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Bioterrorism and High Consequence Biological Threats
Topic Collection
November 6, 2019

Topic Collection: Bioterrorism and High Consequence Biological Threats

Bioterrorism and other high consequence biological events can result in mass casualties, epidemic illness, healthcare worker illness, environmental contamination, legal issues, and cause unease within the medical community and the community at large. In addition to agents of concern due to their possible use in a bioterrorist attack, this Topic Collection (TC) contains information on other potential high consequence threats from emerging diseases, accidental releases, and scientific advances, such as dual use research and synthetic biology. Biological incidents call for collaboration between multiple disciplines including healthcare, public health, emergency management, and law enforcement and require specific planning and response interventions.

The resources in this TC highlight recent research, promising practices, and model procedures for preparing for, responding to, and recovering from an act of bioterror or widespread illness caused by a high consequence biological agent. This TC is intended as a contemporary annotated bibliography of articles and resources and is not intended to present a comprehensive review of the literature. It provides information about biodefense and bioterrorism and selected specific agents. Medical countermeasure distribution information is found in a separate TC.

Information on additional biological threats and some specific agents may be found in the following TCs (listed alphabetically): Epidemic/Pandemic Influenza; SARS/MERS; VHF/Ebola; and Zika. Information on additional terrorist threats may be found in these TCs: Chemical Hazards, Explosives and Mass Shooting, and Radiological and Nuclear.

Related information can be found in the following TCs: Crisis Standards of Care, Disaster Ethics, Fatality Management, Healthcare-Related Disaster Legal/ Regulatory/ Federal Policy, Hospital Patient Decontamination, Mental/Behavioral Health, Pharmacy, Pediatric, Pre-Hospital Patient Decontamination, and Responder Safety and Health. Please click here for a list of all comprehensively developed TCs. 

Must Reads


Adalja, A., Toner, E., and Inglesby, T. (2015). Clinical Management of Potential Bioterrorism-Related Conditions. New England Journal of Medicine. 372:954-62.
The authors review the clinical management of five diseases caused by category A agents: anthrax, smallpox, pneumonic plague, botulism, and tularemia. For anthrax, they discuss the three forms found in humans, special considerations for children and women, diagnosis, treatment, and prevention. For the other four diseases, they describe cardinal features, diagnosis, and treatment and prevention.
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APIC Bioterrorism Task Force and CDC Hospital Infections Program Bioterrorism Working Group. (1999). Bioterrorism Readiness Plan: A Template for Healthcare Facilities.
In cooperation with the Centers for Disease Control and Prevention (CDC), APIC produced this Bioterrorism Readiness Plan to serve as a reference document and initial template to facilitate preparation of bioterrorism readiness plans for individual institutions.
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Arnon, S., Schechter, R., Inglesby, T., et al. (2001). Botulinum Toxin as a Biological Weapon. Journal of the American Medical Association, 285(16):2081.
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of botulinum toxin. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Botulism as a weapon.
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Ashford, D.A., et al. (2003). Planning against Biological Terrorism: Lessons from Outbreak Investigations. Emerging Infectious Diseases. May 9(5):515-519.
This article examines outbreak investigations conducted around the world from 1988 to 1999 and describes lessons learned from outbreak investigations that involved biologic agents with potential for bioterrorism.
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Association of Public Health Laboratories and American Society for Microbiology. (2016). Clinical Laboratory Preparedness and Response Guide.
This comprehensive guide includes tools and standards that can help laboratories recognize that a specimen contains a biological threat agent, handle said specimens, and notify appropriate state and federal partners. It includes helpful graphics, charts, and links to related resources.
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This report identifies the need for improvement in biological threat readiness in several areas: achieving coordination and accountability, elevating collaboration, and driving innovation. The panel provides recommendations to address these three areas.
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Bush, L.M. and Perez, M.T. (2012). The Anthrax Attacks 10 Years Later. Annals of Internal Medicine. 156(1_Part_1):41–44.
This article reviews the lessons learned during the first documented case of the 2001 anthrax attacks. The authors provide in depth details of the initial arrival of the patient to the hospital, physician identification of the agent, internal and external alerting protocols, criminal investigation, challenges within vaccination protocols, and the importance of surveillance for rapid disease identification.
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California Department of Health Services. (2002). California Hospital Bioterrorism Planning Response Planning Guide.
This guide includes recommendations, references, and standards to help hospitals prepare for a bioterrorism event involving plague, smallpox, and/or viral hemorrhagic fevers. Organized into three planning sections which cover reporting requirements, internal and external communication protocols, and detailed agent information the guide can be modified as needed to integrate into existing emergency response plans.
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Dembek, Z. (2007). Medical Aspects of Biological Warfare. Office of the Surgeon General, Department of the Army.
This free on-line textbook provides an in-depth historical overview of biological weapons, includes chapters on specific bioterror agents, and provides information on laboratory identification, consequence management, medical management, medical countermeasures, and biosafety and biosurety.
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This document describes the framework for the federal government’s response to and recovery from a naturally-occurring or terrorist-caused biological incident. The annex consists of a base annex that applies to all biological incidents and a branch plan for suspected or actual biological attacks.
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Grundmann, O. (2014). The Current State of Bioterrorist Attack Surveillance and Preparedness in the US. Risk Management and Healthcare Policy.7:177–187.
The author shares the history and lessons learned from bioterrorism-related events between 1990 and 2010. The article highlights the importance of using critical risk management approaches such as surveillance, monitoring, and risk assessments to enhance preparedness and response capabilities during future bioterrorism events
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Henderson, D., Inglesby, T., Bartlett, J. (1999). Smallpox as a Biological Weapon: Medical and Public Health Management. Journal of American Medical Association. 281(22): 2127-2137.
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of Smallpox. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Smallpox as a weapon.
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Inglesby, T., Dennis, D., Henderson, D. et al. (2000). Plague as a Biological Weapon Medical and Public Health Management. Journal of American Medical Association. 283(17): .
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of Plague. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Plague as a weapon.
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This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of Anthrax. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Anthrax as a weapon.
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Los Angeles County Department of Public Health and Los Angeles County Emergency Medical Services Agency. (2012). Terrorism Agent Information and Treatment Guidelines for Clinicians and Hospitals.
Clinicians and others can use this manual to further their knowledge on bioterrorism agents, chemical and radiological terrorism, infection control, and management of exposed persons.
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McCarty, C., Angelo, K., Beer, K., et al. (2015). Notes from the Field: Large Outbreak of Botulism Associated with a Church Potluck Meal - Ohio, 2015. Morbidity and Mortality Weekly Report (MMWR).64(29):802-803.
This report provides a summary of the 2015 botulism outbreak in Fairfield County, Ohio. The authors review the public health and medical response from the initial onset of the outbreak through the investigation and identification of the botulism source. The report highlights the importance of coordination among healthcare responders during botulism outbreaks.
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National Academies of Science and US Department of Homeland Security. (2004). Biological Attack: Human Pathogens, Biotoxins, and Agricultural Threats.
This report brief provides clear, concise information to the media, public, and health care workers on the characteristics, dangers, and consequences associated with various types of attacks.
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National Academies of Sciences, Engineering, and Medicine. (2018). Biodefense in the Age of Synthetic Biology. The National Academies Press.
This report reviews the uses of synthetic biology and explores potential misuses. The authors develop a framework to assess the security concerns related to advances in synthetic biology, ranks those concerns, and identifies options that could help mitigate the concerns.
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National Ebola Training and Education Center. (n.d.). Special Pathogens of Concern. (Accessed 6/25/2018.)
This online course informs healthcare workers of factors of special pathogens that may warrant treatment of infected patients in biocontainment units. The course includes clinical presentation descriptions of viral hemorrhagic fevers and highly pathogenic respiratory viruses.
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Rainisch, G., Meltzer, M., Shadomy, S., et al. (2017). Modeling Tool for Decision Support During Early Days of an Anthrax Event. Emerging Infectious Diseases. 23(1): 46-55.
The authors developed a model based on the first three days of case data to project cases, peak hospital caseload, and deaths from an inhalational anthrax incident and the effects of interventions on these projections.
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San Francisco Department of Public Health. (2011). Infectious Disease Emergency Response Plan.
This plan contains the following sections: command, plans section (by unit), operations section, logistics, and finance. Four annexes that focus on different threats are included, as are sample forms and other appendices.
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Smith, P., Anderson, A., Christopher, G., et al. (2006). Designing a Biocontainment Unit to Care for Patients with Serious Communicable Diseases: A Consensus Statement. (Abstract only.) Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 4(4):351-365.
The authors synthesized consensus recommendations collected from a conference of civilian and military professionals who are involved in the various aspects of biocontainment patient care units. Appendices include in-depth information on medical care issues (e.g., staffing the units, pathology, housekeeping), infection control issues (e.g., personal protective equipment, dealing with infectious waste), facility issues (e.g., air-handling, communication), and psychosocial and ethical issues.
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This position paper describes a proposal to establish a national bioterrorism incident response capability through the development of trained and equipped teams. The authors review gaps in bioterrorism response capability and suggest using hazardous materials response teams as a model for teams involved in the initial phases of incident characterization and response.
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Toner, E., Shearer, M., Kirk Sell, T., et al. (2017). Health Sector Resilience Checklist for High Consequence Infectious Diseases – Informed by the Domestic U.S. Ebola Response. Johns Hopkins Bloomberg School of Public Health Center for Health Security.
This document provides action steps for responding to isolated cases or limited outbreaks of high-consequence infectious diseases, including those that are: novel or rare in the community, moderate to highly contagious, moderate to highly lethal, not easily controlled by medical countermeasures and other interventions, and have the potential to cause exceptional public concern. The document includes a general checklist and population-specific checklists for public health, healthcare, emergency medical services, and elected officials.
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This issue report reviews lessons learned during the 2001 anthrax attacks through in-depth interviews with responding professionals from local, state, and federal public health agencies. They discuss their experiences during the 2001 attacks, reflect on the progress made within the 10 years since the attack, identify ongoing preparedness gaps, and provide recommendations for sustaining public health emergency response capabilities through all hazards planning.
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U.S. Army Medical Research Institute on Infectious Diseases. (2014). Medical Management of Biological Casualties Handbook, 8th Edition.
Known informally as the “Blue Book,” this handbook provides an overview of the history of biological warfare and current threats and information on distinguishing between naturally-occurring and intentional disease outbreaks, discusses biosurveillance, offers ten steps in the management of potential biological casualties, notes emerging threats and potential biological weapons, and provides information on personal protection, field detection, and decontamination. Chapters are devoted to specific bacterial agents, viral agents, and biological toxins.
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U.S. Environmental Protection Agency. (2016). Best Practices for Management of Biocontaminated Waste.
This document provides best practices for waste management activities during a biological incident response.
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This handbook offers an overview of infectious disease threats and the importance of effectively managing them, provides 10 key facts on 15 deadly diseases, and contains three toolboxes (the role of WHO, the International Coordinating Group on vaccine provision, and tables for laboratory diagnosis and shipment of infectious substances).
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Biodefense Policy and Strategy


This recorded conference session features staff from the Centers for Disease Control and Prevention, the Department of Defense, and the U.S. Agency for International Development describing their work in global health security.
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This report identifies the need for improvement in biological threat readiness in several areas: achieving coordination and accountability, elevating collaboration, and driving innovation. The panel provides recommendations to address these three areas.
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Blue Ribbon Panel on Biodefense. (2018). Transnational Biological Threats and Global Security.
This public meeting recording features presentations on current biological threats, global homeland defense and security, global efforts to combat these types of threats, international public health security, and elevating global health security as a priority.
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* National Academies of Sciences, Engineering, and Medicine. (2018). Biodefense in the Age of Synthetic Biology. The National Academies Press.
This report reviews the uses of synthetic biology and explores potential misuses. The authors develop a framework to assess the security concerns related to advances in synthetic biology, ranks those concerns, and identifies options that could help mitigate the concerns.
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Schoch-Spana, M., Cicero, A., Adalja, A. et al. (2017). Global Catastrophic Biological Risks: Toward a Working Definition. Health Security. 15(4): 323-328.
This article analyzes potential global catastrophic biological risks to further enhance dialogue, clearly define the category of risks, and improve preparedness and response efforts to minimize the impacts of disasters and epidemics associated with such biological threats. The authors review past epidemics such as H5N, 2009 H1N1, 1918 Flu Pandemic and hypothesize the impact of additional biological, and technological events which could damage, national governments, international relationships, societal stability, and global security.
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This report identifies nine priority areas and accompanying action items to address the threat of diseases with pandemic potential. Among these are having a coordinated national biodefense policy with strong, centralized leadership to guide it and building and sustaining a public health infrastructure that can prevent, detect, and respond to naturally-occurring and human-caused infectious disease incidents.
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This position paper describes a proposal to establish a national bioterrorism incident response capability through the development of trained and equipped teams. The authors review gaps in bioterrorism response capability and suggest using hazardous materials response teams as a model for teams involved in the initial phases of incident characterization and response.
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This Executive Order: expresses the importance of scientific research with biological select agents and toxins as it relates to national security; highlights security requirements relative to misuse, theft, loss, and accidental release; and emphasizes the need for security that balances their efficacy with the minimization of adverse impacts on legitimate use.
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The authors compared and analyzed laboratory biosafety category lists and biological agent biodefense lists from multiple countries. They recommended increased consistency in naming biological and assigning risk levels to improve laboratory safety, communication, and situation management. They also suggested that developing nations develop their own biodefense lists reflecting their threats and capabilities. The authors note that international collaboration is required to achieve their recommendations
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* Toner, E., Shearer, M., Kirk Sell, T., et al. (2017). Health Sector Resilience Checklist for High Consequence Infectious Diseases – Informed by the Domestic U.S. Ebola Response. Johns Hopkins Bloomberg School of Public Health Center for Health Security.
This document provides action steps for responding to isolated cases or limited outbreaks of high-consequence infectious diseases, including those that are: novel or rare in the community, moderate to highly contagious, moderate to highly lethal, not easily controlled by medical countermeasures and other interventions, and have the potential to cause exceptional public concern. The document includes a general checklist and population-specific checklists for public health, healthcare, emergency medical services, and elected officials.
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This notice summarizes the Centers for Disease Control and Prevention’s required biennial review of the list of biological agents and toxins with potential to pose a severe threat to public health and safety.
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U.S. Food and Drug Administration. (n.d.). MCM Legal, Regulatory and Policy Framework. (Accessed 11/25/2019.)
The FDA works within this framework to ensure that U.S. laws, regulations and policies help support preparedness and response for potential chemical, biological, radiological, nuclear (CBRN) and emerging infectious disease threats. This webpage includes links to related legislation, emergency use authorities of the FDA, and legal and policy presentations, publications, and other information.
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U.S. Government Accountabily Office. (2017). Federal Efforts to Develop Biological Threat Awareness.
This report describes how federal agencies develop biological threat awareness, use that information to support investment decisions, share threat awareness among agencies, and determine additional threat characterization knowledge to pursue.
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Wagar, E. (2016). Bioterrorism and the Role of the Clinical Microbiology Laboratory. Clinical Microbiology Reviews. 29(1):175-189 .
This article provides an overview of the history of bioterrorism, the development of the Laboratory Response Network, and the important role of clinical microbiology labs in supporting response efforts. The author reviews agents that pose a high risk of occupational exposure and discusses the importance of risk assessments and management resources such as templates and checklists to worker safety and laboratory performance.
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Clinical Management


Adalja, A. (2018). Biothreat Agents and Emerging Infectious Disease in the Emergency Department. (First page only.) Emergency Medicine Clinics of North America. 36(4):823-834.
The author describes the role of emergency department clinicians in recognizing and containing potential emerging infectious disease outbreaks.
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Adalja, A., Toner, E., and Inglesby, T. (2015). Clinical Management of Potential Bioterrorism-Related Conditions. New England Journal of Medicine. 372:954-62.
The authors review the clinical management of five diseases caused by category A agents: anthrax, smallpox, pneumonic plague, botulism, and tularemia. For anthrax, they discuss the three forms found in humans, special considerations for children and women, diagnosis, treatment, and prevention. For the other four diseases, they describe cardinal features, diagnosis, and treatment and prevention.
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Busl, K. and Bleck, T. (2012). Treatment of Neuroterrorism. Neurotherapeutics. 9(1):139-157.
The authors discuss the neurological effects of biological and chemical agents/toxins that may be used for terrorism, and the role that neurologists must play in identifying and treating them. This includes how to determine when observed neurological effects are the result of exposure to biological or chemical terrorism, or the result of naturally-occurring disease.
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Centers for Disease Control and Prevention. (2019). Smallpox: Prevention and Treatment.
This webpage explains how the smallpox vaccine can help prevent infection (prior to or within days of exposure) and lists three antiviral drugs that have been shown effective against smallpox: Tecovirimat, Cidofovir, and Brincidofovir.
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Petersen, B., Damon, I., Pertowski, C., et al. (2015). Clinical Guidance for Smallpox Vaccine Use in a Postevent Vaccination Program. Morbidity and Mortality Weekly Report. 64(RR02):1-26.
This report provides recommendations for the clinical use of the three smallpox vaccines included in the Strategic National Stockpile for persons exposed to the virus or at high risk for infection during a post-event vaccination program. Descriptions, administration and dosage, regulatory status, efficacy, and safety information are included for each vaccine. The report also includes recommendations on use, including considerations for contraindications and special populations, and identifies remaining knowledge gaps and areas for future research.
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The authors reviewed literature to identify new prophylaxis and post-exposure treatment research and recommendations for bioterror agents. They provided a summary table of biological agents by type with mode/mechanism of action and signs and symptoms of infection followed by current prophylaxis and treatment options.
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Education and Training


Ashford, D.A., et al. (2003). Planning against Biological Terrorism: Lessons from Outbreak Investigations. Emerging Infectious Diseases. May 9(5):515-519.
This article examines outbreak investigations conducted around the world from 1988 to 1999 and describes lessons learned from outbreak investigations that involved biologic agents with potential for bioterrorism.
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Department of Emergency Health Services. (n.d.). Emerging Infectious Diseases Videos for Prehospital Providers. (Accessed 6/28/2019.) University of Maryland Baltimore County.
This instructional series, comprised of nine modules, includes an introduction to infectious diseases, basic infection control concepts, considerations for personal protective equipment (including donning and doffing), personnel decontamination, patient transport, and transfer of patient care for patients with Ebola and other highly infectious diseases.
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National Ebola Training and Education Center. (n.d.). Special Pathogens of Concern. (Accessed 6/25/2018.)
This online course informs healthcare workers of factors of special pathogens that may warrant treatment of infected patients in biocontainment units. The course includes clinical presentation descriptions of viral hemorrhagic fevers and highly pathogenic respiratory viruses.
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Siegal, D., Strauss-Riggs, K. et al. (2014). Prioritization of Pediatric CBRNE Disaster Education and Training Needs. Clinical Pediatric Emergency Medicine. 15(4):309-317.
This article summarizes the 2011 Pediatric Disaster Preparedness Conference convened by the National Center for Disaster Medicine and Public Health. Multidisciplinary subject matter experts identified and prioritized roles in need of training in three settings: EMS/first responder, hospitals, and ambulatory care. For each role in each setting, experts identified training topics, key content, and level of training required. The authors suggest that a steering committee oversee development and implementation of related curriculum.
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U.S. Army Medical Research Institute on Infectious Diseases. (n.d.). Medical Management of Chemical and Biological Capabilities Course. (Accessed 7/10/2019.)
This six-day course includes classroom instruction, laboratory experience, and field exercises. Participation is open to military and civilian physicians, nurses, physician assistants, senior medical non-commissioned officers, and other medical professionals.
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Williams, M. and Sizemore, D. (2019). Biologic, Chemical, and Radiation Terrorism Review. StatPearls.
This article outlines biologic, chemical, and radiation terrorism and related issues for healthcare providers. The authors provide guidance on personal protective equipment, decontamination, and preparedness. A quiz based on information presented in the article is included as an additional education aide.
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World Health Organization. (n.d.). Pandemic and Epidemic-Prone Diseases. (Accessed 7/10/2019.)
This six-hour online course provides information on the management of outbreaks of 13 infectious hazards with pandemic and epidemic potential.
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This handbook offers an overview of infectious disease threats and the importance of effectively managing them, provides 10 key facts on 15 deadly diseases, and contains three toolboxes (the role of WHO, the International Coordinating Group on vaccine provision, and tables for laboratory diagnosis and shipment of infectious substances).
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Guidance and Guidelines


Association of Public Health Laboratories and American Society for Microbiology. (2016). Clinical Laboratory Preparedness and Response Guide.
This guide includes tools and standards to help laboratories recognize that a specimen contains a biological threat agent, reference testing standards, and notify appropriate state and federal partners.
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ASTM. (n.d.). Standard Guide for Operational Guidelines for Initial Response to a Suspected Biothreat Agent. (Abstract only; PDF available for purchase; accessed 7/10/19.) West Conshohocken, PA, ASTM International.
These standards can help responder agencies build operational guidelines for the preparedness for, response to, and recovery from a potential biothreat agent.
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California Department of Health Services. (2002). California Hospital Bioterrorism Planning Response Planning Guide.
This guide includes recommendations, references, and standards to help hospitals prepare for a bioterrorism event involving plague, smallpox, and/or viral hemorrhagic fevers. Organized into three planning sections which cover reporting requirements, internal and external communication protocols, and detailed agent information the guide can be modified as needed to integrate into existing emergency response plans.
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Centers for Disease Control and Prevention. (2016). Smallpox ACIP Vaccine Recommendations.
This webpage includes links to current smallpox vaccine recommendations developed by the Advisory Committee on Immunization Practices. Current guidance is available for: use of smallpox vaccine in laboratory and health care personnel at risk for occupational exposure to orthopoxviruses, notice of newly licensed vaccine, surveillance guidelines for vaccine adverse reactions, and recommendations for using smallpox vaccine in a pre-event vaccination program.
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Dembek, Z. (2007). Medical Aspects of Biological Warfare. Office of the Surgeon General, Department of the Army.
This free on-line textbook provides an in-depth historical overview of biological weapons, includes chapters on specific bioterror agents, and provides information on laboratory identification, consequence management, medical management, medical countermeasures, and biosafety and biosurety.
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This document includes guidance for 10 specific agents and has one chapter on “other infectious diseases” and another on agents for which no treatment can be recommended (e.g., ricin and viral encephalitis). Some medications and trade names differ from those available in the United States.
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Heymann, D.L. (2014). Control of Communicable Diseases Manual, 20th Edition. (Book available for purchase) American Public Health Association (APHA) Press.
This book (available for purchase as hard copy or electronic download) provides information on more than 130 infectious diseases. It contains information about the occurrence, transmission, and methods of control for each disease. It also includes information on availability and location of available medical treatment stockpiles.
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Infectious Diseases Society of America. (2016). ID-Focused Hospital Efficiency Improvement Program.
This guide for infectious disease physician executives identifies service lines and related metrics to mitigate infectious disease-related issues. The guide addresses four areas: infection prevention and control; antimicrobial stewardship; outpatient parenteral antimicrobial therapy hospital admission/readmission avoidance; and bio-security, bio-preparedness, and emerging infectious diseases.
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Los Angeles County Department of Public Health and Los Angeles County Emergency Medical Services Agency. (2012). Terrorism Agent Information and Treatment Guidelines for Clinicians and Hospitals.
Clinicians and others can use this manual to further their knowledge on bioterrorism agents, chemical and radiological terrorism, infection control, and management of exposed persons.
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* National Academies of Science and US Department of Homeland Security. (2004). Biological Attack: Human Pathogens, Biotoxins, and Agricultural Threats.
This report brief provides clear, concise information to the media, public, and health care workers on the characteristics, dangers, and consequences associated with various types of attacks.
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Workshop participants discussed the need for shared terminologies; data needs, sources, and collection methodologies; considerations for conducting rapid clinical research on medical countermeasures (MCM) during a public health emergency; and the federal perspective on MCM. Lessons from a 2012 fungal infection outbreak, anthrax, and H1N1 are shared in sidebars throughout the proceedings.
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Nolte, K., Hanzlick, R., Payne, D., et al. (2004). Medical Examiners, Coroners, and Biologic Terrorism: A Guidebook for Surveillance and Case Management. Morbidity and Mortality Weekly Report. 53(RR08):1-27.
This report provides information that can help medical examiners and coroners understanding their roles in bioterrorism surveillance and response. It provides details on biological threats and laboratory testing procedures, biosafety concerns related to conducting autopsies and dealing with contaminants, and coordination with partners in surveillance, data analysis, evidence collection, and communications.
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Rebmann, T. (2014). Infectious Disease Disasters: Bioterrorism, Emerging Infections, and Pandemics. APIC Text of Infection Control and Epidemiology.
This book chapter (available for viewing in PDF form) defines infectious disease disasters and highlights the need for specialized emergency planning and response, particularly for infection preventionists.
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Southern Illinois University School of Medicine. (n.d.). Overview of Potential Agents of Biological Terrorism. (Accessed 7/10/2019.)
This webpage includes information on how infectious agents can be used in mass casualty incidents and historical background and trends. The following information is provided for select category A, B, and C agents: microbiology and epidemiology, clinical features, laboratory diagnosis, antimicrobial therapy, post exposure prophylaxis, vaccination, and infection control procedures/ management.
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U.S. Army Medical Research Institute on Infectious Diseases. (2014). Medical Management of Biological Casualties Handbook, 8th Edition.
Known informally as the “Blue Book,” this handbook provides an overview of the history of biological warfare and current threats and information on distinguishing between naturally-occurring and intentional disease outbreaks, discusses biosurveillance, offers ten steps in the management of potential biological casualties, notes emerging threats and potential biological weapons, and provides information on personal protection, field detection, and decontamination. Chapters are devoted to specific bacterial agents, viral agents, and biological toxins.
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This document provides guidance on federal funding of research involving potential pandemic pathogens and highlights the potential benefits of the research and the potential to create, transfer, or use an enhanced potential pandemic pathogen.
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U.S. Department of Health and Human Services, U.S. Department of Homeland Security, U.S. Department of Labor, and U.S. Environmental Protection Agency. (2012). Guidance for Protecting Responders’ Health During the First Week Following a Wide-Area Aerosol Anthrax Attack.
This document provides guidance on post-exposure prophylaxis and vaccination, personal protective equipment, personal decontamination and hygiene, administrative and engineering controls, and pre-event vaccination for first responders, emergency management staff, public health and medical professionals, skilled support personnel, and critical infrastructure personnel who participate in the response to an anthrax attack.
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U.S. Environmental Protection Agency. (2016). Best Practices for Management of Biocontaminated Waste.
This document provides best practices for waste management activities during a biological incident response.
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U.S. Food and Drug Administration. (2018). Products Approved for Other Bioterrorism Emergencies.
This webpage includes links to information and guidance on products approved for use during bioterrorism emergencies, specifically for botulism, Ebola virus disease, plague, smallpox, tularemia, and Zika virus disease.
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U.S. Food and Drug Administration. (2019). Emergency Use Authorization.
This authorization allows the Food and Drug Administration to facilitate the availability and use of medical countermeasures to assist during public health emergencies. Links to information on current authorizations (e.g., anthrax, Ebola, and nerve agent) is provided on this page.
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U.S. Food and Drug Administration. (2019). Medical Countermeasure Monitoring and Assessment.
This webpage is focused on the need to build and maintain a national capability to monitor and assess medical countermeasures (MCMs) after they are dispensed or administered in response to a chemical, biological, radiological, or nuclear threat or an emerging infectious disease. Links to “FDA Information about Past and Current MCM Monitoring and Assessment Projects” are included
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Various Authors. (2014). Special Issue. Clinical Microbiology and Infection. 20(6).
This issue includes several articles that dispel bioterrorism-related myths and provide clear insight on the impacts to healthcare workers, dual use research, and historical perspective on biological warfare.
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Based on extensive federal interagency coordination and stakeholder input, the guidance in this document can help those who work in healthcare facilities, medical transportation operations, and laboratories better understand infectious waste and how to manage it.
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This is a summary of a guidance document based on extensive federal interagency coordination and stakeholder input and designed to help those who work in healthcare facilities, medical transportation operations, and laboratories better understand infectious waste and how to manage it. Access the full report at https://www.phmsa.dot.gov/sites/phmsa.dot.gov/files/docs/transporting-infectious-substances/6821/cat-waste-planning-guidance-final-2019-08.pdf.
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Williams, M. and Sizemore, D. (2019). Biologic, Chemical, and Radiation Terrorism Review. StatPearls.
This article outlines biologic, chemical, and radiation terrorism and related issues for healthcare providers. The authors provide guidance on personal protective equipment, decontamination, and preparedness. A quiz based on information presented in the article is included as an additional education aide.
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Wright, J., Quinn, C., Shadomy, S., et al. (2010). Use of Anthrax Vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. Morbidity and Mortality Weekly Report. 59(RR06):1-30.
This Mortality and Morbidity Weekly Report provides recommendations from the Advisory Committee on Immunization Practices (ACIP) for anthrax vaccine adsorbed (AVA). The report discusses updated information on anthrax epidemiology, and summarizes the evidence regarding the effectiveness and efficacy, immunogenicity, and safety of the AVA vaccine. Authors identify areas for future research and conclude by providing recommendations for pre-exposure and post-exposure use in general and specific subpopulations, including children, pregnant and breastfeeding women, and those with various occupational exposures.
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Lessons Learned


Ashford, D.A., et al. (2003). Planning against Biological Terrorism: Lessons from Outbreak Investigations. Emerging Infectious Diseases. May 9(5):515-519.
This article examines outbreak investigations conducted around the world from 1988 to 1999 and describes lessons learned from outbreak investigations that involved biologic agents with potential for bioterrorism.
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Bush, L.M. and Perez, M.T. (2012). The Anthrax Attacks 10 Years Later. Annals of Internal Medicine. 156(1_Part_1):41–44.
This article reviews the lessons learned during the first documented case of the 2001 anthrax attacks. The authors provide in depth details of the initial arrival of the patient to the hospital, physician identification of the agent, internal and external alerting protocols, criminal investigation, challenges within vaccination protocols, and the importance of surveillance for rapid disease identification.
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Chess, C. and Clarke, L. (2007). Facilitation of Risk Communication During the Anthrax Attacks of 2001: The Organizational Backstory. American Journal of Public Health. 97(9): 1578–1583.
This article provides lessons learned in risk communication by New Jersey-based hospital, public health, and emergency management responders during the 2001 anthrax attacks. The authors identified interorganizational relationships, organizational culture, and differences in medical and scientific interpretation as attributing to communication challenges faced by responders. The article concludes by reinforcing the importance of command and control while highlighting the need for additional research on organizational culture and the impact it has on risk communication.
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Dworkin, M.S, Ma, X., and Golash, R.G. (2003). Fear of Bioterrorism and Implications for Public Health Preparedness. Emerging Infectious Diseases. April 9(4):503-505.
This article describes the dramatic increase in the number of environmental and human samples submitted as a result of human anthrax cases and exposures in 2001, and discusses implications for laboratory surge capacity planning.
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Grundmann, O. (2014). The Current State of Bioterrorist Attack Surveillance and Preparedness in the US. Risk Management and Healthcare Policy.7:177–187.
The author shares the history and lessons learned from bioterrorism-related events between 1990 and 2010. The article highlights the importance of using critical risk management approaches such as surveillance, monitoring, and risk assessments to enhance preparedness and response capabilities during future bioterrorism events
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* National Academies of Science and US Department of Homeland Security. (2004). Biological Attack: Human Pathogens, Biotoxins, and Agricultural Threats.
This report brief provides clear, concise information to the media, public, and health care workers on the characteristics, dangers, and consequences associated with various types of attacks.
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* National Academies of Sciences, Engineering, and Medicine. (2005). The Smallpox Vaccination Program: Public Health in the Age of Terrorism.
This document reviews the Centers for Disease Control and Prevention’s implementation of its smallpox vaccination program. The report explores the history of smallpox and its control, provides a policy context for the program, offers a chronology of the program’s implementation, and discusses lessons learned.
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Smith, P., Anderson, A., Christopher, G., et al. (2006). Designing a Biocontainment Unit to Care for Patients with Serious Communicable Diseases: A Consensus Statement. (Abstract only.) Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 4(4):351-365.
The authors synthesized consensus recommendations collected from a conference of civilian and military professionals who are involved in the various aspects of biocontainment patient care units. Appendices include in-depth information on medical care issues (e.g., staffing the units, pathology, housekeeping), infection control issues (e.g., personal protective equipment, dealing with infectious waste), facility issues (e.g., air-handling, communication), and psychosocial and ethical issues.
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This issue report reviews lessons learned during the 2001 anthrax attacks through in-depth interviews with responding professionals from local, state, and federal public health agencies. They discuss their experiences during the 2001 attacks, reflect on the progress made within the 10 years since the attack, identify ongoing preparedness gaps, and provide recommendations for sustaining public health emergency response capabilities through all hazards planning.
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This planning aid can help multijurisdictional urban area planners manage the recovery from a biological, chemical, or radiological event. Developed from lessons learned during events in Seattle (WA) and Denver (CO), the document provides a recovery planning template along with corresponding planning support annexes for each of the three hazards.
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Weiss, S., Yitzhaki, S., and Shapira, S.C. (2015). Lessons to be Learned from Recent Biosafety Incidents in the United States. Israeli Medical Association Journal. 17(5):269-273.
The authors described lessons learned from three major biosafety incidents that occurred at the Centers for Disease Control and Prevention, the National Institutes of Health, and the U.S. Food and Drug Administration. They discuss the importance of establishing biosafety management programs and maintaining a culture of safety and reliability to prevent future biosafety incidents
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Plans, Tools, and Templates


Agency of Healthcare Research & Quality (AHRQ). (2004). Community-Based Mass Prophylaxis: A Planning Guide for Public Health Preparedness. Agency for Healthcare Research and Quality.
Planning guide to help state, county, and local officials meet federal requirements to prepare for public health emergencies. Outlines five components of mass prophylaxis response to epidemic outbreaks. Addresses dispensing operations using a comprehensive operational structure for Dispensing/Vaccination Centers (DVCs) based on the National Incident Management System (NIMS).
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Alabama Department of Public Health. (n.d.). Hospital Template for Serious Infectious Disease Procedures. (Accessed 7/11/2019.)
This eight-page template is for the use of hospital administration and planning personnel to identify and communicate key elements of the policy and procedures for screening, identification, and initial management of a suspected serious infectious disease patient. It is intended to be used as a tool to assist in the effective preparation for, implementation, and execution of facility serious infectious disease response plans.
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American Biological Safety Association. (n.d.). Select Agents Fact Sheet. (Accessed 7/10/19.)
This fact sheet lists diseases, their pathogen, genus species, host range, transmission, symptoms, incubation period, and available treatments. Presents a wide range of pathogens and their general presentation and treatment in a very brief table format.
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APIC Bioterrorism Task Force and CDC Hospital Infections Program Bioterrorism Working Group. (1999). Bioterrorism Readiness Plan: A Template for Healthcare Facilities.
In cooperation with the Centers for Disease Control and Prevention (CDC), APIC produced this Bioterrorism Readiness Plan to serve as a reference document and initial template to facilitate preparation of bioterrorism readiness plans for individual institutions.
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Army Center for Health Promotion and Preventive Medicine Aberdeen Proving Ground. (2000). The Medical NBC Battlebook.
This downloadable PDF serves as a quick reference guide for medical personnel in the field. The authors provide information on the following threats: nuclear, radiological hazards, biological, chemical, and lasers/ radiofrequency.
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Association of Public Health Laboratories. (2013). Infectious Disease Planning and Response Framework Checklist. (Log in required.)
This checklist guides the actions to be taken by public health laboratories when a disease outbreak occurs or threat emerges. Covered categories include: partner and stakeholder actions, communications, safety, regulatory requirements, sample/specimen transport, testing, reporting and data management, staffing, and surge considerations
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Association of Public Health Laboratories. (2015). A Biosafety Checklist: Developing a Culture of Biosafety.
This comprehensive checklist is intended to assist laboratories in assessing their biosafety practices and planning for emergencies. It is divided into 6 sections beginning with risk assessment and includes a list of planning resources for each section.
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This tool is intended to assist laboratories in assessing their surge capacity. The authors recommend laboratories review the tool annually or any time their space allocation, instruments, or staffing change.
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Association of Public Health Laboratories. (2017). Biothreat Agent Bench Cards for the Sentinel Laboratory.
In cooperation with the Centers for Disease Control and Prevention (CDC), APIC produced this Bioterrorism Readiness Plan to serve as a reference document and initial template to facilitate preparation of bioterrorism readiness plans for individual institutions. Some recommendations and language are dated. Brucella species, Burkholderia mallei, Burkholderia pseudomallei, Francisella tularensis, and Yersinia pestis. The deck also includes information about the Laboratory Response Network and biochemical reactions, a checklist for sentinel clinical laboratories, and a select agent response algorithm.
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This model practice provides guidelines to public health laboratories and first responders on their respective actions during an incident involving a suspicious sample.
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Association of Public Health Laboratories and American Society for Microbiology. (2016). Clinical Laboratory Preparedness and Response Guide.
This comprehensive guide includes tools and standards that can help laboratories recognize that a specimen contains a biological threat agent, handle said specimens, and notify appropriate state and federal partners. It includes helpful graphics, charts, and links to related resources.
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This document describes the framework for the federal government’s response to and recovery from a naturally-occurring or terrorist-caused biological incident. The annex consists of a base annex that applies to all biological incidents and a branch plan for suspected or actual biological attacks.
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Los Angeles County Department of Public Health and Los Angeles County Emergency Medical Services Agency. (2012). Terrorism Agent Information and Treatment Guidelines for Clinicians and Hospitals.
Clinicians and others can use this manual to further their knowledge on bioterrorism agents, chemical and radiological terrorism, infection control, and management of exposed persons.
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Minnesota Department of Health, Association for Professionals in Infection Control and Epidemiology - Minnesota, and Health Care Coalitions of Minnesota. (n.d.). High Consequence Infectious Disease (HCID) Toolbox for Frontline Health Care Facilities. (Accessed 7/11/2019.)
This toolbox includes a variety of resources to assist frontline facilities in their readiness activities related to patients with high consequence infectious diseases. Included are planning and training tools, exercise templates, and the components (e.g., screening guide, checklists, posters) to create a readiness binder.
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* Misener, M., Starr, D., Scaccia, A., and Arya, V. (2018). Screening for Anthrax Postexposure Antibiotic Prophylaxis—The New York City Approach. Health Security. 16(4).
The authors explain the city's anthrax antibiotic screening algorithm in the event of a deliberate anthrax release. They also share reasons behind the use and exclusion of screening questions and explain how they plan to incorporate additional medical evaluation as necessary.
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National Ebola Training and Education Center. (n.d.). Exercise Templates. (Accessed 11/16/2019.)
This web page includes links to various Homeland Security Exercise and Evaluation Program-compliant templates to assist healthcare coalitions, frontline facilities, assessment hospitals, state-designated Ebola treatment centers, regional Ebola and special pathogen treatment centers, and their respective response partners in the planning and conduct of exercises on the identification, assessment, treatment, management, transport, and transfer of high risk patients. The site includes templates for drills, tabletops, functional, and full-scale exercises. There is also a beginners guide to assist users new to exercise planning.
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National Library of Medicine. (n.d.). Wireless Information System for Emergency Responders (WISER). (Accessed 7/10/2019.)
The Wireless Information System for Emergency Responders (WISER) is a searchable database providers may use to quickly obtain treatment information for various weapons of mass destruction, including biological agents. Users may access information via the online version, or through a downloaded application. WISER is particularly helpful for chemical response but lists biologic agents of terrorism as well.
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New York City Health + Hospitals. (2019). Frontline Hospital Planning Guide: Special Pathogens.
This planning guide from New York City Health + Hospitals provides high-level planning information for frontline hospital multidisciplinary teams to support planning and training for the initial care of suspected special pathogen patients while determining whether and when they will be transferred to another facility for further assessment and treatment.
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Office of the Assistant Secretary for Preparedness and Response. (2019). National Health Security Strategy. U.S. Department of Health and Human Services.
The goal of the National Health Security Strategy (NHSS) is to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies. This webpage includes links to the full text of the plan, an overview, the NHSS Implementation Plan, the NHSS Evaluation of Progress, and an NHSS Archive.
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San Francisco Department of Public Health. (2011). Infectious Disease Emergency Response Plan.
This plan contains the following sections: command, plans section (by unit), operations section, logistics, and finance. Four annexes that focus on different threats are included, as are sample forms and other appendices.
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The Society for Healthcare Epidemiology of America. (2017). Outbreak Response Training Program (ORTP).
This webpage contains links to four free toolkits that were developed to provide healthcare providers immediate access to key infectious disease outbreak information and resources. The toolkits contain guidance on incident management, emerging pathogens, horizontal strategies, communication, negotiation, and implementation. Each toolkit contains checklists, guidance documents, case studies, and fillable tables to meet the planning and response needs prior to or during an infectious disease outbreak.
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* Toner, E., Shearer, M., Kirk Sell, T., et al. (2017). Health Sector Resilience Checklist for High Consequence Infectious Diseases – Informed by the Domestic U.S. Ebola Response. Johns Hopkins Bloomberg School of Public Health Center for Health Security.
This document provides action steps for responding to isolated cases or limited outbreaks of high-consequence infectious diseases, including those that are: novel or rare in the community, moderate to highly contagious, moderate to highly lethal, not easily controlled by medical countermeasures and other interventions, and have the potential to cause exceptional public concern. The document includes a general checklist and population-specific checklists for public health, healthcare, emergency medical services, and elected officials.
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U.S. Army Medical Research Institute on Infectious Diseases. (2012). Pocket Reference Guide to Biological Select Agents and Toxins.
This guide can help clinicians and other healthcare providers recognize bioagent diseases. It includes an overview table showing risk factors followed by one page overviews of the signs and symptoms, diagnostic tools, treatment, and precautions for various agents and toxins.
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This planning aid can help multijurisdictional urban area planners manage the recovery from a biological, chemical, or radiological event. Developed from lessons learned during events in Seattle (WA) and Denver (CO), the document provides a recovery planning template along with corresponding planning support annexes for each of the three hazards.
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Pediatric and Maternal Health Issues


American Academy of Pediatrics. (n.d.). Biological Terrorism and Agents. (Accessed 7/10/2019.)
This webpage provides an overview of children and bioterrorism, and the response role of pediatricians during bioterrorism incidents. It includes links to information on Category A, B, and C bioterrorism agents, information on pediatrician-specific roles and responsibilities, strategies for office practice, and recommendations for future collaborative efforts.
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Bartenfeld, M., Peacock, G., and Griese, S. (2014). Public Health Emergency Planning for Children in Chemical, Biological, Radiological, and Nuclear (CBRN) Disasters. Biosecurity and Bioterrorism. 12(4):201-207.
The authors discuss the distinguishable physical, developmental, and social traits and characteristics of children in the context of chemical, biological, radiological, and nuclear (CBRN) incidents. This includes the science behind exposure, health effects, and treatment for exposure to potential agents during CBRN events.
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Bradley, J., Peacock, G., Krug, S., et al. (2014). Pediatric Anthrax Clinical Management. Pediatric Anthrax Clinical Management. Pediatrics. 133(5):E1411-E1436.
This clinical report provides guidance on the prophylaxis and treatment of patients up to age 21 following an intentional anthrax release, with particular focus on areas where clinical recommendations for children differ from those for adults. The report discusses clinical presentations, post-exposure prophylaxis, infection control, management of patients with suspected and confirmed anthrax, and special considerations for breastfeeding infants.
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Cooper, W., Hernandez-Diaz, S., Arbogast, P., et al. (2009). Antibiotics Potentially Used in Response to Bioterrorism and the Risk of Major Congenital Malformations. Pediatric and Perinatal Epidemiology. 23(1):18-28.
The authors compared infants with fetal exposure to several antibiotics recommended for use following a bioterror attack and one antibiotic not recommended for such use to infants with no fetal exposure to antibiotics to assess the risk of major congenital malformations from pregnancy-related exposures to antibiotics in the event of bioterrorism. Study findings suggest that fetal exposure to ciprofloxacin, azithromycin, doxycycline, or amoxicillin following a bioterror attack should not result in a greater incidence of major congenital malformations overall, but additional research is needed.
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Disaster Preparedness Advisory Council. (2016). Medical Countermeasures for Children in Public Health Emergencies, Disasters, or Terrorism. Pediatrics. 137(2).
The Council shares that many medical countermeasures (MCM) are more likely to be approved for adult use and may not take the unique needs of children into account. They drafted this policy statement to suggest recommendations that address the gaps for the development and use of MCMs in children during public health emergencies or disasters.
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Griese, S., Kisselburgh, H., Bartenfeld, M., et al. (2018). Pediatric Botulism and Use of Equine Botulinum Antitoxin in Children: A Systematic Review. Clinical Infectious Diseases. 66(suppl_1):s17-s29.
The authors conducted a systematic review of peer-reviewed and non-peer-reviewed literature to identify signs and symptoms that may aid diagnosis of botulism in children. They also described the effects of botulinum antitoxin in the pediatric population.
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Hamele, M., Poss, W., and Sweney, J. (2014). Disaster Preparedness, Pediatric Considerations in Primary Blast Injury, Chemical, and Biological Terrorism. World Journal of Critical Care Medicine. 3(1):15-23.
The authors review the presentation, pathophysiology, and treatment of pediatric victims of blast injury, chemical weapons, and biological weapons, with a focus on those injuries not commonly encountered in critical care practice.
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The Board explored challenges regarding Anthrax Vaccine Absorbed (AVA) and considered options for pre- and post-event research. AVA is not licensed for use in children and there is no clinical data on its use in pediatric populations for pre- or post-exposure prophylaxis in children. The Board recommended that HHS plan and conduct a pre-event research study.
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Siegal, D., Strauss-Riggs, K. et al. (2014). Prioritization of Pediatric CBRNE Disaster Education and Training Needs. Clinical Pediatric Emergency Medicine. 15(4):309-317.
This article summarizes the 2011 Pediatric Disaster Preparedness Conference convened by the National Center for Disaster Medicine and Public Health. Multidisciplinary subject matter experts identified and prioritized roles in need of training in three settings: EMS/first responder, hospitals, and ambulatory care. For each role in each setting, experts identified training topics, key content, and level of training required. The authors suggest that a steering committee oversee development and implementation of related curriculum.
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U.S. Food and Drug Administration. (2018). Pediatric Medical Countermeasures.
Pediatric patients may react differently to certain medications, making the development of safe and effective medical countermeasures (MCM) for young patients critical to public health emergency preparedness. This webpage includes links to resources specific to bioterrorism emergencies and radiation emergencies.
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Specific Threats: Anthrax


Morbidity and Mortality Weekly Report. 64(RR04):1-28. This report can help clinicians, hospital administrators, state and local health officials, and planners develop crisis protocols for an anthrax mass casualty incident. The authors share a clinical framework for the adaptation of existing evidence-based guidance and rational use of stockpiled medical countermeasures for the treatment of anthrax during a mass-casualty incident that triggers a shift to contingency or crisis standards of care. This framework addresses elements of hospital-based acute care (e.g., prioritization of antitoxins, intravenous antimicrobial use, and the diagnosis and management of common anthrax-specific complications).
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This webpage provides links to factsheets for healthcare providers and others on the use of doxycycline and ciprofloxacin in the event of a mass casualty incident involving anthrax.
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Centers for Disease Control and Prevention. (2017). Anthrax.
This webpage includes information on the types of anthrax, prevention, testing, treatment, and targeted resources for specific groups.
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Centers for Disease Control and Prevention. (2018). Anthrax (Bacillus anthracis) Case Definition.
This case definition provides a description of each clinical type of anthrax, clinical criteria for surveillance, laboratory criteria for diagnosis, epidemiological linkages, criteria to distinguish new cases, and suspected, probable, and confirmed case classifications
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This article reviews the history, biology, life cycle, pathogenicity, virulence, epidemiology and potential of anthrax as a biological weapon. The author suggests that active surveillance, proper animal immunization, and awareness can result in the rapid and accurate diagnosis for treatment and implementation of control strategies to prevent further disease spread. The author concludes that rapid and inexpensive serodiagnosis tests can serve as strong tools for surveillance of anthrax and that active surveillance can minimize the risks of agriculture- or occupation-related anthrax.
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Hendricks, K., Wright, M., Shadomy, S., et al. (2018). Centers for Disease Control and Prevention Expert Panel Meetings on Prevention and Treatment of Anthrax in Adult. Emerging Infectious Diseases. 20(2):e130687.
This article provides an overview of the panel discussions of anthrax experts convened by the Centers for Disease Control and Prevention to review and update guidelines for prevention and treatment of anthrax. The authors discuss anthrax pathogenicity and provide guidelines on: critical care measures and procedures, antimicrobial selection considerations for prevention and treatment, anthrax prevention, and the use of antitoxins.
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Huang, E., Pillai, S., Bower, W., et al. (2014). Antitoxin Treatment of Inhalation Anthrax: A Systematic Review. Health Security. 13(6):365-377.
The authors completed a systematic review (albeit with limited data) of human and animal studies on antitoxin treatment of inhalational anthrax. They found that early treatment with antimicrobial monotherapy or antimicrobial-antitoxin therapy were both associated with survival in animal studies. When treatment was delayed in animal studies, data suggested improved survivability for antimicrobial-antitoxin therapy compared to antimicrobial monotherapy. During large-scale anthrax incidents in which demand for antitoxin may exceed supply, the authors suggest that antitoxins be reserved for those who present with severe illness at onset but have a reasonable chance of survival and those who have not shown a clinical benefit from antimicrobials alone. The authors discussed numerous limitations to their study and emphasized the need for additional research.
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This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of Anthrax. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Anthrax as a weapon.
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Katharios-Lanwermeyer, S., Holty, J., Person, M., et al. (2016). Identifying Meningitis During an Anthrax Mass Casualty Incident: Systematic Review of Systemic Anthrax Since 1880. Clinical Infectious Disease. 62(12):1537-1545 .
Based on a systematic review of 132 cases of anthrax meningitis, the authors developed a four item, evidence-based screening tool to assess severe headache, altered mental status, meningeal signs, and other neurological signs. The authors suggest that patients who screen positive on two or more of the responses could be categorized as presumptive anthrax meningitis. Use of the tool could improve patient outcomes and resource allocation during an anthrax mass casualty incident.
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The authors examined the cost-effectiveness of a response to an anthrax attack based on pre- and post-attack prophylaxis and/or vaccination. Their results indicated that post-attack antibiotic prophylaxis and vaccination of all exposed people would be the most cost-effective response strategy for a large-scale anthrax attack.
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Meaney-Delman, D., Zotti, M., Creanga, A., et al. (2014). Special Considerations for Prophylaxis for and Treatment of Anthrax in Pregnant and Postpartum Women. Emerging Infectious Diseases. 20(2). .
The authors present information regarding vaccine, antimicrobial drug prophylaxis and treatment, clinical considerations, and other factors healthcare practitioners must take into consideration when treating pregnant and postpartum women after an anthrax exposure.
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The authors integrated the cytokine IL-15 and the PA gene of B. anthracis into the Wyeth strain of vaccina virus derived from the licensed smallpox vaccine to create a dual vaccine effective against both smallpox and anthrax. Studies in rabbits and mice demonstrated superior immunogenicity and efficacy of Wyeth/IL-15/PA compared to existing licensed smallpox and anthrax vaccines.
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* Misener, M., Starr, D., Scaccia, A., and Arya, V. (2018). Screening for Anthrax Postexposure Antibiotic Prophylaxis—The New York City Approach. Health Security. 16(4).
The authors explain the city's anthrax antibiotic screening algorithm in the event of a deliberate anthrax release. They also share reasons behind the use and exclusion of screening questions and explain how they plan to incorporate additional medical evaluation as necessary.
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The Board explored challenges regarding Anthrax Vaccine Absorbed (AVA) and considered options for pre- and post-event research. AVA is not licensed for use in children and there is no clinical data on its use in pediatric populations for pre- or post-exposure prophylaxis in children. The Board recommended that HHS plan and conduct a pre-event research study.
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Rainisch, G., Meltzer, M., Shadomy, S., et al. (2017). Modeling Tool for Decision Support During Early Days of an Anthrax Event. Emerging Infectious Diseases. 23(1): 46-55.
The authors developed a model based on the first three days of case data to project cases, peak hospital caseload, and deaths from an inhalational anthrax incident and the effects of interventions on these projections.
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The authors provide guidance for effective post exposure treatment periods to assist healthcare practitioners with the management of large populations exposed to inhalation anthrax. Their results indicated administering antitoxins along with antibiotics could potentially provide an increased postexposure treatment period in comparison to solely antibiotic treatment.
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U.S. Department of Health and Human Services. (2015). Anthrax Medical Countermeasures-Amendment.
This amendment includes an updated “description of covered countermeasures and the disease threat; extend[s] the effective time period of the declaration;” and clarifies the terms of the declaration.
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U.S. Department of Health and Human Services, U.S. Department of Homeland Security, U.S. Department of Labor, and U.S. Environmental Protection Agency. (2012). Guidance for Protecting Responders’ Health During the First Week Following a Wide-Area Aerosol Anthrax Attack.
This document provides guidance on post-exposure prophylaxis and vaccination, personal protective equipment, personal decontamination and hygiene, administrative and engineering controls, and pre-event vaccination for first responders, emergency management staff, public health and medical professionals, skilled support personnel, and critical infrastructure personnel who participate in the response to an anthrax attack.
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U.S. Food and Drug Administration. (2018). Products Approved for Anthrax.
This webpage provides information on and links to resources specific to products approved to treat anthrax and maintained in the Strategic National Stockpile (SNS).
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Wright, J., Quinn, C., Shadomy, S., et al. (2010). Use of Anthrax Vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. Morbidity and Mortality Weekly Report. 59(RR06):1-30 .
This Mortality and Morbidity Weekly Report provides recommendations from the Advisory Committee on Immunization Practices (ACIP) for anthrax vaccine adsorbed (AVA). The report discusses updated information on anthrax epidemiology, and summarizes the evidence regarding the effectiveness and efficacy, immunogenicity, and safety of the AVA vaccine. Authors identify areas for future research and conclude by providing recommendations for pre-exposure and post-exposure use in general and specific subpopulations, including children, pregnant and breastfeeding women, and those with various occupational exposures.
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Specific Threats: Botulism


Arnon, S., Schechter, R., Inglesby, T., et al. (2001). Botulinum Toxin as a Biological Weapon. Journal of the American Medical Association, 285(16):2081.
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of botulinum toxin. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Botulism as a weapon.
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Centers for Disease Control and Prevention. (n.d.). Botulism. (Accessed 7/10/2019.)
This webpage includes basic information about botulism, prevention, symptoms, diagnosis, treatment, and resources for specific populations.
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Centers for Disease Control and Prevention. (2018). Botulism (Clostridium botulinum) 2011 Case Definition.
This case definition provides clinical descriptions, laboratory criteria for diagnosis, and case classification for foodborne, infant, wound, and other subtypes of botulism.
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McCarty, C., Angelo, K., Beer, K., et al. (2015). Notes from the Field: Large Outbreak of Botulism Associated with a Church Potluck Meal - Ohio, 2015. Morbidity and Mortality Weekly Report (MMWR).64(29):802-803.
This report provides a summary of the 2015 botulism outbreak in Fairfield County, Ohio. The authors review the public health and medical response from the initial onset of the outbreak through the investigation and identification of the botulism source. The report highlights the importance of coordination among healthcare responders during botulism outbreaks.
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The authors created a tool to aid in clinical assessment for botulism based on frequency of signs and symptoms of confirmed cases. While the tool cannot be used for diagnostic purposes, the authors suggest it can be useful in triaging patients and helping clinicians identify possible cases.
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Rao, A., Lin, N., Griese, S., et al. (2018). Pediatric Botulism and Use of Equine Botulinum Antitoxin in Children: A Systematic Review. Clinical Infectious Diseases. 66(suppl_1):s17-s29.
The authors conducted a systematic review of peer-reviewed and non-peer-reviewed literature to identify signs and symptoms that may aid diagnosis of botulism in children. They also described the effects of botulinum antitoxin in the pediatric population.
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Specific Threats: Dual Use Research


DiEuliis, D., and Gronvall, G. (2018). A Holistic Assessment of the Risks and Benefits of the Synthesis of Horsepox. mSphere. 3(2):e00074-18.
This study reviews the re-creation of the horsepox virus and provides an analytical framework to assess the risks and potential benefits of dual use research. The researchers also provide insight on the biodefense enterprise in the U.S., which includes the acquisition of medical countermeasures. The authors conclude risk/benefit assessments are needed at the onset of dual-use research, throughout the development process, and to inform communications about the research.
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National Academies of Sciences, Engineering, and Medicine. (2017). Dual Use Research of Concern in the Life Sciences: Current Issues and Controversies. The National Academies Press.
This report is based on a review of potential mechanisms to balance the open dissemination of research findings with concerns for biosecurity. The report recommends training on dual use research of concern, engagement of advisory bodies for monitoring and enforcement, international harmonization, engagement with international entities, guidelines for publishers, policy development and regulatory oversight, and increased public engagement.
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* National Academies of Sciences, Engineering, and Medicine. (2018). Biodefense in the Age of Synthetic Biology. The National Academies Press.
This report reviews the uses of synthetic biology and explores potential misuses. The authors develop a framework to assess the security concerns related to advances in synthetic biology, ranks those concerns, and identifies options that could help mitigate the concerns.
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This report highlights results of a survey of AAAS life sciences members on their knowledge of and attitudes about dual use research. Among the findings, survey results indicated that many respondents had already taken precautionary measures in the absence of guidelines or restrictions on dual use research, were open to scientific community-driven mechanisms to reduce risk, supported training and education on dual use concerns, and agreed that the need exists to better define the scope of research of concern.
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Specific Threats: Other (VHF, Category B & C Agents)


Adalja, A., Watson, M., Toner, E., et al. (2018). The Characteristics of Pandemic Pathogens. Johns Hopkins University Center for Health Security.
The authors of this report identify traits of global catastrophic biological risk organisms (GCBRs; "biological agents...[that] could lead to sudden, extraordinary, widespread disaster beyond the collective capability of national and international governments and the private sector to control.” Based on a literature review, subject matter expert interviews, and a meeting of experts, they argue that a framework based on biologic and epidemiologic traits provides an open-ended, pathogen-agnostic approach to preparedness.
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Anderson, A., Bijlmer, H., Fournier, P., et al. (2013). Diagnosis and Management of Q Fever – United States, 2013: Recommendations from CDC and the Q Fever Working Group. https://www.cdc.gov/mmwr/PDF/rr/rr6203.pdf?s_cid=bb-rzb-QfeverNationalRecommendations-001&utm_source=external&utm_medium=banner&utm_content=rzb-QfeverNationalRecommendations-001&utm_campaign=glgb.
This document describes the epidemiology, signs and symptoms, diagnosis, treatment and management, and surveillance and reporting of Q fever. Considerations for pregnant women, children, and occupational exposures are included.
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Centers for Disease Control and Prevention. (2010). Brucellosis (Brucella spp.) 2010 Case Definition.
This case definition provides a clinical description, laboratory criteria for diagnosis, and case classification for brucellosis.
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Centers for Disease Control and Prevention. (2012). Melioidosis.
This webpage includes basic information on melioidosis (Whitmore’s disease; caused by Burkholderia pseudomallei) transmission, signs and symptoms, treatment, prevention, exposure risks, bioterrorism risks, and resources for specific groups
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Centers for Disease Control and Prevention. (2017). Glanders.
This webpage includes basic information on glanders (caused by Burkholderia mallei) transmission, signs and symptoms, treatment, prevention, exposure risks, bioterrorism risks, and resources for specific groups.
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Centers for Disease Control and Prevention. (2017). Q Fever.
This webpage includes basic information on Q fever (caused by Coxiella burnetii) transmission, signs and symptoms, treatment, prevention, diagnosis and testing, bioterrorism risks, and resources for specific groups.
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Lipsitz, R., Garges, S., Aurigemma, R., et al. (2010). Workshop on Treatment of and Postexposure Prophylaxis for Burkholderia pseudomallei and B. mallei Infection, 2010. Emerging Infectious Diseases. 18(12) .
Workshop attendees reviewed the current state of knowledge on melioidosis and glanders (caused by Burkholderia pseudomallei and B. mallei infections) and developed consensus recommendations for postexposure prophylaxis and treatment. The authors emphasized the need for standardized animal models and B. pseudomallei strains for further research on therapeutic options and training of laboratorians and physicians to improve diagnosis and treatment.
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The authors provide an overview of monkeypox and note the lack of clinical management guidelines for monkeypox patients. They summarize clinical syndromes and possible treatment options, for both developed and low-resource settings, and offer performance indicators and clinical metrics for case management.
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Specific Threats: Plague


Centers for Disease Control and Prevention. (n.d.). Plague. (Accessed 7/10/2019.)
This webpage includes general information on plague, transmission, prevention, diagnosis, treatment, and resources for specific groups
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Centers for Disease Control and Prevention. (2010). Plague (Yersinia pestis) 1996 Case Definition.
This case definition provides a clinical description, laboratory criteria for diagnosis, and case classification for plague. The 1996 case definition was reviewed and republished by the Council of State and Territorial Epidemiologists in 2009. The 1996 and 2010 versions of the case definition are identical.
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Inglesby, T., Dennis, D., Henderson, D. et al. (2000). Plague as a Biological Weapon Medical and Public Health Management. Journal of American Medical Association. 283(17): .
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of Plague. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Plague as a weapon.
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Kool, J. (2005). Risk of Person-to-Person Transmission of Pneumonic Plague. Clinical Infectious Diseases. 40(8): 1166-1172.
The author reviews the historical literature and anecdotal evidence on plague transmission and discusses how simple protective measures can reduce the risk of infection.
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This document provides step-by-step guidance on preparing to collect the sample, donning and doffing of personal protective equipment, collection procedures, and sample preparation for shipping.
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Specific Threats: Smallpox


Centers for Disease Control and Prevention. (2016). Smallpox ACIP Vaccine Recommendations.
This webpage includes links to current smallpox vaccine recommendations developed by the Advisory Committee on Immunization Practices. Current guidance is available for: use of smallpox vaccine in laboratory and health care personnel at risk for occupational exposure to orthopoxviruses, notice of newly licensed vaccine, surveillance guidelines for vaccine adverse reactions, and recommendations for using smallpox vaccine in a pre-event vaccination program.
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Centers for Disease Control and Prevention. (2017). Smallpox.
This webpage includes information on the history of smallpox, transmission, signs and symptoms, prevention and treatment, and resources for specific groups.
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Centers for Disease Control and Prevention. (2017). Smallpox Enhanced Surveillance and Case Reporting.
This webpage includes the case definition and case reporting requirements for smallpox.
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Centers for Disease Control and Prevention. (2018). Administering ACAM2000 Smallpox Vaccine Videos.
This series of videos introduces smallpox vaccination with ACAM2000; how to reconstitute, properly handle, and store the vaccine; administer using the multiple-puncture technique with a bifurcated needle; care for the vaccination site; identify common reactions; learn about potential serious adverse events and how to treat them; screen for contraindications and special populations; and learn about two products.
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Food and Drug Administration. (2019). Smallpox Preparedness and Response Updates from FDA.
This webpage includes information on smallpox facts, medical countermeasures, consumer protection, and smallpox updates and additional industry guidance.
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Henderson, D., Inglesby, T., Bartlett, J. (1999). Smallpox as a Biological Weapon: Medical and Public Health Management. Journal of American Medical Association. 281(22): 2127-2137.
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of Smallpox. The group provides a list of symptoms and treatment suggestions. Some recommendations may be dated but the article provides an excellent overview of Smallpox as a weapon.
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Macintyre, C., Costantino, V., Chen, X., et al. (2018). Influence of Population Immunosuppression and Past Vaccination on Smallpox Reemergence. Emerging Infectious Diseases. 24(4):646-53 .
The authors developed a SEIR (susceptible, exposed, infected, recovered) smallpox transmission model for New York City and Sydney, Australia that accounted for age-specific population immunosuppression and residual vaccine immunity. They found that residual immunity was less influential on disease rates in Sydney, which has a vaccination coverage rate half that of New York, and that age-specific death rates were lower in older age groups with higher residual immunity in both cities. Infection and death rates increased in both cities when immunosuppressed parameters were included in the model.
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Merkel, T., Perera, P., Kelly, V., et al. (2010). Development of a Highly Efficacious Vaccinia-Based Dual Vaccine Against Smallpox and Anthrax, Two Important Bioterror Entities. Proceedings of the National Academy of Sciences. 107(42):18092-18096.
The authors integrated the cytokine IL-15 and the PA gene of B. anthracis into the Wyeth strain of vaccina virus derived from the licensed smallpox vaccine to create a dual vaccine effective against both smallpox and anthrax. Studies in rabbits and mice demonstrated superior immunogenicity and efficacy of Wyeth/IL-15/PA compared to existing licensed smallpox and anthrax vaccines.
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Milton, D. (2012). What was the Primary Mode of Smallpox Transmission? Implications for Biodefense. Frontiers in Cellular and Infection Microbiology. 2:150.
Based on a review of existing data and knowledge on smallpox, the author examines whether traditional modeling based primarily on transmission to close contacts via large droplets fully accounts for the possibility of transmission via airborne droplet nuclei through mechanically-recirculated air in the modern built environment.
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* National Academies of Sciences, Engineering, and Medicine. (2005). The Smallpox Vaccination Program: Public Health in the Age of Terrorism.
This document reviews the Centers for Disease Control and Prevention’s implementation of its smallpox vaccination program. The report explores the history of smallpox and its control, provides a policy context for the program, offers a chronology of the program’s implementation, and discusses lessons learned.
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Petersen, B., Damon, I., Pertowski, C., et al. (2015). Clinical Guidance for Smallpox Vaccine Use in a Postevent Vaccination Program. Morbidity and Mortality Weekly Report. 64(RR02):1-26.
This report provides recommendations for the clinical use of the three smallpox vaccines included in the Strategic National Stockpile for persons exposed to the virus or at high risk for infection during a post-event vaccination program. Descriptions, administration and dosage, regulatory status, efficacy, and safety information are included for each vaccine. The report also includes recommendations on use, including considerations for contraindications and special populations, and identifies remaining knowledge gaps and areas for future research.
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Specific Threats: Tularemia


Centers for Disease Control and Prevention. (2017). Tularemia (Francisella tularensis) 2017 Case Definition.
This case definition provides clinical criteria, laboratory criteria for diagnosis, epidemiologic linkages, criteria to distinguish new cases, and class classification for tularemia.
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Centers for Disease Control and Prevention. (2018). Tularemia.
This webpage includes basic information on tularemia transmission, signs and symptoms, diagnosis and treatment, prevention, and resources for specific groups.
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Dennis, D., Inglesby, T., Henderson, D. (2001). Tularemia as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association. 285(21): 2763-2773.
This article highlights recommendations developed by the Working Group on Civilian Biodefense regarding a terrorist event featuring the release of tularemia . The group provides a list of symptoms and treatment suggestions. While some recommendations may be dated, the authors share a helpful overview of the use of tularemia as a weapon
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Agencies and Organizations


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Center for Infectious Disease Research and Policy. Biosecurity Issues.
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Center for Infectious Disease Research and Policy. Bioterrorism Issues.
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Centers for Disease Control and Prevention. Bioterrorism Agents/Diseases.
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National Association of County & City Health Officials. Emerging Infections and Outbreak Response.
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U.S. Department of Health and Human Services, National Institute of Allergy and Infectious Diseases. NIAID Emerging Infectious Diseases/Pathogens.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. 2017-2018 PHEMCE Strategy and Implementation Plan.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. Biomedical Advanced Research and Development Authority (BARDA).
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. Project BioShield.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. Science Safety Security.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. BARDA. Chemical, Biological, Radiological, and Nuclear (CBRN) Threat Programs.
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U.S. Department of Labor, Occupational Safety and Health Administration. Biological Agents.
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U.S. Environmental Protection Agency. Biological Quick Reference Cards.
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