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This course fulfills the bioterrorism continuing education requirement for all nurses licensed or seeking licensure in Nevada.
It is not approved and does not fulfill the bioterrorism CE requirement for physicians or physician assistants.
Defines terrorism, bioterrorism, and weapons of mass destruction and summarizes the diseases and agents most commonly used as chemical, biological, radiologic, and nuclear weapons. Outlines CDC recommendations and best practices and discusses the components and use of the Nevada Health Alert Network (HAN).
ATrain Education, Inc. is an approved provider by the American Occupational Therapy Association. The following course information applies to occupational therapy professionals:
Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias.
No commercial support was received for this activity.
This course will be reviewed every two years. It will be updated or discontinued on February 1, 2020.
Criteria for Successful Completions
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.
ATrain Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
ATrain Education, Inc. is approved as a provider by California Board of Registered Nursing (#CEP15099).
ATrain Education, Inc. is approved provider by the Florida Board of Nursing (#50-10593).
ATrain Education, Inc. is approved as a provider of continuing nursing education by the Washington D.C. Board of Nursing.
When you finish this course you will be able to:
What comes to mind when you hear the word terrorism? Bombings, mass casualties, religious or political zealotry, chemical or biological substances, mass shootings, or a particular incident such as September 11, 2001. Perhaps all of the above. Some may think first of perpetrators of terrorist acts while others may think of reasons given for such acts—and, as a healthcare worker, what comes first to your mind is quite likely all the possible results of terrorist actions.
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).
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 a terrorist act, this distinction may not seem especially pertinent.
There is much debate over the motivations for terrorism. Traditionally it has 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 a motivating element. 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 & Potter, 2015; Abrahms, 2008).
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.
While 9/11 and other events have been planned and executed by large and well-known groups only too willing to claim responsibility, some events suggest that acts of domestic terrorism (ones fitting the FBI definition) are sometimes perpetrated by just one or a few individuals acting not as official members of a group, but claiming to be or appearing to be acting to further a known group’s goals. When those perpetrators die in the act and no charges are filed there may be no official label to be had, but they leave behind enough evidence that it doesn’t seem much of a stretch to call them terrorists.
The Patriot Act defines domestic terrorism as an attempt to “intimidate or coerce a civilian population; to influence the policy of a government by intimidation or coercion; or to affect the conduct of a government by mass destruction, assassination, or kidnapping” (Myre, 2017).
Increasingly, events have occurred that many think of and label as terrorism even though they fall entirely into a definitional and legal gray area. Perhaps most familiar are mass shootings, but a few have been bombings or the weaponizing of vehicles. Some of these include Sandy Hook Elementary School in Newtown, CT, the Aurora Colorado movie theater, and the Wisconsin Sikh temple in 2012; the Boston Marathon in 2013; San Bernardino, CA, and the Charleston, SC, church in 2015; the Orlando, FL, nightclub in 2016; and the Sutherland Springs, TX, church in 2017—sadly, only a small handful of the events of the last twenty years.
Wide access to the Internet means that information about these events travels more quickly, is more widely disseminated, and discussion is more animated and highly charged than ever before. Often these events have obvious things in common with events officially labeled as terrorism, but there are some important distinctions.
As Nevadans became acutely aware in October 2017, with the mass shooting outside the Mandalay Bay Resort in Las Vegas, terrifying events can be perpetrated by a single person using no weapons of mass destruction (chemical, biological, or radiological materials) and with intensely personal reasons and no apparent political motivation. Within the law the label of terrorism is impossible.
These events have sparked debate and calls for change but the issues are complex and there is often little consensus. Citizens are often surprised to find there is no domestic terrorism law that defines these terrifying events as terrorism (Axelrod, 2017; CNN, 2017; Gillin et al., 2017; Myers, 2017: Myre, 2017; Stuart, 2013). Interestingly, Nevada is one of a group of states that do have their own anti-terrorism laws (NRS: Chapter 202) but those laws are seldom invoked (Myre, 2017) and with no one to charge, it’s likely a moot point.
However, one can certainly make the argument that the way in which mass shootings (or bombings or vehicular murders) are perpetrated and the effects they have on victims and near-victims make them terrorism in everything but name. The results can be very similar—mass casualties, surge capacity issues, and widespread fear and panic must all be dealt with by healthcare professionals. Their best defense will always be good preparation.
The U.S. government was already actively working to combat terrorist threats before September 11, 2001 and stepped up its efforts afterwards. For the public and for healthcare workers, education about the proper responses to terrorist activities, along with thorough emergency preparedness, is the best available defense.
In 2003 the Nevada legislature passed Assembly Bill 250, which mandates training for nurses and other healthcare professionals to ensure they have a basic knowledge of potential terrorist threats and how to respond to them.
As noted, the effects of terrorist acts are often not only physical; fear may loom large among citizens, not only among those at the actual site of the attack but also among others much farther away. Healthcare workers need to be prepared to address this fear, even in patients who have sustained little or no physical injury. In addition, psychological effects are recognized consequences of certain types of injuries and will be discussed in the sections that follow.
Analysis of these events and responses to them have resulted in a large body of useful information in the form of 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 (DHS), the Department of Health and Human Services (DHHS), and the CDC remain up-to-date and valuable resources for individuals and institutions.
The State of Nevada has recently restructured its health department and redesigned and updated its corresponding websites and resource links. Contact information and links to both state and federal resources appear at the end of this course.
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, 2017).
The possibility that terrorists might resort to the use of WMD is of grave concern. The four 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.
All four types of WMD offer advantages and obstacles to those who would create and use them. Some require a certain level of skill, others require access to controlled or illegal substances, and still others require significant capital outlay and/or the cooperation of people in positions of security or power. Some weapons could produce significant damage and high death tolls, while the greatest effects of others would be widespread panic and expensive cleanup operations.
The Centers for Disease Control and Prevention (CDC) define bioterrorism as:
. . . biological agents (microbes or toxins) used as weapons to further personal or political agendas. Acts of bioterrorism range from a single exposure directed at an individual by another individual to government-sponsored biological warfare resulting in mass casualties. Bioterrorism differs from other methods of terrorism in that the materials needed to make an effective biological agent are readily available, require little specialized knowledge and are inexpensive to produce (CDC, 2017).
According to the CDC:
A chemical emergency occurs when a hazardous chemical has been released and the release has the potential for harming people’s health. Chemical releases can be unintentional, as in the case of an industrial accident, or intentional, as in the case of a terrorist attack (CDC, 2016).
Some chemicals that are hazardous have been developed by military organizations for use in warfare beginning in World War I. Examples are nerve agents such as sarin and VX, mustards such as sulfur mustards and nitrogen mustards, and choking agents such as phosgene. It might be possible for terrorists to get these chemical warfare agents and use them to harm people (CDC, 2016).
Since the world wars, there has been research and stockpiling of chemicals by many countries, but mutual deterrence has generally prevailed. In 1997 the United States ratified the Chemical Weapons Convention Treaty (CWC), agreeing to destroy any remaining stockpiles of chemical warfare agents no later than April 29, 2012 (CDC, 2016a). One hundred ninety-two countries have signed all or elements of the CWC, which not only requires destruction of chemical weapons but prohibits, among other things, developing, producing, acquiring, stockpiling, and transferring of these weapons (NTI, 2017).
One country that has not signed the CWC is Syria, and in 2013 Syrian president Bashar al-Assad did use chemical weapons against Syrian citizens who were rebelling against his autocratic government.
Many hazardous chemicals are used in industry (eg, chlorine, ammonia, and benzene). Others are found in nature (eg, poisonous plants). Some could be made from everyday items such as household cleaners. These types of hazardous chemicals also could be obtained and used to harm people, or they could be accidentally released (CDC, 2016).
The techniques for making destructive chemical weapons are well understood and the necessary equipment is commonly available. Once made, these 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 17 people and sending 5,500 to the hospital. These incidents made it clear that even small groups could manage the manufacture and dispersal of deadly chemical weapons (NTI, 2015b,e).
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,e).
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—how effectively it kills; its infectivity—how easily it spreads; and its virulence—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 the compound’s stability (NTI, 2015a,e).
Chemical and biological weapons are financially and logistically easier to acquire than are 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 like Radiation Exposure Devices (REDs) and Radiologic 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 (INDs) and small nuclear weapons would result in mass casualties (ORISE, 2017; Waselenko et al., 2004; CISAC, 2002).
Radiologic Dispersal Devices (RDD)—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, 2002; NTI, 2015c,d,e; ORISE, 2017).
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 devices, and transport them (Weiss, 2015). However, the potential for damage, injuries, and death is much higher because they are significantly more powerful weapons.
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 (eg, 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, cases since then involving intentional or inadvertent contamination of food with chemicals 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
Generalized muscle rigidity
Seizure-like, generalized muscle contractions or painful spasms (neck and limbs) and, usually, tachycardia and hypertension
Oropharyngeal pain and ulcerations
Lip, mouth, and pharyngeal ulcerations and burning pain
Peripheral neuropathy and/or neurocognitive effects
Severe gastrointestinal illness, dehydration
Abdominal pain, vomiting, profuse diarrhea (possibly bloody), and hypotension, possibly followed by multisystem organ failure
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 (PPE) needed when treating victims. While PPE 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:
Hematologic 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, they 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 et al., 2004). (See also the CDC resource website at: http://emergency.cdc.gov/bioterrorism/surveillance.asp.)
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
Source: CDC, 2001.
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, 2017a).
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:
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 they:
Agents include emerging infectious diseases such as Nipah virus and hantavirus (CDC, 2017a).
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 people 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 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.
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, inhalation or respiratory tract, gastrointestinal, and injection (has occurred in northern Europe but has never been reported in the United States) (CDC, 2017b).
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, 2014a).
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 deadliest 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, 2014b).
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, 2014c).
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, 2014d).
Injection anthrax symptoms can include:
Botulism is a neuroparalytic illness characterized by symmetric, descending flaccid paralysis of motor and autonomic nerves, always beginning with the cranial nerves.
Signs and symptoms in an adult may include:
Signs and symptoms in foodborne illness may also include:
Signs and symptoms in an infant may include:
If untreated, illness might progress to cause descending paralysis of respiratory muscles, arms, and legs (CDC, 2017c).
Botulism Case Consultation
If you suspect your patient may have botulism, call your state public health department immediately. If there is no answer, contact CDC 24/7 at 770 488 7100.
If clinical consultation with state public health departments and CDC supports botulism, request antitoxin immediately and begin treatment as soon as it is available. Do not wait for laboratory confirmation.
Source: CDC, 2017c.
Botulism is caused by a potent neurotoxin produced from Clostridium botulinum, and rare strains of C. butyricum and C. baratii, which are anaerobic, spore-forming bacteria.
Transmission differs by type of botulism:
Foodborne botulism occurs when a person ingests botulinum toxin, which leads to illness within a few hours to days. Outbreaks of foodborne botulism have potential to be a public health emergency because the contaminated food may be eaten by other people. A frequent source is home-canned foods prepared in an unsafe manner.
Infant botulism occurs each year in a small number of susceptible infants who harbor C. botulinum in their intestinal tract. It occurs when an infant ingests spores of C. botulinum, which in turn colonize the intestinal tract and produce toxin.
Wound botulism is a rare disease that occurs when wounds infected with C. botulinum secrete the toxin. It occurs more frequently among persons who inject drugs, but has also been seen in cases of traumatic injury, such as motorcycle crashes, and surgeries.
Adult intestinal colonization (also called adult intestinal toxemia) is an even rarer type of botulism. It involves intestinal colonization in a person older than one year of age. In the small number of these cases, most patients had a history of gastrointestinal surgery or illness, such as inflammatory bowel disease, which might have predisposed them to enteric colonization. No other specific risk factors have been identified.
Iatrogenic botulism occurs after an overdose of injected botulinum toxin for cosmetic or medical purposes (CDC, 2017c).
Botulism differs from other flaccid paralyses in that it always manifests initially with prominent cranial nerve palsies. It also differs in its invariable descending progression, in its symmetry, and in its absence of sensory nerve dysfunction.
Botulism is frequently misdiagnosed, most often as a polyradiculoneuropathy (Guillain-Barré or Miller-Fisher syndrome), myasthenia gravis, or other diseases of the central nervous system.
Clinical diagnosis of botulism is confirmed by specialized laboratory testing that often requires days to complete. Routine laboratory test results are usually unremarkable (CDC, 2017c).
Initial diagnosis is based on clinical symptoms. Do not wait for laboratory confirmation to begin treatment.
Laboratory confirmation is done by demonstrating the presence of botulinum toxin in serum, stool, or food, or by culturing C. botulinum, C. butyricum, or C. baratii from stool, a wound, or food.
Other tests and laboratory studies to help with clinical diagnosis include:
Administer botulinum antitoxin or BabyBIG as soon as possible. Antitoxin does not reverse paralysis but arrests its progression. Recovery follows the regeneration of new neuromuscular connections.
Exercise meticulous intensive care, including monitoring of respiratory function and, when required, mechanical ventilation. In more severe cases, ventilator support may be required for weeks to months.
Treatment for wound botulism may also include wound debridement to remove the source of toxin‑producing bacteria and antibiotic therapy (CDC, 2017c).
Medical personnel caring for patients with suspected botulism should use standard precautions. Botulism is not transmitted person-to-person.
Patients with botulism do not need to be isolated (CDC, 2017c).
Death can result from respiratory failure or the consequences of extended paralysis. About 5% of patients die. Recovery takes weeks to months. Those who survive may have fatigue and shortness of breath for years (CDC, 2017c).
In 2015 there were 199 cases of laboratory-confirmed botulism reported to the CDC. Of these, 39 were foodborne, 141 were infant botulism, 15 were cases of wound botulism, and 4 cases were of unknown etiology (CDC, 2017c).
Plague is a disease caused by Yersinia pestis (Y. pestis), a bacterium found in rodents and their fleas in many areas around the world (CDC, 2015d).
Bubonic plague is the most common primary manifestation, with a bubo usually occurring in the groin, axilla, or cervical nodes. Buboes are often so painful that patients are generally guarded and have restricted movement in the affected region. The incubation period for bubonic plague is usually 2 to 6 days.
If bubonic plague is untreated, plague bacteria invade the bloodstream and spread rapidly, causing septicemic plague, and if the lungs are seeded, secondary pneumonic plague. Septicemic and pneumonic plague may also be primary manifestations. A person with pneumonic plague may experience high fever, chills, cough, and breathing difficulty and may expel bloody sputum. If pneumonic plague patients are not given specific antibiotic therapy, the disease can progress rapidly to death.
Although the majority of patients with plague present with a bubo, some may have nonspecific symptoms. For example, septicemic plague can present with prominent gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain. Additional rare forms of plague include pharyngeal, meningeal, and cutaneous.
Appropriate diagnostic samples include blood cultures, lymph node aspirates if possible, and/or sputum, if indicated. Drug therapy should begin as soon as possible after the laboratory specimens are taken. If plague is suspected, local and state health departments should be notified immediately. If patients have pneumonic signs, they should also be isolated and placed on droplet precautions (CDC, 2015a).
Pneumonic plague can be transmitted from person to person; bubonic plague cannot. Pneumonic plague affects the lungs and is transmitted when a person breathes in Y. pestis particles. Bubonic plague is transmitted through the bite of an infected flea or exposure to infected material through a break in the skin (CDC, 2015d).
Plague symptoms depend on how the patient was exposed to the plague bacteria.
Bubonic: Sudden onset of fever, headache, chills, and weakness and one or more swollen, tender, and painful lymph nodes (called buboes). This usually results from the bite of an infected flea.
Septicemic: Fever, chills, extreme weakness, abdominal pain, shock, and possibly bleeding into the skin and other organs. This usually results from bites of infected fleas or from handling an infected animal.
Pneumonic: Fever, headache, weakness, and a rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery mucous. Nausea, vomiting, and abdominal pain may also occur. May develop from inhaling infectious droplets or from untreated bubonic or septicemic plague that spreads to the lungs (CDC, 2015a,b,c,d).
Yersinia pestis used in an aerosol attack could cause cases of the pneumonic form of plague. One to six days after becoming infected with the bacteria, people would develop pneumonic plague. Once people have the disease, the bacteria can spread to others who have close contact with them. Because of the delay between being exposed to the bacteria and becoming sick, people could travel over a large area before becoming contagious and possibly infecting others. Controlling the disease would then be more difficult. A bioweapon carrying Y. pestis is possible because the bacterium occurs in nature and could be isolated and grown in quantity in a laboratory. Even so, manufacturing an effective weapon using Y. pestis would require advanced knowledge and technology (CDC, 2015d).
National and state public health officials have large supplies of drugs needed in the event of a bioterrorism attack. These supplies can be sent anywhere in the United States within 12 hours (CDC, 2015d).
Thousands of years ago, variola virus (smallpox virus) emerged and began causing illness and deaths in human populations, with smallpox outbreaks occurring from time to time. Thanks to the success of vaccination, the last natural outbreak of smallpox in the United States occurred in 1949. In 1980 the World Health Assembly declared smallpox eradicated (eliminated), and no cases of naturally occurring smallpox have happened since.
Smallpox research in the United States continues and focuses on the development of vaccines, drugs, and diagnostic tests to protect people against smallpox in the event that it is used as an agent of bioterrorism (CDC, 2016c).
Before smallpox was eradicated, it was a serious infectious disease caused by the variola virus. It was contagious—meaning, it spread from one person to another. People who had smallpox had a fever and a distinctive, progressive skin rash.
Most people with smallpox recovered, but about 3 out of every 10 people with the disease died. Many smallpox survivors have permanent scars over large areas of their body, especially their faces. Some are left blind (CDC, 2016c).
Before smallpox was eradicated, it was mainly spread by direct and fairly prolonged face-to-face contact between people. Smallpox patients became contagious once the first sores appeared in their mouth and throat (early rash stage). They spread the virus when they coughed or sneezed and droplets from their nose or mouth spread to other people. They remained contagious until their last smallpox scab fell off.
These scabs and the fluid found in the patient’s sores also contained the variola virus. The virus can spread through these materials or through the objects contaminated by them, such as bedding or clothing. People who cared for smallpox patients and washed their bedding or clothing had to wear gloves and take care to not get infected.
Rarely, smallpox has spread through the air in enclosed settings, such as a building (airborne route).
Smallpox can be spread by humans only. Scientists have no evidence that smallpox can be spread by insects or animals (CDC, 2016c).
A person with smallpox goes through several stages as the disease progresses. Each stage has its own signs and symptoms.
There is no proven treatment for smallpox disease, but some antiviral drugs may help treat it or prevent it from getting worse. There also is a vaccine to protect people from smallpox. If there were a smallpox outbreak, health officials would use the smallpox vaccine to control it (CDC, 2016c).
Most likely, if smallpox is released into the United States as a bioterrorist attack, public health authorities will learn of it when the first afflicted person goes to a hospital for treatment of an unknown illness. Physicians will examine the person using tools developed by CDC to decide if signs and symptoms are similar to those of smallpox. If they suspect the person has smallpox, they will isolate and care for the person in the hospital so that others do not come in contact with the smallpox virus. The hospital will contact local public health authorities that they have a patient who might have smallpox.
Local public health authorities would then alert public health officials at the state and federal level to help diagnose the disease. If experts confirm the illness is smallpox, then CDC, along with state and local public health authorities, will put into place their plans to respond to a bioterrorist attack with smallpox (CDC, 2016c).
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, is available here: 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 of an incident of bioterrorism 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 the Nevada State Health Division 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.
Nevada Division of Public and Behavioral Health (DPBH)
Main: 775 684 4200
Public Health Emergency: 775 684 5920
Infectious disease reporting: 775 684 5911
Washoe County: 775 328 2447 (24 hr)
Southern Nevada: 702 759 1300, option #2 (24 hr)
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, 2002).
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, 2017).
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, 2002).
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, 2002).
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, 2002; ORISE, 2015).
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, 2002).
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, 2014g).
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, 2014i).
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, 2014f).
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, 2015; CDC, 2014f; REMM, 2016).
Radiation exposure also occurs after internal contamination, ie, when a radioactive material is ingested, inhaled, or absorbed into the bloodstream. This kind of exposure stops only if the radionuclide is eliminated from the body, with or without treatment (REMM, 2016).
An individual exposed only to an external source of radiation, is NOT radioactive or contaminated and may be approached without risk, just as is the case following a chest x-ray or CT scan (REMM, 2016).
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, 2016).
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, 2016a).
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, 2016a).
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, 2016b).
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, 2017e). 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, 2014g).
Basic symptomatic issues of ARS include:
The required conditions for ARS are:
The three classic ARS syndromes are:
The four stages of ARS are:
The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the complex pathological syndrome that results from acute radiation exposure to the skin.
ARS usually will be accompanied by some skin damage. It is also possible to receive a damaging dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or X-rays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes.
When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or moist desquamation can occur. Also, hair follicles may be damaged, causing epilation. Within a few hours after irradiation, a transient and inconsistent erythema (associated with itching) can occur. Then, a latent phase may occur and last from a few days up to several weeks, when intense reddening, blistering, and ulceration of the irradiated site are visible.
In most cases, healing occurs by regenerative means; however, very large skin doses can cause permanent hair loss, damaged sebaceous and sweat glands, atrophy, fibrosis, decreased or increased skin pigmentation, and ulceration or necrosis of the exposed tissue (CDC, 2017e).
The 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, 2014g). 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, 2017).
PPE in Radiation Emergencies
More detailed information about forms of PPE and their efficacy is available from the Radiation Emergency Medical Management website: http://www.remm.nlm.gov/radiation_ppe.htm.
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, and 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, n.d.).
The Health Alert Network (HAN) is a nationwide communications system established by the CDC and implemented by each state. The Nevada HAN provides a 24/7 means of two-way communication for all critical health information among the Nevada Division of Public and Behavioral Health and local and rural healthcare professionals. These professionals include physicians, nurses, hospitals, laboratories, clinicians, public health workers, emergency management, and others (SNHD, 2017).
The Nevada Health Alert Network (NVHAN) is administered by the Division of Public and Behavioral Health (DPBH), Public Health Preparedness Program (PHP). NVHAN is a statewide, bed tracking, availability and alerting system in place throughout the state.
Its digital, high-speed notification system is used to rapidly contact hospitals and healthcare facilities; or thousands of staff with extreme speed and accuracy.
NVHAN is composed of three systems:
Healthcare professionals interested in signing up for NVHAN should visit the Nevada Health Alert Network (NVHAN) website and follow the link to sign up, or for more information contact the administrator at 775 684 3242 (DPBH, 2015).
Healthcare professionals in southern Nevada can also get information from the Southern Nevada Health District HAN Coordinator at 702 759 1299 or sign up at the district’s website (SNHD, 2017).
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.
Health Alert: provides vital, time-sensitive information for a specific incident or situation; warrants immediate action or attention by health officials, laboratorians, clinicians, and members of the public; and conveys the highest level of importance.
Health Advisory: provides important information for a specific incident or situation; contains recommendations or actionable items to be performed by public health officials, laboratorians, and/or clinicians; may not require immediate action.
Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action.
Info Service: provides general public health information; unlikely to require immediate action. (CDC, 2017d)
Nevada Department of Health and Human Services
Division of Public and Behavioral Health (DPBH)
4150 Technology Way
Carson City, NV 89706
775 684 4200
Public Health Preparedness (PHP): 775 684 5948
Public health emergency reporting: 775 684 5920
Southern Nevada Health District Main Facility
280 S. Decatur Blvd.
Las Vegas, NV 89107
702 759 1000
702 759 1671 (Emergency Preparedness Office)
Nevada Department of Business and Industry
Division of Industrial Relations
Occupational Safety and Health Administration (OSHA)
Nevada Department of Public Safety
Division of Emergency Management – Homeland Security
2478 Fairview Drive
Carson City, NV 89701
775 687 0300 (non-emergency calls)
775 687 0400 (emergency calls)
Centers for Disease Control and Prevention (CDC)
1600 Clifton Road
Atlanta, GA 30329
800 232 4636 (800 CDC INFO)
888 232 6348 (TTY)
Emergency Preparedness and Response
Radiation Emergency Assistance Center/Training Site (REAC/TS)
Oak Ridge Institute for Science and Education (ORISE)
PO Box 117, MS-39, Oak Ridge, TN 37831
865 576 3131
865 576 1005 (24-hour emergency # - ask for REAC/TS)
U.S. Department of Health and Human Services (HHS)
Radiation Emergency Medical Management (REMM)
U.S. Department of Homeland Security (DHS)
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Axelrod J. (2017). Why is there no criminal statute for domestic terrorism? CBS News. October 6, 2017. Retrieved December 4, 2017 from https://www.cbsnews.com/news/las-vegas-shooting-domestic-terrorism-not-clear/.
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Centers for Disease Control and Prevention (CDC). (2017). Bioterrorism. What’s the Problem? Gateway to Health Communication and Social Marketing Practice. Retrieved December 2, 2017 from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/bioterrorism.html.
Centers for Disease Control and Prevention (CDC). (2017a). Bioterrorism Agents/Diseases. Retrieved December 3, 2017 from https://emergency.cdc.gov/agent/agentlist-category.asp.
Centers for Disease Control and Prevention (CDC). (2017b). Anthrax. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/index.html.
Centers for Disease Control and Prevention (CDC). (2017c). Information for Health Professionals. Botulism. Retrieved December 3, 2017 from https://www.cdc.gov/botulism/health-professional.html.
Centers for Disease Control and Prevention (CDC). (2017d). Health Alert Network (HAN). Resources for Emergency Health Professionals, Emergency Preparedness and Response. Retrieved November 25, 2017 from http://emergency.cdc.gov/HAN/.
Centers for Disease Control and Prevention (CDC). (2017e) Acute Radiation Syndrome: A Fact Sheet for Physicians. Retrieved December 4, 2017 from http://emergency.cdc.gov/radiation/arsphysicianfactsheet.asp.
Centers for Disease Control and Prevention (CDC). (2016). Chemical Emergencies Overview. Emergency Preparedness and Response, Specific Hazards. Retrieved December 1, 2017 from https://emergency.cdc.gov/chemical/overview.asp.
Centers for Disease Control and Prevention (CDC). (2016a). Overview of U.S. Chemical Weapons Elimination. Retrieved December 3, 2017 from https://www.cdc.gov/nceh/demil/overview.htm.
Centers for Disease Control and Prevention (CDC). (2016b). Specific Hazards. Chemical Emergencies. Chemical Categories. Retrieved December 3, 2017 from https://emergency.cdc.gov/agent/agentlistchem-category.asp.
Centers for Disease Control and Prevention (CDC). (2016c). Smallpox. Retrieved December 4, 2017 from https://www.cdc.gov/smallpox/index.html.
Centers for Disease Control and Prevention (CDC). (2016d). Radiation Emergencies. Medical Management: Countermeasures. Retrieved December 4, 2017 from http://emergency.cdc.gov/radiation/countermeasures.asp.
Centers for Disease Control and Prevention (CDC). (2015). Human plague—United States, 2015. Morbidity and Mortality Weekly Report (MMWR). 64(33);918–19. Retrieved December 3, 2017 from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6433a6.htm?s_cid=mm6433a6_w.
Centers for Disease Control and Prevention (CDC). (2015a). Resources for Clinicians. Plague. Retrieved December 4, 2017 from https://www.cdc.gov/plague/healthcare/clinicians.html.
Centers for Disease Control and Prevention (CDC). (2015b). Human Plague: Transmission from person to person. Retrieved December 4, 2017 from https://www.cdc.gov/plague/resources/Plague_Facts.pdf.
Centers for Disease Control and Prevention (CDC). (2015c). Symptoms. Plague. Retrieved December 4, 2017 from https://www.cdc.gov/plague/symptoms/index.html.
Centers for Disease Control and Prevention (CDC). (2015d). Frequently Asked Questions (FAQ) About Plague / Specific Hazards. Bioterrorism. Plague. Retrieved December 3, 2017 from https://emergency.cdc.gov/agent/plague/faq.asp.
Centers for Disease Control and Prevention (CDC). (2014). Anthrax: Bioterrorism—The Threat. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/bioterrorism/threat.html.
Centers for Disease Control and Prevention (CDC). (2014a). Cutaneous Anthrax. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/basics/types/cutaneous.html.
Centers for Disease Control and Prevention (CDC). (2014b). Inhalation Anthrax. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/basics/types/inhalation.html.
Centers for Disease Control and Prevention (CDC). (2014c). Gastrointestinal Anthrax. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/basics/types/gastrointestinal.html.
Centers for Disease Control and Prevention (CDC). (2014d). Anthrax. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/basics/types/injection.html.
Centers for Disease Control and Prevention (CDC). (2014e). Symptoms. Basic Information, Anthrax. Retrieved December 3, 2017 from https://www.cdc.gov/anthrax/basics/symptoms.html.
Centers for Disease Control and Prevention (CDC). (2014f). Radiation Emergencies: Radioactive Contamination and Radiation Exposure. Retrieved December 4, 2017 from http://emergency.cdc.gov/radiation/contamination.asp.
Centers for Disease Control and Prevention (CDC). (2014g). Transcript: Just In Time Radiation Training Video for Hospital Clinicians. Retrieved December 4, 2017 from https://emergency.cdc.gov/radiation/jittranscript.asp.
Centers for Disease Control and Prevention (CDC). (2014h). Radiation Emergencies: Radiation Dictionary. Retrieved December 4, 2017 from http://emergency.cdc.gov/radiation/glossary.asp.
Centers for Disease Control and Prevention (CDC). (2014i). Radiation Measurement Fact Sheet. Retrieved December 4, 2017 from http://emergency.cdc.gov/radiation/measurement.asp.
Centers for Disease Control (CDC). (2013ca). Chemical Emergencies. Vesicant/Blister Agent Poisoning Toxic Syndrome Description. Retrieved December 3, 2017 from http://emergency.cdc.gov/agent/vesicants/tsd.asp.
Centers for Disease Control (CDC). (2013cb). Chemical Emergencies. Toxic Syndrome Description: Nerve Agent and Organophosphate Pesticide Poisoning. Retrieved December 3, 2017 from http://emergency.cdc.gov/agent/nerve/tsd.asp.
Centers for Disease Control and Prevention (CDC). (2012). Public health surveillance in the United States: Evolution and challenges. Morbidity and Mortality Weekly Report (MMWR) Supplement. 61(03):3–9. Retrieved December 3, 2017 from http://www.cdc.gov/mmwr/preview/mmwrhtml/
Centers for Disease Control and Prevention (CDC). (2010). Updated in a moment’s notice: Surge capacity in terrorist bombings. Retrieved December 4, 2017 from http://stacks.cdc.gov/view/cdc/5713/.
Centers for Disease Control and Prevention (CDC). (2008). Public Health Preparedness: Mobilizing State by State. Retrieved June 28, 2015 from http://www.cdc.gov/phpr/publications/2008/report_2008.pdf.
Centers for Disease Control (CDC). (2004b). Syndromic surveillance: Reports from a national conference, 2003. Morbidity and Mortality Weekly Report (MMWR) Supplement. 53(Suppl). Retrieved December 3, 2017 from http://www.cdc.gov/mmwr/PDF/wk/mm53SU01.pdf. See especially pp. 7–10, What Is Syndromic Surveillance? by Kelly J. Henning.
Centers for Disease Control and Prevention (CDC). (2003). Recognition of illness associated with exposure to chemical agents—United States, 2003. Morbidity and Mortality Weekly Report (MMWR) 52(39): 938–40. Retrieved December 3, 2017 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5239a3.htm.
Centers for Disease Control and Prevention (CDC). (2001). Recognition of illness associated with the intentional release of a biological agent. Morbidity and Mortality Weekly Report (MMWR) 50(41):893–97. Retrieved December 3, 2017 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a2.htm.
Centers for Disease Control and Prevention (CDC). (2001a). Epidemiologic clues that may signal a covert bioterrorism attack. The public health response to biological and chemical terrorism: Interim planning guidance for state public health officials. USDHHS/CDC, July 2001. Page 17. Retrieved December 3, 2017 from https://emergency.cdc.gov/documents/planning/planningguidance.pdf.
Centers for Disease Control and Prevention (CDC). (2000). Biological and chemical terrorism: Strategic plan for preparedness and response recommendations of the CDC Strategic Planning Workgroup. Morbidity and Mortality Weekly Report (MMWR). Recommendations and Reports. 49(RR-4):1–26. Retrieved December 3, 2017 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4904a1.htm.
Centers for Disease Control and Prevention (CDC). (n.d.). Radiological Emergencies: Emergency Management Pocket Guide For Clinicians. Retrieved December 4, 2017 from https://emergency.cdc.gov/radiation/pdf/clinicianpocketguide.pdf.
Dembek ZF, Cochrane DG, Pavlin JA. (2004, July). Syndromic surveillance [letter]. Emerg Infect Dis. dx.doi.org/10.3201/eid1007.031035. Retrieved December 3, 2017 from http://wwwnc.cdc.gov/eid/article/10/7/031035_article.htm#r11.
Department of Defense (DOD). (2017). Department of Defense Dictionary of Military and Associated Terms (Joint Publication 1-02). August 2017. Retrieved December 2, 2017 from http://www.dtic.mil/doctrine/new_pubs/dictionary.pdf.
Gillin J, et al. (2017). The facts on mass shootings in the United States. PolitiFact. November 8, 2017. Retrieved December 2, 2017 from http://www.politifact.com/truth-o-meter/article/2017/nov/08/facts-mass-shootings-united-states/.
Hendricks KA, et al. (2014). Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis. [Internet]. 2014 Feb. Retrieved December 3, 2017 at http://dx.doi.org/10.3201/eid2002.130687.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2003). Health care at the crossroads: Strategies for creating and sustaining community-wide emergency preparedness systems. Retrieved December 4, 2017 from http://www.jointcommission.org/assets/1/18/emergency_preparedness.pdf.
Kelen GD. (2008). Science of Surge Medical Response Capability. Retrieved June 28, 2015 from http://www.orau.gov/DHSSummit/2008/presentations/Mar19/Kelen.pdf.
Myers D. (2017). Hitting home: Nevadans grapple with the legacy of mass murder. Reno News & Review. October 19, 2017. Pp. 11–13.
Myre G. (2017). What Is, And Isn’t Considered Domestic Terrorism? All Things Considered. NPR. October 2, 2017. Retrieved December 2, 2017 from https://www.npr.org/2017/10/02/555170250/what-is-and-isnt-considered-domestic-terrorism.
Nevada Department of Health and Human Services. Division of Public and Behavioral Health (DPBH). (2015). Public Health Preparedness Program. Health Alert Network website. Retrieved November 24, 2017 from http://dpbh.nv.gov/Programs/NVHAN/NVHAN_-_Home/.
Nuclear Threat Initiative (NTI). (2017). Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on Their Destruction (CWC). Retrieved December 3, 2017 from http://www.nti.org/learn/treaties-and-regimes/convention-prohibition-development-production-stockpiling-and-use-chemical-weapons-and-their-destruction-cwc/.
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Nuclear Threat Initiative (NTI). (2015c). The Radiological Threat. Retrieved December 3, 2017 at http://www.nti.org/learn/radiological/.
Nuclear Threat Initiative (NTI). (2015d). The Nuclear Threat. Retrieved December 3, 2017 at http://www.nti.org/learn/nuclear/.
Nuclear Threat Initiative (NTI). (2015e). NTI Education Tutorials. Table of Contents. Retrieved December 1, 2017 from http://tutorials.nti.org/table-of-contents/. All relevant tutorials are accessed from this page.
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from Mass Casualty Incidents Involving the Release of Hazardous Substances. Retrieved January 15, 2018 from https://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html.
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Stuart H. (2013). Boston “Terrorism”: Was the marathon bombing an “act of terror”? Huffington Post, Politics. April 16, 2013. Retrieved December 4, 2017 from https://www.huffingtonpost.com/2013/04/16/boston-terrorism-marathon-bombing_n_3092734.html.
U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). (2005). OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. Retrieved December 3, 2017 from http://www.osha.gov/dts/
osta/bestpractices/html/hospital_firstreceivers.html# OR https://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf.
Waselenko J, MacVittie T, Blakely W, et al. (2004). Medical management of the acute radiation syndrome: Recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med 140:1037–51. Retrieved November 30, 2017 from http://annals.org/data/Journals/AIM/20067/
Weiss, L. (2015). On fear and nuclear terrorism. Abstract. Bulletin of the Atomic Scientists 71(2):75–87.
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