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2

Current Civilian Capabilities

Table 2-1 lists capabilities or actions likely to be required for an effective response to the medical consequences of a chemical or biological incident. It also, in effect, provides an outline of this section of the report, which will describe current preparedness in each of these areas in turn. In nearly every scenario, integrated planning and coordination among different levels of the medical community will be necessary for effective response.

For purposes of this report, we differentiate four levels of medical intervention, primarily on the basis of proximity to the precipitating event or initial victims. Response to a distinct, immediately recognizable terrorist incident (as opposed to a covert release of an agent whose effects would not be apparent for hours or days) would, in most instances, be initiated by law enforcement and fire and rescue personnel, including at some point medical personnel and a hazardous materials (Hazmat) team. This is the group referred to in Table 2-1 as “Local First Responders.” In the same table, “Initial Treatment Facilities” refers to the fixed-site medical facilities to which victims might initially be transported (or transport themselves) or which might initially be called upon for assistance by victims or on-site workers. Under “State” in the table, we refer primarily to state departments of emergency services and public health and regional resources such as poison control centers. A state public health agency would probably initiate the response to a covert release of an agent with delayed effects (i.e., anthrax).

The “Federal” category in Table 2-1 refers to capabilities that are many and varied. Upon request from the governor, FEMA may deploy an emergency response team, the health and medical services portion of which is the responsibility of the HHS, specifically the Office of Emergency Preparedness. The HHS National Counterterrorism Plan includes initiatives both to create or improve local capabilities and to enhance the existing National Disaster Medical System (NDMS). One initiative involves the organizing, equipping, and training groups of local fire and rescue personnel as Metropolitan Medical Strike Teams (MMST) in 25 or more of the nation's largest cities. The first of these teams, in Washington, D.C., became operational in early 1997. Appendix E explains their mission, composition, and major functions.



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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 2 Current Civilian Capabilities Table 2-1 lists capabilities or actions likely to be required for an effective response to the medical consequences of a chemical or biological incident. It also, in effect, provides an outline of this section of the report, which will describe current preparedness in each of these areas in turn. In nearly every scenario, integrated planning and coordination among different levels of the medical community will be necessary for effective response. For purposes of this report, we differentiate four levels of medical intervention, primarily on the basis of proximity to the precipitating event or initial victims. Response to a distinct, immediately recognizable terrorist incident (as opposed to a covert release of an agent whose effects would not be apparent for hours or days) would, in most instances, be initiated by law enforcement and fire and rescue personnel, including at some point medical personnel and a hazardous materials (Hazmat) team. This is the group referred to in Table 2-1 as “Local First Responders.” In the same table, “Initial Treatment Facilities” refers to the fixed-site medical facilities to which victims might initially be transported (or transport themselves) or which might initially be called upon for assistance by victims or on-site workers. Under “State” in the table, we refer primarily to state departments of emergency services and public health and regional resources such as poison control centers. A state public health agency would probably initiate the response to a covert release of an agent with delayed effects (i.e., anthrax). The “Federal” category in Table 2-1 refers to capabilities that are many and varied. Upon request from the governor, FEMA may deploy an emergency response team, the health and medical services portion of which is the responsibility of the HHS, specifically the Office of Emergency Preparedness. The HHS National Counterterrorism Plan includes initiatives both to create or improve local capabilities and to enhance the existing National Disaster Medical System (NDMS). One initiative involves the organizing, equipping, and training groups of local fire and rescue personnel as Metropolitan Medical Strike Teams (MMST) in 25 or more of the nation's largest cities. The first of these teams, in Washington, D.C., became operational in early 1997. Appendix E explains their mission, composition, and major functions.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities TABLE 2-1 Current Capabilities for Responding to Chemical and Biological Incidents   Local First Responders   Initial Treatment Facilities   State   Federal   Capability Chemical Biological Chemical Biological Chemical Biological Chemical Biological Preincident intelligence C C C C B B A A Detection, identification, and quantification of agents in the environment B C C C B B A B Personal protective equipment B B B B B B B B Safe and effective patient extraction C B N/A N/A N/A N/A C B Methods for recognizing symptoms and signs in patients B B B B B B B B Detection and measurement of agent exposure in clinical samples C C B C B B A A Methods for recognizing covert exposure in populations N/A N/A B B B B B B Mass-casualty triage techniques and procedures B B B B B B B B Methods/procedures for decontamination of exposed individuals B B C C C C B B Availability, safety, and efficacy of drugs and other therapies C C B B B B B B Prevention, assessment, and treatment of psychological effects B B B B B B B B NOTE: A = highly capable; B = some capability; C = little or no capability; and N/A = not applicable.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities The NDMS supplements state and local medical resources by delivering direct medical care to disaster victims. Disaster Medical Assistance Teams (DMAT) provide prehospital treatment. Sixty existing teams, some tailored to focus on pediatrics, burns, mental health, and other specialties, are in place around the country. Twenty-one are fully deployable and can be on the scene in 12 to 24 hours. Three teams are being organized and trained specifically to respond to chemical or biological terrorism. NDMS hospitalization assistance is accomplished though a regional network of 72 Federal Coordinating Centers which are run by the Veterans Administration (VA) and the DoD. These centers have agreements with private-sector hospitals to supply a total of more than 100,000 beds; the VA provides medicines, and DoD patient transportation. Further description of NDMS capabilities, including mortuary teams, which, although outside the scope of this study, are nevertheless likely to be a vital resource in a worst-case, mass casualty incident, may be found in Appendix F. The CDC is a widely recognized source of expertise in the diagnosis of infectious agents known to be pathogenic in humans, and their epidemiological and laboratory resources are often called upon to assist state health departments identify and manage outbreaks of severe unexplained illness. In cases of suspected biological or chemical terrorism CDC itself can consult with several DoD medical research units specializing in biological or chemical defense and with experts at academic institutions and research institutes. Other DoD organizations may provide advice and assistance with bomb disposal and decontamination, and under some circumstances a new United States Marine Corps unit called the Chemical Biological Incident Response Force (CBIRF) may provide assistance in evacuation, decontamination, and medical stabilization of victims. This 350-person force is based at Camp LeJeune, North Carolina and can have an advance party airborne 4 hours after notification. However, CBIRF is most likely to play a major role only when deployed in advance to a site where there is reason to suspect an attack (e.g., the 1996 Atlanta Olympics). PREINCIDENT INTELLIGENCE Unfortunately, preincident intelligence is not something medical organizations typically see as their responsibility. As noted above in the section on Legislative Background, the CDC now maintains a database of individuals and organizations possessing any of 36 biological agents (listed in Appendix D) with potential to cause a severe threat to public safety and health. The legislation does not require CDC to share this information with state or local health departments, however, and sharing has not been done in any systematic way. Although facilities willing to report to CDC that they are working with these agents are unlikely to be terrorist threats themselves, they may be targets of terrorists, or the source of an unintended release. Either event will be handled better if the local medical community is aware of the possibility. Of far more importance is an institutionalized linkage between the law enforcement and medical and public health communities. The response of even the most well prepared medical facilities will be markedly improved by advance notice from the law enforcement community. The latter understandably fear compromising ongoing investigations, but may not fully appreciate the substantial impact even very general information about possible incidents can

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities have in facilitating a rapid and effective response by first responders and the medical community should an incident occur. Preparation for a possible mass-casualty event need not involve more than a few key individuals who can review the organization's seldom-used plan and begin to think about where and how to obtain needed antidotes and drugs, make beds available on short notice, ensure adequate staffing and accurate treatment protocols. After-action reports on the Tokyo subway incident (Obu, 1996; Olson, 1996; Yanagisawa, 1996) provide an example of the value of communication between the law enforcement and medical communities as well as an example of a missed opportunity for communication within the medical community that might have made the medical response even more effective than it was. Japanese police had apparently been planning a raid on Aum Shinrikyo facilities throughout Japan, and for that reason the government had ordered medical supplies, including nerve-agent antidotes, not normally stocked in quantity by hospitals (anonymous comments in Obu, 1996). One of the reasons for the raids was the suspected involvement of the Aum Shinrikyo in a previous toxic gas incident in the city of Matsumoto almost a year prior to the Tokyo incident. The release in that city in 1994 of what was subsequently identified as sarin resulted in seven deaths and treatment of an additional 250 people. A group of Matsumoto physicians, recognizing that data from humans exposed to sarin were very rare, collected a great deal of information on these patients, which they sent to Tokyo hospitals and the Ministry of Health and Welfare as soon as they heard of the subway attack. Although the information reportedly was helpful, it seems obvious that a more formal mechanism by which the Matsumoto group could have more rapidly and systematically alerted other cities and hospitals to such an unusual event might have been even more valuable. In this country, the District of Columbia's Emergency Management Office was provided an extensive, although generic, briefing on the terrorism threat just prior to the start of the Gulf War. Similar briefings have no doubt taken place on occasions such as the 1996 Atlanta Olympic Games, and personal relationships may provide good communication between the law enforcement and medical communities in some cities. However, few have the sort of structural links that the MMSTs are attempting to build into their operations —a law enforcement section, headed by a local law enforcement officer, one of whose major duties is to establish relationships with the local FBI office and other law enforcement agencies sufficient to insure that the team has the maximum prior warning of potential nuclear, chemical, or biological incidents. DETECTION AND MEASUREMENT OF AGENTS IN THE ENVIRONMENT Rapid identification of the chemical or biological agents involved in any Hazmat incident is vital to both the protection of first responders and emergency medical personnel at local medical facilities and to the effective treatment of casualties. This section of the report briefly describes a number of devices that can be used for that task. An initial section deals with devices for detecting and identifying chemical agents, and it is followed by a section focused on biological agents, but a potentially important complication of real life that can easily be overlooked is the possibility that a terrorist attack may involve more than one agent.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Therefore, detection of one of the agents being considered in this report could easily bring identification efforts to a halt. Instead, detection of one agent should be taken as an indication that someone is trying to cause harm, and therefore provoke more extensive testing. Chemical Agents Hazmat teams are routinely equipped with a variety of chemical detectors and monitoring kits, primarily chemical-specific tests indicating only presence or absence of the suspected chemical or class of chemical (a negative test means only that a specific substance is not present in significant quantity; a positive response says nothing about the possible presence of other hazardous agents). Hazmat analytical capabilities commonly include tests for chlorine, cyanide, phosgene gas, and organophosphate pesticides. The last of these tests may respond to the military nerve agents, which are also organophosphates, but the requisite calibrations have not been done. Hazmat team tests rarely include a means of detecting the chemical vesicants (i.e., blister agents). Tests, detectors, and monitors of varying sensitivity and specificity have been developed by the armed forces to identify the nerve agents and vesicants (Appendix G). These devices are manufactured by commercial suppliers and are apparently available for purchase by civilian institutions and individuals. The MMSTs being organized and equipped by the Public Health Service (PHS), for example, have purchased M8 and M9 detection paper, M256A1 Detection Kits, an M18 Detection Kit, a Draeger kit, a portable surface-acoustical-wave (SAW) chemical agent detector (SAW MiniCAD), and a chemical agent monitor (CAM). The M8 and M9 detection papers provide a rapid (<1 minute), inexpensive test for the presence of liquid mustard or nerve agents. Neither reacts to vapors, however, and both show false positives to petroleum products, antifreeze, and pesticides (at a minimum). False positives are especially undesirable in a civilian context, where the mere rumor of “nerve gas” may cause hysteria. The M256A1 kit includes detector “tickets,” which detect low concentrations of cyanide, vesicant, and nerve agents in vapor form. The tests take approximately 15 minutes. Sensitivity is such that the tickets may provide a negative reading at concentrations below those immediately dangerous to life and health (IDLH) but still as much as 500 times greater than the acceptable exposure limit (AEL). Occupational Safety and Health Administration (OSHA) rules call for the use of maximum personal protection until concentrations can be shown to be less than 50 times the AEL. The IDHL is the maximum concentration of a contaminant to which a person could be exposed for 30 minutes without experiencing any escape-impairing or irreversible health effects. The AEL is a general term indicating a level of exposure that is unlikely to result in adverse health effects. The M18 detection kit, like the M256A1 kit, is a military item. In fact it might be termed a chemical weapons Draeger kit—a colormetric device measuring the concentration of selected airborne chemicals by drawing air through chemical-specific tubes. The M18 comes with disposable tubes for cyanide, phosgene, Lewisite, mustard, and nerve agents GA (tabun), GB (sarin), GD (soman), and VX. Tests for each take only two to three minutes but must be conducted serially.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities The SAW MiniCAD is a commercially available device that can detect dangerous levels of both airborne mustard and the G agents with a high degree of specificity (i.e., there are fewer false alarms); it can take a measurement every 60 seconds. The CAM uses ion mobility spectrometry to provide a hand-held device for monitoring nerve or vesicant agent vapors. It provides a graduated readout (low, medium, high). Response is dependent on concentration but generally is from 10 to 60 seconds. Minimum levels detectable are about 100 times the AEL for the nerve agents and about 50 times the AEL for vesicants. An obvious drawback to this relative insensitivity to low concentrations is an inability to fully check the efficacy of decontamination efforts, both in the field and subsequently at treatment facilities. Few local governments or private medical facilities or organizations have invested in such equipment to date. This may change as the Army 's Domestic Preparedness Program provides the training it has promised to 120 of the nation's largest metropolitan areas, but it seems likely that it is not simply information on availability but also the cost of some of these devices that has limited sales. The CAM, for example, costs almost $9,000. It is a highly specific device designed to detect nerve and vesicant vapors only. Biological Agents Real-time detection and measurement of biological agents in the environment is daunting because of the number of potential agents to be distinguished, the complex nature of the agents themselves, and the myriad of similar microorganisms that are a constant presence in our environment and the minute quantities of pathogen that can initiate infection. Few, if any, civilian agencies at any level currently have even a rudimentary capability in this area. A number of military units, most notably the Army's Technical Escort Unit, the U.S. Marine Corps Chemical Biological Incident Response Force, and the Army Chemical Corps presently, do have some first-generation technology available. For example, most of the agents under consideration in this document are considered attractive as weapons in part because they can be delivered as aerosols, “stand-off” monitors use near infrared lasers to detect distant clouds containing 5 micrometer (µm) particles of a biological nature. However, the necessity for prior intelligence, subsequent deployment, and then line-of-sight use of the technology would seem to limit its utility in most urban bioterrorism scenarios. The committee will address this technology in more detail in its final report. Point detectors such as the Biological Integrated Detection System (BIDS) actively collect and test samples from their immediate environment. BIDS continuously samples ambient air and determines the background distribution of aerosol particles. Aerosol particles with diameters in the 2 to 10 µm range are concentrated and analyzed for biological activity, as indicated by the presence of adenosine 5′-triphosphate (ATP). Flow cytometry then separates and concentrates bacterial cells, and antibody-based tests are conducted for specific agents. At present, the system detects the bacteria responsible for anthrax and plague, botulinum toxin A, and staphylococcal enterotoxin B.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Much less expensive point detectors are available as prototype “One Step Hand-Held Assay” devices. These instruments are currently produced by the Navy Medical Research Institute (NMRI) at Bethesda, Maryland and are based on antigen capture chromatography. Eight different devices are used to assay liquid samples for the presence of Y. pestis, F. tularensis, B. anthracis, V. cholerae, SEB, ricin, botulinum toxins, and Brucella species, respectively. A color change provides a positive or negative indication within 15 minutes. These devices are strictly screening assays, and the analyses are subject to error from the introduction of other contaminants. Therefore, positive results need to be confirmed with standard microbiology assays, immunoassays, or genome detection via polymerase chain reaction (PCR) technology. Both NMRI and the U.S. Army Research Institute of Infectious Diseases (USAMRIID) at Ft. Detrick, Maryland, have deployable field laboratories that can perform these additional confirmatory assays (and assays for 15 to 20 other potential agents). However, the confirmatory assays do not yield results as quickly. Detectors with higher sensitivity than those presently available will be needed to detect biological aerosols of low but still hazardous concentration and magnitude. Although the NMRI devices and the confirmatory assays referred to here may be employed with clinical samples (blood, urine, sputum) as well as environmental ones, it should be kept in mind that the biological agents being discussed here do not immediately produce effects. As a result, the first indication of a covert attack may be the recognition of an unusual distribution or number of cases of disease, long after the initial aerosol or solution has been dispersed or degraded. Public health surveillance systems and the rapid analysis of information from those systems may provide the first indication of where the biological agent was released. PERSONAL PROTECTIVE EQUIPMENT (PPE) Chemical Agents The term PPE refers to clothing and respiratory gear designed to shield an individual from chemical, biological, and physical hazards. The amount and type of protection required varies with the nature and concentration of the hazard and the duration of exposure anticipated, but a National Institute for Occupational Safety and Health (NIOSH)/OSHA/EPA classification system is often used in describing general levels of protection as follows: Level A provides maximal protection against vapors and liquids. It includes a fully encapsulating, chemical-resistant suit, gloves and boots, and a pressure-demand, self-contained breathing apparatus (SCBA) or a pressure-demand supplied air respirator (air hose) and escape SCBA. Level B is used when full respiratory protection is required but dangers to the skin from vapor is less. It differs from Level A in that it incorporates a nonencapsulating, splash-protective, chemical-resistant suit (splash suit) that provides level A protection against liquids but is not airtight. Level C utilizes a splash suit along with a full-faced positive or negative pressure respirator (a filter-type gas mask) rather than SCBA or air line.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Level D is essentially coveralls or other work clothes, boots, and gloves. OSHA requires Level A protection for workers in environments known to be immediately dangerous to life and health (i.e., where escape will be impaired or irreversible harm will occur within 30 minutes), and specifies Level B as the minimum protection for workers in danger of exposure to unknown chemical hazards. The NIOSH and the Mine Safety and Health Administration designate performance characteristics of respirators and provide approval for all commercially available respirators. Chemical protective clothing is not subject to performance standards established by a government agency, but the American Society for Testing and Materials (ASTM) has developed methods for testing the permeability of protective clothing materials subjected to a battery of liquids and gases. The National Fire Protection Association (NFPA) has incorporated the ASTM test battery into now widely accepted standards for protective suits for hazardous chemical emergencies. A basic rule in selecting PPE, however, is that the equipment be matched to the hazard, and none of the ASTM permeability tests employ military nerve agents or vesicants. Military PPE, on the other hand, has been tested for protection against those agents (e.g., one or more nerve agents, mustard, and lewisite) but generally does not have the certification by NIOSH or NFPA that would allow its purchase and use by civilian workers for any purpose. Some progress in addressing this impasse was made in conjunction with the Army's Chemical Stockpile Emergency Preparedness Program (CSEPP). In order to make recommendations on PPE for civilian emergency response personnel in communities adjacent to military bases that have stockpiles of chemical weapons (Argonne National Laboratory, 1994; Centers for Disease Control and Prevention, 1995b), CSEPP sponsored tests of commercial respirator filters (Batelle Laboratories, Inc., 1993), fabrics used by commercial chemical suit manufacturers (Daugherty et al., 1992), and one commercially available splash suit (Arca et al., 1996), using nerve and mustard agents. Subsequent United States Army testing of four Level A suits, four Level B suits, and four Level C suits has resulted in approval of two Level A commercial suits for use in chemical agent emergencies at Army facilities and an informed purchase of commercial Level A and Level C PPE by MMSTs (United States Army Chemical Demilitarization and Remediation Activity, 1994). In the event of a chemical-agent incident, it is most likely that the first emergency personnel on the scene will be police or firefighters. The former will almost never have chemical PPE and should simply relay observations to the latter. Firefighter “turnout” or “bunker” gear designed for fire resistance provide only minimal protection against hazardous chemicals, but firefighters often have sufficient respiratory protection (SCBA) available to allow for a rapid extraction and initial decontamination of victims at a location away from the primary source. Hazmat teams have a small number of Level A suits, some of which, as mentioned above, may provide good protection against nerve and mustard agents. Most, if not all NFPA-certified commercial Level A suits are likely to provide protection for brief periods or against low concentrations, or both. The current focus of Hazmat team activity is, in fact, short-term operations to control or mitigate a release, rather than sustained efforts locating and extracting victims or doing site remediation.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Emergency medical personnel most often have Level C PPE if they have any at all. This is likely to be appropriate for treatment of decontaminated victims, but unless the agent can be identified and its concentration established as nonlife-threatening, OSHA regulations would call for Level B protection. A similar situation exists at local hospitals that may receive not only field-decontaminated patients but also “walk-ins” who may have bypassed field decontamination. Some authors have argued that Level C protection or even Level D protection (hospital gown, goggles, surgical mask and latex gloves) is adequate for emergency department personnel; others argue for a universal PPE policy that will cover the exceptional cases (e.g., Level B in all cases until thorough decontamination is completed). Although the Joint Commission on Accreditation of Healthcare Organizations has established standards for hospitals calling for Hazmat plans and training, it does not specify details of either, and two recent reviews have suggested that most hospitals in the United States are ill prepared to treat contaminated patients (Cox, 1994; Levitin and Siegelson, 1996). A 1989 study of 45 California hospitals found that only 2 of the 45 actually had any personal protective equipment assigned to the emergency department, and one of those two kept it in an ambulance that was not always at the hospital (Gough and Markus, 1989). Biological Agents Most of the biological agents considered here would be most efficiently delivered by the aerosol route. Thus, goggles, SCBA or small-particle respiratory filters should provide adequate protection (Weiner, 1996). Ordinary clothing and gloves generally provide sufficient protection against cutaneous infection; intact skin itself is a formidable barrier to most biological agents, although T-2 mycotoxin is a significant exception and decontamination procedures similar to those for chemical agents should be employed if T-2 exposure is suspected (Wannamacher et al., 1991; Wannamacher and Wiener, 1997). In cases of covert terrorism, however, medical personnel and facilities might become aware of the attack only after patients develop symptoms, days after the aerosol source has dispersed or been rendered inert by environmental conditions, such as sunlight and temperature extremes. Precautions at that point are primarily directed at avoiding contact with patient blood and other body fluids (gown, gloves, goggles or glasses are effective, although depending on the agent, a personal respirator may be advisable if the patient is coughing, bleeding, or vomiting). Hospitals use a variety of precautions and isolation protocols to reduce the danger of disease transmission when a known or suspected case of a communicable disease arrives. Assessment, and subsequent treatment, should be in a negative-pressured room with nonrecirculated air. Newer hospitals are likely to have at least a small number of such rooms; older ones may not. Garner et al. (1996) provide the most recent CDC guidelines. Aerosol delivery is not the only possible route; although it is the quickest and most efficient means of delivery to the battlefield, other criteria may prevail in the urban terror scenario. Delivery of a biological agent via the water supply, perhaps even incorporating it into an otherwise innocuous organism that thrives in fresh water and tolerates chlorine, for example, would provide a source of continuing new infections, so personal protection could demand

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities water treatment on some scale. Boiling is clearly feasible at all levels of medical treatment, as is the use of bottled water, but in either case logistics would have a noticeable impact on the number of patients who can be handled per hour. SAFE AND EFFECTIVE PATIENT EXTRACTION Fire and rescue personnel are not currently equipped or trained to function for prolonged periods or in large numbers in a contaminated environment, and the typical Hazmat incident has few if any victims in need of extraction. An approach taken at some likely targets (the Pentagon and several metropolitan transit systems) involves establishing a cache or caches of lightweight Israeli-made “escape hoods” for use by employees (Defense Protective Service, 1996). The manufacturer suggests supplying first responders with a multihood package for use in minimizing additional exposure of victims during (or waiting for) the rescue process (Fume Free, Inc., 1997). Both skin and respiratory protection is limited, but better than no protection at all. With or without hoods, rapid removal of at least some persons should be possible, but Hazmat teams are not equipped or trained for search and rescue operations. FEMA Urban Search and Rescue Teams do possess that capability, but they are not equipped or trained to function in a chemically contaminated environment. Furthermore, unless the chemical agent incident takes place in a city where one of these teams is located, it may not arrive on site until 12 to 24 hours after notification, much too late to help victims trapped in a contaminated building. The psychological impact on emergency response personnel of large numbers of deceased victims will no doubt be considerable, and could conceivably be a significant hindrance to on-scene operations. METHODS FOR RECOGNIZING SIGNS AND SYMPTOMS IN VICTIMS/PATIENTS Emergency medical personnel, both at the scene of a hazardous materials incident and at hospital emergency departments, have a wide selection of reference materials to call upon for guidance in patient management. These include traditional textbooks, handbooks such as the three-volume set of medical managment guidelines prepared by the Agency for Toxic Substances and Disease Registry (United States Department of Health and Human Services, 1994a), and paper, CD-ROM, or on-line Material Safety Data Sheets. Some of these sources provide information on nerve and mustard agents, but most of these resources are organized by chemical rather than by symptom complex. That is, given some independent knowledge of the identity of the hazardous substance, one can readily ascertain the likely effects and appropriate treatment. Deducing the substance from the effects is far more difficult. Poison Centers are routinely faced with this problem and are a good source of help. The Washington, D.C. MMST has addressed this difficulty by incorporating a symptom checklist tool called the “NBC Indicator Matrix” into their training (Defense Protective Service, 1996). First developed by the Defense Protective Service, which provides security at the Pentagon, it is a paper-and-pencil checklist of symptoms. A system for scoring and processing the results leads to a

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities suggested agent or agents. For Hazmat incidents at the Pentagon, and by definition, for incidents which lead to a request for help from the MMST, first responders are highly likely to turn to such a tool. At other locales, they may need some reason to suspect terrorism in order to consider using the matrix. The matrix may have some utility even in its present form, especially in cases in which exposures are mild. Difficulties seem likely when victims are critically ill or have preexisting illnesses, or in incidents involving more than a single agent. The addition of a number of other signs and symptoms may be helpful in this regard. With the exception of botulinum toxin, and possibly the hemorrhagic fevers, the initial signs and symptoms produced by the biological agents considered here are nonspecific—fever, chills, fatigue, headache, muscle or joint pain, a cough or chest pain. Blood in the excreta or petechiae (pinpoint-sized, hemorrhagic spots in the skin) may lead an astute clinician to consider a hemorrhagic fever, but few United States practitioners are likely to recognize the other diseases associated with biological weapons on the basis of signs and symptoms alone. Correct diagnosis will almost certainly depend on perception of an unusual epidemiologic picture by regional poison control centers or public health epidemiologists. This is an area where preincident intelligence could have a major impact in reducing the number of casualties. DETECTION AND MEASUREMENT OF AGENT EXPOSURE IN CLINICAL SAMPLES FROM PATIENTS Chemical Agents Nerve Agents Persons exposed to high concentrations usually develop signs and symptoms within a matter of minutes after exposure. Therefore, initial patient diagnoses and treatment are likely to be based on observations of signs and symptoms by the paramedic or other health care professional on the scene. Emergency medical personnel are, in any case, not equipped, trained, or encouraged to attempt clinical chemistry. At the hospital level, treatment will continue to be guided by signs and symptoms and monitored at this level by electrocardiogram, chest X-ray, blood gas measurement, and other measures of physiologic status. Because cholinesterase activity is inhibited by nerve agents, laboratory tests estimating the level of this activity in red blood cells or plasma can be used in estimating the degree of acute exposure. However, many hospitals cannot perform this test on site, enzyme inhibition may only be loosely correlated with clinical signs and symptoms, and, because of high inter-individual variability, only comparison between a baseline level of inhibition and the level just after exposure to a nerve agent will provide unambiguous evidence of a small or moderate exposure to nerve agents.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Brucellosis Brucellosis is another disease of domesticated animals, and usually occurs in humans as a result of ingestion of unpasteurized dairy products. Person-to-person transmission is very rare. The infectious agent is one of six species of the Brucella bacterium. Although nonsporulating, brucellae are aerobic organisms viable for long periods outside a host. Its ready transmission by the aerosol route led the United States to experiment with weaponizing Brucella during World War II, although the resulting bombs were never used. Fever, chills, and body aches occur in nearly all cases and regardless of route of infection. Brucellae disseminate widely and may cause disease in nearly any organ system, so additional signs and symptoms vary widely. Although rarely fatal, brucellosis can be debilitating for weeks or months if not treated. See Hoover and Friedlander (1997) for additional information. Preexposure Prophylaxis There is no approved Brucella vaccine for humans. Postexposure Therapy According to Franz et al. (1997), patients should be treated with combinations of antibiotics because treatment with a single antibiotic causes poor response or relapse. Usually, a combination of doxycycline and rifampin is given orally for six weeks. Trimethoprim-sulfamethoxazole can be substituted for rifampin, although relapse rates may be as much 30 percent (Franz et al, 1997). The recommended treatment for bone and joint infections, endocarditis, and central nervous system disease is streptomycin or another aminoglycoside, and therapy should be extended. Pneumonic Plague Plague is well known as the cause of The Black Death, which took the lives of 80 million Europeans in the fourteenth century. The infectious agent is Yersina pestis, a nonsporulating bacillus maintained in nature in fleas, most notably the rat flea. In humans the bite of an infected flea leads to a high fever, chills, and headache, often accompanied by nausea and vomiting. Six to eight hours later, very painful swelling of one or more lymph nodes (a bubo, hence bubonic plague) develops. Without treatment, septicemia will develop in 2 to 6 days, with a mortality rate of 33 percent. Inhalation of Y. pestis aerosol will lead to pneumonic plague (extensive, fulminant pneumonia with bloody sputum), which is almost always fatal if not treated within 24 hours of symptom onset. Patients in terminal stages of pneumonic or septicemic plague may develop large subcutaneous hemorrhages, which may have given rise to the name “Black Death.” Additional information is available in McGovern and Friedlander (1997). Preexposure Prophylaxis A licensed, killed whole-cell vaccine is available. Although some epidemiologic evidence supports the efficacy of this vaccine against bubonic plague, its efficacy against aerosolized Y. pestis has not been established.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Postexposure Therapy Plague pneumonia is almost always fatal if treatment is not initiated within 24 hours of the onset of symptoms. Streptomycin is administered intramuscularly for 10 days (2 doses each day). Gentamicin can be substituted for streptomycin. Plague meningitis and cases of circulatory compromise are treated with chloramphenicol given intravenously. Intravenous doxycycline administered for 10 to 14 days is also effective. Q Fever Q fever is an incapacitating but rarely fatal disease caused by the rickettsia-like agent Coxiella burnetti. A large number of mammalian species can serve as host for C burnetti, but humans are apparently the only hosts in which infection results in a disease. Although the organism cannot grow or replicate outside host cells, inhalation of a single organism can result in disease. The usual route of human infection is through contact with domestic livestock, but this may be very indirect contact, because a spore-like form that is extremely resistant to heat, desiccation, and many standard antiseptic treatments, allowing the organism to survive on inanimate surfaces for weeks or months. Human infection is usually the result of inhalation of infected aerosols, and signs and symptoms appear 10 to 40 days after exposure, sometimes abruptly and sometimes very gradually. There is no characteristic set of signs and symptoms, although fever and chills are nearly universal. Headache, fatigue, muscle aches, anorexia, and weight loss are common. Fatalities from Q fever are very rare, and although malaise and fatiguability may persist for months, most other effects last only 2 to 3 weeks. For additional information see Byrne (1997). Preexposure Prophylaxis Q fever vaccines in the United States are still investigational, although an effective vaccine, Q-Vax, is licensed in Australia. Postexposure Therapy The most common treatments for Q fever are tetracyclines. Macrolide antibiotics, such as erythromycin and azithromycin, are also effective. Other agents used to treat Q fever include quinolones, chloramphenicol, and trimethoprim-sulfamethoxazole. Clinical experience with these drugs is limited. Treatment is most effective when administered during the 10- to 40-day incubation period. Tularemia Tularemia results from infection by the insect-borne bacterium Francisella tularensis. In North America, the tick is the principal reservoir, and the rabbit is the vertebrate most closely associated with transmission. As few as 10 organisms can give rise to a clinical infection in humans, and transmission may be via inhalation, ingestion, or, most commonly, through breaks in the skin. The disease is characterized by fever, localized ulceration, enlarged lymph glands, and, in about 50 percent of patients, pneumonia. Without treatment with antibiotics, patients may have a prolonged illness with malaise, weakness and weight loss persisting for months. Treatment with appropriate antibiotic drugs reduces the duration and severity of the disease, and overall mortality is quite low (1 to 2 percent).

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Preexposure Prophylaxis The United States Army Medical Research and Material Command is the IND holder for a live attenuated tularemia vaccine that appears to be effective against inhalational exposure. Postexposure Therapy Streptomycin is administered intramuscularly in two divided doses daily for approximately 10 to 14 days. Gentamicin is also effective. Tetracycline and chloramphenicol are also effective but tend to be associated with significant relapse rates (Franz et al., 1997). See Evans and Friedlander (1997) for additional information. Smallpox Until very recently, smallpox was an important cause of morbidity and mortality in the developing world. The causative agent of smallpox is variola, one of a family of large, enveloped deoxyribonucleic acid (DNA) poxviruses. Unlike many of the agents discussed above, the variola virus thrives only in human hosts, and as a result, aggressive case finding and vaccination programs (using the closely related but nonpathogenic vaccinia virus) are thought to have eradicated smallpox. The last known cases occurred in 1978. Concerns about its use as a weapon persist, however, because variola virus is highly stable and retains its infectivity for long periods outside the host, and because enough is known of its sequencing that biotechnology might be used to create variola or a pathogenic variation of variola. Although characteristic pustular skin lesions provided the name for this disease, and virus can be recovered from scabs throughout convalescence, smallpox is infectious by aerosol. Regardless of route of transmission, clinical manifestations begin with fever, malaise, headache, and vomiting, and the infection is a systemic one that produced mortality rates of 20 to 30 percent in unvaccinated populations (McClain, 1997). Preexposure Prophylaxis Individuals who were vaccinated during the WHO smallpox eradication campaign throughout the 1970s were considered to have immunity to smallpox for at least 3 years, but protection diminishes over time. The only vaccine still available in the United States is a live vaccinia virus manufactured by Wyeth. The CDC holds the entire remaining stock (less than 12 million doses). The Department of Defense has developed a replacement that has IND status. Given the eradication of endemic smallpox, it is hard to imagine collecting the efficacy data generally required for FDA approval. For the same reason, United States pharmaceutical companies have little interest in manufacturing new lots of the old vaccine. Postexposure Therapy Vaccination will give protection to an exposed individual if it is administered within a few days of exposure, regardless of time since any prior vaccination. There is no chemotherapeutic agent with proven effectiveness against smallpox, but Franz et al. (1997) suggest that preclinical tests against other poxviruses indicate that chemotherapy with cidofovir might be useful. Vaccinia-immune globulin (VIG) may also be of use if given within the first week following exposure (preferably within 24 hours). VIG, which is prepared from the blood of repeatedly vaccinated persons, is available from the CDC in extremely minute

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities quantities. Because almost no one is being vaccinated anymore, there is little prospect of producing a large stockpile of VIG. Viral Encephalitides Although other viruses can also produce encephalitis, three closely related enveloped RNA viruses of the Alphavirus genus initially recovered from moribund horses in the 1930s are considered the primary candidates for weaponization: Venezuelan equine encephalomyelitis virus (VEE), eastern equine encephalomyelitis virus (EEE), and western equine encephalomyelitis (WEE). All could be inexpensively produced in quantity, are relatively stable, and are readily amenable to genetic manipulations that might confound defenses against them. Natural infections are acquired through mosquito bites, but these viruses are also highly infectious as aerosols. Victims develop an incapacitating combination of fever, headache, and fatigue, and the most severe of the three, EEE, results in fatality rates of 50 to 75 percent. Survivors may be left with seizures, sensorimotor deficits, or cognitive impairment. See Smith et al., (1997) for additional information. Preexposure Prophylaxis A live attenuated vaccine for VEE exists (TC-83), but it causes more than 20 percent of recipients to experience high fever, malaise, and headache. Inactivated vaccines for VEE, WEE, and EEE in humans also exist; they require multiple injections and have poor immunogenicity. All vaccines, including TC-83, are available only in IND status. Postexposure Therapy No specific therapy exists for these alphavirus encephalitides and treatment is directed at management of specific symptoms (e.g., convulsions, respiratory infection, and high fever). Even treatment with virus-neutralizing antisera (antibody-containing serum from the blood of previously-infected patients or animals) will fail to stop progression of established encephalitis. Antimosquito precautions should also be implemented. Viral Hemorrhagic Fevers Viral hemorrhagic fever is a term indicating an acute febrile illness accompanied by circulatory abnormalities and increased vascular permeability. Similar diseases result from infection with any of about a dozen RNA viruses belonging to four different genera: Lassa, Argentine, Bolivian, Venezuelan, Brazilian, Rift Valley, Congo-Crimean, Marburg, Ebola, Dengue, and Yellow. All of these diseases are normally transmitted to humans through contact with infected animal reservoirs and/or arthropod vectors (mosquito or tick). All are relatively stable and highly infectious as fine-particle aerosols. Patients generally present with high fever and some indication of vascular involvement: low blood pressure, flushing, or small subcutaneous hemorrhage. Progression of the disease typically means bleeding from mucous membranes, signs of pulmonary, liver or kidney failure, and shock. Mortality varies widely among the diseases, from 5 to 20 percent for most, but as high as 90 percent for Ebola virus. See Jahrling (1997) for further information.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Preexposure Prophylaxis Vaccines are available for yellow fever (YF), Rift Valley fever (RVF), and Argentine hemorrhagic fever (Junin virus, JUN). Cross protection against Bolivian hemorrhagic fever may also be provided by the Junin vaccine. These are the only vaccines available for any of this set of diseases and will be effective only if personnel are immunized before exposure. Only yellow fever vaccine is licensed by the FDA; the others are used in the United States under IND protocols and can only be obtained through the CDC. Postexposure Therapy Vaccines have no application in treatment of exposed targets. Intravenous administration of the antiviral drug ribavirin is recommended for therapy of infections with Lassa virus and with Hantaan and other Old World Hantaan-related viruses. Ribavirin may also be useful for treatment of infections by other arenaviruses and Congo-Crimean hemorrhagic fever virus, but data proving efficacy are lacking. Ribavirin for these infections is used under IND protocols. It is not thought likely to be effective against filoviruses such as Ebola or flaviviruses such as YF or Dengue. There is no proven chemotherapeutic drug available. Human immune serum is efficacious for treatment of persons exposed to Junin virus. Some anecdotal evidence suggests that ebola human convalescent serum may be effective in preventing death from Ebola virus, but no scientifically controlled studies have been reported. Case management includes careful monitoring of fluid and electrolytes and intravenous corrective therapy where needed. Hospitalization under barrier precautions (gloves and gowns, face shields, or surgical masks and eye protection, for all those coming within 3 feet of the patient) is usually adequate to prevent transmission of Ebola, Lassa, CCHF, and other hemorrhagic fevers, but isolation of the patient provides an added measure of safety and is preferred, if facilities are available. Disinfection of bedding, utensils, and excreta by heat or chemicals is recommended for all of the viral diseases under consideration. Quarantine, defined by Benenson (1995) as “restriction of the activities of well persons or animals who have been exposed to a case of communicable disease during its period of communicability, to prevent disease transmission during the incubation period if infection should occur,” may be indicated following an act of bioterrorism. If the agent is already identified, the decision to quarantine should be made based on the known communicability of the agent. Quarantine, for instance is not recommended for those exposed to anthrax, but is recommended for those exposed to plague if chemoprophylaxis is not available. If the agent is not identified, then quarantine should be considered. CDC has provided detailed instructions on the management of suspected hemorrhagic cases, including handling and laboratory testing of potentially infectious materials (Centers for Disease Control and Prevention, 1988, 1995a). Botulinum Toxins Botulism, an often lethal form of poisoning associated with improperly canned or stored foods, is the result of neurotoxins produced by the spore-forming anaerobic bacterium Clostridium botulinum. The botulinum toxins are the most toxic substances known. It has an estimated LD50 (the dose lethal to 50 percent of the population exposed) of 1 nanogram/kilogram of body weight (Gill, 1982). Some in-vitro work suggests that these

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities neurotoxins act presynaptically to block the release of acetylcholine and perhaps other neurotransmitters (Habermann, 1989), but the exact mechanism is as yet unknown. It is known that whether ingested, inhaled, or injected, the clinical course is similar. Several hours to 1 or 2 days later, dry mouth, difficulty swallowing, and double vision may be reported, followed by a progressive muscle weakness culminating in respiratory failure from skeletal muscle paralysis. See Middlebrook and Franz (1997) for additional information. Preexposure Prophylaxis The currently available vaccine is a formalin-fixed supernatant from cultures of C. botulinum. It protects against botulinum toxin types A through E, but is available only as an IND product, with a license held by the CDC. A series of three vaccinations must be started 12 weeks before exposure, and yearly boosters are required to maintain protection. Postexposure Therapy Foodborne botulism is treated with a licensed trivalent equine antitoxin (serotypes A, B, and E) that is available only from the CDC. A despeciated equine heptavalent antitoxin that has been developed by the U.S. Army specifically for aerosol exposures to serotypes A–G has IND status (Franz et al., 1997). There is no other approved therapy for airborne botulism, although animal studies show that botulinum antitoxin can be very effective if given before the manifestation of clinical signs of disease. Mechanical ventilation is invariably necessary, due to paralysis of respiratory muscles, if antitoxin is not given before the onset of clinical signs (Shapiro et al., 1997). Staphylococcal enterotoxin B (SEB) SEB is one of seven toxins produced by strains of the Staphylococcus aureus bacterium. Like botulinum toxin, it is most often associated with food poisoning. Unlike botulism neurotoxin, SEB appears to exert its effects through overstimulation of cytokine production by the immune system (Ulrich et al., 1997). Ingested SEB is incapacitating rather than lethal, with vomiting and nausea prominent. SEB is relatively stable in aerosol, however, and the consequences of inhalation may be much more severe, possibly even a fatal “toxic shock” syndrome involving high fever, a rapid drop in blood pressure, and multiple organ failure. Preexposure Prophylaxis No human vaccine against SEB is available, although there are several vaccines in development (Ulrich et al, 1997). Postexposure Therapy Because there is no approved antitoxin, therapy is currently limited to supportive care focused on reductions of fever, vomiting, and coughing. Respiratory symptoms may follow exposure to aerosolized SEB, and mechanical ventilation may be necessary. Most patients usually recover in 1 to 2 weeks without residual effects.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Ricin Ricin is a protein found in the bean of the castor plant, Ricinis communis, which has been widely cultivated for its oil since ancient times. Ricin remains in the castor meal after the oil is extracted, but is readily separated and concentrated. Although its lethal toxicity is about 1,000-fold less than that of the botulinum toxins, the worldwide availability, in quantity, of castor beans makes ricin a potential biological weapon. At the cellular level, ricin kills through inhibition of protein synthesis. Clinical signs and symptoms appear 8 to 24 hours after exposure and vary with the route of exposure: respiratory distress and airway lesions after inhalation; vomiting, diarrhea, gastrointestinal, liver and kidney necrosis after ingestion. Ricin is not dermally active. Although intramuscular injection of ricin was used in the highly publicized assassination of Bulgarian defector Georgi Markov in 1978 (Crompton and Gall, 1980), little human data exists on mortality rates after ricin poisoning by the aerosol route. The death rate in cases of castor bean ingestion has been low—under 10 percent (Rauber and Heard, 1985). Preexposure Prophylaxis Although preclinical testing in animals has encouraged the US Army to submit an IND application to the FDA for a formalin-treated toxoid immunization, no human testing has been conducted, and no vaccine is available for clinical use. Postexposure Therapy Activated charcoal lavage may be helpful immediately after ingestion of castor beans or ricin, but ricin acts rapidly and irreversibly, which makes treatment very difficult after signs and symptoms appear. Symptomatic care is the only intervention presently available to clinicians treating aerosol ricin poisoning. Additional information on ricin may be found in Franz and Jaax (1997). T-2 Mycotoxin Mycotoxins are by-products of fungal metabolism. A wide variety of fungi produce substances that produce adverse health effects in animals and humans, but mycotoxin production is most commonly associated with the terrestrial filamentous fungi called molds. T-2 mycotoxin is one of a family of nearly 150 toxins produced by Fusarium and related fungi that infect wheat and other grains that are important human food (T-2 mycotoxin-contaminated grain is thought to have been responsible for the deaths of more than 10 percent of the population of the Russian town of Orenburg in the 1940s). These toxins are nonvolatile, low molecular weight (250–550) compounds that are insoluble in water and highly resistant to heat. T-2 toxin has been the most extensively studied. Its primary toxic effects appear to be caused by inhibition of protein synthesis. Clinical effects of acute exposure, in addition to local effects specific to route of exposure (unlike the other biological agents described here, T-2 mycotoxin can penetrate intact skin [Wannamacher et al., 1991; Wannamacher and Wiener, 1997]), include vomiting and diarrhea, weakness, dizziness, ataxia, and acute vascular effects leading to hypotension and shock. In the 1970s, the United States government accused the Soviet Union and its allies of using trichothecene mycotoxins as weapons in conflicts in southeast

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Asia and Afghanistan (Ember, 1984). See Wannamacher and Wiener (1997) for more treatment. Preexposure Prophylaxis No vaccine is currently available for protection against any of the trichothecene mycotoxins. Two topical skin protectants in advanced development by DoD have been shown to protect rabbits from the dermal effects of T-2 toxin for at least 2 hours, but neither is available for human use. Postexposure Therapy No specific therapy for trichothecene mycotoxin poisoning is currently available. Skin decontamination with soap and water can be used effectively up to six hours after exposure. Treatment of respiratory, dermal, and GI effects will have to be symptom-based and supportive in nature. PREVENTION, ASSESSMENT, AND TREATMENT OF PSYCHOLOGICAL EFFECTS Incidents of chemical and biological terrorism may involve large numbers of individuals, across all age groups and in both sexes. The survivors of and responders to such incidents will not only suffer physical injury requiring decontamination and medical care but also will undoubtedly undergo extreme psychological trauma. Thus, chemical or biological weapons of mass destruction could produce both acute and chronic psychiatric problems. Unlike storms or floods, chemical disasters occur with little or no warning and are accompanied by continuing fears of ongoing illness and premature death (Bowler et al., 1997). In the case of terrorism, particularly when the aggressor is unknown, a potentially beneficial expression of anger cannot be directed at the appropriate source, producing a futile sense of helplessness, depression, demoralization, and hopelessness. At the acute stage of the aftermath of a biological or chemical terrorist attack, acute autonomic arousal and panic may result in both the victims and the emergency responders (hazmat teams, police, fire, medical), potentially incapacitating the assistance infrastructure. Appropriately trained triage teams, including trained psychological personnel, are essential in providing immediate treatment and crisis intervention and in diminishing long-term trauma effects. Research on posttraumatic stress disorder (PTSD) has expanded far beyond studies of Vietnam veterans in the last 20 years, including a few studies on large-scale industrial accidents, among them chemical spills (Bowler et al, 1994, in press). The latter have most often been epidemiological in nature, focusing on sequelae rather than treatment methods and their efficacy, but a technique aimed at helping field rescue personnel cope with the stress of extraordinary traumatic events has gained widespread popularity. Critical Incident Stress Debriefing (CISD) (Mitchell and Everly, 1996) was originally devised as a relatively rapid technique designed to alleviate stress symptoms and prevent burnout of rescue workers. It involves organized group meetings for all personnel in the rescue unit, with or without symptoms, emphasizes peer support, and is led by a combination of unit members and mental health professionals. CISD in some form has gained wide acceptance among field emergency

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities workers and is increasingly used with hospital-based emergency personnel, military service members, public safety personnel, volunteers, victims, witnesses, and even schoolmates of victims. It can reasonably be expected that many local police, fire, and emergency medical units will be familiar with the CISD process, have access to trained debriefers, and plans for their use. The Metropolitan Medical Strike Teams being organized by the Public Health Service call for CISD as part of their standard operating procedures. Objective evidence of CISD effectiveness is nevertheless limited and contentious (see for example Raphael et al., 1995; Kenardy et al., 1996; Hamling, 1997). Similarly, most, if not all, hospitals will have behavioral health staff (psychiatrists, psychologists, psychiatric nurses, and social workers) present or on call. Their experience with PTSD, large-scale disasters, and terrorist acts is likely to be highly variable, and accurate information on chemical or biological agents will be very rare, at least initially. Such information will nevertheless be critical for identifying and providing help to those suffering psychological effects (Vyner, 1988). At the federal level, the National Disaster Medical Service (NDMS) includes Disaster Medical Assistance Teams with a focus on mental health. Another federal program is the Crisis Counseling Assistance and Training Program (CCP). Funded by the Federal Emergency Management Agency (FEMA) and administered by the Center for Mental Health Services (CMHS) in the Substance Abuse and Mental Health Services Administration, CCP provides supplemental funding to states for short-term crisis counseling services to victims of major disasters. These services are designed to help disaster survivors recognize typical reactions and emotions that occur following a disaster and to regain control over themselves and their environment. Although the focus is on short-term interventions, helping people with normal reactions to abnormal experiences rather than long-term therapy for pathological conditions, the program provides for up to 9 months of services, and local mental health workers and other disaster workers are eligible for training (similar training is offered year-round, for a fee, by FEMA's Emergency Management Institute). Project Heartland, the CCP effort following the Oklahoma City bombing, provided counseling or education to over 40,000 individuals. CMHS also provides training and field support for a cadre of FEMA employees who provide stress management services to disaster workers. In addition to meeting the psychological needs of individuals, emergency management officials must deal with the reactions of the community as a whole. An important part of any large-scale threat to public health is the psychological effects it engenders in the general public. This will be especially important in the case of chemical or biological terrorism, one goal of which is often to produce fear, panic, demoralization, and loss of confidence in government. Little is known about the fears and feeling engendered by the threat of infection, but considerable research on risk perception and risk communication has been conducted in connection with hazardous waste sites, nuclear power plants and other real and perceived environmental threats, and general guidelines for government officials have been produced (Hance et al., 1988; National Research Council, 1989; Stern and Fineberg, 1996). Timely provision of accurate information about the nature of the threat and the action being taken to combat it is a central tenet of this advice. Training being provided to 120 major cities through the Army 's Domestic Preparedness Program should make that information available (although only 6 cities had received training by December 1997). The committee has not been able to

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities determine whether these or other cities have prepared information packages of their own for use in informing the press and the public in the event of a terrorism incident, but such preparation will surely be necessary if public officials are to maintain the confidence of a community deluged with information of widely varying accuracy in the news media and, increasingly, on the internet.

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