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Bioterrorism and High Consequence Biological Threats
Topic Collection
April 6, 2026

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): Influenza Epidemic/Pandemic; Coronaviruses (e.g., SARS, MERS and COVID-19); Ebola/VHF; and Zika. Information on additional terrorist threats may be found in the Chemical Hazards, Active Shooter and Explosives, and Radiological and Nuclear Collections.

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

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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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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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ASPR TRACIE. (2025). Biological Incidents.
Biological incidents requiring an emergency management response span a wide range of impacts and scenarios. This chapter reviews the hierarchy of controls and the identify, isolate, inform framework and details some considerations for epidemics and pandemics, special pathogens, and 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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Blue Ribbon Panel on Biodefense. (2015). A National Blueprint for Biodefense: Leadership and Major Reform Needed to Optimize Efforts – Bipartisan Report of the Blue Ribbon Study Panel on Biodefense.
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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Federal Emergency Management Agency. (2023). Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans.
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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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. (Abstract only.) Journal of American Medical Association. 283(17):2281- 2290.
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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Inglesby, T., Henderson, D., Bartlett, J. (2000). Anthrax as a Biological Weapon: Medical and Public Health Management. Working Group on Civilian Biodefense. (Abstract only.)
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 Emerging Special Pathogen 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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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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  • Bridget Kanawati Thank you for letting us know. The link has been updated with the new URL.
    7/27/2023 10:32:26 AM
  • Jonathan Pearson This link seems to be broken.
    7/27/2023 10:07:17 AM
Trust for America’s Health. (2011). Remembering 9/11 and Anthrax Attacks: Public Health’s Vital Role in National Defense.
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. (2020). Medical Management of Biological Casualties Handbook, 9th 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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World Health Organization. (2018). Managing Epidemics: Key Facts about Major Deadly Diseases.
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

The White House. (2010). Executive Order 13546: Optimizing the Security of Biological Select Agents and Toxins in the United States. Federal Register. 75(130):39439-39442.
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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Clinical Management

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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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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Education and Training

ASPR TRACIE. (2025). Biological Incidents.
Biological incidents requiring an emergency management response span a wide range of impacts and scenarios. This chapter reviews the hierarchy of controls and the identify, isolate, inform framework and details some considerations for epidemics and pandemics, special pathogens, and bioterrorism.
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Department of Emergency Health Services. (2018). Emerging Infectious Diseases Videos for Prehospital Providers. University of Maryland Baltimore County.
This instructional series, comprised of nine modules (listed at the top of the page), 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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Mountain Plains Regional Disaster Health Response System. (2024). Just-in-Time Learning Series.
This webpage provides links to various recordings healthcare providers can use "just in time" to treat patients who have been exposed to a variety of threats (e.g., biological, radiological, and chemical agents) or who may be practicing outside of their area of expertise in a medical surge event. Subject matter experts present on a diverse range of topics relevant to disaster preparedness and response in these 15-30 minutes modules. Considerations are also made for treating special populations (e.g., older patients and pregnant patients) in a disaster setting.
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U.S. Army Medical Research Institute on Infectious Diseases. (n.d.). Medical Management of Chemical and Biological Casualties Course. (Accessed 3/6/2023.)
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. (2018). Managing Epidemics: Key Facts about Major Deadly Diseases.
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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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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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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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 Emerging Special Pathogens Training and Education Center. (2024). EMS Procedural Guidelines for Special Pathogens.
These model procedural guidelines, created by NETEC's EMS/Patient Transport Work Group, are designed to help EMS agencies develop standard operating procedures for the transport and management of patients suspected or confirmed to have a high-consequence infectious disease. The guidelines address personal protective equipment (PPE) donning and doffing, EMS provider down, PPE breaches, biohazard spills, waste management, ambulance modification, and ambulance cleaning and disinfection. They complement ASPR TRACIE's EMS Infectious Disease Playbook (https://files.asprtracie.hhs.gov/documents/aspr-tracie-transport-playbook-508.pdf).
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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 understand 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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U.S. Army Medical Research Institute on Infectious Diseases. (2020). Medical Management of Biological Casualties Handbook, 9th 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. 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. (2019). Products Approved for Other Bioterrorism Emergencies. U.S. Department of Health and Human Services.
This webpage includes links to information and guidance on products approved for use during bioterrorism emergencies, specifically for botulism, Ebola virus disease, glanders and melioidosis, plague, smallpox, tularemia, and Zika virus disease.
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Various Federal Agencies. (2024). Managing Solid Waste Contaminated with a Category A Infectious Substance.
This guidance document is 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.
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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

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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Trust for America’s Health. (2011). Remembering 9/11 and Anthrax Attacks: Public Health’s Vital Role in National Defense.
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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Pediatric and Maternal Health Issues

American Academy of Pediatrics. (2024). Biological Terrorism and Agents.
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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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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* National Biodefense Science Board. (2011). Challenges in the Use of Anthrax Vaccine Adsorbed (AVA) in the Pediatric Population as a Component of Post-Exposure Prophylaxis (PEP).
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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Plans, Tools, and Templates

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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ASPR TRACIE. (2021). Step-by-Step Guide to Implementing the Coalition Infectious Disease Annex TTX Template (PDF).
This guide is part of a toolkit that can help emergency planners create an interactive, discussion-based exercise focusing on impacts to healthcare coalition and healthcare facilities caused by large numbers of patients seeking healthcare following exposure to an infectious agent.
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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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Association of Public Health Laboratories. (2015). Surge Capacity Planning Tool for the Laboratory Response Network for Biological Threats Preparedness (LRN-B).
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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Association of Public Health Laboratories. (2022). Algorithm and Guidelines for Responding to an Incident Involving a Suspicious Non-Clinical Sample, Version 3.0.
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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Federal Emergency Management Agency. (2023). Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans.
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. (2019). High Consequence Infectious Disease (HCID) Toolbox for Frontline Health Care Facilities.
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.). NETEC Exercise Templates. (Accessed 9/9/2024.)
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 Emerging Special Pathogens Training and Education Center. (2023). Long-Term Care Special Pathogens Infection Prevention and Control Workbook. (Free with registration.)
This workbook assists long-term care facilities assess their readiness for special pathogens and improve their infection prevention programs.
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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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United States Army Medical Research Institute of Infectious Diseases. (2021). USAMRIID's Biodefense Tool.
This app is built on the Medical Management of Chemical and Biological Casualties course taught by USAMRIID and can help first responders identify and treat conditions related to biological agents. (For Android devices, visit https://play.google.com/store/apps/details?id=com.tradocmobile.bio&hl=en&gl=US.)
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Specific Threats: Anthrax

Bower, W., Hendricks, K., Pillai, S., et al. (2015). Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident. 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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Bower, W., Yu, Y., Person, M., et al. (2023). CDC Guidelines for the Prevention and Treatment of Anthrax, 2023. Morbidity and Mortality Weekly Report (MMWR). 72(6):1-47.
This report provides an update to CDC guidance for prevention and treatment of exposure to anthrax, based on systematic reviews of the literature. This report improves on past CDC recommendations by providing alternative antimicrobial drug recommendations when first line treatments are contraindicated. It also provides information on diagnosis and treatment of anthrax meningitis.
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Centers for Disease Control and Prevention. (2025). Clinical Overview of Anthrax.
This webpage includes information on the types of anthrax, prevention, testing, treatment, and targeted resources for specific groups.
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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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Inglesby, T., Henderson, D., Bartlett, J. (2000). Anthrax as a Biological Weapon: Medical and Public Health Management. Working Group on Civilian Biodefense. (Abstract only.)
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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* 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 Biodefense Science Board. (2011). Challenges in the Use of Anthrax Vaccine Adsorbed (AVA) in the Pediatric Population as a Component of Post-Exposure Prophylaxis (PEP).
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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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. (2023). Anthrax.
This webpage provides information on and links to resources specific to vaccines approved to prevent disease.
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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. (2024). Botulism. U.S. Department of Health and Human Services.
This webpage includes basic information about botulism, prevention, symptoms, diagnosis, treatment, and resources for specific populations.
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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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Rao, A., Lin, N., Griese, S., et al. (2018). Clinical Criteria to Trigger Suspicion for Botulism: An Evidence-Based Tool to Facilitate Timely Recognition of Suspected Cases During Sporadic Events and Outbreaks.
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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Rao, A., Sobel, J., Chatham-Stephens, K., and Luquez, C. (2021). Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021. Morbidity and Mortality Weekly Report. 70(2):1-30.
These clinical guidelines provide background information on botulism and details about diagnosis and treatment. Considerations are included for conventional, contingency, and crisis care.
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Specific Threats: Dual Use Research

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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Specific Threats: Other (VHF, Category B & C Agents)

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. Morbidity and Mortality Weekly Report. 62(3):1-30.
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. (2024). About Melioidosis. U.S. Department of Health and Human Services.
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. (2024). Mpox in the United States and Around the World: Current Situation. U.S. Department of Health and Human Services.
This page includes various resources about monkeypox, including signs and symptoms, prevention, transmission, treatment, and information specific to clinicians, laboratory personnel, and veterinarians.
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Centers for Disease Control and Prevention. (2024). Q Fever. U.S. Department of Health and Human Services.
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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Specific Threats: Plague

Centers for Disease Control and Prevention. (2024). About Plague. U.S. Department of Health and Human Services.
This webpage includes general information on plague, transmission, prevention, diagnosis, treatment, and resources for specific groups
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Inglesby, T., Dennis, D., Henderson, D. et al. (2000). Plague as a Biological Weapon: Medical and Public Health Management. (Abstract only.) Journal of American Medical Association. 283(17):2281- 2290.
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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Nelson, C., Meaney-Delman, D., Fleck-Derderian, S., et al. (2021). Antimicrobial Treatment and Prophylaxis of Plague: Recommendations for Naturally Acquired Infections and Bioterrorism Response. Morbidity and Mortality Weekly Report. 70(3):1-27.
These guidelines provide recommendations to healthcare providers on treatment and prophylaxis of plague resulting from naturally occurring disease or a bioterrorism attack.
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Specific Threats: Smallpox

Centers for Disease Control and Prevention. (2024). About Smallpox. U.S. Department of Health and Human Services.
This webpage includes information on the history of smallpox, transmission, signs and symptoms, prevention and treatment, and resources for health care providers, public health practitioners, and the general public.
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Food and Drug Administration. (2025). Smallpox Preparedness and Response. U.S. Department of Health and Human Services.
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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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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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. (2024). About Tularemia. U.S. Department of Health and Human Services.
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

Bipartisan Commission on Biodefense.
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Center for Health Security.
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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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National Association of County & City Health Officials. Infectious Disease.
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National Emerging Special Pathogens Training and Education Center.
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U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. Public Health Emergency Medical Countermeasures Enterprise.
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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. 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. 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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This ASPR TRACIE Topic Collection was comprehensively reviewed in July 2018 by the following subject matter experts (listed in alphabetical order): Eric R. Alberts, CEM, CHS-V, FPEM, FPEM-HC, CDP-1, CHPP, CHEP, SEM, CFRP, FABCHS, Manager, Emergency Preparedness, Orlando Health, Inc. (Hospital System); Gerrit Bakker, Senior Director, Public Health Preparedness, Association of State and Territorial Health Officials; James Bolen, MS, Planning and Operations Manager, Butler County (Ohio) Emergency Management Agency; Julie Bulson, MPA, BSN, RN, NE-BC, Director, Emergency Preparedness, Spectrum Health; Dan Hanfling, MD (Panel Chair, Editor) Contributing Scholar, UPMC Center for Health Security, Member, InterAgency Board, Attending Physician, BestPractices, Inc. (a division of EmCare), and Clinical Professor of Emergency Medicine, George Washington University; John Hick, MD, U.S. Department of Health and Human Services, Assistant Secretary for Preparedness and Response and Hennepin County Medical Center; Jodi Keller, RN, Associate Director of Healthcare System Emergency Preparedness, Central Ohio Trauma System; Jenna Mandel-Ricci, Vice President, Regulatory and Professional, Legal, Regulatory, and Professional Affairs, Greater New York Hospital Association; John O’Connor, MS, Associate Director for Communication Science, National Center for Emerging and Zoonotic Infectious Disease, Centers for Disease Control and Prevention; Terri Postma, MD Medical Officer Performance-Based Payment Policy Staff Centers for Medicare & Medicaid Services; Aaron Resnick, MA, Northwest Healthcare Response Network (Tukwila, WA); Mary Russell, EdD, MSN, Healthcare Emergency Response Coalition, Palm Beach County FL; and Brian Wilson, State Medical System Response Coordinator, Oklahoma Department of Health.
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