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Neutropenia: Viral and Fungal Infections Antifungal coverage with amphotericin B is indicated for certain situations, including: • Clinical evidence of infection in patients who remain persistently febrile for 7 days or more on antimicrobial therapy. • A new instance of fever on or after day 7 of antimicrobial therapy. Oral and pharyngeal mucositis and esophagitis suggest Herpes simplex infection or candidiasis. Either empirical antiviral therapy, antifungal therapy, or both, should be considered in this situation. Neutropenia: Prophylactic Antimicrobials Prophylactic antimicrobials should also be considered in any individuals exposed to doses >2 Gy, when the absolute neutrophil count is
to pursue stem cell transplantation will need to be carefully considered for a narrow subset of patients with exposures between 8 and 10 Gy and no other significant comorbidity. The limitations of stem cell transplantation include potential complications (e.g., graft-versus-host disease), potential for morbidity associated with other organ toxicity, and a limited pool of suitable donors. In the rare instance in which a syngeneic donor (i.e., a twin sibling) or previously harvested stem cells are available, stem cell transplantation may be considered for those with exposures of 4–10 Gy. This recommendation applies to both adults and children. Medical Treatment: Internal Contamination External decontamination should be performed before treatment of internal contamination, which depends on the chemical nature of the radioisotope, its physical quantity, and the nature of radioactivity. A risk/benefit decision must be made. For small amounts of radioactive material or those with a short half-life, treatment may be unnecessary. Medical providers need to consult health physicists or medical physicists for information about the nature and amount of internal contamination. The National Council on Radiation Protection and Measurements Report No. 65 Management of Persons Accidentally Contaminated with Radionuclides is a valuable reference. Treatment of internal contamination reduces the absorbed radiation dose and the risk of future biological effects. Administration of diluting and blocking agents enhances elimination rates of radionuclides. Treatment with mobilizing or chelating agents should be initiated as soon as practical when the probable exposure is judged to be significant. Gastric lavage and emetics can be used to empty the stomach promptly and completely after the ingestion of poisonous materials. Purgatives, laxatives, and enemas can reduce the time that radioactive materials are present in the colon. Radioactive Iodine: Potassium Iodide Thyroid uptake of radioactive iodine can be reduced if potassium iodide (KI) is taken before or shortly after exposure. The main exposure routes for radioiodine are through inhalation and through ingestion of contaminated food, milk, or water. In 1986 during the Chernobyl nuclear reactor disaster, large populations in the proximity of Chernobyl— most notably in Belarus, northern Ukraine, and the Russian Federation—were not initially aware of the danger and were not evacuated, sheltered, or treated with KI. Since 1990, the incidence of thyroid cancer in children has increased significantly. To date, the largest public health action involving the use of KI involved the distribution of 18 million doses to children and adults in Poland after the Chernobyl accident. KI was distributed to 90% of the children younger than 16 years and to about 25% of the adults in Poland from the 4 th day to the 7 th day after the beginning of the release of radioactivity from the Chernobyl power plant. Although no significant increase in thyroid cancer has been noted in KI-treated populations in Poland, there are several factors that may have contributed to this difference. The dose of radioactive iodine to the Polish population may have been less than that to the population closer to Chernobyl. Also, the children in the Chernobyl area may have been more iodine-deficient than the children in Poland and therefore more susceptible to uptake of the radioactive iodine from Chernobyl. 188
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Bioterrorism and Other Public Healt
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Contents Chapter 1. Introduction ..
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Q Fever............................
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Basic Principles...................
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Chapter 9. Integrating Terrorism an
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Table 5.4 Nerve agent triage and do
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There are many gaps in knowledge, e
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injured or killed (see also Chapter
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Head injury is common in children.
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In situations of disaster, caregive
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maintaining and securing the airway
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• Schonfeld DJ. In times of crisi
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Types of Disasters Chapter 2. Syste
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problems noted above for flooding,
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Federal Response The United States
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The scope of ESF #8 is broad and in
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• Centers for Disease Control and
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Table 2.1 Types of disasters, hazar
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Medical staffs need to know what wi
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information, health and safety educ
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y private physicians. Approximately
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even required (particularly if a pe
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ICS structure is hierarchical. For
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• Provide community education so
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• Provide for crisis counseling.
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incident command officer is most of
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Figure 3.1 National Response Plan D
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Background History of Bioterrorism
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Epidemiology of a Terrorist Attack
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and may be watery, purulent, or blo
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fluid in these vesicles. A painless
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determined to be due to an agent of
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cared for using standard precaution
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may be providing longer term and mo
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The vaccine has a number of common
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Vaccination Large-scale vaccination
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cutaneous lesions; however, previou
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common food source is identified du
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treated people experience some degr
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treatment for plague meningitis. An
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Smallpox is spread most commonly in
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focal, intensely suppurative necros
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Control measures. Some viruses that
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Control measures. Person-to-person
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Signs and symptoms. The incubation
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currently used for individuals trav
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Accessed July 12, 2006. • Centers
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• Roffey R, Tegnell A, Elg HF. Bi
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Figure 4.2. Neurological signs, bot
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Figure 4.4. Physical distribution o
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Figure 4.6. Varicella lesions Note:
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Figure 4.8a. Febrile rash illness a
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Table 4.1. Early clinical signs and
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Table 4.2. Infection control transm
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Table 4.3. Diagnostic procedures, i
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Table 4.4a. Diagnostic tests for an
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Table 4.6. Treatment recommendation
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Introduction Chapter 5. Chemical Te
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likely manifest as an acute onset o
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exposures (Table 5.3). For an in-de
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Neuromuscular effects. At the neuro
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children. Finally, routine administ
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Treatment Management of cyanide poi
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Sulfur mustard is stockpiled both i
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decontamination is therefore extrem
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Pulmonary Agents Toxic industrial c
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Type I agents, the significance of
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After dispersal of riot control age
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• Kales SN, Christiani DC. Acute
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• Gray EA, Love JW, Arnold JL. CB
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Table 5.2. Chemical weapons - Summa
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Table 5.3 Representative classes of
Page 148 and 149: Table 5.4. Nerve agent triage and d
Page 150 and 151: Table 5.5. Clinical effects from su
Page 152 and 153: Table 5.7. Medical treatment of rio
Page 154 and 155: Chapter 6. Radiological and Nuclear
Page 156 and 157: from ground zero. For weapons large
Page 158 and 159: (1000 rem), resulting in four fatal
Page 160 and 161: cooling systems at Mayak exploded,
Page 162 and 163: pediatric practices. This put infan
Page 164 and 165: energy, releasing two photons of ex
Page 166 and 167: need to be shielded, although the a
Page 168 and 169: adioactive isotope of potassium. Ba
Page 170 and 171: An integrated, interactive human bo
Page 172 and 173: Biodosimetry and Radiological Terro
Page 174 and 175: primitive/progenitor cells and othe
Page 176 and 177: permits bacterial translocation and
Page 178 and 179: To assess radiation dose, a researc
Page 180 and 181: status? 4. Conduct an initial surve
Page 182 and 183: explosion, when it is concentrated
Page 184 and 185: Skin pathway. Although intact skin
Page 186 and 187: personnel should also take a wipe s
Page 188 and 189: • Geiger-Mueller or G-M counters
Page 190 and 191: • Protective clothing— Disposab
Page 192 and 193: Decontamination priorities are as f
Page 194 and 195: These effects can occur anywhere fr
Page 196 and 197: manifestations of ARS may range fro
Page 200 and 201: The main reason for targeting pregn
Page 202 and 203: No significant side effects from it
Page 204 and 205: axilla, groin, and skin folds. Radi
Page 206 and 207: Followup Care, Including Risk of Ca
Page 208 and 209: artificial because followup in almo
Page 210 and 211: adioactive material in an accident.
Page 212 and 213: 131, canned milk or other milk prod
Page 214 and 215: home immediately after the incident
Page 216 and 217: • National Council on Radiation P
Page 218 and 219: • U.S. Nuclear Regulatory Commiss
Page 220 and 221: Radiation Detection, PPE, Monitorin
Page 222 and 223: • National Council on Radiation P
Page 224 and 225: • Peter RU, Gottlober P. Manageme
Page 226 and 227: Recommendations for State and Local
Page 228 and 229: Figure 6.2. Environmental exposure
Page 230 and 231: Figure 6.4. Bone marrow irradiated
Page 232 and 233: Figure 6.6. Classic Andrews diagram
Page 234 and 235: Figure 6.8. Examples of radiation s
Page 236 and 237: Figure 6.10. Localized radiation ef
Page 238 and 239: Table 6.2. Biodosimetry based on ac
Page 240 and 241: Table 6.4. Diagnostic steps in acut
Page 242 and 243: Table 6.6. Dose assessment summary
Page 244 and 245: Table 6.8. Antibiotics for treatmen
Page 246 and 247: Table 6.10. Radionuclide specific t
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Introduction Chapter 7. Blast Terro
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Spalling effect. When a blast wave
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Clinical findings and diagnosis. Cl
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highest position. Because of the pr
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perilymph in the membranous labyrin
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• Hemoptysis. • Subcutaneous em
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management and immediately involve
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considered (see Chapter 4, Biologic
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• Circumstances (weather conditio
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Bibliography Explosives, Incendiary
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Trauma Systems and Planning/Mitigat
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Table 7.2 Spectrum of primary blast
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Table 7.3 Principles of Advanced Tr
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Determine the severity of the burn
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Chapter 8. Mental Health Issues Men
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• Amnesia for important parts of
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Treatment. Treatment should be guid
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• Before notifying the family, br
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• Be conscious of nonverbal commu
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sadness, anger, guilt, or a sense o
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was mean to my father yesterday and
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these roles, they should work close
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• Lack of availability of trauma-
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The structure provided by a preexis
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necessarily meet the children’s n
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Make Psychological Contact Tune in
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A communications goal of “educati
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• Schonfeld D. Crisis interventio
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Chapter 9. Integrating Terrorism an
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Chain of command. A chain of comman
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The chain of command established by
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Advice for families of children wit
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Quarantine procedures. Quarantine p
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Chapter 10. Working with Government
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need under the 12 Emergency Service
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ecognizes that community clinicians
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Chapter 11. Conclusion This report
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Planning for special medical needs
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Table 11.1 Environmental constraint
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Table 11.2 Pediatric medical compla
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• The post-storm environment is h
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Acronyms AAP American Academy of Pe
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RIA RTG SCIWORA SEB SI SNS SSRI STA
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Appendix A. Pediatric Terrorism and
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1. List which biological agents (mi
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19. Identify chemical terrorism tox
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39. Provide followup care, being mi
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Learning Objectives: At the end of
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Lead Editors Appendix B. List of Co
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James Tsung, MD, FAAP Attending Phy
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Gerald S. Braley, PhD Major, United
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Kobi Peleg, PhD Michael Stein, MD J
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Lou E. Romig MD, FAAP, FACEP Childr
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Maternal & Child Health Bureau Dan
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