tive air pressure to prevent infectious agents from being spread outside of the rooms. They also have anterooms where medical personnel put on personal protective equipment [PPE] before entering the room and are decontaminated before leaving the room.) Some 400 physicians are said to be resident in the county, about 250 of whom are currently in practice and providing care to county residents. There are few infectious disease specialists.

USAMRIID has a special immunizations program (SIP) clinic, which is an outpatient research facility and health care provider for USAMRIID employees involved in biocontainment laboratory work. The clinic provides both licensed and investigational vaccines, if available, to staff who are at risk of exposure to biohazard agents. The vaccines augment protection provided by PPE and engineering controls for working with biohazard agents. Personnel with work-related injuries or symptoms of illness (especially fevers) are expected per standard operating procedures to report to the SIP clinic. Five physicians are dedicated to the SIP clinic, with an additional four who participate in after hours on-call and a medical-monitor physician, who serves as a patient advocate for subjects enrolled in studies of investigational new drug products. Five of the physicians, including the medical monitor, are board certified infectious disease specialists. The clinic has a clinical laboratory and a research serology laboratory. The research laboratory has the ability to perform serological testing for the types of pathogens under study at USAMRIID. The SIP clinic also has a biosafety level (BSL)-3/4 observation/isolation suite on site.

General medical care for USAMRIID staff is provided by the Barquist Army Health Clinic, except for those handling infectious agents under the SIP with illnesses that might be caused by agents under study. Should there be an incident requiring further medical care, a Memorandum of Agreement (Commander, USAMRIID; Commander, U.S. Army Garrison; Commander, Barquist Army Health Clinic; and Vice-President for Medical Affairs, Frederick Memorial Hospital, March 27, 2009) provides for USAMRIID patients to be received and treated at the Frederick Memorial Hospital. Further medical care for military staff is provided by Walter Reed Army Medical Center. A Memorandum of Understanding (Commander, Barquist Army Health Clinic, and Vice-President for Medical Affairs, Frederick Memorial Hospital, June 4, 2009) provides for mutual support between USAMRIID and Frederick Memorial Hospital staff to deal with a public health emergency or terrorist attack. It calls for USAMRIID physicians to provide quarterly training for hospital staff and for the Director of Safety and Security at the hospital to receive annually updated material on USAMRIID’s medical management of biological casualties. To facilitate care, each USAMRIID staff member is provided a contact card identifying him/her as an employee so as to expedite access to subject matter experts for consultation. The Barquist Army Health Clinic has an ongoing and good relationship with Frederick County’s Health Department, such that the county has confidence that it will be informed of any reportable medical incidents of which the clinic is aware. Notwithstanding the above resources and guidelines, there are case incidents where individual workers have not reported illnesses in accordance with

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