Ten Critical Steps for Handling Possible Bioterrorism Events
1. Maintain an Index of Suspicion
In an otherwise healthy population, some associations are very suggestive, especially when seen in clusters, high numbers or unusual presentations.
Flaccid Paralysis: Botulism
Purpura: Viral Hemorrhagic Fevers (VHF)
Wide Mediastinum: Anthrax
Centripetal* Rash: Smallpox
*Rash more abundant on face and extremities
2. Protect Yourself and Your Patients
Use appropriate personal protection equipment (PPE). For smallpox, triage and evaluate patient in an isolation room; wear an appropriate respirator (N-95 or higher).
3. Adequately Assess the Patient
Review and assess the patient’s history. Also, ask:
Are others ill?
Has the patient been traveling?
Were there any unusual events?
What is the patient’s immunization record?
Was there a possible contaminated food item?
What is the patient's occupation?
Was there vector exposure?
Perform a physical examination with special attention to the respiratory system, nervous system, skin condition and hematologic and vascular status.
4. Decontaminate as Appropriate
Do not use bleach on exposed people. Soap, water and shampoo are perfectly adequate for all biological and most chemical agents. Chemically contaminated clothes should be removed and discarded safely. Biologically contaminated clothes can be laundered with soap, water and, perhaps, bleach.
5. Establish a Diagnosis
Think clinically and epidemiologically; always send specimens for culture.
||Anthrax, tularemia, plague, staph enterotoxin B (SEB)|
||Botulism, Venezuelan equine encephalitis (VEE)|
||VHF, ricin, plague (late)|
|Rash (various types)
||VHF, T2 mycotoxin, smallpox, plague|
|Immediate Symptoms (large numbers)
||SEB, mustard, Lewisite, phosgene, cyanide|
||Nerve gases, cyanide |
|Delayed Symptoms (large numbers)
||Biologic agents, mustard, phosgene|
||Botulism, VEE, other encephalitis|
6. Render Prompt Treatment
Doxycycline can be used to treat virtually everything (except virals or toxins) while awaiting lab results.
Inhalational anthrax should be treated with two or more antibiotics, including doxycycline or ciprofloxacin plus one or more other antibiotics. Observe pediatric precautions as appropriate.
Prophylaxis (antibiotics and/or vaccines) should be administered according to public health recommendations.
7. Provide Good Infection Control
Recommended isolation precautions (in addition to standard precautions) for biologic agents include:
Anthrax: Contact precautions for cutaneous anthrax
Pneumonic Plague: Droplet precautions; contact precautions if draining buboes present
Smallpox: Airborne and contact precautions
Tularemia: Contact precautions if lesions present
Viral Hemorrhagic Fevers: Contact precautions; airborne precautions especially in late stages
8. Alert the Proper Authorities
310-477-6565 (Los Angeles)
858-565-1255 (San Diego)
415-553-7400 (San Francisco)
|Municipal Police/County Sheriff
|California State Police
|County Health Department
|California State Health Department
|Local Emergency Medical Services Unit
Centers for Disease Control and Prevention
9. Assist in Epidemiologic Investigations so as to Determine Who May be at Risk
Steps in an epidemiologic investigation:
10. Know and Spread This Information