Bioterrorist Attack Clues:
• Large epidemic with high illness and death
rate;
• Immunocompromised individuals may have
first susceptibility;
• Respiratory symptoms predominate;
• Infection non-endemic for region;
• Multiple, simultaneous outbreaks;
• Multi-drug-resistant pathogens;
• Sick or dead animals;
• Delivery vehicle or intelligence information.
Anthrax – Cutaneous
• Incubation period: 1–12 days.
• Begins as a papule → vesicular stage →
depressed black necrotic ulcer (eschar);
• Edema, redness, and/or necrosis without
ulceration may occur;
• Usually NOT painful;
• Form most commonly encountered in
naturally occurring cases.
• May see cutaneous anthrax with inhalational
anthrax cases
• Medication: Ciprofloxacin, Doxycycline
PPE: Universal Precautions, Level B or C if
exposed to spores
Anthrax – Inhalational
• Incubation period: 1-6 days;
• Prodrome: resembles a “viral-like” illness
characterized by muscle aches, fatigue, fever,
with or without respiratory symptoms, followed
by hypoxia and difficulty breathing
• Initial Symptoms: malaise, fever, fatigue,
non-productive cough, chest discomfort;
• Confusion, neck stiffness, headache suggests
meningitis (seen in 50% of patients);
• Will often see cases of cutaneous anthrax with
cases of inhalational anthrax.
• Medication: IV Ciprofloxacin, Doxycycline
PPE: Universal Precautions, Level B or C if
exposed to spores.
Bubonic Plague
• Incubation period 1-8 days (mode 3-5 days)
• Sudden onset of flu-like syndrome
• Fever, rigors, malaise, myalgias, nausea
• Bubo formation within 24 hours
• Swollen, infected lymph node (painful!)
• Cutaneous findings in 25% of cases (bruises,
acral gangrene).
• Medication: Doxycycline, Ciprofloxacin
 PPE: Universal precautions.
Pneumonic Plague
HIGHLY CONTAGIOUS
• Incubation period 2-3 days, followed by high
fever, myalgias, chills, headache
• Cough with bloody sputum within 24 hours
• Shortness of breath, stridor, cyanosis,
dyspnea, chest pain
• Medication: IV Gentamicin, Doxycycline,
Ciprofloxacin
 PPE: Level B or C; N95 mask as a
minimum.
 Isolation of patient
Smallpox
HIGHLY CONTAGIOUS
• Incubation period: 7-17 days (mean 12)
• Acute malaise, fever, rigors, headache
• Symptoms of viral-type syndrome
• Synchronous rash eruption: papules →
vesicles → pustules → scabbing/crusting
• Centrifugal rash pattern
• Patient is infectious until all scabs separated
• Treatment: Supportive Care
 PPE: Level C; N95 mask as a minimum;
 Isolation of patient
BotulinumToxin
• Time to Onset: 12-36 hours, varies with route
and amount of exposure.
• Descending paralysis, Bulbar Palsies
• Blurred and/or Double vision
• Dilated pupils, Drooping eyelids (ptosis)
• Light intolerance
• Difficulty swallowing, dry mouth
• Difficulty speaking
• Respiratory failure due to muscle paralysis
• Treatment: Antitoxin, Mechanical
ventilation
 PPE: None needed for treatment of patient;
Level B or C for contaminated environment
Venezuelan Equine Encephalitis
(VEE)
• Incubation: 1 to 5 day incubation
• Febrile syndrome lasting 3 days, 100- 104º
fever, chills, headache, photophobia, sore throat
• Severe cases may have seizures
• Treatment: Supportive Care
 PPE: Universal precautions; NOT
contagious person-to-person
Viral Hemorrhagic Fevers
(VHFs)
HIGHLY CONTAGIOUS
• Incubation period: Variable, 4-21 days
• Fever, muscle aches, severe malaise
• Easy bruising and bleeding, bloody stools
and/or vomiting, petechiae,
• Severe shock and prostration
• Treatment: ?Ribivarin, Supportive care,
blood products
 PPE: Level B or C; N95 mask as a
minimum.
 Isolation of patient
Handling of Suspicious Mail
• Do not shake, empty contents;
• Do not carry, show others, or allow others to
examine it;
• Do not sniff, touch, look closely at it, or any
contents that may have spilled;
• Leave on stable surface, alert others; leave
area, close doors, shut off ventilation;
• Wash hands with soap and water;
• Notify law enforcement;
• Create list of persons with potential
contact.
Scene Assessment and Control
At the scene of a WMD event, a first
responder must:
Size up the incident:
• What is the agent(s)?
• Is the agent still present?
• What are the health and safety risks?
• What are the scene conditions (rain,
temperature, wind direction)?
• Obtain as much information regarding
situation from all available sources.
Establish control zones and areas:
Hot Zone:
Restricted Access
Warm Zone: Decontamination, Triage &
Treatment area
Cold Zone: Staging area, Command
Center
Public Protection:
• Determine need for and means of public
evacuation.
Bioterrorism Reference Card
Association of Occupational and
Environmental Clinics
www.aoec.org
• Means to notify public (e.g. media,
loudspeakers)
• Establish safe, accessible routes of egress.
• Is it safer to shelter-in-place?
Scene Security:
• Initial scene security very difficult.
• Must control all entry/exit from scene.
• Initial security likely will be mix of 1st
responders (EMS, Fire, Police)
• Law enforcement must enforce perimeter
• Be aware of secondary devices!
Also:
• Assign one responder as safety officer for
scene
PHONE NUMBERS
Local Incident Commander for
your Facility or Organization:
Office:
Pager:
Home:
Local Security for your Facility:
__________________________________
Safety Officer for your Facility:
__________________________________
Local Public Health Department:
__________________________________
Local HAZMAT Response:
__________________________________
Incident Commander Duties
• Establish Command
• Risk and Hazard Assessment
• Notification of other agencies
• Site Safety
• PPE level(s)
• Resource Management
• Logistical Support
• Information Control
• Control Hazards
• Evaluate Progress
• Public Protection
• Responder Protection
• Incident Termination
Local FBI Office:
__________________________________
Centers for Disease Control:
(800) 311-3435
(404) 639-3534
NIOSH:
1-800-35-NIOSH (1-800-356-4674)
Outside the U.S. 513-533-8328
OSHA:
EMERGENCY 1-800-321-OSHA (6742)