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Bioterrorism Nursing CE Course

4.0 ANCC Contact Hours

About this course:

Symptoms and treatments for victims of chemical and radioactive agents

Course preview



Upon completion of this activity, participants should be able to:

  1. Define acts of terrorism and weapons of mass destruction
  2. Identify appropriate personal protective equipment required for acts of terrorism
  3. Discuss common symptoms and treatment for exposure to chemical, biological, radioactive, and nuclear agents
  4. Describe syndromic surveillance and reporting procedures for acts of terrorism that involve biological agents
  5. Discuss the information available on, and the use of the Health Alert Network.


According to Rebmann and Carrico (2017) nurses play a critical and important role in protecting the health of patients, visitors, and fellow staff members during routine clinical practice and in biological disasters such as bioterrorism. Failure to implement correct infection prevention and control practices can result in health care associated disease transmission and occupational exposure for health care workers, which can impact community health. 

The word “bioterrorism” refers to biological agents (microbes or toxins) used as weapons to further personal or political agendas (CDC, 2917). Acts of bioterrorism range from a single exposure directed at an individual by another individual to government-sponsored biological warfare resulting in mass casualties. Bioterrorism differs from other methods of terrorism in that the materials needed to make an effective biological agent are readily available, require little specialized knowledge and are inexpensive to produce. Until the aftermath of 9/11, few instances of bioterrorism were documented in the United States.

A bioterrorist attack could be caused by virtually any pathogenic microorganism. The agents of greatest concern are anthrax (a bacterium) and smallpox (a virus). Both can be lethal. Anthrax is not communicable while smallpox is readily transmitted from person to person. In humans, the three forms of anthrax are inhalational, cutaneous and intestinal. Symptoms vary depending upon how the person was exposed but generally occur within 7 days of the exposure. Initial symptoms of inhalational anthrax may resemble the flu. If untreated, symptoms will progress to breathing difficulties and eventual shock. The incubation period for smallpox is 7 to 19 days following exposure. Symptoms include high fever, fatigue, and head and back pain. A characteristic rash follows in 2 to 3 days.

Who is at Risk?

In the U.S., the risk of contracting anthrax is extremely low. The intentional release of anthrax following the events of 9/11 resulted in only twenty-two recognized cases of cutaneous and inhalational anthrax. Any risk for inhalational anthrax due to cross-contaminated mail is also very low, even for postal workers. The possibility does exist, however, that if anthrax was dispersed in a public place, a large number of people could be affected. Smallpox has not occurred in the U.S. since 1949. If the virus was intentionally released, the number of people affected could run to the tens of thousands.

Can It Be Prevented?

Bioterrorism differs from other methods of terrorism in that the effects are not always immediately apparent.  This is of particular concern to nurses, infection prevention and control practitioners and other members of the healthcare team. An attack may be difficult to distinguish from a naturally occurring infectious disease outbreak. The first evidence of an attack will be in hospital emergency rooms where the proper diagnosis will be essential in treating and preventing the spread of the disease. In the event of intentional anthrax distribution, people at risk should take a 60-day course of prophylactic antibiotics, either doxycycline or ciprofloxacin. Vaccination against smallpox is not recommended to prevent the disease in the general public. In people exposed to smallpox, however, the vaccine can lessen the severity of, or even prevent, illness if given within 4 days of exposure. The Centers for Disease Control and Prevention maintains the National Strategic Stockpile that has a supply of vaccine for emergency use.

The Federal Bureau of Investigation (FBI) defines two types of terrorism: 

International terrorism: Perpetrated by individuals and/or groups inspired by or associated with designated foreign terrorist organizations or nations (state-sponsored).

--for example, the December 2, 2015 shooting in San Bernardino, CA, that killed 14 people and wounded 22 which involved a married couple who radicalized for some time prior to the attack and were inspired by multiple extremist ideologies and foreign terrorist organizations.

Domestic terrorism: Perpetrated by individuals and/or groups inspired by or associated with primarily U.S.-based movements that espouse extremist ideologies of a political, religious, social, racial, or environmental nature.
--for example, the June 8, 2014 Las Vegas shooting, during which two police officers inside a restaurant were killed in an ambush-style attack, which was committed by a married couple who held anti-government views and who intended to use the shooting to start a revolution.

According to the FBI, three factors have contributed to the evolution of the terrorism threat landscape:

The Internet: International and domestic actors have developed an extensive presence on the Internet through messaging platforms and online images, videos, and publications, which facilitate the groups’ ability to radicalize and recruit individuals receptive to extremist messaging. Such message is constantly available to people participating in social networks dedicated to various causes, particular younger people comfortable with communicating in the social media environment.

Use of Social Media: In addition to using the Internet, social media has allowed both international and domestic terrorists to gain unprecedented, virtual access to people living in the U.S. in an effort to enable homeland attacks. ISIS, in particular, encourages sympathizers to carry out simple attacks where they are located against targets—in particular, soft targets—or to travel to ISIS-held territory in Iraq and Syria and join its ranks as foreign fighters. This message has resonated with supporters in the U.S. and abroad, and several recent attackers have claimed to be acting on ISIS’ behalf.

Homegrown Violent Extremists (HVEs): The FBI, however, can’t focus solely on the terrorist threat emanating from overseas—we also must identify those sympathizers who have radicalized and become HVEs within the U.S. and aspire to attack our nation from within. HVEs are defined by the Bureau as global-jihad-inspired individuals who are based in the U.S., have been radicalized primarily in the U.S., and are not directly collaborating with a foreign terrorist organization. Currently, the FBI is investigating suspected HVEs in every state. 

Individuals need to protect themselves from terrorism threats, both online and face to face (in person) and report any suspicious activity. Three strategies are key:

  • Remain aware of your surroundings (situational awareness);
  • Refrain from oversharing personal information; and
  • Say something if you see something.

According to the United States Department of Homeland Security (2017) a weapon of mass destruction is defined as a nuclear, radiological, chemical, biological, or other device that is intended to harm a large number of people. 

Triage in Bioterrorism

There are two different triage systems that are used in health care. Emergency room triage patients as:

  • Emergent: first priority (highest acuit

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y, most critically injured, includes patients in cardiac arrest) 
  • Urgent: second priority (major injuries that require immediate treatment)
  • Non-urgent: third priority (minor injuries)
  • Disaster Triage 

    Disaster Triage differs from triage in the emergency room setting because in a disaster, unlike the emergency room setting, there are limited resources (supplies, medical personnel, medications. durable medical equipment) that need to be allocated and used to treat a large number of casualties. Disaster victims are triaged into one of four categories:

    • Immediate (Red triage tag) require significant treatment within thirty minutes up to two hours
    • Delayed (Yellow triage tag) require significant treatment, such as surgery, but can wait longer than two hours
    • Minimal (Green triage tag) referred to walking wounded (minor injuries or illness).
    • Expectant (Black triage tag) also referred to as expected to die. The issue with expectant casualties is that they are either dead on arrival to the triage point, or so severely injured that the they cannot be saved with the resources on hand, without causing the death of other casualties.

    Personal Protective Equipment

    When considering the appropriate isolation precautions and personal protective equipment for agents of bioterrorism, it is important to start with the basics. According to the Centers for Disease Control and Prevention (CDC), Standard Precautions are used in the care of all patients. 

    Standard Precautions

    The table, below, summarizes the key aspects of Standard Precautions:

    Hand hygieneAfter touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts
    Personal Protective Equipment (PPE): GlovesFor touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin
    PPE: GownDuring procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
    PPE: Mask, eye protection (goggles), face shieldDuring procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation; during aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols wear a fit-tested N95 or higher respirator in addition to gloves, gown and face/eye protection
    Soiled patient-care equipmentHandle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene
    Environmental ControlDevelop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas
    Textiles and laundryHandle in a manner that prevents transfer of microorganisms to others and to the environment
    Needles and other sharpsDo not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container
    Patient resuscitationUse mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions
    Patient placementPrioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection
    Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter e.g.. triage and reception areas in emergency departments and physician offices)Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, 3< feet if possible

    source: http://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/standard-precautions.html

    According to both the Centers for Disease Control and Prevention and the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) Medical Management of Biological Casualties Handbook (2014) standard precautions should be used in every health care encounter, and transmission-based precautions should be used in addition to standard precautions when there is a high probability of disease transmission. It is also important that transmission-based precautions need to be implemented when a communicable disease is suspected. Health care providers should not wait until the diagnosis is confirmed. This is the optimal evidence-based method to prevent the transmission of communicable diseases. 

    Transmission Based Precautions

    There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions. Transmission-Based Precautions are used when the route(s) of transmission is (are) not completely interrupted using Standard Precautions alone. For some diseases that have multiple routes of transmission (for example smallpox), more than one Transmission-Based Precautions category may be used. Transmission based precautions are used in addition to standard precautions.

    Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient’s environment. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment.

    Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options. Healthcare personnel wear a surgical mask (an N 95 fit tested respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of the room should wear a surgical mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.

    Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (for example smallpox). The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with negative pressure handling air and ventilation capacity that meet the American Institute of Architects/Facility Guidelines Institute (AIA/FGI) standards for AIIRs (i.e., monitored negative pressure relative to the surrounding area, 12 air exchanges per hour for new construction and renovation and 6 air exchanges per hour for existing facilities, air exhausted directly to the outside or recirculated through HEPA filtration before return).Some states require the availability of such rooms in hospitals, emergency departments, and nursing homes that care for patients with M. tuberculosis. A respiratory protection program that includes education about use of respirators, fit-testing, and user seal checks is required in any facility with AIIRs. In settings where Airborne Precautions cannot be implemented due to limited engineering resources (e.g., physician offices), masking the patient, placing the patient in a private room (e.g., office examination room) with the door closed, and providing N95 or higher level respirators or masks if respirators are not available for healthcare personnel will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an AIIR or returned to the home environment, as deemed medically appropriate. Healthcare personnel caring for patients on Airborne Precautions wear a fit tested N 95respirator that is donned prior to room entry. Whenever possible, non-immune HCWs should not care for patients with vaccine-preventable airborne diseases (e.g., measles, chickenpox, and smallpox).

    Specific transmission-based precautions and necessary personal protective equipment will be covered as part of each chemical, biological, radioactive or nuclear agent discussed in this course. Additional guidance on isolation precautions from the Centers for Disease Control and Prevention (2017) can be found at this link.

    The Strategic National Stockpile

    The Centers for Disease Control and Prevention maintains the strategic national stockpile, the nation’s largest supply of potentially life-saving pharmaceuticals and medical supplies for use in a public health emergency severe enough to cause local supplies to run out. The stockpile ensures the right medicines and supplies are available when and where needed to save lives.

    When state, local, tribal, and territorial responders request federal assistance to support their response efforts, the stockpile ensures that medicine and supplies get to those who need them most during an emergency. Organized for scalable response to a variety of public health threats, the repository contains enough supplies to respond to multiple large-scale emergencies, simultaneously

    The stockpile contains more than $7 billion worth of medicines and medical supplies referred to as the formulary. The Public Health Emergency Medical Countermeasures Enterprise collaborates to determine which items to include based on specific threats to the United States, including the medical vulnerability of U.S. civilians and other factors. The group reviews the stockpile’s formulary annually and makes recommendations regarding changes based on current scientific evidence about future procurements. Organized for flexible response, the stockpile is structured in four categories: Managed Inventory, 12-hour Push Package, CHEMPACK and Federal Medical Stations.

    Stockpiled products include:

    • Antibiotics
    • Chemical antidotes
    • Antitoxins
    • Vaccines
    • Antiviral drugs
    • Personal protective equipment
    • Ventilators
    • Other medical supplies

    While many items included in the stockpile formulary are readily available, some are not available in the marketplace. To provide these items, the Biomedical Advanced Research and Development Authority helps develop new medical countermeasures―medicine and medical supplies that can prevent or treat diseases related to a public health emergency―to treat specific disease conditions. With access to these, the stockpile can respond to:

    • Bacterial and viral diseases
    • Pandemic influenza
    • Radiation/nuclear emergencies
    • Chemical attacks
    • Natural disasters

    Why Do We Stockpile Materials?

    • A product required to treat a specific disease or condition is not available to the general public.
    • A product may not be available in the timeframe in which it is needed.
    • A product may not be available in the projected amount required.

    Click here for source.

    Biological Agents

    According to the Centers for Disease Control and Prevention (2018) there are three categories of biological agents that could potentially be used in a bioterrorism attack. Category A agents are the highest priority because these agents are most easily disseminated, followed by category B agents, and then category C agents, also known as emerging pathogens. Each of the Category A agents will be discussed in detail, as these are the agents of most concern with regard to potential bioterrorism attack using a biological agent. 

    Category B Agents and Category C Agents are defined and listed. For specifics on symptoms, transmission, incubation period, and clinical management the learner is referred to an evidence-based resource that is updated regularly, the Centers for Disease Control and Prevention (2018) Bioterrorism Agents/Diseases by Category website.

    Category A Biological Agents

    The U.S. public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States. High-priority agents include organisms that pose a risk to national security because they:can be easily disseminated or transmitted from person to person; result in high mortality rates and have the potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness.

    Category A Agents/Diseases

    Listed below are the diseases that are caused by Category A Agents, along with the specific causative organism:


    Anthrax is caused by the Bacillus anthracis   bacterium. The incubation period typically ranges from 1 to 6 days, although incubation periods for inhalation anthrax up to two months have occurred. There are three types of anthrax: cutaneous anthrax, gastrointestinal anthrax, and inhalation anthrax. Recently a fourth type of anthrax has been reported cutaneous anthrax associated with illicit injection drug use. 

    Symptoms of cutaneous anthrax include: the presence of painless skin lesions that are initially vesicles, then ulcers and finally eschar. Gastrointestinal anthrax is linked to the exposure to or ingestion of meat from infected animals. Initial symptoms of inhalation anthrax include flu like symptoms and upper respiratory symptoms such as congestion and rhinorrhea. 

    Anthrax is diagnosed by bacterial culture of the cutaneous lesion(s). Inhalation anthrax is diagnosed by the presence of Bacillus anthracis in blood cultures and in some cases the cerebrospinal fluid. The presence of pleural effusions and a widened mediastinum are found on chest x-ray of individuals diagnosed with inhalation anthrax. Treatment of anthrax includes antibiotic therapy (ciprofloxacin or doxycycline) and supportive care. Anthrax vaccination has been required as pre-exposure prophylaxis for United States military members who deploy to high threat areas. Post exposure prophylaxis for patients exposed to inhalation anthrax includes antibiotic therapy (ciprofloxacin or doxycycline for sixty days duration) and administration of the anthrax vaccine, Health care providers should use standard precautions when caring for patients with anthrax.


    Botulism is caused by the Clostridium botulinumtoxin, Symptoms include cranial nerve palsies, drooping eyelids blurred vision, dry mouth and dysphagia. This progresses to flaccid paralysis, generalized weakness and respiratory failure. The incubation period for botulism ranges from 12 to 36 hours. Botulism is diagnosed based on the clinical presentation of the affected patients. A bioterrorism attack should be suspected if multiple patients present at the same time with symptoms suggestive of botulism.

    Botulism is treated by administration of Heptavalent Botulism Antitoxin. Supportive care, including intubation, ventilator use, and tracheostomy may be required for patients who experience respiratory failure. Standard precautions are recommended for health care providers who are caring for patients with suspected or confirmed botulism.


    Plague is caused by Yersinia pestis, a gram-negative bacterium. The disease is manifested when humans have contact with infected rodents or fleas. There are three forms of plague that can occur in humans: bubonic plague, septicemic plague and pneumonic plague.  

    Bubonic plagueresults after an infected flea (vector) bites a human host, The incubation period for bubonic plague ranges from two to eight days. Initial symptoms include high fever (up to104 degrees Fahrenheit), headache, malaise, myalgias, nausea and vomiting. Buboes (swollen, red, infected lymph nodes develop simultaneously or subsequently in patients with bubonic plague. 

    Septicemic plague occurs in approximately one fourth of patients who present initially with bubonic plague. Septicemic plague can develop from untreated bubonic plague or can occur as the first symptom of plague. Symptoms of septicemic plague include: fever, chills, weakness, malaise, hypertension, tachycardia, tachypnea, nausea, vomiting and diarrhea.

    Pneumonic plaguecan develop as a secondary infection as a result of untreated septicemic or bubonic plague. Primary bubonic plague develops from inhalation of infectious droplets containing Yersinia pestis. The incubation period for pneumonic plague ranges from one to six days. Primary pneumonic plague is the form of plague that is of most concern as an aerosolized biological weapon. Symptoms of pneumonic plague include high fever, chills, malaise, myalgias, tachypnea, cough and hemoptysis. Nausea, vomiting and diarrhea may also occur. 

    Plague is diagnosed based on the clinical presentation and symptoms. Laboratory testing can be done to confirm the presence of Yersinia pestis in sputum, blood or cerebrospinal fluid samples. Antibiotic treatment is initiated promptly, based on the patient’s clinical symptoms and is not delayed for a pending confirmatory laboratory diagnosis. The preferred antibiotic treatment for plague is streptomycin or gentamycin. Individuals who are exposed to pneumonic plague patients (face to face contacts) or plague aerosolized in a biologic agent attack, should be treated with post exposure antibiotics. There is currently no vaccine to prevent plague.

    Standard precautions are used when caring for patients with bubonic or septicemic plague. Patients with suspected or confirmed pneumonic plague require respiratory droplet transmission-based precautions.


    Smallpox is caused by the Variola major virus. During the Revolutionary war, blankets and other objects that contained the smallpox virus were used as a biological weapon by the British soldiers against their adversaries. 

    The incubation period for smallpox ranges from seven to nineteen days after exposure. Initial symptoms, also referred to as the prodromal phase of smallpox include malaise, fever, rigors, vomiting, headache, and backache.  Two to three days after the initial symptoms, lesions appear on the tongue and mouth, then a rash appears on the face, arms and legs, later progressing to the lower extremities and the trunk. Lesions progress from macules to papules to pustules. The initial diagnosis of smallpox is based upon symptoms and the clinical presentation. Smallpox lesions progress through several stages. The initial stage lasts from four to five days where lesions progress from pustules to vesicles. The next stage lasts from one to two days where vesicular lesions become larger pustules. In the third stage the lesions (nine to fourteen days after symptom onset) lesions begin to crust. Once all of the lesion crusts fall off the patient is no longer considered to be contagious. A key diagnostic feature of smallpox, which differs from other pox type illnesses, such as Varicella,is that with smallpox the lesions exhibit the same stage of development in any area of the body at the same time.  

    In addition to Standard Precautions the transmission- based precautions required for smallpox are both Contact Precautions and Airborne Precautions. Treatment for smallpox focuses on supportive care (hydration, analgesics, antipyretics and management of secondary infections). Vaccination with the smallpox vaccine is most effective when the vaccine is administered within four days of exposure.         


    Tularemia is caused by the Francisella tularemia, a small aerobic gram-negative coccobacillus. Tularemia is a zoonotic disease, also known as rabbit fever or deer fly fever. The incubation period for tularemia is typically three to six days; but can range from one to twenty-one days. A shorter incubation period is thought to be associated with a higher infective dose of the Francisella tularemiabacteria. 

    Tularemia manifests as two different types: typhoidal tularemiaor ulcer glandular tularemia. The symptoms of typhoidal tularemiainclude: fever, chills, headache, malaise, a nonproductive cough and chest discomfort. Symptoms of ulcer glandular tularemiainclude: symptoms similar to typhoidal tularemia, plus an obvious portal of entrysuch as a local ulcer with regional adenopathy. Diagnosis of tularemia is dependent upon chest x-ray and laboratory results. The chest x-ray will show pulmonary effusion and pulmonary infiltrates. Laboratory findings will include an elevated white blood cell count, and tularemia recovered in blood cultures, and other cultures, such as ulcers. Tularemia is definitively diagnosed based on the recovery of Francisella tularemia from blood cultures, other cultures (ulcers, gastric washings), cerebrospinal fluid or conjunctival exudates. 

    Treatment of tularemia includes parenteral antibiotics (streptomycin or gentamycin). Post exposure prophylaxis includes empiric antibiotics (doxycycline or ciprofloxacin) started within twenty-four hours of exposure and continued for fourteen days. Standard precautions are recommended for health care workers. 

    Viral Hemorrhagic Fever

    Viral hemorrhagic fevers include Lassa Fever, Ebola, Marburg, Yellow Fever andDengue Fever.Lassa feveris an acute viral illness that usually occurs in West Africa (Sierra Leone, Liberia, Guinea and Nigeria). Ebolawas first recognized in the Sudan and Zaire. The reservoir host for Marburg virus is the fruit bat. Marburghas been diagnosed in Uganda, Zimbabwe, the Democratic Republic of the Congo, Kenya, Angola, and South Africa. Yellow feveris the only viral hemorrhagic fever that has a pre-exposure vaccine. Dengue feveris a mosquito borne illness that occurs in tropical or subtropical climates. 

    Early symptoms of viral hemorrhagic fevers are nonspecific and include: fever, malaise, muscle aches and headache. Later symptoms are sometimes referred to as the viral hemorrhagic fever syndrome (VHF syndrome) and include: capillary leak, bleeding diathesis, and hemodynamic compromise leading to shock. Definitive diagnosis of the specific viral hemorrhagic fever can be made in a reference laboratory that has bio level safety four capability. Prompt recognition of symptoms and initiation of isolation precautions are critical to the treatment of Viral Hemorrhagic Fever. In addition to standard precautions, health care workers must use both contact (double gloving, gowns shoe covers and leg covers, face shields, goggles) and droplet transmission-based precautions. Treatment for Viral Hemorrhagic Fever involves supportive care including: intravenous fluids, oxygen, medications to manage symptoms such as fever, vomiting, diarrheas, pain, or a secondary infection.

    The concern raised when looking at Viral Hemorrhagic Fevers as a potential bioterrorism agent is twofold. First, all of the Viral Hemorrhagic Fevers are highly contagious, and with the exception of Dengue Fever (which can be transmitted by splashes of blood), may be aerosolized. Second, Viral Hemorrhagic Fevers have fatality rates which range from fifteen to eighty percent.

    Category B Biological Agents

    Second highest priority agents include those that are moderately easy to disseminate; result in moderate morbidity rates and low mortality rates; and require specific enhancements of’ the Centers for Disease Control and Prevention’s diagnostic capacity and enhanced disease surveillance.

    Category B Agents/Diseases

    Listed below are the diseases that are caused by Category B Agents, along with the specific causative organism:

    Category C Biological Agents

    Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of availability; ease of production and dissemination; and potential for high morbidity and mortality rates and major health impact. According to the CDC, Category C Agents include emerging infectious diseases, such as Nipahvirus and hantavirus.

    Chemical Agents

    Chemical agents of concern with regard to potential use in bioterrorism include: pulmonary agents or choking agents (such as phosgene or chlorine), vesicants or blister agents (such as, mustard or lewisite), nerve agents (such as sarin, tabun or VX) or blood agents (such as arsine).

    The nerve agent sarin was used in two terrorist attacks in Japan in 1994 and 1995. The use of arsine as a chemical warfare agent was studied during World War II, but it was never used on the battlefield. Phosgene was used extensively as a choking agent during World War I.

    Chemical Threat Agents National Biomonitoring Program

    The Centers for Disease Control and Prevention (2017) has a Division of Laboratory Sciences (DLS) and National Biomonitoring Program (NBP) provide effective laboratory support for the public health response to chemical threat agents and threats involving selected toxins.

    Chemical threat agents can be poisonous vapors, aerosols, liquids or solids that have toxic effects on people. These chemicals can be naturally occurring in the environment or synthetically produced. Chemical releases can be unintentional, as in the case of an industrial accident, or intentional, as in the case of a terrorist attack. Early detection and accurate identification are critical to enable effective treatment and to prevent additional exposures of chemical threats.

    Rapid Toxic Screen

    The CDC laboratory developed and performs the Rapid Toxic Screen (RTS), a series of tests that analyzes 150 chemical agents in people’s blood and urine. Results of the Rapid Toxic Screen help identify which chemicals were used, who was exposed to the chemicals, and how much of a particular chemical their bodies absorbed. This information is critical to medical and public health personnel managing a chemical public health emergency.

    Chemical Emergency Response Team

    CDC maintains 24-7 laboratory response capability and can deploy the Chemical Emergency Response Team within two hours of a request to assist with specimen collection, packaging, storage, and shipment. DLS scientists work with state and local officials to collect samples and transport them to CDC where testing can be done to assess people’s exposure to chemical agents. Within 24 hours of arrival in the lab, using the Rapid Toxic Screen, the chemical agent of concern can be identified. Within 36 hours, up to 40 samples can be tested and results reported to decision makers.

    Laboratory Response Network for Chemical Threats (LRN-C)

    CDC sponsored the creation of the Laboratory Response Network-Chemical (LRN-C), a national network for responding to chemical terrorism and other public health emergencies. LRN-C integrates 55 state and local public health laboratories that operate 24/7 to provide laboratory diagnostics and the surge capacity for chemical emergencies.

    Pre-hospital Concerns in Chemical Hazard Emergencies

    When a chemical hazard emergency, to include an act of bioterrorism via an intentional chemical release, occurs this requires a Hazardous Material (HAZMAT) response team to report to the scene of the incident, and coordinate the on-scene decontamination effort. HAZMAT team members are specially trained first responders who must wear the appropriate level of PPE to protect themselves at the scene. Careful selection and use of adequate personal protective equipment (PPE) should protect individuals involved in chemical emergencies from hazards effecting the respiratory system, skin, eyes, face, hands, feet, head, body, and hearing. No single combination of protective equipment and clothing is capable of protecting against all hazards. PPE should be used in conjunction with other protective methods, including exposure control procedures and equipment. The onsite incident commander will define the PPE ensemble required based on the conditions at the scene. For first receivers and hospitals, PPE selection is based on the institution's chemical emergency procedures. 

    Levels of PPE in Chemical Hazard Emergencies

    Personal protective equipment is divided into four categories based on the degree of protection afforded. 

    Level A protection should be worn when the highest level of respiratory, skin, eye and mucous membrane protection is needed. A typical Level A ensemble includes:

    • Positive pressure (pressure demand), self-contained breathing apparatus (SCBA) (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA
    • Fully encapsulating chemical protective suit 
    • Gloves, inner, chemical resistant 
    • Gloves, outer, chemical resistant
    • Boots, chemical resistant, steel toe and shank; (depending on suit boot construction, worn over or under suit boot) 

    Level B protection should be selected when the highest level of respiratory protection is needed, but a lesser level of skin and eye protection is needed. Level B protection is the minimum level recommended on initial site entries until the hazards have been further identified and defined by monitoring, sampling, and other reliable methods of analysis, and equipment corresponding with those findings utilized. A typical Level B ensemble includes: 

    • Positive-pressure (pressure-demand), self-contained breathing apparatus (NIOSH approved), or positive-pressure supplied air respirator with escape SCBA
    • Chemical resistant clothing (overalls and long-sleeved jacket, coveralls, hooded two-piece chemical splash suit, disposable chemical resistant coveralls) 
    • Gloves, outer, chemical resistant
    • Gloves, inner, chemical resistant
    • Boots, outer, chemical resistant, steel toe and shank. 

    Level C protection should be selected when the type of airborne substance is known, concentration measured, criteria for using air-purifying respirators met, and skin and eye exposure is unlikely. Periodic monitoring of the air must be performed. A typical Level C ensemble includes: 

    • Full-face or half-mask, air-purifying respirator (NIOSH approved)
    • Chemical resistant clothing (one-piece coverall, hooded two-piece chemical splash suit, chemical resistant hood and apron, disposable chemical resistant coveralls)
    • Gloves, outer, chemical resistant
    • Gloves, inner, chemical resistant
    • Boots, steel toe and shank, chemical resistant

    Level D protection is primarily a work uniform and is used for nuisance contamination only. It requires only coveralls and safety shoes/boots. Other PPE is based upon the situation (types of gloves, etc.). It should not be worn on any site where respiratory or skin hazards exist. 

    According to the REMM (2018) Classification of PPE the Level D classification includes first receivers (emergency room staff). When working in post-decontamination areas, first receivers should use Standard Precautions  and wear PPE (per protocol) for infection control purposes. Standard precautions PPE and procedures used to prevent transmission of infections within healthcare settings provides adequate protection against low levels of radiological contamination that may be found in post-decontamination areas of the hospital (e.g., emergency department and surgical suites). No formal PPE is required to be worn when delivering care to persons with high dose radiation exposure although reverse isolation procedures will need to be observed as neutropenia becomes prominent.

    Source: https://chemm.nlm.nih.gov/ppe.htm

    Emergency Room Procedures in Chemical Hazard Emergencies


    1.  Try to determine agent identity.

    2.  Break out personal protection equipment, decontamination supplies, antidotes, etc.

    3.  Is chemical hazard certain or very likely? YES:

    • Put on personal protective equipment.
    • Set up hot line.

    4. Clear and secure all areas which could become contaminated.

    5.  Prepare to or secure hospital entrances and grounds.

    6.  Notify local emergency management authorities if needed.

    7.  If chemical is a military agent and Army has not been informed, call them.

    8. If an organophosphate is involved, notify hospital pharmacy that large amounts of atropine and 2-PAM may be needed.


    Initial Treatment and Identification of the Chemical Agent

    1.  Establish airway if necessary.

    2.  Give artificial respiration if not breathing.

    3.  Control bleeding if hemorrhaging.

    4.  Symptoms of cholinesterase poisoning?

    • Pinpoint pupils
    • Difficulty breathing (wheezing, gasping, etcetera)
    • Local or generalized sweating
    • Fasciculations
    • Copious secretions
    • Nausea, vomiting, diarrhea
    • Convulsions
    • Coma
    • YES: Go to Nerve Agent Protocol(below)

    5.  History of chlorine poisoning?

    YES: Go to Chlorine Protocol(below)

    6.  Burns that began within minutes of poisoning?

    YES: Go to 7

    NO: Go to 8

    7. Thermal burn?

       YES: Go to 9.

        NO: Go to Lewisite Protocol  (below)

    8. Burns or eye irritation beginning 2-12 hours after exposure?

       YES: Go to Mustard Protocol(below)

       NO: Go to 9.

    9. Is phosgene exposure possible?

    • Known exposure to phosgene
    • Known exposure to hot chlorinated hydrocarbons
    • Respiratory discomfort beginning a few hours after exposure
    • YES: Go to Phosgene Protocol(below)

    10. Check other possible chemical exposures:

    • Known exposure
    • Decreased level of consciousness without head trauma.
    • Odor on clothes or breath
    • Specific signs or symptoms 
    Phosgene ProtocolMustard Protocol
    1. Restrict fluids, chest x-ray, blood gases
      Results consistent with Phosgene Poisoning? YES: Go to #4
    2. Dyspnea? YES: Oxygen, positive end-expiratory pressure
    3. Observe closely for at least 6 hours
      • If SEVERE DYSPNEA develops, go to #4
      • If MILD DYSPNEA develops after several hours, go to #1
    4. Severe Dyspnea develops or x-ray or blood gases consistent with Phosgene Poisoning:
      • Admit
      • Give oxygen under positive end-expiratory pressure
      • Restrict fluids
      • Take chest x-ray
      • Get blood gases
      • Put on seriously ill list
    1. Airway obstruction? YES: Tracheotomy
    2. If there are large burns:
      • Establish IV line - do not push fluids as for thermal burns
      • Drain vesicles - unroof large blisters and irrigate area with tropical antibiotics
    3. Treat other symptoms appropriately:
      • Antibiotic eye ointment
      • Sterile precautions PRN
      • Morphine PRN (generally not needed in emergency treatment; might be appropriate for in-patient treatment)
    Lewisite ProtocolChlorine Protocol
    1. Survey extent of injury
    2. Treat affected skin with British Anti-Lewisite (BAL) ointment (if available)
    3. Treat affected eyes with BAL opthalmic ointment (if available)
    4. Treat pulmonary/severe effects
      • BAL in oil, 0.5ml/25lbs. body weight, deep IM to max of 4.0ml. Repeat q 4h x 3 (at 4, 8, and 12 hours)
      • Morphine PRN
    5. Severe poisoning? YES: shorten interval for BAL injections to q 2 h
    1. Dyspnea?
      • Try bronchodilators
      • Admit
      • Give oxygen by mask
      • Take chest x-ray
    2. Treat other problems and reevaluate (consider phosgene)
    3. Respiratory system ok? YES: Go to #5
    4. Is phosgene poisoning possible? YES: Go to Phosgene Protocol
    5. Give supportive therapy; treat other problems or discharge
    Nerve Agent Protocol
    1. Severe respiratory distress? YES:
      • Intubate and ventilate
      • ATROPINE
        Adults: 6mg IM or IV
        Inf/ped: 0.05 mg/kg IV
      • 2-PAM C1
        Adults: 600-1000mg IM or slow IV
        Inf/ped: 15 mg/kg slow IV
    2. Major secondary symptoms? NO: Go to #6
      • ATROPINE
        Adults: 4mg IM or IV
        Inf/ped: 0.02-0.05 mg/kg IV
      • 2-PAM C1
        Adults: 600-1000mg IM or slow IV
        Inf/ped: 15 mg/kg
      • OPEN IV LINE
    3. Repeat atropine as needed until secretions decrease and breathing easier
    Adults: 2mg IV or IM
    Inf/ped: 0.02-0.05 mg/kg IV

    4. Repeat 2-PAM C1 as needed
    Adults: 1.0gm IV over 20-30min (Repeat q lh x 3 prn)
    Inf/ped: 15 mg/kg slow IV

    5. Convulsions? YES:
    Adults: DIAZEPAM 10mg slow IV
    Inf/ped: 0.2 mg/kg IV
    NO: Go to #6

    6. Reevaluate q 3-5min
    IF SIGNS WORSEN: Repeat from #3

    NOTE: Warn the hospital pharmacy that unusual amounts of atropine and 2-PAM may be needed

    Radioactive and Nuclear Agents

    The most comprehensive evidence-based resource for health care providers on radioactive and nuclear agents of bioterrorism is the Radiation Emergency Medical Management (REMM) website https://www.remm.nlm.gov/This purpose of this website is to provide guidance for health care providers about clinical diagnosis and treatment of radiation injury during radiological and nuclear emergencies. Another key feature of the REMM website is the mobile application which can be downloaded and used as a point of care ready reference from https://www.remm.nlm.gov/downloadmremm.htm

    According to REMM (2018) standard precautions, PPE and procedures used to prevent transmission of infections within healthcare settings provides adequate protection against low levels of radiological contamination that may be found in post-decontamination areas of the hospital (e.g., emergency department and surgical suites). No formal PPE is required to be worn when delivering care to persons with high dose radiation exposure although reverse isolation procedures will need to be observed as neutropenia becomes prominent.

    According to the REMM Guidance for Emergency Department Personnel on Diagnosis and Treatment for Health Care Providers: Managing Patients After a Nuclear Detonation (n. d.) there are several key issues that you can anticipate to be present and must be dealt with in terms of accepting patients, triaging, treating, and protecting healthcare workers who are caring for these patients. These key issues include:

    Immediate Protective Actions for Everyone after Nuclear Detonation

    • Get inside: Building interiors and basements provide the greatest protection.
    • Stay inside: This minimizes exposure to fallout and other environmental hazards. Be prepared to shelter for 12-24 hours if the facility could be in the fallout area
    • Stay tuned: Emergency Alert System/Response Managers will update instructions.

    Protecting Health Care Providers

    • For managing patients potentially or known contaminated with radiation: gown, gloves, boots, eye protection, and surgical mask or N95 as appropriate.
    • For managing patients exposed but NOT contaminated: standard precautions, if appropriate for traumatic injury.
    • For yourself: Wear a personal dosimeter if assigned one or monitor background radiation and know your dose limits. Coordinate with nuclear medicine/radiation safety personnel.

    Management Priorities in the Emergency Department

    • Configure flow of ED patients, staff, and materiel to minimize cross contamination.
    • Match ED triage and treatment protocols to local medical resource availability and “prevailing scarce resource allocation plans” available at https://www.remm.nlm.gov/stdsofcare.htm
    • Consult senior medical and administrative staff regarding crisis care implementation.
    • Consider “Nuclear Detonation Scarce Resources Triage Tool” if resource availability is severely compromised. Available at https://www.remm.nlm.gov/triagetool_intro.htm

    Manage Patients with Radiation Contamination 

    • Perform life-saving care before managing radiation issues
    • Coordinate radiation surveys of patients and decontamination procedures with facility radiation response personnel (if available) Tool available at https://www.remm.nlm.gov/howtosurvey.htm
    • Remove patient’s clothing to eliminate a significant proportion of external contamination.
    • Rinsing skin with soap and water may also help, but avoid heavy brushing, scraping/abrading skin. Control contaminated run-off when possible. Critical patient care interventions precede formal decontamination efforts (unlike chemical contamination)
    • Radiation decontamination guidance: https://www.remm.nlm.gov/ext_contamination.htm
    • Bag, label (date, time, name), remove contaminated clothing/personal effects of victims from the area
    • Consult radiation experts if internal contamination is suspected because the radiation survey remains significantly positive after external decontamination is completed https://disasterinfo.nlm.nih.gov/apps

    Manage Patients with Radiation Exposure

    • Look for early clinical signs and symptoms of Acute Radiation Syndrome: e.g., vomiting, diarrhea.
      More details: http://www.remm.nlm.gov/physicalexam.htm
    • Use Radiation Bio-dosimetry Tools to estimate whole body radiation dose
    • Obtain CBC with differential and platelet count
    • Input absolute lymphocyte count(s) value(s) into Interactive Calculator to estimate whole body radiation dose
      Resource https://www.remm.nlm.gov/ars_wbd.htm
    • Repeat CBC every 24 hours, if possible, to increase accuracy of dose estimate and management. If this is not possible values from a single or two CBCs can still be very valuable.In the absence of lab capacity, symptoms can provide a rough guide to exposure and prognosis
    • Consider myeloid cytokines and antibiotics if whole body dose estimate ≥ 2 Gray and/or neutrophil count at or expected to reach ≤ 0.500 x 109 cells/liter
    • See prototype admission orders: http://www.remm.nlm.gov/adultorderform.htm
    • Consider BOTH patient signs/symptoms AND radiation dose estimate when making clinical decisions about triage/treatment/transfer
    • Re-assess each patient at regular intervals, as the clinical status may change over time
      Resource https://www.remm.nlm.gov/hospitalapproach_algo.htm
    • Consider that radiation exposure PLUS trauma or burn worsens a patient’s prognosis. This may alter triage decisions.  Resource https://www.remm.nlm.gov/TriageToolscombined.pdf 

    Assess carefully those at higher of morbidity from radiation exposure:

    • Young children, older adults, patients with immunosuppression and/or severe chronic illnesses
    • Consult algorithm for “Hospital Approach to Patients Presenting After a Nuclear Detonation”. This algorithm assumes hospital resources are “inadequate for demand but not overwhelmed”
      Resource  https://www.remm.nlm.gov/hospitalapproach_algo.htm 

    Plan for Follow-up

    • Ensure all patients and staff are registered in an incident database.
    • Determine resources for follow-up for all ambulatory patients with suspected or proven radiation exposure and/or contamination who are not admitted
    • Contact the Radiation Injury Treatment Network (RITN) for assistance with specialized radiation care: https://ritn.net/  E-mail: ritn@nmdp.org

    Syndromic Surveillance and Reporting Procedures

    The purpose of syndromic surveillance is to allow public health professionals, infection prevention and control professionals and other health care providers to gather surveillance data that could enable the early detection of infection control disasters, pandemics, and bioterrorism incidents. Traditional syndromic surveillance looks at data such as: influenza like symptoms, rash, severe bleeding disorder without a discernable cause, gastrointestinal symptoms, chief complaint on emergency room visit or hospital admission. The concept of syndromic surveillance later expanded to include additional data such as: number of hospital admissions, number of ambulance runs in a certain time period, number of purchases of over the counter flu medications or over the counter diarrhea medications.

    Syndromic surveillance works in conjunction with the Center for Disease Control and Prevention’s National Syndromic Surveillance Network (NSSP). The NSSP uses syndromic data and statistical tools to detect, monitor and characterize unusual activity for further public health action (investigation or response). The Bio-Sense platform, launched by the Centers for Disease Control and Prevention in 2003 is part of the NSSP and initially focused on detection and response to bioterrorism- related events. Bio-Sense was expanded in 2011 to also include a situational awareness all hazards approach to preparedness and response. The Bio-Sense Platform is a secure cloud based integrated electronic health information system which allows users to rapidly collect, evaluate, share and store syndromic surveillance data.

    The Health Alert Network (HAN)

    The Centers for Disease Control and Prevention (CDC) Health Alert Network (HAN) is the CDC’s primary method of sharing cleared information about urgent public health incidents with public information officers; federal, state, territorial, tribal, and local public health practitioners; clinicians; and public health laboratories.

    CDC’s HAN collaborates with federal, state, territorial, tribal, and city/county partners to develop protocols and stakeholder relationships that will ensure a robust interoperable platform for the rapid distribution of public health information.

    The HAN is a strong national program, providing vital health information and the infrastructure to support dissemination at state and local levels, and beyond. The vast majority of the state-based HAN programs have over 90% of their populations covered under the umbrella of HAN. The HAN messaging system directly and indirectly transmits: Health Alerts, Advisories, Updates, and Info Services to over one million recipients.

    Health Alert: provides vital, time-sensitive information for a specific incident or situation; warrants immediate action or attention by health officials, laboratorians, clinicians, and members of the public; and conveys the highest level of importance.

    Health Advisory: provides important information for a specific incident or situation; contains recommendations or actionable items to be performed by public health officials, laboratorians, and/or clinicians; may not require immediate action.

    Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action.

    Info Service: provides general public health information; unlikely to require immediate action

    Health care providers can sign up to receive email update from the Health Alert Network by accessing https://emergency.cdc.gov/han/updates.aspand following the steps on this page. 

    Additional Resources

    The websites listed below provide ready resources for nurses to access the most current information to provide evidence-based nursing care for patients exposed to chemical, biological. radioactive and nuclear agents of terrorism. Many of the resources listed below are free of charge and can be accessed by the nurse at the bedside or point of care. 

    The Centers for Disease Control and Prevention


    This website provides information on current evidence-based isolation precautions, and infectious diseases, including agents of bioterrorism. The Centers for Disease Control and Prevention has a robust mobile application, available for both android and iPhone, as a free download. 

    Medline Plus: Health Topics – Biodefense and Bioterrorism


    This website provides up to date evidence-based resources on bioterrorism and biodefense. Some of the resources are available in both English and Spanish and are appropriate for educating the general public. Links to peer reviewed journal article references and abstracts from MEDLINE/PubMed are included.

    United States Army Medical Research Institute of Infectious Diseases Medical Management of Biological Casualties, Eight Edition (September 2014)


    The United States military has conducted research on biological agents and biodefense since World War II. This resource has been informally known to health care providers as the blue book. Information included in this resource includes: management of potential biological casualties, bacterial agents, viral agents, biological toxins, emerging threats and personal protection. 

    Medical Management of Chemical Casualties, 5thEdition (2014). Fort Sam Houston, TX: Borden Institute US Army Medical Department Center and School


    This resource is geared toward military medical professionals but contains valuable insights and information for health care providers in the civilian sector who want a current evidence-based resource on chemical casualty care.


    The purpose of this course was to provide nurses and other health care providers with current information on the recognition and clinical management of biologic, chemical and/or radioactive and nuclear agents of bioterrorism. Information on necessary personal protective equipment, syndromic surveillance, and the Health alert Network have been included in this course. It is critical that nurses who practice in a variety of health care settings have a basic understanding of bioterrorism and can access current evidence-based resources on bioterrorism.


    1. Banks, D. E. (Ed.) (2014). Medical Management of Chemical Casualties, 5thEdition. Fort Sam Houston, TX: Borden Institute US Army Medical Department Center and School. Accessed from http://www.cs.amedd.army.mil/borden/bookDetail.aspx?ID=a0968070-71b0-46c0-a139-9362d1b13265&pageTitle=Medical%20Management%20of%20Chemical%20Casualties%20Handbook
    2. Benitez, J. G. (2013). Chemical Agents of Concern. In Veenema, T. G. (Ed.) Disaster Nursing and Emergency Preparedness for Chemical, Biological. And Other Hazards, 3rdEdition. New York, NY: Springer Publishing
    3. Centers for Disease Control and Prevention (September 15, 2017). Bioterrorism. Accessed from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/Bioterrorism.html
    4. Centers for Disease Control and Prevention (April 3. 2018). Bioterrorism Agents/Diseases by Category. Accessed from https://emergency.cdc.gov/agent/agentlist-category.asp
    5. Centers for Disease Control and Prevention (April 7, 2017), Chemical Threat Agents. Accessed from https://www.cdc.gov/biomonitoring/chemical_threat_agents.html
    6. Centers for Disease Control and Prevention (June 25, 2013). Emergency Room Procedures in Chemical Hazard Emergencies. Accessed from https://www.cdc.gov/nceh/demil/articles/initialtreat.htm
    7. Centers for Disease Control and Prevention (April 4, 2018). Facts about Arsine. Accessed from https://emergency.cdc.gov/agent/arsine/basics/facts.asp
    8. Centers for Disease Control and Prevention (April 4, 2018). Facts about Phosgene. Accessed from https://emergency.cdc.gov/agent/phosgene/basics/facts.asp
    9. Centers for Disease Control and Prevention (April 4, 2018). Facts About Sarin. Accessed from https://emergency.cdc.gov/agent/sarin/basics/facts.asp
    10. Centers for Disease Control and Prevention (June 11, 2018). Health Alert Network. Accessed from https://emergency.cdc.gov/han/index.asp
    11. Centers for Disease Control and Prevention (October 31, 2017). Isolation Precautions. Accessed from https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
    12. Centers for Disease Control and Prevention (June 19, 2018). National Syndromic Surveillance Program. Accessed from https://www,cdc.gov//nssp
    13. Centers for Disease Control and Prevention {September 27, 2016). Standard Precautions, Accessed from https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/standard-precautions.html
    14. Centers for Disease Control and Preventions (January 19, 2018). Strategic National Stockpile. Accessed from https://www.cdc.gov/phpr/stockpile/index.htm
    15. Centers for Disease Control and Prevention (November 5, 2015).  Transmission Based Precautions. Accessed from https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html
    16. Federal Bureau of Investigation (n. d.) Terrorism. Accessed from https://www.fbi.gov/investigate/terrorism
    17. Rebmann, T, (2014). Infectious Disease Disasters: Bioterrorism. Emerging Infections and Pandemics. In Association for Professionals in Epidemiology and Control (Ed.). APIC Text of Infection Control and Epidemiology Text (4thedition)). Washington DC: Association for Professionals in Infection Control and Epidemiology.
    18. Rebmann, T., & Carrico, R. (2017). Consistent Infection Prevention: Vital During Routine and Emerging Infectious Diseases Care. Online Journal of Issues in Both contact precautions and airborne precautions are required when caring for patients with suspected or confirmed smallpox Nursing, 22(1), 1. doi:10.3912/OJIN.Vol22No01Man01
    19. United States Department of Health and Human Services Chemical Hazards Emergency Management (September 29, 2017). Personal Protective Equipment. Accessed from https://chemm.nlm.nih.gov/ppe.htm
    20. United States Department of Health and Human Services: Radiation Emergency Medical  Management (March 15, 2018). Personal Protective Equipment Classification. Accessed from https://www.remm.nlm.gov/ppe_classification.htm
    21. United States Department of Health and Human Services: Radiation Emergency Medical  Management (n. d.) Managing Patients After a Nuclear Detonation. Accessed from https://www.remm.nlm.gov/SummaryInitialActionsPostIND_EDStaff.pdf
    22. United States Department of Homeland Security (December 7, 2017). Weapons of Mass Destruction. Accessed from https://www.dhs.gov/topic/weapons-mass-destruction
    23. Withers, M. R. (Ed.) (September 2014). USAMRIID’s Medical Management of Biological Casualties Handbook,8thEdition. Fort Detrick, MD: United States Army Medical Research Institute. Accessed from http://www.usamriid.army.mil/education/bluebookpdf/USAMRIID%20BlueBook%208th%20Edition%20-%20Sep%202014.pdf

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