UCLA Center for Public Health and Disasters Bioterrorism Training for Physicians Updated March 2003 Over 1700 Downloads Since Going Online October 2001 Available at: http://www.ph.ucla.edu/cphdr/bioterrorism

1
UCLA Center for Public Health and
DisastersBioterrorism Training for
PhysiciansUpdated March 2003 Over 1700
Downloads Since Going Online October
2001Available at http//www.ph.ucla.edu/cphdr/b
ioterrorism
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BIOTERRORISM
Are You Prepared?
3
Bioterrorism 101

• Why is this a problem?
• Who and what
• are the agencies worrying about?

4
Biological Terrorism

• Intentional or threatened use of viruses,
  bacteria, fungi or toxins from living organisms
  to produce death or disease in humans, animals or
  plants

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Anthrax Mail Attacks - 2001
8
Biological Terrorism Why?

• Small amounts devastating effects
• Invisible, odorless, tasteless
• Easy to obtain
• Difficult to detect
• Civilian populations unprotected
• Delayed onset - difficult to trace
• Publicity, fear, chaos

9
What Happens in a Bioterrorism Incident?

• That depends on whether the attack is
• OVERT
• or
• COVERT

10
Overt Attack

• Threat Validation
• Coordinated System Response
• Traditional First Responders Fire, Police, EMS
• Hospitals
• Community Practitioners
• Public Health - Information Management
• Law Enforcement

11
Overt Attack

• Problems
• Verifying if an attack has taken place
• Fear, chaos
• Large numbers of worried well
• Decontamination
• Limited supply of treatment, prophylactic drugs,
  and vaccines

12
Real or Hoax?

• Public health and law enforcement will determine
  credibility, and need for decontamination or
  prophylaxis
• Test results may take 24-48 hours

13
Covert Attack

• EMS system may be used by cases (not yet
  recognized as a bioterrorist event)
• Likely detected through hospitals, medical care
  practitioners
• Clinical labs contact local PH department
• PH department refers to State or CDC

14
Covert Attack

• Problems with recognition
• Symptoms overlap common illnesses
• Delayed onset of symptoms
• Victims present to different centers
• Secondary spread may occur before attack is
  recognized

15
Likely Scenarios

• Aerosol release
• Major city, large event, or key function
• Victims presenting to different centers
• Recognition of attack through symptoms,
  epidemiologic patterns or microbio lab

16
Aerosol Delivery

• Considered the most likely route for BT
• Aim is to generate invisible clouds of particles
  0.5-10 microns in diameter
• Can stay suspended for long periods of time
• Perfect size to reach the alveoli in lungs
• Aerosols of most agents produce systemic disease

17
Key Indicators of a BT Event

• Sudden increase in severity or incidence of
  illness
• Appearance of unusual (non-endemic) illness or
  syndrome in your community
• Geographic and/or temporal pattern of illness
• Occurrence of vector-borne disease where there is
  no vector

18
Key Indicators of a BT Event

• Cluster of sick or dead animals
• Atypical seasonality
• Unusual expression of endemic disease
• Multi drug-resistant pathogens

19
Bioterrorism The Agents

• Category A
• Top Priority
• Easily disseminated or transmitted
• High mortality
• Causes social disruption
• Special preparation needed

• Category A Agents
• Anthrax
• Botulism
• Plague
• Smallpox
• Tularemia
• Viral Hemorrhagic Fevers

20
Bioterrorism The Agents

• Category B
• Q Fever
• Brucellosis
• Viral encephalitides
• Staphylococcal enterotoxin B
• Food/Waterborne
• Ricin

• Category C
• Nipah virus
• Hantavirus
• Tickborne hemorrhagic fever
• Yellow fever
• Multidrug-resistant TB

21
Overview of the AgentsClinical Manifestations
and Treatment
22
Pneumonic Syndromes

• Inhalational Anthrax
• Pneumonic Plague
• Pneumonic/Typhoidal Tularemia

23
Anthrax

• Source Bacillus anthracis
• Bacterial spores and toxins
• Cutaneous, inhalational and intestinal

24
Cutaneous Anthrax
25
Cutaneous Anthrax

• Incubation 1-12 days
• Papule gt vesicle or ulcer gt black centerover
  several days
• Diagnosis Gram stain and culture of unroofed
  vesicle, base of ulcer, under edge of eschar
• Usually responds well to treatment

26
Inhalational Anthrax

• Incubation 1 - 6 days (rarely up to gt 60 days)
• Prodrome 1-2 d fever, malaise, dry cough
• Severe respiratory distress, septic shock, may
  have meningitis
• Diagnosis
• Hemorrhagic mediastinitis wide on CXR
• Isolation
• Standard not contagious

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Inhalational AnthraxMediastinal Widening
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Anthrax vs. Viral Illness

• Anthrax Flu Other Viral
• Elev. Temp 70 68-77 40-73
• Cough 90 84-93 72-80
• SOB 80 6 6
• Pleuritic Pain 60 35 23
• Headache 50 84-91 74-89
• Sore Throat 20 64-84 64-84
• Rhinorrhea 10 79 68
• Nausea / Vom. 80 12 12
• MMWR Nov 9 200150984

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Evaluation of Possible Inhalation Anthrax

• History of exposure or risk Symptoms
• WBC (bandemia), Blood culture highest yield
• CXR wide mediastinum, effusion, or infiltrate
  Consider CT if CXR normal
• If results abnormal or pt. seriously ill
• Multi-drug treatment
• If results normal and pt mildly ill
• Observe and initiate single-drug prophylaxis

30
Anthrax - Treatment

• Combination Rx for seriously ill
• Cipro or Doxy other drug(s)
• Other drugs with activity include
• Rifampin, Vancomycin, Clindamycin, Imipenem,
  Clarithromycin, PCN
• Post-Exposure Prophylaxis
• Cipro or Doxy X 60 d
• (X 30 d if given with vaccine)

31
Anthrax Exposure?

• Most patients need only reassurance
• Higher risk
• Threatening message
• Sandy brown color powder
• Suspicious letter or package
• High-profile person or postal worker
• If exposure is credible, contact police
• Nasal swab NOT sensitive enough to r/o exposure
  for an individual

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Plague

• Source
• Bacterium Yersinia pestis
• Forms
• Bubonic, septicemic, and pneumonic
• Suspect Bioterrorism

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Pneumonic Plague

• Incubation 2-3 d
• Symptoms
• Fulminant pneumonia, bloody sputum, septic shock,
  high fever, chills, headache, possible
  disseminated intravascular coagulation
• Diagnosis
• Laboratory Gram stain blood, sputum, node
• Small, Gram-neg, bipolar (safety-pin), poorly
  staining coccobacilli

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Pneumonic Plague

• Isolation
• Highly contagious
• Strict respiratory isolation until Rx for 3d
• Followed by standard respiratory droplet
  precautions (masks, gown, gloves, eye protection)
• Treatment
• Streptomycin, doxycycline, or chloramphenicol
• High mortality, but may respond to early treatment

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Tularemia

• Source
• Bacterium Francisella
• tularensis
• Gram neg. coccobacillus
• Zoonotic (rabbit fever)
• Forms
• Ulceroglandular and typhoidal/pneumonic
• Suspect Bioterrorism

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Tularemia

• Incubation 2-10 days
• Prodrome
• Fever, headache, chills, myalgia, cough, nausea,
  vomiting, diarrhea
• May present as pneumonia
• Diagnosis
• Laboratory Culture/Gram stain blood, sputum,
  node
• Culture can be difficult and is risky to lab
  personnel

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Tularemia

• Isolation
• Standard not contagious
• No human-human transmission
• Treatment
• Streptomycin, gentamicin, or doxycycline
• If exposed watch for 7 days, treat if fever
  develops
• Vaccine under review by FDA
• Mortality 30 untreated lt 10 treated

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Paralytic Syndrome

• Botulism

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Botulism

• Source
• Clostridium botulinum
• neurotoxin
• Types A, B, E, and F
• Most potent toxin known
• Lethal dose 1 ng/kg
• 100,000 times more toxic than sarin

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Botulism

• Incubation 1-5 days
• Symptoms
• Blocks cholinergic synapses
• Dry mouth, blurred/diplopia, muscle weakness,
  dysphagia
• Descending flaccid paralysis can last for weeks
  to months
• Diagnosis
• Clinical
• A few labs can do serum toxin assay
• Death from respiratory failure

41
Botulism

• Isolation
• Standard not contagious
• No human-human transmission
• Decontaminate clothing, skin with soap and water
• Treatment
• Ventilatory support
• Botulinum antitoxin - equine
• Skin test for horse serum sensitivity
• More effective if given early will not reverse
  paralysis that has already occurred

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Rash and Fever Syndromes

• Smallpox
• Viral Hemorrhagic Fevers

43
Smallpox Variola major
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Smallpox Presentation

• Incubation 12 days (up to 17 days)
• Early symptoms nonspecific
• Fever, malaise, aches for 2-4 days then severe
  illness
• Rash then appears on extremities with uniform
  appearance

• Scabs over in 1-2 weeks
• Contagious until ALL scabs have fallen off

45
Smallpox

• Notify Public Health IMMEDIATELY
• Diagnosis
• Laboratory
• Rule out chickenpox PCR
• Isolation
• Strict contact and respiratory isolation
  (negative pressure)
• Trace contacts up to 17 days prior to illness
• Treatment
• None known effective
• Questionable effectiveness of Cidofovir
• Mortality 30

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Smallpox vs. Chickenpox

• Variola Varicella
• Incubation 7-17 d 14-21 d
• Prodrome 2- 4 d minimal/none
• Distribution extremities trunk
• Progression similar growth dissimilar growth
• Scab formation 10-14 d p rash 4-7 d p rash
• Scab separation 14-28 d p rash lt14 d p rash

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Smallpox vs Chickenpox
Rash trunk, different stages of development

• Rash extremities, uniform size

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Smallpox Vaccine

• Live Vaccinia virus
• Given intradermal on bifurcated needle
• Pustule scab in 1 week, mild fever
• Can potentially spread to others until scab is
  gone
• Lifelong immunity is questionable
• Vaccinated persons probable reduced risk of
  mortality
• Vaccine is effective up to several days AFTER
  exposure

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Administering the Vaccine
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Administering the Vaccine
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Vaccinia Common Reactions

• Sore arm
• Adenopathy
• Fever
• Up to 1/3 may have reactions severe enough to
  miss work, school, or usual activities

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Smallpox Vaccine - Reactions

• Risks for primary vaccinees
• Accidental Inoculation gt 500 / million
• Generalized Vaccinia 242 / million
• Eczema Vaccinatum 12 39 / million
• Progressive Vaccinia 1 2 / million
• Encephalitis 3 12 / million
• Death 1 - 2 / million
• Risks are much less if previously vaccinated

53
Vaccinia Immune Globulin-VIG

• Primary treatment for adverse reactions
• Produced from plasma of vaccinated individuals
• Stored at CDC
• IM forms only at present

• Indications for use
• Eczema vaccinatum
• Progressive vaccinia
• Accidental implantations (extensive lesions)
• Generalized vaccinia(severe)
• Not recommended in vaccinia keratitis

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Accidental Inoculation
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Generalized Vaccinia
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Eczema Vaccinatum
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Progressive Vaccinia
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Progressive Vaccinia
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Fetal Vaccinia
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Viral Hemorrhagic Fever (VHF)

• Ebola
• Lassa
• Marburg
• Sabia Brazilian HF
• Machupo Bolivian HF
• Rift Valley Fever
• Crimean-Congo HF

Ebola virus
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Viral Hemorrhagic Fever

• Incubation 4-21 days
• Symptoms vary between viruses
• Fever, myalgia, prostration
• Petechiae, hemorrhage, shock
• Neurologic, pulmonary, hepatic involvement
• Mortality varies 10 90

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Viral Hemorrhagic Fever

• Diagnosis
• Primarily clinical
• Viral isolation, serology, immunohist. at CDC
• Isolation
• Strict contact isolation
• Strict respiratory isolation
• Strict bodily fluid isolation

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Viral Hemorrhagic Fever

• Treatment
• Supportive
• Fluids, transfusion
• Watch for pulmonary edema
• Avoid unnecessary lines, procedures, etc.
• Ribavirin may be effective for Lassa, Bolivian
  HF, Crimean-Congo HF, Rift Valley Fever

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Risk of Secondary Transmission

• Agents to worry about
• Smallpox
• Plague
• Viral Hemorrhagic Fever

• Isolation is critical if any of these are
  suspected
• Notify hospital infection control immediately

65
Bioterrorism Agents Decon

• For most agents, it is very unlikely that anyone
• would be infected from clothing, skin, etc.
• Decon when there is
• Gross contamination by dust, powders, spray, etc.
• A body fluid agent, such as in the case of Ebola
• Generally, no special equipment needed
• Remove clothing and seal it in plastic bag
• Shower with soap water

66
Laboratory Risks of BT Agents

• Agent BSL Laboratory Risk
• B. anthracis 2 low
• Y. pestis 2 medium
• Botulinum toxin 2 medium
• F. tularensis 2/3 high
• Smallpox 4 high
• Viral Hemorrhagic Fever 4 high

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Laboratory Response Network for Bioterrorism
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Special Problems with BT

• Identifying a covert attack
• Social disruption
• Prophylaxis for large populations
• National Pharmaceutical Stockpile (NPS)
• Vaccination plans
• Secondary transmission

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Special Problems with BT

• Specialized labs needed for some agents
• Risks to laboratory workers
• Communication between agencies

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Limited Health Care Resources

• Isolation rooms
• Ventilators
• Protective Equipment
• Medications
• Vaccines
• Morgue facilities

71
Challenges in Recognizing a Bioterrorist Attack

• Delayed onset - hours to weeks
• Early signs/symptoms nonspecific
• Physicians/laboratorians not familiar with rare
  diseases/organisms
• Current public health surveillance may not be
  adequate for early detection

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Early Detection of a BT EventFinding a Zebra
Among Horses

• Early detection and control of bioterrorism will
  depend on alert clinicians reporting unusual
  illnesses or patterns of illness to Public Health
• BEFORE definitive diagnosis
• When you hear hoof beats, think zebras
• (as well as horses)

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Public Health Bioterrorism Surveillance Plan

• Enhance traditional surveillance for all
  potential BT agents and unusual illnesses
• Novel surveillance methods
• Hospital diversion data
• Medical examiner data
• Syndrome-based ER/ICU admissions
• School absences
• Animal disease surveillance
• Pharmacy sales

74
Agencies Responding to a BT Attack

• Local
• Public Health
• Police, Fire, EMS
• State
• Public Health
• Disaster management
• National Guard

• Federal
• CDC
• FBI, Dept of Justice
• Homeland Security, FEMA
• Dept of Defense

75
BT Hospital Preparedness IssuesDevelop plans for

• Infection control
• Lab support
• A large influx of patients triage, pt placement,
  pt transport
• Pharmacy inventories
• Psychological aspects of BT

76
BT Hospital Preparedness IssuesDevelop plans for

• Hospital Emergency Incident Command System
  (HEICS)
• Internal and external communication
• Evidence collection
• Discharging or post-mortem care
• Decon

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Preparation for a BT Attack

• Familiarize medical staff with BT agents
• Incorporate into disaster planning
• Infection control and decontamination
• Communication plan with key agencies
• Public Health Dept
• Laboratory, CDC, police, FBI, etc.
• Identify contacts to obtain stockpiled supplies
  antibiotics, immune sera, vaccines, antidotes,
  decon equipment, PPEs, etc.
• Security preparations

78
Local Health Department Actions

• Determine whether situation is unusual
• Case finding/case investigation
• Laboratory confirmation
• Alert medical community
• Identify source of outbreak and at-risk persons
• Coordinate with State DHS, CDC, FBI, and other
  authorities

79
Public Healths Role in Bioterrorism Event

• Incorporation of State Epidemiology BT Materials
• Epi/surveillance
• Labs
• Notification
• Media/Public Information Officer (PIO)
• Integration with FBI
• Integration with CDC

80
Public Healths Role in Bioterrorism Event

• Infectious Disease/epidemiology tracks infectious
  diseases
• Public Health Laboratories identify agents
  (either in-house or through referral to State or
  CDC)
• Environmental Health assesses sanitation and
  safety of food and water

81
Public Healths Role in Bioterrorism Event

• Health Officer coordinates information for the
  public and medical providers
• Community Health and PH nurses provide education,
  information to the public and to community
  providers
• Treatment and prophylaxis
• Quarantine

82
What To Do if You Suspect a Bioterrorist Disease

• IMMEDIATELY NOTIFY
• Hospital Infection Control
• Isolation Smallpox, plague, hemorrhagic fevers
• Laboratory
• Hospital Administration
• Local Public Health Department

83
Case Studies
84
Case 1 - Dyspnea, Hypotension

• 46 year old stock trader
• Fever, malaise, cough 2 days prior
• Abrupt onset severe dyspnea
• 38.1o 115 86/40 32 O2sat 83
• Diaphoretic, Disoriented
• CXR - no infiltrate, small pleural eff.

85
Mediastinal Widening
86
Case 1 - Dyspnea, Hypotension

• Patient admitted to ICU
• Fluids, Intubation, Ceftriaxone, Vanco., Gent.
• Later the same day a similar patient presents
• Also a stock trader in the same building
• Both patients deteriorate and die the next day

87
Case 2 - Rapid Progressive Pneumonia

• 10 y/o boy with fever, dry cough for 1 day
• 8 y/o sister also ill
• VS 38.6o 110 96/60 91 sat
• Scattered crackles in both lungs
• CXR - Bilateral infiltrates
• Later develops severe dyspnea, hemoptysis, shock

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Case 3 - Fever

• 52 y/o male c/o 3 days malaise, fever, vomiting,
  myalgias
• 39.1o 92/50 124 28
• WBC 18 platelets 45 BUN 48 Creatinine
  2.9
• Within hours becomes confused, vomits blood

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Case 4 Vesicular Rash

• 34 y/o woman with fever, malaise X 2 days
• Today, a rash appeared
• 39.4o 106/78 116 18
• A O X 3 Lungs clear

90
Case 5 - Overt Attack

• A terrorist group says they have released 10 kg
  of botulinum toxin over your city
• Clostridium botulinum neurotoxin Lethal dose 1
  ng/kg

91
Bioterrorism Addendum A

• Selected Category B and C Agents

92
Q Fever

• Source
• Bacterium Coxiella burnetii
• Resistant to heat, drying and many common
  disinfectants
• Incubation 10-40 d
• Sx variable - Fever, HA, myalgia, malaise
• Occ. cough, rales, CXR infiltrate
• WBC usually normal, but LFTs common
• Low mortality, but malaise may last months

93
Q Fever

• Diagnosis
• Laboratory serology, antibody or ELISA
• Isolation Standard
• Treatment
• Antibiotics will shorten course
• Tetracyclines
• Erythromycin, azithromycin, quinolones,
  Chloramphenicol, TMP/SMX

94
Brucellosis

• Source
• Brucella species
• Zoonotic
• Slow-growing gram negative rod
• Presentation Incubation 5-60 d or longer
• May last weeks or months, but rarely fatal

95
Brucellosis

• Diagnosis
• Serology Culture of bone marrow, liver or spleen
  tissue
• Isolation
• Standard
• Contact if open lesions
• Treatment
• Combination antibiotics
• Most recover even without antibiotics

96
Viral Encephalitis

• Alphaviruses Venezuelan, Eastern, Western Equine
  Encephalitis
• Presentation Incubation 2-14 d
• Fever, HA, myalgia, photophobia, vomiting
• Small of VEE progress to neurologic Sx
• Delirium, coma, seizures

97
Viral Encephalitis

• Diagnosis
• Viral isolation or serology, PCR for some
• Isolation Standard
• Treatment
• Supportive analgesics, anticonvulsants
• Vaccines available, but poorly immunogenic

98
Ricin
99
Ricin

• Source
• Derived from castor beans (Ricinus communis)
• 1 million tons of castor beans produced annually
  worldwide
• 5 ricin by weight
• Stable
• Inhibits protein synthesis via ribosome
• Toxic via inhalation, ingestion, injection

100
Ricin

• Ricin was used to assassinate Bulgarian exile
  Georgi Markov in London in 1978.
• A weapon disguised as an umbrella was used to
  implant a ricin-containing pellet

101
Ricin

• Symptoms begin in 4-8 hours
• Weakness, fever, cough, hypothermia, sweating
• Inhalation
• Severe respiratory symptoms from necrosis and
  edema, hypoxia with respiratory failure in 36-72
  hours
• Ingestion
• Nausea, vomiting, diarrhea, GI hemorrhage,
  vascular collapse, death in 3 d
• May cause DIC, multi-organ failure

102
Ricin

• Diagnosis
• Serum ELISA available in few labs
• Treatment
• Primarily supportiveO2, hydration
• If ingested
• Gastric lavage
• Activated charcoal

103
Staphylococcal Enterotoxin B

• Presentation Incubation 1-6 hrs
• Diagnosis
• Clinical and epidemiological
• Isolation Standard
• Treatment
• Supportive

104
Clostridium perfringens Toxin

• Source
• Episilon toxin of Clostridium perfringens
• Organism ubiquitous in soil
• Present in stool of every vertebrate
• Can produce gas gangrene, necrotizing
  enterocolitis, food poisoning
• Secretes gt 12 toxins
• Could be toxic if inhaled or ingested

105
C. perfringens Toxin

• Symptoms within hours
• GI symptoms prominent, rare fever
• If inhaled, could cause resp. distress
• Mortality
• Death is rare
• Could result from vascular leaks, lung damage

106
C. perfringens Toxin

• Diagnosis Clinical
• Stool tests for enterotoxin are not widely
  available
• Treatment
• Supportive
• Antibiotics active against organism penicillin,
  clindamycin

107
Trichothecene Mycotoxins

• Source
• Group of gt 40 fungal toxins
• Produced by Fusarium, other common fungi
• Stable to heat and UV
• Inhibits protein and nucleic acid synthesis
  affecting rapidly proliferating tissues
• If aerosolized, appears as yellow droplets,
  yellow rain
• Toxic via inhalation, ingestion, and skin

108
Trichothecene Mycotoxins

• Symptoms onset minutes to 4 hours
• Skin blistering, eye irritation, nose/throat
  pain,
• Cough, dyspnea, chest pain, hemoptysis
• Abdominal pain, vomiting, bloody diarrhea
• Bone marrow suppression can lead to diffuse
  hemorrhage
• If severe prostration, ataxia, shock and death
  in hours to days

109
Trichothecene Mycotoxins

• Diagnosis
• Urine, blood, tissue samples for liquid
  chromatography-mass spectrometry in specialized
  labs
• Treatment Supportive
• Remove and isolate clothing, irrigate eyes, wash
  with soap/water
• If ingested, Activated charcoal
• ? Benefit of ascorbic acid, dexamethasone

110
Case 1 Headache, Vomiting

• 39 y/o woman presents with 2 d worsening HA,
  nausea, vomiting, fever, malaise
• Better after fluids, acetaminophen and is
  released
• Returns following day with confusion, seizure

111
Case 2 Vomiting, Diarrhea

• Multiple patients present to ER with
• Vomiting, diarrhea, headache, myalgias, malaise,
  fever, chills, cough
• All had been at a large outdoor festival

112
Case 3 Malaise

• High numbers of people present to ERs and clinics
  over several weeks in Nov. - Dec.
• Fevers, malaise, cough, headaches
• Some have pneumonia on CXR
• Most have elevated LFTs
• Public health department finds no influenza or
  other pathogens

113
Bioterrorism Addendum B

• Additional Resources and References

114
Additional Web Resources

• Centers for Disease Control and Prevention (CDC)
• www.bt.cdc.gov
• US Army Medical Research Institute on Infectious
  Disease (USAMRIID)
• www.usamriid.army.mil
• World Health Organization (WHO) Communicable
  Disease Surveillance and Response (CSR)
• www.who.int/emc/

115
Additional Print Resources

• Emergency Medicine Clinics of North America May
  2002 (entire issue devoted to bioterrorism)
• Kortepeter MG and Parker GW. Potential
  biological weapons threats. Emerging Infectious
  Diseases. 1999 5 523-27.
• Inglesby TV et al. Anthrax as a Biological
  Weapon, 2002 Updated Recommendations for
  Management. JAMA. May 01, 2002287(17)
  2236-2252.
• Arnon SS et al. Botulinum Toxin as Biological
  Weapon Medical and Public Health Management.
  JAMA. Feb 8, 2001285(8) 1059-1070, 2081.
• Inglesby TV et al. Plague as a Biological
  Weapon Medical and Public Health Management.
  JAMA. May 03,2000283(17) 2281-2290.

116
Additional Print Resources

• Henderson DA et al. Smallpox as a Biological
  Weapon Medical and Public Health Management.
  JAMA. June 09, 1999 281(22)2127-2137.
• Dennis DT et al. Tularemia as a Biological
  Weapon Medical and Public Health Management.
  JAMA. June 02, 2001 285(21)2763-2773.
• Borio L et al. Hemorrhagic Fever Viruses as
  Biological Weapons Medical and Public Health
  Management. JAMA. May 08, 2002 287(18)
  2391-2405.
• Franz DR, Jahrling PB, Friedlander DJ et al.
  Clinical recognition and management of patients
  exposed to biological warfare agents. JAMA.
  1997278(5)399-411.

117
Additional Print Resources

• Bryan JL, Fields HF. An ounce of prevention is
  worth a pound of cure shoring up the public
  health infrastructure to respond to bioterrorist
  attacks. Amer J of Infection Control.
  199927465-7.
• CDC. Biological and Chemical Terrorism
  Strategic Plan for Preparedness and Response.
  Recommendations of the CDC Strategic Planning
  Workgroup. MMWR. April 21,2000, Vol 49, No.
  RR-4.
• Wetter DC, Daniell WE and Treser CD. Hospital
  preparedness for victims of chemical or
  biological terrorism. Amer J of Public Health.
  200191(5)710-16.

118
Additional Print Resources

• Pavlin J. Epidemiology of bioterrorism. Emerging
  Infectious Diseases. 19995528-530
• Macintyre AG, Christopher GW, Eitzen E et al.
  Weapons of Mass Destruction Events with
  Contaminated Casualties Effective Planning for
  Health Care Facilities. JAMA. 2000
  283242-249.
• Meltzer MI, Damon I, LeDuc JW, and Millar JD.
  Modeling potential responses to smallpox as a
  bioterrorist weapon. Emerging Infectious
  Diseases. 20017(6)959-969.
• DiGiovanni C Jr . Domestic terrorism with
  chemical or biological agents psychiatric
  aspects. Am J Psychiatry 19991561500-5.

119
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• 1145 Gayley Avenue, Suite 304
• Los Angeles, CA 90024
• Tel [phone]
• Fax [phone]
• Email cphdr_at_ucla.edu
• http//www.ph.ucla.edu/cphdr