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determined to be due to an agent of bioterrorism. Infection control precautions may also include the use of masks, gowns, gloves, and equipment for eye protection, depending on each situation. Once the initial history and physical examination have been completed, if a disease related to bioterrorism is suspected, the pediatrician must notify the proper authorities, including the infection-control practitioner (if one is available at the facility) and local public health authorities. Each local public health system is organized slightly differently, so pediatricians should become familiar with their own local public health agency and phone number for local reporting. Rapid reporting to authorities is essential. Each agency level has developed and continues to refine response plans to handle a bioterrorist event. Rapid activation of these plans provides the best opportunity to limit disease spread during an outbreak. Local authorities may initiate an immediate investigation or seek assistance from the State health department. For a list of State health department websites, see http://www.cdc.gov/other.htm#states. For a list of State epidemiologists, see http://www.cste.org/members/state_and_territorial_epi.asp. States report their investigations to and request epidemiologic assistance from the CDC. The CDC can provide public health consultation, epidemiologic support, and other technical assistance to State health departments. The CDC usually becomes involved in a State’s investigation at the request of the lead State epidemiologist or health officer. The CDC can be reached during all hours through the CDC Director’s Emergency Operation Center at 770-488-7100. Health Department Each State has a public health system, although the structure and reporting network varies from State to State. In some States, the State health department has authority over county and local health departments. In other States, county and local health departments function autonomously. State health departments facilitate consultations with specially designated laboratories that are capable of responding to public health emergencies (see the following section, Laboratory Response Network). State bioterrorism response plans will reflect these differences. All pediatricians and health care facilities should learn the structure of their local public health system and the point of contact for reporting illnesses suspected of being related to bioterrorism. Hospital Most hospitals have started to develop bioterrorist response plans that may be part of a larger hospital disaster plan. Hospitals play a very large role in the care of bioterrorist victims and anxious or worried parents and others. Optimally, hospitals should have been included in the response planning of local public health agencies. Office and hospital-based pediatricians can become better prepared to respond to a bioterrorist attack by becoming familiar with local hospital bioterrorist and disaster plans. In addition, pediatricians are uniquely qualified to ensure that the special needs of children (e.g., medical supplies and therapeutics specific for children) 55
are addressed in local medical response plans. (See also Chapter 9. Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice). Law Enforcement All suspected cases of bioterrorism are subject to criminal investigation. Public health authorities are responsible for notifying local and Federal law enforcement. In many jurisdictions, these relationships are already established and detailed in State and local public health bioterrorist response plans. Laboratory Support and Submission of Specimens Collecting the appropriate clinical laboratory specimens in a case of actual or suspected bioterrorist-related illness is critical for the medical care of the patient, as well as for public health and legal investigations. Specimen collection varies by the agent suspected and should be done in consultation with public health authorities. Local and State public health authorities can advise on specific specimen collection and shipping in each case and consult with the CDC as needed. For detailed information regarding specimen collection, packaging, and shipping, see http://www.bt.cdc.gov/labissues/index.asp. Laboratory Response Network The Laboratory Response Network (LRN) is a national network of local, State, and Federal public health, hospital-based, veterinary, agriculture, food, and environmental testing laboratories that provide laboratory diagnostic capability to respond to biological and chemical terrorism and to other public health emergencies. The CDC, along with the Association of Public Health Laboratories and the Federal Bureau of Investigation (FBI), created the LRN, which has been operational since 1999. There are more than 100 LRN laboratories across the United States, and the network continues to expand. Consultation with LRN facilities is facilitated through State health departments. For more information, see http://www.bt.cdc.gov/lrn/. Limiting Spread Rapidly detecting and isolating patients with an infectious illness related to bioterrorism is essential to prevent transmission in health care settings. If an infection related to bioterrorism is suspected, the patient should be placed on contact precautions and airborne infection isolation, in addition to standard precautions, until preliminary test results are available and the transmissibility of disease can be reevaluated. Agents of bioterrorism are generally not transmitted from person to person. The release of an agent is most likely from a point source. However, smallpox, VHFs, and pneumonic plague may be highly transmissible from person to person via respiratory droplet and, in some cases, by aerosol spread. Standard Precautions All patients in a health care facility and all patients suspected of infection with a Category A bioterrorist agent (anthrax, botulinum toxin, plague, smallpox, tularemia, and VHFs) should be 56
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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
Page 15 and 16: injured or killed (see also Chapter
Page 17 and 18: Head injury is common in children.
Page 19 and 20: In situations of disaster, caregive
Page 21 and 22: maintaining and securing the airway
Page 23 and 24: • Schonfeld DJ. In times of crisi
Page 26 and 27: Types of Disasters Chapter 2. Syste
Page 28 and 29: problems noted above for flooding,
Page 30 and 31: Federal Response The United States
Page 32 and 33: The scope of ESF #8 is broad and in
Page 34 and 35: • Centers for Disease Control and
Page 36: Table 2.1 Types of disasters, hazar
Page 39 and 40: Medical staffs need to know what wi
Page 41 and 42: information, health and safety educ
Page 43 and 44: y private physicians. Approximately
Page 45 and 46: even required (particularly if a pe
Page 47 and 48: ICS structure is hierarchical. For
Page 49 and 50: • Provide community education so
Page 51 and 52: • Provide for crisis counseling.
Page 53 and 54: incident command officer is most of
Page 55 and 56: Figure 3.1 National Response Plan D
Page 58 and 59: Background History of Bioterrorism
Page 60 and 61: Epidemiology of a Terrorist Attack
Page 62 and 63: and may be watery, purulent, or blo
Page 64 and 65: fluid in these vesicles. A painless
Page 68 and 69: cared for using standard precaution
Page 70 and 71: may be providing longer term and mo
Page 72 and 73: The vaccine has a number of common
Page 74 and 75: Vaccination Large-scale vaccination
Page 76 and 77: cutaneous lesions; however, previou
Page 78 and 79: common food source is identified du
Page 80 and 81: treated people experience some degr
Page 82 and 83: treatment for plague meningitis. An
Page 84 and 85: Smallpox is spread most commonly in
Page 86 and 87: focal, intensely suppurative necros
Page 88 and 89: Control measures. Some viruses that
Page 90 and 91: Control measures. Person-to-person
Page 92 and 93: Signs and symptoms. The incubation
Page 94 and 95: currently used for individuals trav
Page 96 and 97: Accessed July 12, 2006. • Centers
Page 98 and 99: • Roffey R, Tegnell A, Elg HF. Bi
Page 100 and 101: Figure 4.2. Neurological signs, bot
Page 102 and 103: Figure 4.4. Physical distribution o
Page 104 and 105: Figure 4.6. Varicella lesions Note:
Page 106 and 107: Figure 4.8a. Febrile rash illness a
Page 108 and 109: Table 4.1. Early clinical signs and
Page 110 and 111: Table 4.2. Infection control transm
Page 112 and 113: Table 4.3. Diagnostic procedures, i
Page 114 and 115: 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
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Table 5.4. Nerve agent triage and d
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Table 5.5. Clinical effects from su
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Table 5.7. Medical treatment of rio
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Chapter 6. Radiological and Nuclear
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from ground zero. For weapons large
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(1000 rem), resulting in four fatal
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cooling systems at Mayak exploded,
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pediatric practices. This put infan
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energy, releasing two photons of ex
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need to be shielded, although the a
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adioactive isotope of potassium. Ba
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An integrated, interactive human bo
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Biodosimetry and Radiological Terro
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primitive/progenitor cells and othe
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permits bacterial translocation and
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To assess radiation dose, a researc
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status? 4. Conduct an initial surve
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explosion, when it is concentrated
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Skin pathway. Although intact skin
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personnel should also take a wipe s
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• Geiger-Mueller or G-M counters
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• Protective clothing— Disposab
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Decontamination priorities are as f
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These effects can occur anywhere fr
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manifestations of ARS may range fro
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Neutropenia: Viral and Fungal Infec
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The main reason for targeting pregn
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No significant side effects from it
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axilla, groin, and skin folds. Radi
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Followup Care, Including Risk of Ca
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artificial because followup in almo
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adioactive material in an accident.
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131, canned milk or other milk prod
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home immediately after the incident
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• National Council on Radiation P
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• U.S. Nuclear Regulatory Commiss
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Radiation Detection, PPE, Monitorin
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• National Council on Radiation P
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• Peter RU, Gottlober P. Manageme
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Recommendations for State and Local
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Figure 6.2. Environmental exposure
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Figure 6.4. Bone marrow irradiated
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Figure 6.6. Classic Andrews diagram
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Figure 6.8. Examples of radiation s
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Figure 6.10. Localized radiation ef
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Table 6.2. Biodosimetry based on ac
Page 240 and 241:
Table 6.4. Diagnostic steps in acut
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Table 6.6. Dose assessment summary
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Table 6.8. Antibiotics for treatmen
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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
Page 332 and 333:
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
Page 346 and 347:
James Tsung, MD, FAAP Attending Phy
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Gerald S. Braley, PhD Major, United
Page 350 and 351:
Kobi Peleg, PhD Michael Stein, MD J
Page 352 and 353:
Lou E. Romig MD, FAAP, FACEP Childr
Page 354:
Maternal & Child Health Bureau Dan
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