National Center for Biotechnology Law
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USAMRIID's
MEDICAL MANAGEMENT
OF BIOLOGICAL CASUALTIES
HANDBOOK
Fourth Edition
February 2001
U.S. ARMY
MEDICAL RESEARCH
INSTITUTE OF
INFECTIOUS DISEASES
FORT
DETRICK
FREDERICK,
MARYLAND
QUICK
LINKS
Table of Contents
Quick Summaries
Emergency Contacts
Acknowledgements
Preface
Disclaimer
Executive Order 13139
Editors:
LTC Mark
Kortepeter
Lt. Col. George Christopher
COL Ted Cieslak
CDR Randall
Culpepper
CDR Robert Darling
MAJ Julie Pavlin
LTC John Rowe
COL Kelly McKee, Jr
COL Edward Eitzen, Jr
Comments and suggestions are appreciated
and should be addressed to:
Operational Medicine Department
ATTN: MCMR-UIM-O
U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID)
Fort Detrick, MD 21702-5011
Sources of information / Emergency Contacts:
National
Response Center (for Chem-Bio hazards & Terrorist events):
1-800-424-8802 or 1-202-267-2675
National
Domestic Preparedness Office (for civilian use): 1-202-324-9025
USAMRIID Emergency Response Line: 1-888-872-7443
CDC's
Emergency Response Line: 1-770-488-7100
John's Hopkins Center for Civilian Biodefense Studies: 1-410-223-1667
QUICK SUMMARIES
Venezuelan Equine Encephalitis
The Medical Management of Biological Casualties Handbook, which has become affectionately known as the "Blue Book," has been enormously successful - far beyond our expectations. Since the first edition in 1993, the awareness of biological weapons in the United States has increased dramatically. Over 100,000 copies have been distributed to military and civilian health care providers around the world, primarily through USAMRIID's on-site and road Medical Management of Biological Casualties course and its four annual satellite broadcasts on this subject.
This fourth edition has been completely re-edited and updated. New chapters have been added on melioidosis, the medical management of a biological weapon attack, and the use of epidemiologic clues in determining whether an outbreak might have been intentionally spread. In addition, a reference appendix has been added for those interested in more in-depth reading on this subject.
Our goal is to make this a reference for the health care provider on the front lines, whether on the battlefield or in a clinic, who needs basic summary and treatment information quickly. We believe we have been successful in this regard. We appreciate any feedback that might make future editions more useful. Thank you for your interest in this important subject.
-The Editors
ACKNOWLEDGMENTS
This handbook would not be possible
without the generous assistance and support of LTC(P) Les Caudle (editor of
prior editions), Dr. Richard Dukes, COL(ret) David Franz, COL Gerald Parker,
COL Gerald Jennings, SGM Raymond Alston, COL James Arthur, COL W. Russell
Byrne, Dr. John Ezzell, COL Arthur Friedlander, Dr. Robert Hawley, COL Erik
Henchal, COL(ret) Ted Hussey, Dr. Peter Jahrling, LTC Ross LeClaire, Dr. George
Ludwig, Mr. William Patrick, Dr. Mark Poli, Dr. Fred Sidell, Dr. Jonathon
Smith, Mr. Richard Stevens, Dr. Jeff Teska, COL Stanley Wiener and others too
numerous to mention.The exclusion of anyone on this page is purely accidental
and in no way lessens the gratitude we feel for contributions received.
The Palm OS Version of this Handbook was made possible by the Countermeasures to Biological and Chemical Threats Program: Dr. Steve Kornguth, Countermeasures Program Director, The Institute for Advance Technology (IAT); Dr. Harry Fair, Director, The Institute for Advanced Technology (IAT); Dr. Jerry Davis, Director, The Center for Strategic Analysis (CSA); COL Daniel J. Dire, MC, USAR, U.S. Army War College Senior Service Fellow, Center for Strategic Analysis at The University of Texas at Austin; and Mr. D. Hampton Finger, Systems Administrator for The Institute for Advanced Technology.
DISCLAIMER
The purpose of this Handbook is to provide concise supplemental reading material to assist in education of biological casualty management.Although every effort has been made to make the information in this handbook consistent with official policy and doctrine (see FM 8-284), the information contained in this handbook is not official Department of the Army policy or doctrine, and it should not be construed as such.
As you review this handbook, you will find specific therapies and prophylactic regimens for the diseases mentioned.The majority of these are based on standard treatment guidelines; however some of the regimens noted may vary from information found in standard reference materials.The reason for this is that the clinical presentation of certain biological weapon diseases may vary from the endemic form of the disease.For ethical reasons, human challenge studies can only be done with a limited number of these agents.Therefore, treatment and prophylaxis regimens may be derived from in vitro data, animal models, and limited human data.Occasionally you will find various investigational new drug (IND) products mentioned.They are often used in the laboratory setting to protect healthcare workers.These products are not available commercially, and can only be given under a specific protocol with informed consent.They are mentioned for scientific completeness of the handbook, and are not necessarily to be construed as recommendations for therapy.
EXECUTIVE ORDER 13139:
IMPROVING HEALTH PROTECTION OF MILITARY PERSONNEL PARTICIPATING IN PARTICULAR MILITARY OPERATIONS
On 30 September 1999, the President of the United States issued Executive Order 13139, which outlines the conditions under which IND and off-label pharmaceuticals could be administered to U.S. servicemembers.This handbook discusses numerous pharmaceutical products, some of which are investigational new drugs (IND). In certain other cases, licensed pharmaceuticals are discussed for use in a manner or for a condition other than that for which they were originally licensed (ie. An "off-label" indication).
This executive order does not intend to alter the traditional physician-patient relationship or individual physician prescribing practices. Health care providers remain free to exercise clinical judgement and prescribe licensed pharmaceutical products as they deem appropriate for the optimal care of their patients. This policy does, however, potentially influence recommendations that might be made by U.S. government agencies and that might be applied to large numbers of servicemembers outside of the individual physician-patient relationship. The following text presents a brief overview of EO 13139 for the benefit of the individual provider.
EO13139:
--Provides the Secretary of Defense guidance regarding the provision of IND products or products unapproved for their intended use as antidotes to chemical, biological, or radiological weapons;
--Stipulates that the US Government will administer products approved by the Food and Drug Administration (FDA) only for their intended use;
--Provides the circumstances and controls under which IND products may be used.
--In order to administer an IND product:
--Informed consent must be obtained from individual servicemembers;
--The President may waive informed consent (at the request of the Secretary of Defense and only the Secretary of Defense) if:
--Informed consent is not feasible
--Informed consent is contrary to the best interests of the servicemember
--Obtaining informed consent is not in the best interests of national security.
History of Biological Warfare and Current Threat
Distinguishing Between Natural and Intentional Disease Outbreaks
Ten Steps in the Management of Biological Casualties on the Battlefield
Venezuelan Equine Encephalitis
Appendix A: Glossary of Medical Terms
Appendix B: Patient IsolationPrecautions
Appendix C: BW Agent Characteristics
Appendix D: BW Agent Vaccines, Therapeutics and Prophylactics
Appendix E: Medical Sample Collection for BW Agents
Appendix F: Specimens for Laboratory Diagnosis
Appendix G: BW Agent Laboratory Identification
Appendix H: Differential Diagnosis - Toxins vs. Nerve Agents
Appendix I: Comparative Lethality - Toxins vs. Chemical Agents
Appendix K: References and Emergency Response Contacts
Federal Bureau of Investigation (FBI) Field
Offices
Telephone Directory of State and Territorial Public Health Directors
INTRODUCTION
Medical defense against biological
warfare or terrorism is an area of study unfamiliar to most military and
civilian health care providers during peacetime. In the aftermath of Operations Desert
Shield/Desert Storm, it became obvious that the threat of biological attacks
against our soldiers was real. Increased incidents and threats of domestic
terrorism (e.g., New York City World Trade Center bombing, Tokyo subway sarin
release, Oklahoma City federal building bombing, Atlanta Centennial Park
bombing) as well as numerous anthrax hoaxes around the country have brought the
issue home to civilians as well.
Other issues, including the
disclosure of a sophisticated offensive biological warfare program in the
Former Soviet Union (FSU), have reinforced the need for increased training and
education of health care professionals on how to prevent and treat biological
warfare casualties.
Numerous measures to improve preparedness for and response to biological warfare or terrorism are ongoing at local, state, and federal levels. Training efforts have increased both in the military and civilian sectors. The Medical Management of Chemical and Biological Casualties Course taught at both USAMRIID and USAMRICD trains over 560 military medical professionals each year on both biological and chemical medical defense. The highly successful 3-day USAMRIID satellite course on the Medical Management of Biological Casualties has reached over 40,000 medical personnel over the last three years.
Through this handbook and the training courses noted above, medical professionals will learn that effective medical countermeasures are available against many of the bacteria, viruses, and toxins, which might be used as biological weapons against our military forces or civilian communities. The importance of this education cannot be overemphasized and it is hoped that our physicians, nurses, and allied medical professionals will develop a solid understanding of the biological threats we face and the medical armamentarium useful in defending against these threats.
The global biological warfare threat is serious, and the potential for devastating casualties is high for certain biological agents. There are at least 10 countries around the world currently that have offensive biological weapons programs. However, with appropriate use of medical countermeasures either already developed or under development, many casualties can be prevented or minimized.
The purpose for this handbook is to serve as a concise pocket-sized manual that will guide medical personnel in the prophylaxis and management of biological casualties. It is designed as a quick reference and overview, and is not intended as a definitive text on the medical management of biological casualties.
HISTORY OF BIOLOGICAL WARFARE AND CURRENT THREAT
The use of biological weapons in warfare has been recorded throughout history. Two of the earliest reported uses occurred in the 6th century BC, with the Assyrians poisoning enemy wells with rye ergot, and Solon's use of the purgative herb hellebore during the siege of Krissa. In 1346, plague broke out in the Tartar army during its siege of Kaffa (at present day Feodosia in Crimea). The attackers hurled the corpses of plague victims over the city walls; the plague epidemic that followed forced the defenders to surrender, and some infected people who left Kaffa may have started the Black Death pandemic, which spread throughout Europe. Russian troops may have used the same tactic against Sweden in 1710.
On several occasions, smallpox was used as a biological weapon. Pizarro is said to have presented South American natives with variola-contaminated clothing in the 15th century, and the English did the same when Sir Jeffery Amherst provided Indians loyal to the French with smallpox-laden blankets during the French and Indian War of 1754 to 1767.Native Americans defending Fort Carillon sustained epidemic casualties which directly contributed to the loss of the fort to the English.
In this century, there is evidence that during World War I, German agents inoculated horses and cattle with glanders in the U.S. before the animals were shipped to France. In 1937, Japan started an ambitious biological warfare program, located 40 miles south of Harbin, Manchuria, in a laboratory complex code-named "Unit 731". Studies directed by Japanese General Ishii continued there until 1945, when the complex was burned. A post World War II investigation revealed that the Japanese researched numerous organisms and used prisoners of war as research subjects. Slightly less than 1,000 human autopsies apparently were carried out at Unit 731, mostly on victims exposed to aerosolized anthrax. Many more prisoners and Chinese nationals may have died in this facility - some have estimated up to 3,000 human deaths. Following reported overflights by Japanese planes suspected of dropping plague-infected fleas, a plague epidemic ensued in China and Manchuria. By 1945, the Japanese program had stockpiled 400 kilograms of anthrax to be used in a specially designed fragmentation bomb.
In 1943, the United States began research into the use of biological agents for offensive purposes. This work was started, interestingly enough, in response to a perceived German biological warfare (BW) threat as opposed to a Japanese one. The United States conducted this research at Camp Detrick (now Fort Detrick), which was a small National Guard airfield prior to that time, and produced agents at other sites until 1969, when President Nixon stopped all offensive biological and toxin weapon research and production by executive order. Between May 1971 and May 1972, all stockpiles of biological agents and munitions from the now defunct U.S. program were destroyed in the presence of monitors representing the United States Department of Agriculture, the Department of Health, Education, and Welfare, and the states of Arkansas, Colorado, and Maryland. Included among the destroyed agents were Bacillus anthracis, botulinum toxin, Francisella tularensis, Coxiella burnetii, Venezuelan equine encephalitis virus, Brucella suis, and Staphylococcal enterotoxin Bathe United States began a medical defensive program in 1953 that continues today at USAMRIID.
In 1972, the United States, UK, and USSR signed the Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction, commonly called the Biological Weapons Convention. Over 140 countries have since added their ratification. This treaty prohibits the stockpiling of biological agents for offensive military purposes, and also forbids research into such offensive employment of biological agents. However, despite this historic agreement among nations, biological warfare research continued to flourish in many countries hostile to the United States. Moreover, there have been several cases of suspected or actual use of biological weapons. Among the most notorious of these were the "yellow rain" incidents in Southeast Asia, the use of ricin as an assassination weapon in London in 1978, and the accidental release of anthrax spores at Sverdlovsk in 1979.
Testimony from the late 1970's indicated that Laos and Kampuchea were attacked by planes and helicopters delivering aerosols of several colors. After being exposed, people and animals became disoriented and ill, and a small percentage of those stricken died. Some of these clouds were thought to be comprised of trichothecene toxins (in particular, T2 mycotoxin). These attacks are grouped under the label "yellow rain". There has been a great deal of controversy about whether these clouds were truly biological warfare agents. Some have argued that the clouds were nothing more than feces produced by swarms of bees.
In 1978, a Bulgarian exile named Georgi Markov was attacked in London with a device disguised as an umbrella. The device injected a tiny pellet filled with ricin toxin into the subcutaneous tissue of his leg while he was waiting for a bus. He died several days later. On autopsy, the tiny pellet was found and determined to contain the toxin. It was later revealed that the Bulgarian secret service carried out the assassination, and the technology to commit the crime was supplied by the former Soviet Union.
In April, 1979, an incident occurred in Sverdlovsk (now Yekaterinburg) in the former Soviet Union which appeared to be an accidental aerosol release of Bacillus anthracis spores from a Soviet Military microbiology facility: Compound 19.Residents living downwind from this compound developed high fever and difficulty breathing, and a large number died. The Soviet Ministry of Health blamed the deaths on the consumption of contaminated meat, and for years controversy raged in the press over the actual cause of the outbreak. All evidence available to the United States government indicated a massive release of aerosolized B. anthracis spores. In the summer of 1992, U.S. intelligence officials were proven correct when the new Russian President, Boris Yeltsin, acknowledged that the Sverdlovsk incident was in fact related to military developments at the microbiology facility. In 1994, Meselson and colleagues published an in-depth analysis of the Sverdlovsk incident (Science 266:1202-1208). They documented that all of the cases from 1979 occurred within a narrow zone extending 4 kilometers downwind in a southerly direction from Compound 19.There were 66 fatalities of the 77 patients identified.
In August, 1991, the United Nations carried out its first inspection of Iraq's biological warfare capabilities in the aftermath of the Gulf War. On August 2, 1991, representatives of the Iraqi government announced to leaders of United Nations Special Commission Team 7 that they had conducted research into the offensive use of Bacillus anthracis, botulinum toxins, and Clostridium perfringens (presumably one of its toxins). This open admission of biological weapons research verified many of the concerns of the U.S. intelligence community. Iraq had extensive and redundant research facilities at Salman Pak and other sites, many of which were destroyed during the war.
In 1995, further information on Iraq's offensive program was made available to United Nations inspectors. Iraq conducted research and development work on anthrax, botulinum toxins, Clostridium perfringens, aflatoxins, wheat cover smut, and ricin. Field trials were conducted with Bacillus subtilis (a simulant for anthrax), botulinum toxin, and aflatoxin. Biological agents were tested in various delivery systems, including rockets, aerial bombs, and spray tanks. In December 1990, the Iraqis filled 100 R400 bombs with botulinum toxin, 50 with anthrax, and 16 with aflatoxin. In addition, 13 Al Hussein (SCUD) warheads were filled with botulinum toxin, 10 with anthrax, and 2 with aflatoxin. These weapons were deployed in January 1991 to four locations. In all, Iraq produced 19,000 liters of concentrated botulinum toxin (nearly 10,000 liters filled into munitions), 8,500 liters of concentrated anthrax (6,500 liters filled into munitions) and 2,200 liters of aflatoxin (1,580 liters filled into munitions).
The threat of biological warfare has increased in the last two decades, with a number of countries working on the offensive use of these agents. The extensive program of the former Soviet Union is now primarily under the control of Russia. Former Russian president Boris Yeltsin stated that he would put an end to further offensive biological research; however, the degree to which the program was scaled back is not known. Recent revelations from a senior BW program manager who defected from Russia in 1992 outlined a remarkably robust biological warfare program, which included active research into genetic engineering, binary biologicals and chimeras, and industrial capacity to produce agents. There is also growing concern that the smallpox virus, now stored in only two laboratories at the CDC in Atlanta and the Institute for Viral Precautions in Moscow, may be in there countries around the globe.
There is intense concern in the West about the possibility of proliferation or enhancement of offensive programs in countries hostile to the western democracies, due to the potential hiring of expatriate Russian scientists. It was reported in January 1998 that Iraq had sent about a dozen scientists involved in BW research to Libya to help that country develop a biological warfare complex disguised as a medical facility in the Tripoli area. In a report issued in November 1997, Secretary of Defense William Cohen singled out Libya, Iraq, Iran, and Syria as countries "aggressively seeking" nuclear, biological, and chemical weapons.
Finally, there is an increasing amount of concern over the possibility of the terrorist use of biological agents to threaten either military or civilian populations. There have been cases of extremist groups trying to obtain microorganisms that could be used as biological weapons. The 1995 sarin nerve agent attack in the Tokyo subway system raised awareness that terrorist organizations could potentially acquire or develop WMD's for use against civilian populations. Subsequent investigations revealed the organization had attempted to release botulinum toxins and anthrax on several occasions. The Department of Defense has been leading a federal effort to train the first responders in 120 American cities to be prepared to act in case of a domestic terrorist incident involving WMD. The program will be handed over to the Department of Justice on October 1, 2000.In the past two years, first responders, public health and medical personnel, and law enforcement agencies have dealt with the exponential increase in biological weapons hoaxes around the country.
Certainly the threat of biological
weapons being used against U.S. military forces and civilians is broader and
more likely in various geographic scenarios than at any point in our
history. Therefore, awareness of this
potential threat and education of our leaders, medical care providers, public
health officials, and law enforcement personnel on how to combat it are crucial.
DISTINGUISHING BETWEEN NATURAL AND INTENTIONAL DISEASE OUTBREAKS
With a covert biological agent attack, the most likely first indicator of an event would be an increased number of patients presenting with clinical features caused by the disseminated disease agent. Therefore, health care providers must use epidemiology to detect and respond rapidly to a biological agent attack.
A sound epidemiologic investigation of a disease outbreak, whether natural or human-engineered, will assist medical personnel in identifying the pathogen, as well as instituting the appropriate medical interventions. Documenting the affected population, possible routes of exposure, signs and symptoms of disease, along with rapid laboratory identification of the causative agents, will greatly increase the ability to institute an appropriate medical and public health response. Good epidemiologic information can guide the appropriate follow-up of those potentially exposed, as well as assist in risk communication and responses to the media.
Many diseases caused by weaponized biological agents present with nonspecific clinical features that could be difficult to diagnose and recognize as a biological attack. The disease pattern that develops is an important factor in differentiating between a natural and a terrorist or warfare attack. Epidemiologic clues that can potentially indicate an intentional attack are listed in Table 1.While a helpful guide, it is important to remember that naturally occurring epidemics can have one or more of these characteristics and a biological attack may have none.
Once a biological attack or any outbreak of disease is suspected, the epidemiologic investigation should begin. The conduct of the investigation will not differ significantly whether or not the outbreak is intentional. The first step is to confirm that a disease outbreak has occurred. A case definition should be constructed to determine the number of cases and the attack rate. The case definition allows investigators who are separated geographically to use the same criteria when evaluating the outbreak. The use of objective criteria in the development of a case definition is very important in determining an accurate case number, as additional cases may be found and some cases may be excluded, especially as the potential exists for hysteria to be confused with actual disease. The estimated rate of illness should be compared with rates during previous years to determine if the rate constitutes a deviation from the norm.
Once the attack rate has been determined, the outbreak can be described by time, place, and person. These data will provide crucial information in determining the potential source of the outbreak. The epidemic curve is calculated based on cases over time. In a point-source outbreak, which is most likely in a biological attack or terrorism situation, the early parts of the epidemic curve will tend to be compressed compared with propagated outbreaks. The peak may be in a matter of days or even hours. Later phases of the curve may also help determine if the disease appears to spread from person to person, which can be extremely important for determining effective disease control measures.
Well before any event, public health authorities must implement surveillance systems so they can recognize patterns of nonspecific syndromes that could indicate the early manifestations of a biological warfare attack. The system must be timely, sensitive, specific, and practical. To recognize any unusual changes in disease occurrence, surveillance of background disease activity should be ongoing, and any variation should be followed up promptly with a directed examination of the facts regarding the change.
It is important to remember that recognition of and preparation for a biological attack is similar to that for any disease outbreak, but the surveillance, response, and other demands on resources would likely be of an unparalleled intensity. A strong public health infrastructure with epidemiologic investigation capability, practical training programs, and preparedness plans are essential to prevent and control disease outbreaks, whether they are naturally occurring or otherwise.
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Table 1.Epidemiologic Clues of
a Biologic Warfare or Terrorist Attack
.The presence
of a large epidemic with a similar disease or syndrome, especially in a
discrete population
.Many cases of unexplained diseases or deaths
.More severe disease than is usually expected for a specific pathogen or failure to respond to standard therapy
.Unusual routes of exposure for a pathogen, such as the inhalational route for diseases that normally occur through other exposures
.A disease that is unusual for a given geographic area or transmission season
.Disease normally transmitted by a vector that is not present in the local area
.Multiple simultaneous or serial epidemics of different diseases in the same population
.A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers)
.A disease that is unusual for an age group
.Unusual strains or variants of organisms or antimicrobial resistance patterns different from those circulating
.Similar genetic type among agents isolated from distinct sources at different times or locations
.Higher attack rates in those exposed in certain areas, such as inside a building if released indoors, or lower rates in those inside a sealed building if released outside
.Disease outbreaks of the same illness occurring in noncontiguous areas
.A disease outbreak with zoonotic impact
.Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery of munitions or tampering
TEN
STEPS IN THE MANAGEMENT OF BIOLOGICAL CASUALTIES ON THE BATTLEFIELD
Military
personnel on the modern battlefield face a wide range of conventional and
unconventional threats. Compared to conventional, chemical, and nuclear weapon
threats, biological weapons are, perhaps, somewhat unique in their ability to
cause confusion, disruption and panic. It is useful for medical care providers
to understand the factors (Table 1) that account for this ability and for the
difficulties they would be expected to face in dealing with biological
casualties.
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Table 1.Characteristics of Biological Weapons and Warfare
--Potential
for massive numbers of casualties
--Ability to produce lengthy illnesses requiring prolonged and extensive care
--Ability of certain agents to spread via contagion
--Paucity of adequate detection systems
Diminished role for self-aid & buddy aid, thereby increasing sense of helplessness
--Presence of an incubation period, enabling victims to disperse widely
--Ability to produce non-specific symptoms, complicating diagnosis
--Ability to mimic endemic infectious diseases, further complicating diagnosis
-------------------------------------------------
In light of
these somewhat unique properties of biological weapons, medical personnel will
require a firm understanding of certain key elements of biological defense in
order to manage effectively the consequences of a biological attack amidst the
confusion expected on the modern battlefield. Understanding the behavior,
pathogenesis, modes of transmission, diagnostic modalities, and available
treatment options for each of the potential agents thus becomes imperative.
Acquiring such an understanding is relatively straightforward once the identity
of the agent is known; many references (FM 8-9, FM 8-33, FM 8-284), including
this handbook, exist to assist medical personnel in agent-based therapy. Proper
and thorough evaluation and management of a potential biological attack, before
a causative agent is identified, however, is likely to be complex and
problematic. For this reason, we recommend a ten-step process to guide medical
personnel in such evaluation and management.
I. Maintain an index of suspicion. The health-care provider on the modern battlefield must first possess a high index of suspicion regarding the potential employment of biological weapons. This is due to the fact that, with many of the biological warfare (BW) diseases, very early treatment is mandatory if patients are to be salvaged. Anthrax, botulism, plague, and smallpox are readily prevented if patients are provided proper antibiotics, antisera, and/or immunization promptly following exposure. Conversely, all of these diseases may prove fatal if therapy or prophylaxis is delayed until classic symptoms develop. Unfortunately, symptoms in the early, or prodromal, phase of illness are non-specific, making diagnosis difficult. Moreover, many potential BW diseases, such as Brucellosis, Q-fever, and Venezuelan Equine Encephalitis (VEE), may never present as more than non-specific febrile illnesses. Without a high index of suspicion, it is unlikely that the battlefield provider, especially at lower echelons, removed from sophisticated laboratory and preventive medicine resources, will promptly arrive at a proper diagnosis and institute appropriate therapy.
II. Protect Thyself. Before medical personnel approach a potential biological casualty, they must first take steps to protect themselves. These steps may involve a combination of physical, chemical, and immunologic forms of protection. On the battlefield, physical protection typically consists of a protective mask. Designed primarily with chemical vapor hazards in mind, the M-40 series mask certainly provides adequate protection against all inhalational BW threats. In fact, a HEPA-filter (or even a simple surgical) mask will afford adequate protection against BW (although not against chemical) threats. Chemical protection refers, in general, to the pre- and/or post-exposure administration of antibiotics; such strategies are discussed on an agent-specific basis elsewhere in this book. Immunologic protection principally involves active immunization and, in the present climate, applies mainly to protection against anthrax. Again, specific immunization strategies are discussed throughout this book.
III. Assess the Patient. This initial assessment is somewhat analogous to the primary survey of ATLS management. As such, airway adequacy should be assessed and breathing and circulation problems addressed before attention is given to specific management. The initial assessment is conducted before decontamination is accomplished and should thus be brief. Historical information of potential interest to the clinician might include information about illnesses in other unit members, the presence of unusual munitions, food and water procurement sources, vector exposure, immunization history, travel history, occupational duties, and MOPP status. Physical exam at this point should concentrate on the pulmonary and neuromuscular systems, as well as unusual dermatologic and vascular findings.
IV. Decontaminate as Appropriate. Decontamination plays a very important role in the approach to chemical casualty management. The incubation period of biological agents, however, makes it unlikely that victims of a BW attack will present for medical care until days after an attack. At this point, the need for decontamination is minimal or non-existent. In those rare cases where decontamination is warranted, simple soap and water bathing will usually suffice. Certainly, standard military decontamination solutions (such as hypochlorite), typically employed in cases of chemical agent contamination, would be effective against all biological agents. In fact, even 0.1% bleach reliably kills anthrax spores, the hardiest of biological agents. Routine use of caustic substances, especially on human skin, however, is rarely warranted following a biological attack. More information on decontamination is included elsewhere in this text.
V. Establish a Diagnosis. With decontamination (where warranted) accomplished, a more thorough attempt to establish a diagnosis can be carried out. This attempt, somewhat analagous, to the secondary survey used in the ATLS approach, should involve a combination of clinical, epidemiologic, and laboratory examinations. The amount of expertise and support available to the clinician will vary at each echelon of care. At higher echelons, a full range of laboratory capabilities should enable definitive diagnosis. At lower echelons, every attempt should be made to obtain diagnostic specimens from representative patients and forward these through laboratory channels. Nasal swabs (important for culture and PCR, even if the clinician is unsure which organisms to assay for), blood cultures, serum, sputum cultures, blood and urine for toxin analysis, throat swabs, and environmental samples should be considered.
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Table 2. Diagnostic Matrix: Chemical & Biological
Casualties.
Respiratory Casualties
Rapid-Onset
Nerve Agents
Cyanide
Mustard
Lewisite
Phosgene
SEB Inhalation
Delayed Onset
Inhalational
Anthrax
Pneumonic
Plague
Pneumonic
Tuleremia
Q Fever
SEB Inhalation
Ricin Inhalation
Mustard
Lewisite
Phosgene
Neurological Casualties
Rapid-Onset
Nerve Agents
Cyanide
Delayed Onset
Botulism-peripheral
symptoms
VEE-CNS
Symptoms
---------------------------------------------------
While awaiting laboratory confirmation, a diagnosis must be made on clinical grounds. Access, at higher echelons, to infectious disease, preventive medicine, and other specialists, can assist in this process. At lower echelons, the clinician should, at the very least, be familiar with the concept of syndromic diagnosis. Chemical and biological warfare diseases can be generally divided into those that present "immediately" with little or no incubation or latent period (principally the chemical agents) and those with a considerable delay in presentation (principally the biological agents). Moreover, BW diseases are likely to present as one of a limited number of clinical syndromes. Plague, Tularemia, and SEB disease all may present as pneumonia. Botulism and VEE may present with peripheral and central neuromuscular findings, respectively. This allows the construction of a simple diagnostic matrix as shown in Table 2. Even syndromic diagnosis, however, is complicated by the fact that many BW diseases (VEE, Q-Fever, Brucellosis) may present simply as undifferentiated febrile illnesses. Moreover, other diseases (Anthrax, Plague, Tularemia, Smallpox) have undifferentiated febrile prodromes.
VI. Render Prompt Treatment. Unfortunately, it is precisely in the prodromal phase of many diseases that therapy is most likely to be effective. For this reason, empiric therapy of pneumonia or undifferentiated febrile illness on the battlefield might be indicated under certain circumstances. Table 3 is constructed by eliminating from consideration those diseases for which definitive therapy is not warranted, not available, or not critical. Empiric treatment of respiratory casualties (patients with undifferentiated febrile illnesses who might have prodromal anthrax, plague, or tularemia would be managed in a similar manner) might then be entertained. Doxycycline, for example, is effective against most strains of B. anthracis, Y. pestis, and F. tularensis, as well as against C. burnetii, and the Brucellae. Other tetracyclines and fluoroquinolones might also be considered. Keep in mind that such therapy is, in no way, a substitute for a careful and thorough diagnostic evaluation, when battlefield conditions permit such an evaluation.
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Table 3. CW & BW Diseases Potentially Requiring Prompt
Empiric Therapy.
Respiratory Casualties
Rapid-Onset
Cyanide
Delayed Onset
Inhalational
Anthrax
Pneumonic
Plague
Pneumonic
Tuleremia
Neurological Casualties
Rapid-Onset
Nerve Agents
Delayed Onset
Botulism
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VII. Practice Good Infection Control. Standard precautions provide adequate protection against most infectious diseases, including those potentially employed in BW. Anthrax, Tularemia, Brucellosis, Glanders, Q-Fever, VEE, and the Toxin-Mediated diseases are not generally contagious, and victims can be safely managed using standard precautions. Such precautions should be familiar to all clinicians. Under certain circumstances, however, one of three forms of transmission-based precautions would be warranted. Smallpox victims should, wherever possible, be managed using airborne precautions. Pneumonic Plague warrants the use of droplet precautions, and certain VHFs require contact precautions.
VIII. Alert the Proper Authorities. In any military context, the command should immediately be appraised of casualties suspected due to chemical or biological agents. The clinical laboratory should also be notified. This will enable laboratory personnel to take proper precautions when handling specimens and will also permit the optimal use of various diagnostic modalities. Chemical Corps and Preventive Medicine personnel should be contacted to assist in the delineation of contaminated areas and the search for further victims.
IX. Assist in the Epidemiologic Investigation. All health care providers require a basic understanding of epidemiologic principles. Even under austere conditions, a rudimentary epidemiologic investigation may assist in diagnosis and in the discovery of additional BW victims. Clinicians should, at the very least, query patients about potential exposures, ill unit members, food/water sources, unusual munitions or spray devices, vector exposures, and develop a line listing of potential cases. Such early discovery might, in turn, permit post-exposure prophylaxis, thereby avoiding excess morbidity and mortality. Preventive medicine officers, field sanitation personnel, epidemiology technicians, environmental science officers, and veterinary officers are all available to assist the clinician in conducting an epidemiologic investigation.
X. Maintain Proficiency and Spread the Gospel. Fortunately, the threat of BW has remained a theoretical one for most medical personnel. Inability to practice casualty management, however, can lead to a rapid loss of skills and knowledge. It is imperative that the medic maintains proficiency in dealing with this low probability, but high consequence problem. This can be done, in part, by availing oneself of several resources. The OTSG (www.nbc-med.org) and USAMRIID (www.usamriid.army.mil) Web Sites provide a wealth of information, including the text of this handbook. Annual satellite television broadcasts, sponsored by USAMRIID, provide in-depth discussion and training in medical biodefense as well. A CD-ROM training aid is being developed, and a new field manual (Army FM 8-284) summarizes BW disease management recommendations. Finally, medical personnel, once aware of the threat and trained to deal with it, must ensure that other personnel in their units receive training as well. It is only through ongoing training that you will be ready to deal with the threat posed by biological weapons. By familiarizing yourself with the contents of this handbook, you have taken a large step towards such readiness.
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BACTERIAL AGENTS