cross have combined to create this informative website with
information about what types of emergency supplies, including food and water, you should maintain,
information about quarantine and isolation, and tools for coping.
Health Resources and Services Administration
(www.hrsa.gov)
The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of
Health and Human Services, is the primary Federal agency for improving access to health care
services for people who are uninsured, isolated or medically vulnerable.
Department of Homeland Security
(www.dhs.gov)
The National Strategy for Homeland Security and the Homeland Security Act of 2002 served to
mobilize and organize our nation to secure the homeland from terrorist attacks.
Federal Emergency Management Agency
(www.fema.gov)
The Federal Emergency Management Agency (FEMA) describes its role as follows: FEMA's role in
managing terrorism includes both antiterrorism and counterterrorism activities (FEMA, 2006).
Nevada is part of Region IX of FEMA, with its regional office located in Oakland, CA.
Federal Bureau of Investigation
(www.fbi.gov)
The Federal Bureau of Investigation (FBI) is part of the U.S. Department of Justice. FBI priorities
outlined in 2003 include protecting the United States from terrorist attack (FBI, n.d.).
State Links
There are three key links in the State Section: Nevada Office of Homeland Security
(http://www.dhs.gov/), Nevada Division of Emergency Management (http://www.nemaweb.org/), and
Nevada Department of Agriculture (http://agri.nv.gov/). The Nevada Office of Homeland Security is
the state section of the national department. The Nevada Division of Emergency Management is part
of the Nevada Department of Public Safety. It contains information and communication about issues
that affect the public safety of the citizens of Nevada. The Nevada Department of Agriculture is also
included due to threats to water and wildlife.
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County Links
There are a number of helpful links to differing health services agencies in Nevada. Many of the links
include information specific to individuals and families as they make their plans for disaster
management. (http://dem.nv.gov/links/)
Conclusion
Much work was done after 2001 to put plans and resources in place to protect the world from
bioterrorism and chemical warfare. However, the level of fear that was present after the bombings
and the anthrax mailings has or is diminishing. Stronger more focuses legislation is tantamount to a
safer future for all.
The information contained in this module empowers healthcare workers to support changes in the
healthcare environments so that safe practices are developed and maintained to deal with biological
agents, whether they are accidental or part of a well laid out plan.
Remember, 2015, and the Ebola epidemic! What is next?
Resources
Knowing what resources to use is critical in the event of a biological attack. The following list of
resources is one that provides both federal and state specific information on bioterrorism, response,
and treatment issues.
Centers for Disease Control (www.cdc.gov). The central federal government agency with information
about infectious diseases
Department of Homeland Security (www.dhs.gov). The federal agency tasked with making sure the
nation is secure.
Federal Emergency Management Agency (www.fema.gov). The federal agency within DHS whose
responsibility is emergency response at the federal level to all types of emergencies, including
bioterrorist attacks.
U.S Army Medical Research Institute of Infectious Diseases (USAMRIID)
(www.usamriid.army.mil/education). A key source of critical information on various potential biological
weapons.
References
Agency for Toxic Substances and Disease Registry Division (2012). Retrieved from
www.atsdr.cdc.gov
Virginia Tech Office of the Vice President for Research. (2005). Opportunity Update. Retrieved from
www.research.vt.edu/funding/ou/prev/ou041505.html .
Centers for Disease Control and Prevention (CDC). (2016). Bioterrorism Agents/Disease. Retrieved
from http://www.bt.cdc.gov/agent/agentlist-category.asp#b
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National Institute Allergy and Infectious Disease (NIAH). (2015). NIAID Emerging
Infectious Diseases/Pathogens. Retrieved from:
https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx
National Institute for Occupational Safety & Health [NIOSH] (2012). Respirators. Workplace Safety &
Health Topic. Retrieved from: http://www.cdc.gov/niosh/topics/respirators/
Nevada State Health Division. (2012). Nevada Health Alert Network. Retrieved from
http://health.nv.gov/PHP_HealthAlertNetwork.htm .
Porter, L. (2012). Bioterrorism Legislation in the U.S. Retrieved from:
http://macaulay.cuny.edu/eportfolios/laraporter/2012/04/10/bioterrorism-legislation-in-the-us/
U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) (2005). USAMRIID’s
medical management of biological casualties handbook.
At the time this course was constructed all URL's in the reference list were current and accessible. rn.com. is committed to
providing healthcare professionals with the most up to date information available.
© Copyright 2005, AMN Healthcare, Inc.
Please Read:
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publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.
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