If you are licensed in Nevada, your state-mandated course is Nevada: Bioterrorism and Weapons of Mass Destruction.
Defines terrorism, bioterrorism, and weapons of mass destruction and summarizes the diseases and agents most commonly used as chemical, biologic, radiologic, and nuclear weapons. Outlines CDC recommendations and best practices.
The following information applies to occupational therapy professionals:
Criteria for Successful Completion
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.
Objectives: When you finish this course you will be able to:
The Federal Bureau of Investigation (FBI) uses a definition of terrorism that includes “the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (28 C.F.R. Section 0.85).
From the Centers for Disease Control and Prevention (CDC) comes a comprehensive definition of bioterrorism:
A bioterrorism attack is the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants. These agents are typically found in nature, but it is possible that they could be changed to increase their ability to cause disease, make them resistant to current medicines, or to increase their ability to be spread into the environment. Biological agents can be spread through the air, through water, or in food. Terrorists may use biological agents because they can be extremely difficult to detect and do not cause illness for several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread from person to person and some, like anthrax, can not. (CDC, 2007).
While the use of violence lies at the heart of most definitions of terrorism, arriving at a more nuanced definition often depends on the political, ethnic, or religious perspective of those doing the defining. In addition, terrorism is sometimes categorized as either “domestic” or “international,” referring not to where the terrorist act takes place, but to the origin of the individuals or groups responsible for it. For healthcare professionals facing the medical consequences of such an act, this distinction may not seem particularly relevant.
There is much debate over the motivations for terrorism. They have traditionally been thought to reflect religious, political, or ideological beliefs, and the targets of attacks to be symbolic in some way. Sparking fear in victims and the wider public is often an element of motivation. Recent research suggests motivations may include a personal desire on the part of perpetrators to further their membership in the terrorist community and can be affected by various internal structural issues within terrorist groups (Abrahms, 2015, 2008). However, the bottom line for healthcare professionals is that debates over definitions, motivations, and other factors are not necessarily relevant to understanding how to care for victims of terrorist acts.
Terrorist acts have occurred throughout history, but after the Oklahoma City bombing in 1995 and the events of September 11, 2001 in the United States, such behavior became an ongoing element of the public consciousness. Acts of terrorism and the means by which they might be carried out are of special concern to healthcare professionals, who would be called upon to treat people following a terrorist attack. In fact, several states have mandated training for nurses and other healthcare professionals to ensure they have a basic knowledge of potential terrorist threats and how to respond to them.
Man covered with ashes assisting a woman who is holding a particle mask to her face following the September 11 terrorist attack on the World Trade Center, New York City. Photographer: Don Halasy. Source: Wikimedia Commons.
The effects of terrorist acts are not only physical, and fear may loom large among citizens. Healthcare workers need to be prepared to address this fear, even in patients who have sustained little or no physical injury. Additional psychological effects are recognized consequences of certain types of injuries and will be discussed in the sections that follow.
The U.S. government was already actively working to combat terrorist threats before September 11, 2001, and has since stepped up its efforts. For the general public and for healthcare workers, education about the proper responses to terrorist activities, along with thorough emergency preparedness, are the best available defense. Absent shocking new events close to home, it can be tempting to relegate emergency preparedness for terroristic events to the back of the mind, but all sorts of things can happen, both small and large, that would require quick thinking and proper training.
Events since 2001 have resulted in a large body of useful information and many resources for individuals and organizations seeking to educate and prepare themselves. The changing nature of the Internet means that some of these resources may come and go, but websites maintained by the Department of Homeland Security, the Department of Health and Human Services (DHHS), and the CDC remain up-to-date and valuable resources for individuals and institutions. (See Resources at the end of this course for relevant links.)
Weapons of mass destruction (WMD) is a term that has become increasingly familiar through its use in the media. Not everyone means precisely the same thing when they use the term, but the definition used by the U.S. military may be the simplest and most generally understood. WMD are:
. . .chemical, biological, radiological, or nuclear weapons capable of a high order of destruction or causing mass casualties. (DOD, 2010/2015)
The possibility that terrorists might resort to the use of WMD is of grave concern. The types of WMD vary in their ability to cause damage, in their ease of production and use, in the kinds of physical and human damage they can be expected to cause, and in their likelihood of use by terrorist organizations.
Chemical weapons use the toxic properties of chemicals to cause harm, up to and including death. Only a relatively small amount of a chemical agent is needed to produce significant physical and psychological effects. Historically, chemical weapons have been the most widely used and proliferated type of WMD, but they receive far less attention than do biological and nuclear weapons (NTI, 2015b).
Biological weapons utilize microorganisms and natural toxins to produce disease in humans, animals, or plants, and “gram for gram. . . are the deadliest weapons ever produced.” Derived from a variety of sources, these compounds, when paired with a delivery system, become weapons. The potential danger of a given weapon is measured by its lethality, or how effectively it kills; its infectivity, or how easily it spreads; and its virulence, or how likely it is to cause disease. Other important considerations include how easily is it dispersed, whether it can be treated medically, whether there is a vaccine, what dose is needed to cause disease, and how stable the compound is (NTI, 2015a).
Chemical and biological weapons are financially and logistically easier to acquire than radiologic or nuclear weapons. They will cause more casualties and have a greater psychological impact than conventional weapons, but cause less destruction than devices involving radiation. Chemical weapons are somewhat easier than other weapons for terrorist groups (or even individuals) to manufacture because the manufacturing knowledge is readily available, many precursor chemicals have legitimate uses and are thus legally available, there is poor security around these chemicals in some countries, and small chemical manufacturing equipment is commonly available.
Radiologic and nuclear weapons rely on the same sources for damage—explosive power and radiation—but there is a distinction in their forms. In addition, true nuclear weapons produce tremendous heat, which can cause burns and start fires. In the last fifty years, most radiation injuries have been the result of accidents; however, the intentional deployment of a nuclear or radiologic device is a potential terrorist threat.
Modern nuclear threats can be divided into five general categories:
Both radiologic and nuclear devices can damage and contaminate. Incidents involving simple devices and radiological dispersal devices (RDDs)—any device that causes intentional dissemination of radioactive material without a nuclear detonation—would probably cause a limited number of casualties; however, those involving improvised nuclear devices and small nuclear weapons would result in mass casualties (ORISE, 2013; Waselenko et al., 2004; CISAC, n.d.-a).
Radiologic dispersal devices—commonly known as dirty bombs—are seen as more likely to be used by terrorists. These devices require little more skill than is needed to make a conventional bomb and their components are easier to acquire. RDDs utilize conventional explosives to disperse a radioactive material packaged in the device, as opposed to a nuclear device, which creates radiation with its explosion.
While it is unlikely that many people would die from radiation poisoning as a result of the explosion of an RDD, there would be some deaths and injuries and the costs of cleanup could be considerable. These devices are attractive to some groups because they are relatively easy to create and they will not generally do a great deal of damage, but they will play on the heightened fear of radiation among the general public to cause widespread panic and disruption, which is often a group’s real goal. Because of this, public education and good response preparation are important counter measures (CISAC, n.d.-a; NTI, 2015c,d; ORISE, 2013).
Nuclear weapons present significantly higher obstacles in terms of the skill needed to produce them and the financial and logistical support needed to acquire materials, prepare the device, and transport it (Weiss, 2015). However, the potential for damage, injuries, and death is much higher because they are significantly more powerful weapons.
Modern chemical warfare can be traced to World Wars I and II. Since then, there has been research and stockpiling of chemicals by many countries but mutual deterrence has generally prevailed. A modern exception was the use of chemical weapons in 2013 by Syrian president Bashar al-Assad against Syrian citizens who were rebelling against his autocratic government. Through intense negotiating, the United Nations was able to persuade Assad to allow outsiders to come into Syria and remove or destroy the chemical weapons he had stockpiled and by 2014 they had been reported destroyed or removed.
The techniques for making very destructive chemical weapons are well understood and the necessary equipment is commonly available. Once made, weapons can be easily concealed. In 1995 a Japanese cult group known as Aum Shinrikyo made and dispersed the nerve agent sarin several times in the Tokyo subway, killing twelve people on one occasion. These incidents made it clear that even small groups could manage the manufacture and dispersal of deadly chemical weapons (NTI, 2015b).
Chemical weapons agents are classified as either nonpersistent or persistent. Nonpersistent agents dissipate within a few hours and are most threatening to the lungs. Persistent agents may take up to one month to dissipate if they have been deposited on soil, vegetation, or objects. They are most threatening to the skin.
Scientists often categorize hazardous chemicals by the type of chemical or by the effects a chemical would have on people exposed to it. The categories/types used by CDC are as follows:
Poisons that come from plants or animals
Chemicals that severely blister the eyes, respiratory tract, and skin on contact
Poisons that affect the body by being absorbed into the blood
Chemicals that burn or corrode people’s skin, eyes, and mucus membranes (lining of the nose, mouth, throat, and lungs) on contact
Chemicals that cause severe irritation or swelling of the respiratory tract (lining of the nose, throat, and lungs)
Drugs that make people unable to think clearly or that cause an altered state of consciousness (possibly unconsciousness)
Poisons that prevent blood from clotting properly, which can lead to uncontrolled bleeding
Agents that consist of metallic poisons
Highly poisonous chemicals that work by preventing the nervous system from working properly
Agents that damage the tissues of living things by dissolving fats and oils
Riot Control Agents/Tear Gas
Highly irritating agents normally used by law enforcement for crowd control or by individuals for protection (for example, mace)
Poisonous alcohols that can damage the heart, kidneys, and nervous system
Chemicals that cause nausea and vomiting
Since September 11, 2001, concern has increased about potential terrorist attacks involving the use of chemical agents. In addition, recent cases involving intentional or inadvertent contamination of food with chemicals have highlighted the need for healthcare providers and public health officials to be alert for patients in their communities who have signs and symptoms consistent with chemical exposures (CDC, 2003).
Intentional release of chemical agents may be an overt event, one whose nature reveals itself, such as release of a nerve agent in a subway or a large explosion of a chemical container. On the other hand, a chemical release might be a covert event, an unrecognized release in which the presence of sick people could be the first sign of an exposure; this could include deliberate contamination of food, water, or a consumer product.
To increase the likelihood that healthcare providers recognize a chemical release-related illness, and that public health authorities will implement the appropriate emergency response and public health actions, the CDC has identified examples of chemical-induced illness (see table below under “Identifying Chemical Agents”) and created appropriate guidance for healthcare providers and public health personnel (CDC, 2003).
The CDC recognizes that the covert release of a chemical agent might not be easily identified, for at least five reasons:
Identifying a covert release of a chemical agent may depend on alert healthcare professionals as they begin to see victims of the release. First receivers (eg, hospital-based emergency staff), may be in the best position to observe epidemiologic clues that suggest such a release. These clues include:
Because various chemical agents could be used as covert weapons, the actual clinical syndrome varies depending on the type of agent, the amount and concentration of the chemical, and the route of the exposure. However, some clinical presentations may be more common with a covert chemical release. Certain syndromes are associated with groups of chemical agents with similar toxic properties that have been used previously, have high toxicity, or are easily available (see table) (CDC, 2003).
Clinical Syndromes and Potential Chemical Etiologies*
Potential chemical etiology
Oropharyngeal pain and ulcerations
Peripheral neuropathy and/or neurocognitive effects
Severe gastrointestinal illness, dehydration
As noted above, it is likely that a covert chemical release would be first recognized by healthcare providers, public health agencies, and poison control centers as they become aware of patterns while assessing illness and treating patients. Familiarity of healthcare professionals with the general characteristics of a covert chemical release, plus recognition of epidemiologic clues and related clinical syndromes, could reduce morbidity and mortality as these workers implement the appropriate emergency response.
Public health agencies and healthcare providers might render the most appropriate, timely, and clinically relevant treatment possible by using treatment modalities based on syndromic categories (eg, burns, respiratory depression, neurologic damage, shock). Because of the hundreds of new chemicals introduced globally each month, it is more pragmatic to treat exposed persons by clinical syndrome rather than specific agent (CDC, 2003; CDC, 2000).
The Centers for Disease Control and Prevention (CDC) provide many reference materials for recognizing and treating the effects of all types of chemical compounds. These include “reference cards” for dozens of individual chemical compounds that outline essential information for emergency and hospital personnel, including the type of personal protective clothing and equipment needed when treating victims. While personal protective equipment and clothing is necessary for treating virtually anyone who has been exposed to a chemical agent, specifics vary according to the agent involved. It is critical to have this information on hand and for staff to be trained to consult it.
Following are the CDC guidelines for two of the common categories of chemical agents—vesicants and nerve agents. These guidelines provide information on recognizing signs and symptoms, initial treatment, and alternative diagnoses. Remember that the details will differ for other agents and you should always know how to access reference materials quickly at your facility.
Vesicants, also referred to as “blister agents,” were the most commonly used chemical warfare agents during World War I. Likely routes of exposure are inhalation, dermal contact, and ocular contact. Vesicants are highly reactive chemicals that combine with proteins, DNA, and other cellular components to result in cellular changes immediately after exposure.
Depending on the vesicant, clinical effects may occur immediately (as with phosgene oxime, lewisite) or may be delayed for 2 to 24 hours (as with mustards). Following exposure, the most commonly encountered clinical effects include dermal (skin erythema, blistering), respiratory (pharyngitis, cough, dyspnea), ocular (conjunctivitis, burns), and gastrointestinal (nausea, vomiting).
The amount and route of exposure to the vesicant, the type of vesicant, and the premorbid condition of the person exposed contribute to the time of onset and the severity of illness. For example, ingestion of a vesicant leads to gastrointestinal symptoms more prominent than those that would result from inhalation exposure to the same dose and type of vesicant (CDC, 2013ca).
The following is a more comprehensive list of signs and symptoms that may be encountered in a person exposed to a vesicant. Signs and symptoms are not listed in order of presentation or specificity. Also, partial presentations (an absence of some of the following signs/symptoms) do not necessarily imply less severe disease.
Respiratory signs and symptoms include:
Dermal signs and symptoms include:
Ocular signs and symptoms include:
Cardiovascular signs include:
Gastrointestinal signs and symptoms (prominent if ingestion is a route of exposure) include:
Central nervous system signs and symptoms (with exposure to high doses) include:
Hematological signs and symptoms:
Although it is a nonspecific finding, leukopenia can indicate vesicant exposure. It usually begins 3 to 5 days after exposure. With a white blood cell count <500, the prognosis is poor.
Note: The actual clinical manifestations of a vesicant exposure may be more variable than the syndrome described above (CDC, 2013ca).
Nerve agents are chemical warfare agents that have the same mechanism of action as organophosphate (OP) pesticides. They are potent inhibitors of acetylcholinesterase. Inhibition of acetylcholinesterase leads to an accumulation of acetylcholine in the central and peripheral nervous system. Excess acetylcholine produces a predictable cholinergic syndrome consisting of copious respiratory and oral secretions, diarrhea and vomiting, sweating, altered mental status, autonomic instability, and generalized weakness that can progress to paralysis and respiratory arrest.
The amount and route of exposure to the nerve agent or OP pesticide, the type of nerve agent or pesticide, and the premorbid condition of the exposed person contribute to the time of onset and the severity of illness. For example, inhalation of a nerve agent or an OP pesticide leads to a quicker onset of poisoning with more severe symptoms than dermal exposure, given the same amount of agent (CDC, 2013cb).
The following are more comprehensive lists of signs and symptoms that may be encountered in a person exposed to a nerve agent or OP pesticide. Signs and symptoms are not listed in order of presentation or specificity. Also, partial presentations (an absence of some of the following signs/symptoms) do not necessarily imply less severe disease.
Central nervous system signs and symptoms include:
Respiratory signs and symptoms include:
Cardiovascular signs include:
Gastrointestinal signs and symptoms include:
Musculoskeletal signs and symptoms include:
Skin and mucous membrane signs and symptoms include:
Interpreting cholinesterase activity:
Red Blood Cell Cholinesterase
Note: The actual clinical manifestations of an exposure to a nerve agent or an OP pesticide may be more variable than the syndrome described in this document (CDC, 2013cb).
From a scientific and medical perspective, bioterrorism—using biological weapons to produce disease in humans—can be viewed as a variation of the problem of emerging infectious diseases, the only difference being that increased virulence or intentional release are deliberate acts. The United States public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in this country.
As with chemical agents, the intentional release of biological agents can be either covert or overt. A covert release is unannounced and hidden, and may go unnoticed for days or even weeks. The presence of ill individuals may be the first sign of a release, and those infected may have inadvertently infected others. An infected person may seek medical care anywhere within the healthcare system, possibly at a distance from the release area.
An overt release is immediately apparent and may even be announced. In an overt release, the healthcare system and public health officials may be overwhelmed by requests for information and treatment. Hospitals, clinics, emergency responders, and communication systems will be pressed into immediate service. An overt release has the potential to cause widespread panic.
Whether the release is covert or overt, healthcare providers should be alert to illness patterns and diagnostic clues that indicate an unusual infectious disease outbreak that could be associated with intentional release of a biological agent. In addition that should watch for increases in unexpected or unexplained illnesses and know how to activate the public health response system if an outbreak is suspected (CDC, 2001). Well-trained and educated first responders, first receivers, and public health personnel are essential to an organized and successful response.
Healthcare providers, clinical laboratory personnel, infection control professionals, and public health departments play critical and complementary roles in the recognition and response to illness caused by the intentional release of biological agents. Syndrome descriptions, epidemiologic clues, and laboratory recommendations provide basic guidance that can improve recognition of these events (CDC, 2001).
Since 9/11, state and local health departments have initiated activities to improve recognition, reporting, and response, ranging from enhancing communications to conducting special surveillance projects. This includes active tracking for changes in the number of hospital admissions, emergency department visits, and occurrence of specific syndromes. Bioterrorism preparedness activities and work with emerging infectious diseases have helped public health agencies prepare for the intentional release of a biological agent (CDC, 2001). The CDC’s Emergency Preparedness and Response website has links to and information on the various tools available, as well as other resources.
Work continues on syndromic surveillance projects and the CDC maintains current data on this research. The term syndromic surveillance means watching for health-related data that signal sufficient probability of a case or an outbreak to warrant further public health response. Historically, syndromic surveillance was used in investigating potential cases, but its utility for detecting outbreaks associated with bioterrorism is increasingly being explored by public health officials. Technology changes and the plethora of programs and data have also affected these efforts (CDC, 2004b, 2012; Dembek, 2004). (See also the CDC resource website).
The release of a biological agent may not have an immediate impact because of the delay between exposure and onset of illness, and because outbreaks associated with intentional releases may resemble naturally occurring ones. Nevertheless, healthcare workers should be familiar with indications of intentional release of a biological agent and know when, and to whom, to report a suspected outbreak.
These indications include unusual clustering of illness, patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak, unusual age distribution for common diseases, and a large number of cases of acute flaccid paralysis with prominent bulbar palsies, which is suggestive of a release of botulinum toxin (CDC, 2001).
Epidemiologic Clues That May Signal a Covert Bioterrorism Attack
As noted earlier, a variety of factors affect the potential public health impact of an intentionally released biological agent:
It may be difficult to pinpoint the time and location of a biological agent’s release because of the variation in incubation period among organisms. Some diseases show a rapid onset of symptoms and early treatment is critical. For example, plague has a rapid onset and is potentially fatal within 12 to 24 hours if untreated; botulism toxin also has a rapid onset and requires immediate supportive treatment. On the other hand, smallpox can be treated effectively by vaccination within 2 to 3 days of symptom onset. But smallpox, like plague, is highly contagious and has the potential to cause widespread panic, and in the case of smallpox, which is believed to have been eradicated, not enough vaccine exists should a widespread outbreak occur. Conversely, plague and anthrax, despite their potential for causing serious illness and death, are effectively treated with antibiotics.
Bioterrorism agents can be separated into three categories, depending on how easily they can be spread and the severity of illness or death they cause. Category A agents are considered the highest risk and Category C agents are those that are considered emerging threats for disease (CDC, 2007).
Category A diseases or agents are high priority and include organisms that pose the highest risk to the public and national security because they:
Category A bioterrorism agents are:
A letter sent in 2001 to Senate Majority Leader Tom Daschle contained anthrax powder. Beginning one week after the September 11 attacks, letters containing anthrax spores were mailed to several news media offices and two U.S. Senators, killing five people and infecting 17 others. Source: Wikimedia Commons.
Category B diseases or agents are the second highest priority because they:
Category B diseases or agents include:
Category C diseases or agents are the third highest priority and include emerging pathogens that could be engineered for mass dissemination in the future because:
Four category A diseases have been the focus of the CDC’s efforts to educate the healthcare community about bioterrorism potential: anthrax, botulism, plague, and smallpox. The CDC does not prioritize these agents in any order of importance or likelihood of use. Other agents with bioterrorism potential include those that cause tularemia and viral hemorrhagic fevers (category A), brucellosis, Q fever, viral encephalitis, and disease associated with staphylococcal enterotoxin, category B. Other important category B agents include any organism that threatens the water or food supply.
Anthrax has been recognized as an infectious disease of animals and humans for millennia. Within the United States, animal anthrax is reported in most years, but naturally occurring human anthrax is rare. Worldwide, however, the disease is common in wild and domestic animals and not uncommon among persons who interact with animals in agricultural regions of South and Central America, sub-Saharan Africa, central and southwestern Asia, and southern and eastern Europe (Hendricks, et al. [CDC], 2014).
Bacillus anthracis, the causative agent of anthrax, is a nonmotile spore-forming, gram-positive, rod-shaped bacterium. Biodefense experts often place B. anthracis at or near the top of the list for potential threat agents. Inhalation anthrax is particularly deadly, as demonstrated by the 1979 accidental release of B. anthracis from a military microbiology facility in the Sverdlovsk region of Russia; 88% (66/75) of patients reported with inhalation anthrax died. More recently, humans have acquired disease from exposure to spores released purposefully as a bioterrorist weapon and accidentally from naturally occurring sources (Hendricks, et al. [CDC], 2014).
If a bioterrorist attack were to happen, Bacillus anthracis would be one of the biological agents most likely to be used. Biological agents are germs that can sicken or kill people, livestock, or crops. Anthrax is one of the most likely agents to be used because:
Anthrax has been used as a weapon around the world for nearly a century. In 2001, powdered anthrax spores were deliberately put into letters that were mailed through the U.S. postal system. Twenty-two people, including 12 mail handlers, got anthrax, and five of these 22 people died.
A subset of select agents and toxins have been designated as Tier 1 because these biological agents and toxins present the greatest risk of deliberate misuse with significant potential for mass casualties or devastating effect to the economy, critical infrastructure, or public confidence, and pose a severe threat to public health and safety. Bacillus anthracis is a Tier 1 agent.
An anthrax attack could take many forms. For example, it could be placed in letters and mailed, as was done in 2001, or it could be put into food or water. Anthrax also could be released into the air from a truck, building, or plane. This type of attack would mean the anthrax spores could easily be blown around by the wind or carried on people’s clothes, shoes, and other objects. It only takes a small amount of anthrax to infect a large number of people.
If anthrax spores were released into the air, people could breathe them in and get sick with anthrax. Inhalation anthrax is the most serious form and can kill quickly if not treated immediately. If the attack were not detected by one of the monitoring systems in place in the United States, it might go unnoticed until doctors begin to see unusual patterns of illness among sick people showing up at emergency rooms (CDC, 2014).
There are four clinical forms of anthrax: cutaneous or skin, respiratory tract or inhalation, gastrointestinal, and injection anthrax (has occurred in Europe but not in the US) (CDC, 2013b).
When anthrax spores get into the skin, usually through a cut or scrape, a person can develop cutaneous anthrax. This can happen when a person handles infected animals or contaminated animal products like wool, hides, or hair. Cutaneous anthrax is most common on the head, neck, forearms, and hands. It affects the skin and tissue around the site of infection.
Cutaneous anthrax is the most common form of anthrax infection, and it is also considered to be the least dangerous. Infection usually develops from 1 to 7 days after exposure. Without treatment, up to 20% of people with cutaneous anthrax may die. However, with proper treatment, almost all patients with cutaneous anthrax survive (CDC, 2013b).
Cutaneous anthrax symptoms can include:
When a person breathes in anthrax spores, they can develop inhalation anthrax. People who work in places such as wool mills, slaughterhouses, and tanneries may breathe in the spores when working with infected animals or contaminated animal products from infected animals. Inhalation anthrax starts primarily in the lymph nodes in the chest before spreading throughout the rest of the body, ultimately causing severe breathing problems and shock.
Inhalation anthrax is considered to be the most deadly form of anthrax. Infection usually develops within a week after exposure, but it can take up to 2 months. Without treatment, only about 10% to 15% of patients with inhalation anthrax survive. However, with aggressive treatment, about 55% of patients survive (CDC, 2013b).
Inhalation anthrax symptoms can include:
When a person eats raw or undercooked meat from an animal infected with anthrax, they can develop gastrointestinal anthrax. Once ingested, anthrax spores can affect the upper gastrointestinal tract (throat and esophagus), stomach, and intestines.
Gastrointestinal anthrax has rarely been reported in the United States. Infection usually develops from 1 to 7 days after exposure. Without treatment, more than half of patients with gastrointestinal anthrax die. However, with proper treatment, 60% of patients survive (CDC, 2013b).
Gastrointestinal anthrax symptoms can include:
Recently, another type of anthrax infection has been identified in heroin-injecting drug users in northern Europe. This type of infection has never been reported in the United States.
Symptoms may be similar to those of cutaneous anthrax, but there may be infection deep under the skin or in the muscle where the drug was injected. Injection anthrax can spread throughout the body faster and be harder to recognize and treat. Lots of other more common bacteria can cause skin and injection site infections, so a skin or injection site infection in a drug user does not necessarily mean the person has anthrax (CDC, 2013b).
Injection anthrax symptoms can include:
Botulism is a neuroparalytic (muscle-paralyzing) disease whose agent is the toxin produced by Clostridium botulinum—an encapsulated, anaerobe, gram-positive, spore-forming, rod-shaped bacterium (CDC, 2006). Botulism neurotoxin is an extremely potent organism; less than 1 microgram causes fatality in adults. It causes paralysis by inhibiting the release of acetylcholine at the neuromuscular junction; respiratory paralysis and death result if left untreated. There are four forms of naturally occurring botulism:
Botulism is not transmissible from person to person. For foodborne botulism, symptoms begin within 6 hours to 10 days after exposure (often within 12–36 hours), and could be shorter in inhalational botulism (CDC, 2006b).
Symptoms, Diagnosis, and Treatment of Botulism
Plague is an acute and potentially fatal bacterial infection that affects humans and animals and is caused by Y. pestis. Plague usually presents as 1 of 5 principal clinical syndromes: bubonic, pneumonic, septicemic, plague meningitis, or pharyngeal. Plague is a naturally occurring disease that has been endemic in the United States since 1900. Approximately 5 to 15 cases occur per year, with the greatest concentration of cases in Arizona, Colorado, and New Mexico (CDC, 2004a).
An immediate and coordinated public health and medical response would be required in the event of the intentional use of plague. Therefore, any case of plague should be reported to the state health department immediately. Reporting is especially important when a case of plague occurs outside of a typically affected area (CDC, 2004a).
With bubonic plague, the infection is transmitted by the bite of an infected flea or exposure to infected material through a break in the skin. Bubonic plague cannot be transmitted from person to person. If bubonic plague is not treated, the bacteria can spread through the bloodstream and infect the lungs, causing a secondary infection of pneumonic or septicemic plague (CDC, 2004a).
Pneumonic plague is a pulmonary infection that occurs upon inhalation of plague bacteria. Pneumonic plague can be transmitted person to person through respiratory droplets with direct close contact, and without early treatment in less than 24 hours, pneumonic plague almost universally leads to respiratory failure, shock, and rapid death (CDC, 2004a).
Infection via inhalation of infective respiratory droplets or aerosols is rare with naturally occurring plague in the United States, but is the most likely route of transmission in a bioterrorist event. If Y. pestis were to be used as a bioweapon, it would be most dangerous if released as an aerosol. An aerosol release would be expected to result in an outbreak of the pneumonic form of plague and it may also cause the less common pharyngeal plague and ocular plague (CDC, 2004a).
The primary form of septicemic plague results from direct inoculation and multiplication of plague bacilli in the bloodstream, while the secondary form is a development of untreated pneumonic or bubonic plague (CDC, 2004a).
Smallpox is a serious, contagious, and sometimes fatal infectious disease. There is no specific treatment for smallpox disease, and the only prevention is vaccination. The pox part of smallpox is derived from the Latin word for “spotted” and refers to the raised bumps that appear on the face and body of an infected person (CDC, 2004c).
There are two clinical forms of smallpox. Variola major is the severe and most common form of smallpox, with a more extensive rash and higher fever. There are four types of variola major smallpox: ordinary (the most frequent type, accounting for 90% or more of cases); modified (mild and occurring in previously vaccinated persons); flat; and hemorrhagic (both rare and very severe). Historically, variola major has an overall fatality rate of about 30%; however, flat and hemorrhagic smallpox usually are fatal. Variola minor is a less common presentation of smallpox, and a much less severe disease, with death rates historically of 1% or less (CDC, 2004c).
Smallpox is caused by the variola virus, which emerged in human populations thousands of years ago, but the disease is now eradicated after a successful worldwide vaccination program. After the disease was eliminated from the world, routine vaccination against smallpox among the general public was stopped because it was no longer necessary for prevention. Except for laboratory stockpiles, the variola virus has been eliminated. However, in the aftermath of 9/11, there is heightened concern that the variola virus might be used as an agent of bioterrorism. For this reason, the U.S. government is taking precautions for dealing with a smallpox outbreak (CDC, 2004c).
Generally, direct and fairly prolonged face-to-face contact is required to spread smallpox from one person to another. Smallpox also can be spread through direct contact with infected bodily fluids or contaminated objects such as bedding or clothing. Rarely, smallpox has been spread by virus carried in the air in enclosed settings such as buildings, buses, and trains. Humans are the only natural hosts of variola. Smallpox is not known to be transmitted by insects or animals.
A person with smallpox is sometimes contagious with onset of fever (prodrome phase), but the person becomes most contagious with the onset of rash. At this stage the infected person is usually very sick and not able to move around in the community. The infected person is contagious until the last smallpox scab falls off (CDC, 2004c).
The acute clinical symptoms of smallpox resemble other acute viral illnesses, such as influenza, beginning with a 2- to 4-day nonspecific prodrome of fever and myalgias before rash onset. Several clinical features can help clinicians differentiate varicella (chickenpox) from smallpox. The rash of varicella is most prominent on the trunk and develops in successive groups of lesions over several days, resulting in lesions in various stages of development and resolution. In comparison, the vesicular/pustular rash of smallpox is typically most prominent on the face and extremities, and lesions develop at the same time (CDC, 2001; CDC, 2004c).
The only weapons against smallpox are vaccination and patient isolation. Those caring for a patient with smallpox should wear an N95 mask and follow airborne and contact isolation precautions. HEPA filters do remove smallpox virus, but proper procedures must be followed for their effective use. Vaccination before exposure, or within 3 days after exposure, affords almost complete protection against the disease. Vaccination as late as 4 to 7 days after exposure likely offers some protection from disease or may modify the severity of disease (CDC, 2009a,b).
The smallpox vaccine is made from a virus called vaccinia, which is a pox-type virus related to smallpox. The vaccine contains the live vaccinia virus (other vaccines containing live virus include measles, mumps, and German measles) and for that reason the vaccination site must be treated carefully to prevent the virus from spreading. The vaccine can have side effects; however, it does not contain the smallpox virus and cannot give you smallpox (CDC, 2009c).
Healthcare workers risk occupational exposures to biological materials when a hospital receives contaminated patients, particularly during mass casualty events. Hospital employees termed first receivers work at a site removed from where the hazardous release occurred. This means that their exposures are limited to the substances transported to the hospital on the skin, hair, clothing, or personal effects of the victims. The location and limited source of contaminants distinguishes first receivers from first responders such as firefighters, law enforcement, and ambulance service personnel, who typically respond to the incident site (OSHA, 2005).
Worst-case scenarios take into account challenges associated with communication, resources, and victims. During mass-casualty emergencies, hospitals can anticipate little or no warning before victims begin arriving. First receivers can anticipate that information regarding the hazardous agents may not be available immediately. Hospitals can also anticipate a large number of self-referred victims (as many as 80% of the total number of victims) and should assume victims will not have been decontaminated prior to arriving at the hospital (OSHA, 2005).
An employee’s role at a facility and the corresponding hazards the employee might encounter dictate the level of training that must be provided to any individual first receiver. Selection of personal protective equipment (PPE) must be based on a hazard assessment that carefully considers both of these factors, along with the steps taken to minimize the extent of the employee’s contact with hazardous substances (OSHA, 2005). Surge capacity, triage, decontamination, security, and disposal of contaminated wastewater must also be addressed.
In the event of a mass casualty event, healthcare organizations must be able to increase their services quickly in response to the crisis. This is an organization’s surge capacity, “the ability to expand care capabilities in response to sudden or prolonged demand” (JCAHO, 2003; Kelen, 2008). Staffing levels, education and training, decontamination capabilities, vaccination programs for direct caregivers, volunteer resources, and stockpiling of supplies must be assessed while, in most cases, routine care continues.
Individual personnel on an emergency response team have slightly differing concerns and responsibilities when it comes to surge situations. While surge capacity planning is an administrative level concern, individual healthcare providers should understand the basic concept and the need for guidelines in order to participate effectively in training and any necessary implementation. The CDC’s handbook, Updated In a Moment’s Notice: Surge Capacity in Terrorist Bombings, and other good general resources are available at this website: http://stacks.cdc.gov/view/cdc/5713/ (CDC, 2010).
The ability of the organization to “degrade gracefully” must also be considered. A healthcare organization should have a plan to deal with a reduction in services as the number of patients increases. The goal is to engineer and manage failures and thus to avoid “catastrophic failure” (JCAHO, 2003). During a state of emergency, it may be impossible to follow normal practice guidelines. The Joint Commission recommends that hospitals and oversight agencies “provide for waiver of regulatory requirements under conditions of extreme emergency” (JCAHO, 2003).
Pre-decontamination triage serves three purposes:
Post decontamination triage for medical treatment should occur in the hospital post-decontamination zone after victims are inspected and found to be free of contamination. Some hospitals combine decontamination and initial medical treatment (such as antidotes), which means either the healthcare worker attempts medical triage while wearing PPE (preferred) or the worker is at risk of exposure from victims who have not been adequately decontaminated (OSHA, 2005).
Hospitals must identify spaces that will support decontamination activities (including equipment storage) and ensure that operations can continue in the event that one area of the hospital becomes contaminated. Hospitals planning additions or remodeling projects have a unique opportunity to design spaces appropriately. Other hospitals should use creative planning to identify existing architectural features that they can use to their advantage. Nonambulatory victims can require a substantial proportion of first receivers’ time and efforts, and first receivers are likely to experience the greatest exposure while assisting these victims (OSHA, 2005).
If decontamination is necessary, numerous agencies and organizations recommend a shower time of approximately five minutes for contaminated victims brought to a hospital. Despite the fact that there is no empirical data, operational procedures deem this time to be adequate. Numerous agencies and programs recommend the use of water and a liquid soap with good surfactant properties (such as hand dishwashing detergent) to decontaminate victims during emergencies and for mass casualties involving hazardous substances (OSHA, 2005).
Hospitals can use a variety of methods to limit unauthorized access to the emergency department until the victims have been decontaminated. The methods range from a guard at the locked door to sophisticated keycard systems controlled at a central command center. These more complex systems tend to be associated with urban or recently modernized hospitals and are intended for use in any type of disturbance. Hospitals can use these methods if situations suggest that an unruly crowd will force its way into the hospital (OSHA, 2005).
Site security helps maintain order and control traffic around the decontamination facility and the hospital entrances. Security officers might need to control a contaminated individual to prevent other staff from becoming exposed and to protect equipment. Security officers also ensure contaminated victims do not bypass the decontamination hospital or enter the ED without passing inspection. In cases of civil disturbance, properly identified security officers protect the decontamination facility and staff so normal operations can continue (OSHA, 2005).
Hospitals should select personal protective equipment (PPE) such as respirators, suits, gloves, and face and eye protection based on a hazard assessment that identifies the hazards to which employees might be exposed. Under OSHA’s Personal Protective Equipment Standard, or the parallel State Plan standards, all employers, including hospitals, must certify in writing that the hazard assessment has been performed. For first-receiver PPE, hospitals may base the hazard assessment on OSHA’s Best Practices document. Hospitals likely to respond to incidents involving a specific hazard should adjust the PPE accordingly (OSHA, 2005).
OSHA’s Personal Protective Equipment Standard also requires that employees be provided with equipment that fits appropriately. Some hospitals assign a set of protective equipment to a specific individual, and that equipment is stored in a container marked with the individual’s name. Other hospitals maintain general supplies of PPE, storing sets of equipment by size. In this case, the packages are clearly marked only with the size. Each first receiver tries on equipment in advance to determine what size group fits best so that, during an emergency, the employee can quickly locate an appropriate PPE set (OSHA, 2005).
Personal protective equipment selection for first receivers has been a topic of extensive discussion. At the root of this discussion is the need for hospitals to provide adequate protection for the reasonably anticipated worst-case scenario, despite having limited information regarding the nature of the substance with which victims may be contaminated. This lack of information challenges hospitals’ abilities to conduct the hazard assessments on which PPE selection must be based (OSHA, 2005).
Heightened awareness by infection control (IC) professionals facilitates recognition of the release of a biological agent. Infection control professionals are involved with many aspects of hospital operations and several departments, and with their counterparts in other hospitals. As a result, they may recognize changing patterns or clusters in a hospital or in a community that might otherwise go unrecognized (CDC, 2001).
Infection control professionals should ensure that hospitals have current telephone numbers for notification of both internal and external contacts and that they are distributed to the appropriate personnel. They should work with clinical microbiology laboratories, on- or off-site, that receive specimens for testing from their facility to ensure that cultures from suspicious cases are evaluated appropriately (CDC, 2001).
Wastewater from decontamination showers can contain low-level concentrations of the substance(s) with which victims are contaminated. Given the opportunity to plan for decontamination activities (by designing and installing or purchasing decontamination facilities, developing procedures, and preparing staff), hospitals should consider the management of decontamination shower water as part of their emergency preparedness plan (OSHA, 2005).
The hospital emergency management plan should include procedures for cleaning equipment and surfaces during and after an incident. Cleaning should be performed by employees who are properly protected and trained. Items that cannot be decontaminated safely should be processed for appropriate disposal. It is unlikely that portable gear could be adequately decontaminated after an incident involving a persistent or highly toxic agent (OSHA, 2005).
In the event that an incident of bioterrorism occurs in your community, you should know what to report and to whom the report should be sent. First reporters should start at the healthcare organization or hospital level by reporting to the department supervisor, laboratory, and infection control department. Then contact the local health/regional departments, which will contact your state’s health department and the CDC. Successful reporting of a bioterrorism event results from good planning, education, and awareness, as well as regular standardized testing before an occurrence.
In most cases telephone will still be the primary means for immediate reporting because it is direct, rapid, and easy-to-use. There should always be a backup communication plan (eg, cell phones or other means) in case of a telephone system failure. In every institution standards should be established to ensure a reliable and immediate response to notifiable diseases and health conditions.
Radiation is any form of energy propagated as rays, waves, or energetic particles that travel (radiate) from their source. Radiation can travel through the air or through a material medium (CISAC, n.d.-b,c).
There are five primary types of radiation:
Radiation types vary in their size, charge, ability to travel, and ability to penetrate objects. These variations affect their uses, their current and future effects, what materials effectively shield against them, the parts of the body they can potentially damage, and the exposure restrictions mandated by the government (ORISE, 2013).
Radioactive materials are composed of atoms that are unstable. An unstable atom gives off its excess energy until it becomes stable. The energy emitted is radiation. The process by which an atom changes from an unstable state to a more stable state by emitting radiation is called radioactive decay or radioactivity (CISAC, n.d.-b,c).
Radiation is often divided into ionizing and non-ionizing radiation. Radiation that has enough energy to move atoms in a molecule or cause them to vibrate, but not enough to change them chemically, is referred to as non-ionizing radiation. Examples of this kind of radiation are radio waves and visible light (CISAC, n.d.-b).
Radiation that falls within the ionizing radiation range (alpha and beta particles and gamma rays) has enough energy to break the bonds that tie electrons into the atoms or molecules that make up ordinary substances. This is the type that people usually think of as “radiation” when dealing with nuclear dangers. Ironically, this is also the type of radiation that is used for medical treatment and in many manufacturing processes (CISAC, n.d.-b; ORISE, 2014).
Compared with other types of radiation that may be absorbed, ionizing radiation deposits a large amount of energy into a small area. All ionizing radiation is capable, directly or indirectly, of removing electrons from most molecules. This property of ionizing radiation lies at the root of both its usefulness and its dangers (CISAC, n.d.-c).
Radiation cannot be detected by the human senses. A radiologic survey conducted with specialized equipment is the only way to confirm the presence of radiation. If a terrorist event involves the use of radioactive material, both patient exposure and contamination must be assessed.
Exposure occurs when a person is near a radiation source. People exposed to a source of radiation can suffer radiation illness if the dose is high enough, but they do not become radioactive. For example, an x-ray machine is a source of radiation exposure, yet a person does not become radioactive or pose a risk to others following a chest x-ray (CDC, 2014e).
When scientists measure radiation, they use different terms depending on whether they are discussing radiation coming from a radioactive source, the radiation dose absorbed by a person, or the risk that a person will suffer health effects (biological risk) from exposure.
Most scientists in the international community measure radiation using the Système International d’Unités (SI), a uniform system of weights and measures that evolved from the metric system. In the United States, however, the conventional system of measurement is still widely used.
Different units of measure are chosen depending on what aspect of radiation is being measured. For example, the amount of radiation being given off, or emitted, by a radioactive material is measured using the conventional unit curie (Ci), named for the famed scientist Marie Curie, or the SI unit becquerel (Bq).
The radiation dose absorbed by a person (the amount of energy deposited in human tissue by radiation) is measured using the conventional unit rad or the SI unit gray (Gy). The biologic risk of exposure to radiation (the risk that a person will suffer health effects from an exposure to radiation) is measured using the conventional unit rem or the SI unit sievert (Sv) (CDC, 2014g).
The only non-test deployment of nuclear weapons was the 1945 dropping of the atomic bombs on Hiroshima and Nagasaki, Japan, near the end of World War II. Those at the center of impact were killed immediately by thermal and shock forces as well as intense radiation poisoning. Others at varying distances from the bomb’s center were injured and died later. Still others are alive today, but many of them have suffered from the latent effects of radiation exposure. Patterns of aftereffects are known, as are the patterns of radiation illness and injury that follow closely upon exposure. Understanding these patterns will aid in diagnosis and treatment of radiation-induced injury or illness.
Radioactive contamination and radiation exposure could occur if radioactive materials are released into the environment as the result of an accident, an event in nature, or an act of terrorism. Such a release could expose people and contaminate their surroundings and personal property (CDC, 2014b).
Radiation exposure occurs when all or part of the body absorbs penetrating ionizing radiation from an external radiation source. Exposure from an external source stops when a person leaves the area of the source, the source is shielded completely, or the process causing exposure ceases. During exposure, the body may absorb radiation or it may pass completely through the body. This is similar to what happens during an ordinary chest x-ray. An individual who has been exposed in this way is not radioactive and can be treated like any other patient (ORISE, 2014; CDC, 2014b; REMM, 2013).
Radiation exposure also occurs after internal contamination, ie, when a radionuclide is ingested, inhaled, or absorbed into the blood stream. This kind of exposure stops only if the radionuclide is totally eliminated from the body, with or without treatment (REMM, 2013).
An individual exposed only to an external source of radiation, is NOT radioactive or contaminated and may be approached without risk, just like after a chest x-ray or CT scan (REMM, 2013).
Radiation from external exposure alone is either absorbed without the body becoming radioactive, or it can pass through the body completely. Therefore, if a person is scanned with a radiation survey monitor after external exposure alone, the device will not register radiation above the background level (REMM, 2013).
Contamination results when a radioisotope (as gas, liquid, or solid) is released into the environment and then ingested, inhaled, or deposited on the body surface. External contamination results when radioactive material is deposited on skin, hair, eyes, or other external structures, much like mud or dust. External contamination stops when the material is removed by shedding contaminated clothes and/or completely washing off the contamination (REMM, 2013).
Internal contamination results when radioactive material is taken into the body via inhalation or ingestion or open wounds. Internal deposition of radioisotopes in organs results in local exposure at that location. Internal contamination continues until the radioactive material decays, is flushed from the body by natural processes, or is removed by medical countermeasures (REMM, 2013).
After inhalation, ingestion, or wound contamination, small radioisotope particles may be transported via blood or lymphatics into cells, tissues, and organs. Isotopes can be alpha-, beta-, or gamma-emitting. Radioisotopes can be incorporated into one or more organs specific for that isotope, (eg, thyroid, lungs, kidneys, bones/bone marrow, or liver/spleen) resulting in exposure at that site. Medical countermeasures called decorporation agents or other procedures (eg, diuresis) may be needed to remove radioisotopes that have been incorporated into tissues. Toxic effects of radioisotopes may be due to their chemical and/or radiological properties (REMM, 2013).
After inhalation, ingestion, or wound contamination, small radioisotope particles may be transported via blood or lymphatics into cells, tissues, and organs. Isotopes can be alpha-, beta-, or gamma-emitting. Radioisotopes can be incorporated into one or more organs specific for that isotope, (e.g. thyroid, lungs, kidneys, bones/bone marrow, or liver/spleen) resulting in exposure at that site. Medical countermeasures called decorporation agents or other procedures (e.g., diuresis) may be needed to remove radioisotopes that have been incorporated into tissues. Toxic effects of radioisotopes may be due to their chemical and/or radiological properties (REMM, 2013).
Acute radiation syndrome (ARS)—sometimes known as radiation toxicity or radiation sickness—is an acute illness caused by irradiation of the entire body, or most of the body, by a high dose of penetrating radiation in a very short period of time (usually a matter of minutes) (CDC, 2014c). The most probable terrorist events, such as a dirty bomb attack, will likely generate low levels of radiation exposure. If ARS cases are seen, it is likely that casualty numbers will be small (CDC, 2014e).
Basic symptomatic issues of ARS include:
The required conditions for ARS are:
The three classic ARS syndromes are:
The four stages of ARS are:
Injury to the skin and underlying tissues from acute exposure to a large external dose of radiation is referred to as cutaneous radiation injury (CRI). Acute radiation syndrome (ARS) will usually be accompanied by some skin damage; however, CRI can occur without symptoms of ARS. This is especially true with acute exposures to beta radiation or low-energy x-rays, because beta radiation and low-energy x-rays are less penetrating and less likely to damage internal organs than gamma radiation is. Most cases of CRI have occurred when people inadvertently came in contact with unsecured radiation sources from food irradiators, radiotherapy equipment, or well depth gauges (CDC, 2014a).
Basic symptomatic issues of CRI include:
The Centers for Disease Control and Prevention (CDC) has established general guidelines for managing patients and protecting staff in the event of radiation exposure. These guidelines are specifically designed for small-scale incidents not resulting from a large or nuclear device.
Hospitals and other agencies are also expected to have mass casualty strategies in place, and all appropriate staff should be trained in proper procedures and use of equipment. Many resources are available for establishing triage areas and managing mass casualties (OSHA, 2005).
According to the CDC, addressing contamination issues should not delay treatment of life-threatening injuries. It is highly unlikely that the levels of radioactivity associated with a contaminated patient would pose a significant health risk to care providers. In certain rare instances, the presence of imbedded radioactive fragments or large amounts of external contamination may require expedited decontamination, thus it is recommended to include in-house radiation professionals on the response team (CDC, 2014e). The CDC staff protection guidelines include the following.
Establish an ad hoc triage area:
Use standard precautions to protect staff:
The purpose of protective clothing is to keep bare skin and personal clothing free of external contamination. Paper coveralls, cloth coveralls, and surgical garb are all appropriate protective clothing. Because most people are not used to working in extra layers of clothing they should be monitored for heat stress. “Standard issue particulate protective masks (respirators) afford excellent protection from inhalation and ingestion of most radioactive material” (ORISE, 2013).
PPE in Radiation Emergencies
More detailed information about forms of PPE and their efficacy is available from the Radiation Emergency Medical Management website.
The CDC offers the following guidelines for managing patients who are believed to have been contaminated either externally or internally with radiation. Before beginning treatment, staff should be sure to take care in following their agency’s guidelines for donning protective clothing or equipment.
Survey the patient with a radiation meter:
Remove patient clothing:
Cleanse contaminated areas:
Management of deceased:
Treat vomiting immediately. Repeat CBC analysis with special attention to the lymphocyte count every 2 to 3 hours for the first 8 to 12 hours after exposure (and every 4 to 6 hours for the following 2 to 3 days). Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening, or blistering of the skin. Be sure to include time of onset.
Note and record areas of erythema. If possible, take color photographs of suspected radiation skin damage. Consider tissue and blood typing as well as initiation of viral prophylaxis. Promptly consult with radiation, hematology, and radiotherapy experts about dosimetry, prognosis, and treatment options. Call the Radiation Emergency Assistance Center to record the incident in the Radiation Accident Registry System (see numbers under Resources at the end of this course).
After consultation, begin the following treatment (as indicated):
Consider internal contamination if high survey readings persist following decontamination. Internal contamination generally does not cause early symptoms. Nose or mouth contamination may indicate inhalation or ingestion.
To check for internal contamination:
Treating internal contamination:
Some medical treatments are available for limiting or removing internal contamination depending on the type of radioactive material involved. Medical professionals will determine if any of the following treatments are needed:
In urban areas, hundreds to thousands may seek care. Most will self-refer to the nearest hospital. While many may need decontamination, others may seek radiologic screening even though not contaminated. Many simply seek reassurance. Mental health professionals should always be members of the response team and available in any first-receiver facility to provide such support.
When evaluating patients, healthcare workers need to understand that psychogenic symptoms, such as nausea or vomiting, may manifest. Keep in mind that vomiting due to radiation exposure is usually recurrent rather than episodic.
Have radiation exposure fact sheets available for patients and families and remember that pregnant patients require special counseling. It is likely that separate areas for radiation screening and counseling will be needed for patients with minimal risk of exposure or injury (CDC, 2014e).
CDC’s Health Alert Network (HAN) is CDC’s primary method of sharing cleared information about urgent public health incidents with public information officers; federal, state, territorial, and local public health practitioners; clinicians; and public health laboratories.
CDC’s HAN collaborates with federal, state, territorial, and city/county partners to develop protocols and stakeholder relationships that will ensure a robust interoperable platform for the rapid distribution of public health information (CDC, 2015).
A vast majority of the state-based HAN programs have over 90% of their population covered under the umbrella of HAN. The CDC website provides links to each connected state and local jurisdiction. Check with your state’s HAN program to signup. In addition, persons who wish to sign up to receive HAN Update Alerts from CDC can do so on the CDC website.
CDC HAN messages range from informational updates of general interest to alerts that require immediate action. Examples of the different types of alerts listed below, as well as archives of past alerts, may be found on the CDC Health Alert Network website.
1600 Clifton Road
Atlanta, GA 30329-407
Phone: 800 232 4636 (CDC-INFO)
TTY: 888 232 6348
Emergency Preparedness and Response
Oak Ridge Institute for Science and Education (ORISE)
PO Box 117, MS-39, Oak Ridge, TN 37831
865 576 3131 • 24-hour number 865 576 1005 (ask for REAC/TS)
Radiation Event Medical Management (REMM)
Comprehensive Resource Site for Healthcare Providers
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