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An adequate response to a bioterrorist event of any magnitude
requires early recognition and effective coordination of many disparate
health and medical entities beyond the ED. Although the emergency
physician plays a critical role in these types of events, many other
essential functions must be addressed by individuals and organizations
representing public health, mental health, law enforcement, emergency
management, and others. Emergency physicians may find themselves
working closely with organizations that are not traditionally encountered
in everyday emergency medical practice.
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A bioterrorist incident is the release, or the threat of a release,
of a biologic agent among a civilian population for the purpose
of creating fear, illness, and death. Such an occurrence is a low-probability,
high-impact incident. For example, in the U.S. anthrax
dissemination incident, the U.S. Postal Service was used to deliver
letters containing spores of Bacillus anthracis. Although
the environmental contamination was widespread, only 22 diagnosed
cases of anthrax infection occurred: 11 cases of inhalational and
11 cases of cutaneous anthrax. Five patients died as a direct result
of the anthrax exposure.1 Communities on the Eastern
Seaboard of the U.S. were severely affected, with thousands receiving
prophylaxis for anthrax.2 Fear then spread across
the nation, as concern increased for a wider delivery of anthrax.
Much of this national anxiety may have been exacerbated by the perception
of an inadequate public health response capability, with the deficiencies
demonstrating a critical need to integrate acute care medicine and
the public health response.
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Biologic agents are classified into two groups: biologically
produced toxins and infectious organisms. Biologic toxins usually
act as chemical agents in their human impact. The recognition and
response requirements for these are very similar to those for chemical
incidents (see Chapter 9, Chemical Agents and Mass Casualties), and this chapter focuses on infectious agents. Infectious
agents are subdivided into two categories: contagious (propagating
person to person) and noncontagious. Contagious agents have additional
ramifications, both for protection of the health care workforce
as well as propagation of the disease beyond the initially exposed
population. The contagious agents of greatest concern, such as smallpox,
plague (pneumonic), and certain viral hemorrhagic fevers, are person-to-person infectious
through airborne or droplet transmission. Suspected agents should
be treated as contagious until proven otherwise.
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Certain characteristics make individual organisms particularly
attractive as weapons for generating widespread fear, illness, and
death among civilian populations. The Centers for Disease Control
and Prevention (CDC) identified select organisms and the diseases
they cause as the priority for focused preparation.3 Infectious
agent selection was based on four general criteria:
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1. Potential for public health impact
2. Delivery potential (an estimation of the ease for development
and dissemination, including the potential for person-to-person
transmission of infection)
3. Public perception (fear) of the agent
4. Special requirements for public health preparedness (diagnostic, logistic,
etc.)
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The selected agents were then ranked in three categories, based
on their overall potential for adverse ...