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.

  • Hemoptysis: Plague
  • 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.

Symptom Possible Diagnosis
Pulmonary Anthrax, tularemia, plague, staph enterotoxin B (SEB)
Neuromuscular Botulism, Venezuelan equine encephalitis (VEE)
Bleeding/purpura VHF, ricin, plague (late)
Rash (various types) VHF, T2 mycotoxin, smallpox, plague
Flu-like symptoms Varies


Immediate Symptoms (large numbers) Possible Diagnosis
Pulmonary SEB, mustard, Lewisite, phosgene, cyanide
Neurologic Nerve gases, cyanide


Delayed Symptoms (large numbers) Possible Diagnosis
Pulmonary Biologic agents, mustard, phosgene
Neurologic 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

Agency Telephone Number

310-477-6565 (Los Angeles)

916-481-9110 (Sacramento)

858-565-1255 (San Diego)

415-553-7400 (San Francisco)

Municipal Police/County Sheriff _________________
California State Police _________________
County Health Department _________________
California State Health Department 916-445-4171
Local Emergency Medical Services Unit _________________
Local Hospitals _________________

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:

  • Count cases
  • Relate to the at-risk population
  • Make comparisons
  • Develop hypotheses
  • Test hypotheses
  • Make inferences
  • Conduct studies
  • Interpret and evaluate

10. Know and Spread This Information