Southern Illinois University School of Medicine

[Guest guest]

Southern Illinois University School of Medicine

Department of Internal Medicine

Division of Infectious Diseases

PO Box 19636

Springfield, Illinois 62794-9636

217/545-0181

Division Secretary: 217/545-0181

Fellowship Information: idfellowship@...

ID Nurse: 217/545-9537

http://www.siumed.edu/medicine/infec/patinfo/current/bioterrorism.htm

The Threat of Biological Weapons

For a biological weapon to be highly effective, three conditions

should be optimized. The biological agent should consistently

produce the desired effect of death or disease. It should be highly

contagious with short and predictable incubation period and

infective in low doses. The disease should be difficult to identify

and be suspected as an act of bioterrorism. The agents should be

suitable for mass production, storage, weaponisation, and stable

during dissemination. The target population should have little or no

immunity and little or no access to treatment. The terrorist should

have means to protect or treat their own forces and population

against the infectious agents or the toxins (32).

The agents with potential of biological terrorism include bacterial,

fungal and viral pathogens and toxins produced by living organisms.

Infectious agents that could potentially be used include those

causing anthrax (Bacillus anthracis), plague (Yersinia pestis),

tularemia (Francisella tularensis), equine encephalitides (e.g.

Venezuelan equine encephalitis viruses), hemorrhagic fevers

(arenaviruses, filoviruses, flaviviruses, and bunyaviruses), and

small pox (variola virus). Toxins include botulinum toxin from

Clostridium botulinum; ricin toxin from the castor bean Ricinus

communis; trichothecene mycotoxins from Fusarium, Myrotecium

Trichoderma, Stachybotrys, and other filamentous fungi;

staphylococcal enterotoxins from Staphylococcus aureus; and toxins

from marine organisms such as dinoflagellates, shellfish, and blue-

green algae. Depending on the agents, a lethal or incapacitating

outcome can occur. In a military context, incapacitating agents may

be more effective because the unit will not be able to perform their

mission and casualties will consume scarce medical and evacuation

assets (31).

Agents of Bioterrorism Attacks

Based on the ease of transmission, severity of morbidity, mortality,

and likelihood of use, biological agents can be classified into 3

categories (Table 1) (35). Table 2 summarizes the biological agents

in category A.

Category B Agents

This category (47) contains the second highest priority agents

because they

a. are moderately easy to disseminate

b. cause moderate morbidity and low mortality

c. require specific enhancement of CDC's diagnostic capacity and

enhanced disease surveillance

Table 3 - Category B Bioterrorism Agents

Bacteria Viruses Toxins

iella burnetti

(Q fever)

Brucella species

(Brucellosis) Burkholderia mallei

(Glanders)

Burkholderia pseudomallei

(Melioidosis)

Rickettsia promazekii

(Typhus fever)

Chlamydia psittaci

(Psittacosis) Alpha viruses

Venezuelan encephalomyelitis

Eastern equine encephalomyelitis

Westerm equine encephalomyelitis Ricin toxin

(Ricinus communis)

Epsilon toxin

(Clostridium perfringens)

Enterotoxin B

(Staphylococccus aureus)

T2 - Mycotoxins*

*Not listed under CDC Category B agents

T-2 Mycotoxins

Trichothecene mycotoxins are a group of more than 40 toxins produced

by common molds like Fusarium, Myrotecium, Trichoderma, Stachybotrys

and other filamentous fungi. They are extremely stable in the

environment and the only class of biological toxins that cause skin

damage. Usual hypochlorite solution does not inactivate these

toxins. They retain bioactivity even after autoclaving. Skin

exposure causes pain, pruritus, reduess, vesicles, necrosis and

sloughing. Severe irritant effects are seen on the respiratory

tract, GI tract and eyes on contact. Severe intoxication results in

shock and death. Diagnosis should be suspected if an aerosol attack

occurs in the form of " yellow rain " with contamination of the

clothes and the environment by pigmented oily fluids.

Treatment is supportive only. Soap and water washing can prevent or

significantly reduce dermal toxicity if done within 1 - 6 hours.

Superactivated charcoal should be used for oral intoxication.

No prophylactic chemotherapy or immunotherapy is available in the

field . Exposure during an attack should be prevented by mask and

clothing. Secondary aerosols are not a hazard. Contact with

contaminated skin and contaminated clothing can produce secondary

dermal exposures. Until decontamination is accomplished, contact

precautions are needed. Subsequently, standard precautions are

recommended for health care workers. Environmental decontamination

requires 1% sodium hypochloride with 0.1% NAOH for 1 hour contact

time.

References

Diamond J. Guns, Germs and Steel. New York, NY:wwNorton and Co;1999.

The Global Infectious Disease Threat and its Implication for the

United States. Washington, DC: Natonal Intelligence Council;

2000.Publication NIE 99-170.

Heymann, DL. Strengthening Global Preparedness for Defense Against

Infectious Disease Threats. Committee on Foreign Relations, United

States Senate. Hearing on the Threat of bioterrorism and the Spread

of Infectious Diseases. September 2001.

Gostin LO, Sapsin JW, Teret SP, et.al. The Model Sate Emergency

Health powers Act. JAMA.2002: 288:622-628.

US Commission on National Security in the 21st Century. New World

Coming: American Security in the 21st Century, supporting research

and analysis. September 15, 1999.

O'Toole T, Mair M, Inglesby TV. Shining light on dark winter.

Clinical Infectious Diseases. 2002; 34:972-983.

Inglesby TV, Grossman R, O'Toole T, et.al. A plague on your city:

observations from TOPOFF. Clinical Infectious Diseases. 2001; 32:436-

445.

Hoffman RE, Norton JE. Lessons learned from a full-scale

bioterrorism exercise. Emerging Infectious Diseases. 2000; 6:652-

653.

Barbera J, Macintyre A, Gostin L, et.al. Large scale quarantine

following biological terrorism in the United States. JAMA. 2001;

286:2711-2717.

DA. Testimony Before the Foreign Relations Committee:

Hearing on the Threat of Bioterrorism and the Spread of Infectious

Disease, 107th Cong, 1st Session (September 5, 2001).

Gostin LO,. Public Health Law and Ethics: A Reader. Berkeley and New

York, NY: University of California Press and Milbank Memorial Fund;

2002.

Mair JS, Sapsin J, Teret S. The Model State Emergency Health Powers

Act and Beyond. Biodefense Quarterly. 2002; 3:1-12.

SGJ. Bioterrorism, Public health and civil liberties. New

England Journal Of Medicine. 2002; 345:1337-1342.

Beeching NG, Dance D, Alastair RO, et.al. Biological warfare and

bioterrorism. BMJ. 2002: 321:336-339.

Relman DA, Olson JE. Bioterrorism preparedness: What practitioners

need to know. Infections in Medicine.2001; 18:497-514.

Tucker JB. Historical trends related to bioterrorism: An empirical

analysis. Emerging Infectious Diseases. 199; 5:498-504.

Eitzen EM, Takafuji ET. Historical overview of biological warfare.

In: Sidell FR, Takafuji EF, Franz DR, editiors. Medical aspects of

chemical and biological warfare. Washington, DC: Borden Institute;

1997. p. 415-423

GW, Cieslak TJ, Pavlin JA et al.Biological warfare. A

historical perspective. JAMA.1997; 278:412-417.

CQ Press. Chemical and Biological weapons. The CQ Researcher. 197;

7:8-9.

Wheelis M. Investigating disease outbreaks under a protocol to the

biological and toxin weapons convention. Emerging Infectious

Diseases. 200; 6:595-600.

Dorey E. US rejects stronger bioweapons treaty. Nature

Biotechnology. 2001; 19:793.

CJ. Nuclear blindness: An overview of the biological weapons

programs of the former Soviet Union and Iraq. Emerging Infectious

Diseases. 1999; 5:509-512.

Rorberts B. New Challenges and new policy priorities for the 1990;s.

In: Biologic Weapons; weapons of the future. Washington: Center for

Strategic and International Studies; 1993.

Bartlett JG. Thoughts on Bioterrorism. ls of Internal Medicine.

1999; 131:273-280.

Carus WS. Bioterrorism and Biocrimes: The Illicit Use of Biological

Agents in the 20th Century. Washington: Center for

Counterproliferation Research, National Defense University; Aug

1998, revised Mar 1999.

Henderso DA. Bioterrorism as a public health threat. Emerging

Infectious Diseases. 1998 4:488-492.

Daplan E, Marchell A. The Cult at the End of the World. New York:

Crown Publishing Group; 1996.

Kortepeter MG, GW. Potential biological weapons threats.

Emerging Infectious Diseases. 1999; 5:523-527.

Zalinskas RA. Iraq's biological weapons: The past or future? JAMA.

1997; 278:418-424.

s CF, Burstein JL, Waeckerle JF, et.al. Emergency physicians

and biological terrorism. Ann Emerg Med. 1999; 34:183-190.

Hawley RJ, Eitzen EM Jr. Biological weapons - a primer for

microbiologists. Annu Rev Microbiol. 2001; 55:235-53.

Beeching NJ, Dance DA, AR, et.al. Biological warfare and

bioterrorism. BMJ. 2002; 324:336-339.

Danzig R, Berkowsky PB. Why should we be concerned about biological

weapons. JAMA. 1997; 278:431-432.

Kaufmann AF, Meltzer MI, Schnid GP. The economic impact of a

bioterrorist attack: Are prevention and past attack intervention

programs justifiable? Emerging Infectious Diseases. 1997; 3:83-94.

CDC. Biological and Chemical Terrorism: Strategic Plan for

Preparedness and Response: Recommendatons of the CDC Strategic

Planning Workgroup. MMWR Recomm Rep. 2000; 49(RR-4):1-26.

JM. Agents of bioterrorism; preparing for bioterrorism at the

community health care level. Infect Dis Clinc North Am. 2001;

15:1127-1156.

Inglesby TV, Dennis DT, DA, et al. Plague as a biological

weapon: Medical and public health management. JAMA. 2000; 283; 2281-

2290.

CDC. Pneumonic plague - Arizona, 1992. MMWR Morb Mortal Wkly Rep.

1992; 41:737-739.

Werner SB, Weidmer CE, BC ,et.al. Primary plague pneumonia

contracted from a domestic cat at South Lake Tahoe, CA. JAMA. 1984;

251:929-931.

RD, Fetherson JD. Yersinia pestis - etiologic agent of plague.

Clinical Microbiol Rev. 1997; 10:35-66.

CDC. Fatal human plague - Arizona and Colorado, 1996. MMWR Morb

Mortal Wkly Rep. 1997; 46-617-620.

Galimand M, Guiyoule A, Gerbaud G, et. Al. Multidrug resistance in

Yersinia pestis mediated by a transferable plasmid. New England

Journal of Medicine. 1997; 337:677-680

Darling RG, Catlett CL, Huebner KD, et.al. Threats in bioterrorism.

I:CDC category A agents, Emerg Med Clin North Am. 2002; 20:273-409.

US Army. USAMERIID's Medical Management of Biological Casualties

Handbook. US Army Medical Research Institute of Infectious Diseases,

Fort Detrick, Fredrick, land.

Srinivasan A, Krauscn, DeShazer D, et al. Glanders in a military

research microbiologist. N England J Medicine. 2001; 345:256-258.

American Public health Association. Plague,. In: Benenson AS, ed.

Control of Communicable Diseases Manual. Washington, DC: American

Pubic Health Association; 1995:353-358.

Rotz LD, Khan AS, Lillibridge SR, et. Al. Public Health assessment

of potential biological terrorism agents. Emerging Infectious

Diseases. 2002; 8:225-230.

Dupont HT, Raoult D, Brouqui P. Epidemiologic Features and Clinical

Presentation of Acute Q Fever in Hospitalized Patients: 323 French

cases. The American Journal of Medicine. 1992; 93:427-434.

Biological Warfare. Preparing for the Unthinkable Emergency. 2001;2.

Whitley, RJ, Gnann JW. Viral encephalitis; familiar infections and

emerging pathogens. The Lancet. 2002; 359:507-513.

Boria L, Inglesby T, s CJ et al. Hemorrhagic fever viruses as

biological weapons. JAMA. 2002; 287:239-242.

Franz DR, Jarhling PB, Friendlander AM, et al. Clinical recognition

and management of patients exposed to biological warfare agents.

JAMA.1997;278:339-441

Meyer RF, Moise SA. Bioterrorism preparedness for the public health

and medical communities. May Clin Proc. 2002; 77:619-621.

Khan AS, Moise SA, Lillibridge S. Public health preparedness for

biological terrorism in the USA. The Lancet. 200; 356:1179-1182.

Zoon KC. Vaccines, Pharmaceutical products, and bioterrorism:

Challenges for the US Food and Drug Administration. Emerging

Infectious Diseases. 1999; 5:241-246.

GW, Eitzen EM. Air evacuation under high-level biosafety

containment: The Aeromedical Isolation Team. Emerging Infectious

Diseases. 1999;5:241-246.

English JF et al. Bioterrorism readiness Plan: A template for

Healthcare Facilities. A document prepared by APIC Bioterrorism Task

Force and CDC Hospital Infections Program Bioterorism Working Group.

April 13, 1999.

National Association of Counties. County Public Health preparedness

hHp://www.naco.org/pubs/surveys/pubhealth/index.cfm.

Lazarus R, Kleinman K, Dashevsky I, et al. Use of automated

ambulatory care encounter records for detection of acute illness

clusters, including potential bioterrorism events. Emerging

Infectious Diseases. 2002; 8:753-760.

Casadeva;; A. Passive Antibody Administration (Immediate Immunity)

as a Specific Defense against Biological Weapons. Emerging

Infectious Diseases.2002;8:833-841.

Kaufman AF, Meltzer M, Schmid GP. The Economic Impact of a

bioterrorist attack: Are prevention and post attack intervention

programs justifiable. Emerging Infectious Diseases.1997.; 3:83-204.

[Guest guest]

thanks KC, how do you know? just what I was looking

for.

>

> Southern Illinois University School of Medicine

> Department of Internal Medicine

> Division of Infectious Diseases

> PO Box 19636

> Springfield, Illinois 62794-9636

> 217/545-0181

>

> Division Secretary: 217/545-0181

> Fellowship Information: idfellowship@...

> ID Nurse: 217/545-9537

>

>

>

http://www.siumed.edu/medicine/infec/patinfo/current/bioterrorism.htm

>

> The Threat of Biological Weapons

>

> For a biological weapon to be highly effective, three conditions

> should be optimized. The biological agent should consistently

> produce the desired effect of death or disease. It should be highly

> contagious with short and predictable incubation period and

> infective in low doses. The disease should be difficult to identify

> and be suspected as an act of bioterrorism. The agents should be

> suitable for mass production, storage, weaponisation, and stable

> during dissemination. The target population should have little or

no

> immunity and little or no access to treatment. The terrorist should

> have means to protect or treat their own forces and population

> against the infectious agents or the toxins (32).

>

> The agents with potential of biological terrorism include

bacterial,

> fungal and viral pathogens and toxins produced by living organisms.

> Infectious agents that could potentially be used include those

> causing anthrax (Bacillus anthracis), plague (Yersinia pestis),

> tularemia (Francisella tularensis), equine encephalitides (e.g.

> Venezuelan equine encephalitis viruses), hemorrhagic fevers

> (arenaviruses, filoviruses, flaviviruses, and bunyaviruses), and

> small pox (variola virus). Toxins include botulinum toxin from

> Clostridium botulinum; ricin toxin from the castor bean Ricinus

> communis; trichothecene mycotoxins from Fusarium, Myrotecium

> Trichoderma, Stachybotrys, and other filamentous fungi;

> staphylococcal enterotoxins from Staphylococcus aureus; and toxins

> from marine organisms such as dinoflagellates, shellfish, and blue-

> green algae. Depending on the agents, a lethal or incapacitating

> outcome can occur. In a military context, incapacitating agents may

> be more effective because the unit will not be able to perform

their

> mission and casualties will consume scarce medical and evacuation

> assets (31).

>

> Agents of Bioterrorism Attacks

>

> Based on the ease of transmission, severity of morbidity,

mortality,

> and likelihood of use, biological agents can be classified into 3

> categories (Table 1) (35). Table 2 summarizes the biological agents

> in category A.

>

> Category B Agents

>

> This category (47) contains the second highest priority agents

> because they

> a. are moderately easy to disseminate

> b. cause moderate morbidity and low mortality

> c. require specific enhancement of CDC's diagnostic capacity and

> enhanced disease surveillance

>

> Table 3 - Category B Bioterrorism Agents

>

> Bacteria Viruses Toxins

> iella burnetti

> (Q fever)

> Brucella species

> (Brucellosis) Burkholderia mallei

> (Glanders)

> Burkholderia pseudomallei

> (Melioidosis)

> Rickettsia promazekii

> (Typhus fever)

> Chlamydia psittaci

> (Psittacosis) Alpha viruses

> Venezuelan encephalomyelitis

> Eastern equine encephalomyelitis

> Westerm equine encephalomyelitis Ricin toxin

> (Ricinus communis)

> Epsilon toxin

> (Clostridium perfringens)

> Enterotoxin B

> (Staphylococccus aureus)

> T2 - Mycotoxins*

>

> *Not listed under CDC Category B agents

>

>

> T-2 Mycotoxins

>

> Trichothecene mycotoxins are a group of more than 40 toxins

produced

> by common molds like Fusarium, Myrotecium, Trichoderma,

Stachybotrys

> and other filamentous fungi. They are extremely stable in the

> environment and the only class of biological toxins that cause skin

> damage. Usual hypochlorite solution does not inactivate these

> toxins. They retain bioactivity even after autoclaving. Skin

> exposure causes pain, pruritus, reduess, vesicles, necrosis and

> sloughing. Severe irritant effects are seen on the respiratory

> tract, GI tract and eyes on contact. Severe intoxication results in

> shock and death. Diagnosis should be suspected if an aerosol attack

> occurs in the form of " yellow rain " with contamination of the

> clothes and the environment by pigmented oily fluids.

>

> Treatment is supportive only. Soap and water washing can prevent or

> significantly reduce dermal toxicity if done within 1 - 6 hours.

> Superactivated charcoal should be used for oral intoxication.

>

> No prophylactic chemotherapy or immunotherapy is available in the

> field . Exposure during an attack should be prevented by mask and

> clothing. Secondary aerosols are not a hazard. Contact with

> contaminated skin and contaminated clothing can produce secondary

> dermal exposures. Until decontamination is accomplished, contact

> precautions are needed. Subsequently, standard precautions are

> recommended for health care workers. Environmental decontamination

> requires 1% sodium hypochloride with 0.1% NAOH for 1 hour contact

> time.

>

>

> References

>

> Diamond J. Guns, Germs and Steel. New York, NY:wwNorton and

Co;1999.

> The Global Infectious Disease Threat and its Implication for the

> United States. Washington, DC: Natonal Intelligence Council;

> 2000.Publication NIE 99-170.

> Heymann, DL. Strengthening Global Preparedness for Defense Against

> Infectious Disease Threats. Committee on Foreign Relations, United

> States Senate. Hearing on the Threat of bioterrorism and the Spread

> of Infectious Diseases. September 2001.

> Gostin LO, Sapsin JW, Teret SP, et.al. The Model Sate Emergency

> Health powers Act. JAMA.2002: 288:622-628.

> US Commission on National Security in the 21st Century. New World

> Coming: American Security in the 21st Century, supporting research

> and analysis. September 15, 1999.

> O'Toole T, Mair M, Inglesby TV. Shining light on dark winter.

> Clinical Infectious Diseases. 2002; 34:972-983.

> Inglesby TV, Grossman R, O'Toole T, et.al. A plague on your city:

> observations from TOPOFF. Clinical Infectious Diseases. 2001;

32:436-

> 445.

> Hoffman RE, Norton JE. Lessons learned from a full-scale

> bioterrorism exercise. Emerging Infectious Diseases. 2000; 6:652-

> 653.

> Barbera J, Macintyre A, Gostin L, et.al. Large scale quarantine

> following biological terrorism in the United States. JAMA. 2001;

> 286:2711-2717.

> DA. Testimony Before the Foreign Relations Committee:

> Hearing on the Threat of Bioterrorism and the Spread of Infectious

> Disease, 107th Cong, 1st Session (September 5, 2001).

> Gostin LO,. Public Health Law and Ethics: A Reader. Berkeley and

New

> York, NY: University of California Press and Milbank Memorial Fund;

> 2002.

> Mair JS, Sapsin J, Teret S. The Model State Emergency Health Powers

> Act and Beyond. Biodefense Quarterly. 2002; 3:1-12.

> SGJ. Bioterrorism, Public health and civil liberties. New

> England Journal Of Medicine. 2002; 345:1337-1342.

> Beeching NG, Dance D, Alastair RO, et.al. Biological warfare and

> bioterrorism. BMJ. 2002: 321:336-339.

> Relman DA, Olson JE. Bioterrorism preparedness: What practitioners

> need to know. Infections in Medicine.2001; 18:497-514.

> Tucker JB. Historical trends related to bioterrorism: An empirical

> analysis. Emerging Infectious Diseases. 199; 5:498-504.

> Eitzen EM, Takafuji ET. Historical overview of biological warfare.

> In: Sidell FR, Takafuji EF, Franz DR, editiors. Medical aspects of

> chemical and biological warfare. Washington, DC: Borden Institute;

> 1997. p. 415-423

> GW, Cieslak TJ, Pavlin JA et al.Biological warfare. A

> historical perspective. JAMA.1997; 278:412-417.

> CQ Press. Chemical and Biological weapons. The CQ Researcher. 197;

> 7:8-9.

> Wheelis M. Investigating disease outbreaks under a protocol to the

> biological and toxin weapons convention. Emerging Infectious

> Diseases. 200; 6:595-600.

> Dorey E. US rejects stronger bioweapons treaty. Nature

> Biotechnology. 2001; 19:793.

> CJ. Nuclear blindness: An overview of the biological weapons

> programs of the former Soviet Union and Iraq. Emerging Infectious

> Diseases. 1999; 5:509-512.

> Rorberts B. New Challenges and new policy priorities for the

1990;s.

> In: Biologic Weapons; weapons of the future. Washington: Center for

> Strategic and International Studies; 1993.

> Bartlett JG. Thoughts on Bioterrorism. ls of Internal Medicine.

> 1999; 131:273-280.

> Carus WS. Bioterrorism and Biocrimes: The Illicit Use of Biological

> Agents in the 20th Century. Washington: Center for

> Counterproliferation Research, National Defense University; Aug

> 1998, revised Mar 1999.

> Henderso DA. Bioterrorism as a public health threat. Emerging

> Infectious Diseases. 1998 4:488-492.

> Daplan E, Marchell A. The Cult at the End of the World. New York:

> Crown Publishing Group; 1996.

> Kortepeter MG, GW. Potential biological weapons threats.

> Emerging Infectious Diseases. 1999; 5:523-527.

> Zalinskas RA. Iraq's biological weapons: The past or future? JAMA.

> 1997; 278:418-424.

> s CF, Burstein JL, Waeckerle JF, et.al. Emergency physicians

> and biological terrorism. Ann Emerg Med. 1999; 34:183-190.

> Hawley RJ, Eitzen EM Jr. Biological weapons - a primer for

> microbiologists. Annu Rev Microbiol. 2001; 55:235-53.

> Beeching NJ, Dance DA, AR, et.al. Biological warfare and

> bioterrorism. BMJ. 2002; 324:336-339.

> Danzig R, Berkowsky PB. Why should we be concerned about biological

> weapons. JAMA. 1997; 278:431-432.

> Kaufmann AF, Meltzer MI, Schnid GP. The economic impact of a

> bioterrorist attack: Are prevention and past attack intervention

> programs justifiable? Emerging Infectious Diseases. 1997; 3:83-94.

> CDC. Biological and Chemical Terrorism: Strategic Plan for

> Preparedness and Response: Recommendatons of the CDC Strategic

> Planning Workgroup. MMWR Recomm Rep. 2000; 49(RR-4):1-26.

> JM. Agents of bioterrorism; preparing for bioterrorism at

the

> community health care level. Infect Dis Clinc North Am. 2001;

> 15:1127-1156.

> Inglesby TV, Dennis DT, DA, et al. Plague as a biological

> weapon: Medical and public health management. JAMA. 2000; 283; 2281-

> 2290.

> CDC. Pneumonic plague - Arizona, 1992. MMWR Morb Mortal Wkly Rep.

> 1992; 41:737-739.

> Werner SB, Weidmer CE, BC ,et.al. Primary plague pneumonia

> contracted from a domestic cat at South Lake Tahoe, CA. JAMA. 1984;

> 251:929-931.

> RD, Fetherson JD. Yersinia pestis - etiologic agent of

plague.

> Clinical Microbiol Rev. 1997; 10:35-66.

> CDC. Fatal human plague - Arizona and Colorado, 1996. MMWR Morb

> Mortal Wkly Rep. 1997; 46-617-620.

> Galimand M, Guiyoule A, Gerbaud G, et. Al. Multidrug resistance in

> Yersinia pestis mediated by a transferable plasmid. New England

> Journal of Medicine. 1997; 337:677-680

> Darling RG, Catlett CL, Huebner KD, et.al. Threats in bioterrorism.

> I:CDC category A agents, Emerg Med Clin North Am. 2002; 20:273-409.

> US Army. USAMERIID's Medical Management of Biological Casualties

> Handbook. US Army Medical Research Institute of Infectious

Diseases,

> Fort Detrick, Fredrick, land.

> Srinivasan A, Krauscn, DeShazer D, et al. Glanders in a military

> research microbiologist. N England J Medicine. 2001; 345:256-258.

> American Public health Association. Plague,. In: Benenson AS, ed.

> Control of Communicable Diseases Manual. Washington, DC: American

> Pubic Health Association; 1995:353-358.

> Rotz LD, Khan AS, Lillibridge SR, et. Al. Public Health assessment

> of potential biological terrorism agents. Emerging Infectious

> Diseases. 2002; 8:225-230.

> Dupont HT, Raoult D, Brouqui P. Epidemiologic Features and Clinical

> Presentation of Acute Q Fever in Hospitalized Patients: 323 French

> cases. The American Journal of Medicine. 1992; 93:427-434.

> Biological Warfare. Preparing for the Unthinkable Emergency.

2001;2.

> Whitley, RJ, Gnann JW. Viral encephalitis; familiar infections and

> emerging pathogens. The Lancet. 2002; 359:507-513.

> Boria L, Inglesby T, s CJ et al. Hemorrhagic fever viruses as

> biological weapons. JAMA. 2002; 287:239-242.

> Franz DR, Jarhling PB, Friendlander AM, et al. Clinical recognition

> and management of patients exposed to biological warfare agents.

> JAMA.1997;278:339-441

> Meyer RF, Moise SA. Bioterrorism preparedness for the public health

> and medical communities. May Clin Proc. 2002; 77:619-621.

> Khan AS, Moise SA, Lillibridge S. Public health preparedness for

> biological terrorism in the USA. The Lancet. 200; 356:1179-1182.

> Zoon KC. Vaccines, Pharmaceutical products, and bioterrorism:

> Challenges for the US Food and Drug Administration. Emerging

> Infectious Diseases. 1999; 5:241-246.

> GW, Eitzen EM. Air evacuation under high-level

biosafety

> containment: The Aeromedical Isolation Team. Emerging Infectious

> Diseases. 1999;5:241-246.

> English JF et al. Bioterrorism readiness Plan: A template for

> Healthcare Facilities. A document prepared by APIC Bioterrorism

Task

> Force and CDC Hospital Infections Program Bioterorism Working

Group.

> April 13, 1999.

> National Association of Counties. County Public Health preparedness

> hHp://www.naco.org/pubs/surveys/pubhealth/index.cfm.

> Lazarus R, Kleinman K, Dashevsky I, et al. Use of automated

> ambulatory care encounter records for detection of acute illness

> clusters, including potential bioterrorism events. Emerging

> Infectious Diseases. 2002; 8:753-760.

> Casadeva;; A. Passive Antibody Administration (Immediate Immunity)

> as a Specific Defense against Biological Weapons. Emerging

> Infectious Diseases.2002;8:833-841.

> Kaufman AF, Meltzer M, Schmid GP. The Economic Impact of a

> bioterrorist attack: Are prevention and post attack intervention

> programs justifiable. Emerging Infectious Diseases.1997.; 3:83-204.

>