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training on the effects of the agents and medical responses required, to add infections by these materials to their lists of reportable diseases.

Recommendation 4: Provide additional support for the Army's efforts to test commercial (i.e., OSHA/NIOSH/NFPA-approved) personal protective equipment for protection against nerve agents and vesicants.

Recommendation 5: Convene discussions with FDA on the use of investigational products in mass-casualty situations and on acceptable proof of efficacy for products where clinical trials are not ethical or are otherwise impossible.

Recommendation 6: Develop incentives for hospitals to be ambulance-receiving hospitals, to stockpile nerve agent antidotes and selected antitoxins and put them in the hands of first responders (this may require changes to existing laws or regulations in some states), and to purchase appropriate personal protective equipment and expandable decontamination facilities and train emergency department personnel in their use.

Recommendation 7: Supplement existing state and federal training initiatives with a program to incorporate existing information on possible chemical or biological terror agents into the manuals, SOPs, textbooks, and reference libraries of first responders, emergency departments, and poison control centers. User-friendly online or CD-ROM databases are especially important. Professional societies and journal publishers should be recruited to help in this effort.

Recommendation 8: Intensify Public Health Service efforts to organize and equip Metropolitan Medical Strike Teams (MMST) in high-risk cities throughout the country. Although MMSTs are designed to cope with chemical and biological terrorism, because they use local personnel and resources, they increase the community's general ability to cope with industrial accidents and other mass-casualty events.

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