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4-13. Environmental Detection
The NBC reconnaissance teams collect environmental samples for submission to the supporting medical
laboratory for analysis. Medical personnel collect pulmonary secretions from patients presenting with signs
and symptoms for laboratory analysis.
4-14. Prevention
There is no pre-exposure or post-exposure prophylaxis for C. perfringens.
4-15. Biological Warfare Clinical Presentation
a. Incubation. The incubation period is 1 to 6 hours.
b. Signs and Symptoms. Aerosol challenges of C. perfringens alpha toxin produce lethal
pulmonary disease in laboratory animals. The C. perfringens alpha toxin is a highly toxic phospholipase,
which will result in severe injury to the exposed respiratory tract. An aerosol delivery can produce a severe
pulmonary capillary leak, resulting in adult respiratory distress syndrome (ARDS) and respiratory failure.
Absorbed toxin can lead to intravascular hemolysis, thrombocytopenia, and liver damage.
4-16. Diagnosis
Acute serum and tissue specimens should be collected and transported to the designated reference laboratory
for toxin immunoassay. Clinical laboratory findings could include anemia, thrombocytopenia, abnormal
liver function tests, and hypoxia. The differential diagnosis should include other causes of ARDS including
chemical warfare
(CW) agent (phosgene or mustard) exposure, inhalation injury due to ricin or
staphylococcal enterotoxin B (SEB), Hantavirus pulmonary syndrome, and other diverse etiologies of
ARDS. Pulmonary disease due to SEB will be less severe; also hemolysis, thrombocytopenia, or liver
damage should not occur.
4-17. Treatment
a. Triage Categories. Triage categories will vary according to severity and stage of illness and
available resources.
b. Medical Management. Medical management consist of supportive care. Patients may require
assisted ventilation to relieve the respiratory effects. There are no specific antitoxins or antidotes available
c.
Prognosis. Prognosis is poor.
4-18. Control of Patients, Contacts, and Treatment Areas
Apply Standard Precautions in patient care. The C. perfringens toxin is not communicable person to person.
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4-19. Medical Evacuation
Patients may be evacuated. Apply Standard Precautions during evacuation.
Section IV. RICIN
4-20. General
a. Etiologic Agent. Ricin is a potent cytotoxin derived from the beans of the castor plant (Ricinus
communis). Over one million tons of castor beans are processed annually in the production of castor oil,
which is used for medicinal and industrial purposes including the production of aircraft and marine engine
lubricants, dyes, and paints. The waste mash from this process is approximately 5 percent ricin by weight.
Consequently, large quantities of ricin are easily and inexpensively produced. Ricin consists of two
hemagglutinins and two toxins. These toxins are dimers consisting of cytotoxic A chains and B chains
which serve as transport peptides and bind to cellular membrane receptors. Ricin toxins are potent
inhibitors of DNA replication and protein synthesis. The toxin can be transmitted through contaminated
food and water, percutaneously via small pellets/projectiles designed to carry toxins, or as a BW aerosol.
b. Reservoir. Castor beans.
c.
Transmission. Transmission has been by inhalation of organism during industrial operations.
Also, transmitted through ingestion of castor bean meal.
d. Endemic Disease. There is no endemic disease; however, there have been exposures in
industrial operations. Clinical features vary according to the route of intoxication and toxin dose. Accidental
sublethal aerosol exposures occurred during the 1940s. Patients presented with acute onset of fever, chest
tightness, cough, dyspnea, nausea, and arthralgias 4 to 8 hours after exposure. The onset of profuse
sweating several hours later was the sign of termination of most of the symptoms. Lethal aerosol exposures
in humans have not been reported; however, large aerosol exposures in experimental animals result in
necrosis of upper and lower respiratory epithelium, and perivascular and alveolar edema. Respiratory tract
exposure to a large dose will produce necrosis of the entire exposed respiratory tract; pulmonary capillary
leaks result in extravasation of protein-rich fluid into the alveoli, resulting in pulmonary edema, ARDS, and
respiratory failure. Ingestion results in necrosis of the GI epithelium, local hemorrhage, and hepatic,
splenic, and renal necrosis. Intramuscular injection results in severe local muscle necrosis and visceral
organ involvement.
4-21. Biological Warfare Agent Delivery
The primary threat is delivery of the BW agent by aerosol release. Ricin is less toxic than botulinum. A
larger quantity is required to cover a significant area on a battlefield. This feature may limit the use of ricin
as a tactical weapon; however, it can be used for small-scale operations. The agent may also be delivered
through contamination of food and water supplies.
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4-22. Environmental Detection
The NBC reconnaissance teams collect aerosol samples for supporting laboratory identification. Preventive
medicine/PHS/BEE personnel collect suspect contaminated water samples for laboratory identification.
Veterinary/PVNTMED/PHS personnel collect suspect contaminated food samples. Veterinary personnel
collect specimens from government-owned animals for supporting laboratory identification. Medical
treatment personnel collect specimens from patients presenting with signs and symptoms for laboratory
identification. The supporting laboratory performs an antigen detection (ELISA) test to identify the presence
of toxins in samples or specimens.
4-23. Prevention
a. Pre-exposure prophylaxis is not available; however, candidate vaccines are under development.
b. Post-exposure prophylaxis is not available.
4-24. Biological Warfare Clinical Presentation
a. Incubation Period. The incubation period is 18 to 24 hours.
b. Signs and Symptoms. See endemic disease, paragraph 4-20.
4-25. Diagnosis
Serum and respiratory secretions may be submitted for antigen detection (ELISA). Immunohistochemical
stains of tissue may also be available. Paired acute and convalescent sera for antibody studies can be
submitted from survivors. Nonspecific laboratory and radiographic findings may include neutrophilic
leukocytosis, bilateral interstitial infiltrates compatible with noncardiogenic pulmonary edema. Differential
diagnosis of respiratory disease would include phosgene exposure, SEB, Hantavirus pulmonary syndrome,
atypical pneumonias including Q fever and tularemia, and diverse causes of ARDS.
4-26. Treatment
a. Triage Categories. Triage categories will vary according to severity of illness and available
resources. Respiratory distress would result in placement of the patient in the Immediate category if
respiratory support was available, or Expectant if respiratory support was not available. Patients with
milder presentations would be candidates for the Delayed category.
b. Medical Management.
(1) Supportive care including intensive care measures, such as supplemental oxygen,
endotracheal intubation and mechanical ventilation, positive end-expiratory pressure, and hemodynamic
monitoring, may be required for respiratory disease.
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(2) Gastrointestinal intoxication is best managed by vigorous gastric decontamination with
lavage and superactivated charcoal, followed by use of cathartics such as magnesium citrate. Volume
replacement of GI tract fluid loss is important.
(3) In percutaneous exposures, treatment would be primarily supportive, managing specific
organ system failures.
(4) Specific therapeutic drugs are not currently available.
c.
Prognosis. Prognosis depends on the route and intensity of exposure. Due to a lack of data,
specific prognosis outcomes cannot be stated.
4-27. Control of Patients, Contacts, and Treatment Areas
Apply Standard Precautions in patient care. Ricin is not communicable person to person.
4-28. Medical Evacuation
Patients may be evacuated.
Section V. SAXITOXIN
4-29. General
a. Etiologic Agent. Saxitoxin is the parent compound of a group of related neurotoxins produced
by marine dinoflagellates of the genus Gonyaulax.
b. Reservoir. Shellfish.
c.
Transmission. Saxitoxin is transmitted to humans by ingesting bivalve mollusks, which
accumulate dinoflagellates during filter feeding.
d. Endemic Disease. Paralytic shellfish poisoning
(PSP) is a severe, life-threatening
neuromuscular condition. Saxitoxin is rapidly absorbed from the GI tract following ingestion of
contaminated shellfish. Saxitoxin binds to the sodium channels of nerve and muscle tissue, preventing
propagation of action potentials in excitable cells. This leads to neuromuscular dysfunction, and in severe
cases, death due to respiratory paralysis and respiratory failure. In contrast to botulism, sensory and CNS
symptoms are present in addition to motor symptoms. Symptoms begin as early as 10 minutes to several
hours after ingestion, depending on the ingested dose and host factors. Initial symptoms include numbness
and tingling of the lips, tongue, and fingertips; followed by numbness of the neck and extremities and motor
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incoordination. Cranial nerve involvement can result in diplopia, speech, and swallowing difficulties.
Other symptoms may include light-headedness, dizziness, weakness, confusion, memory loss, and headache.
Flaccid paralysis and respiratory failure are life-threatening complications, and occur within 2 to 12 hours
after ingestion. The toxin is rapidly cleared by renal excretion; however, complete neurologic recovery
may require 7 to 14 days.
4-30. Biological Warfare Agent Delivery
The primary threat is delivery by aerosol release. Saxitoxin may also be delivered by projectiles or by
contamination of food and water. Contamination of food and water supplies would be on a very limited
basis.
4-31. Environmental Detection
The NBC reconnaissance teams collect aerosol samples for supporting laboratory identification. Preventive
medicine/PHS/BEE personnel collect suspect contaminated water samples for laboratory identification.
Veterinary/PVNTMED/PHS personnel collect suspect contaminated food samples. Veterinary personnel
collect specimens from government-owned animals for supporting laboratory identification. Medical
treatment personnel collect specimens from patients presenting with signs and symptoms for laboratory
identification.
4-32. Prevention
a. Pre-exposure Prophylaxis. There is no pre-exposure prophylaxis available. Avoidance of
potentially contaminated food and water will protect individuals from the effects of ingested toxins.
b. Post-exposure Prophylaxis. There is no post-exposure prophylaxis available.
4-33. Biological Warfare Clinical Presentation
a. Incubation. Minutes to hours.
b. Signs and Symptoms. Clinical features would be similar to those discussed above for endemic
disease; animal experiments using aerosol challenges suggest that the clinical course following inhalation is
accelerated and that death occurs within minutes following exposure.
4-34. Diagnosis
Diagnosis is confirmed by antigen (toxin) detection by ELISA test or mouse bioassay. Clinical specimens
which may be submitted for toxin assay include stomach contents, serum, and in a BW context, respiratory
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secretions. Specific toxins can be identified by high-pressure liquid chromatography. Routine clinical
laboratory findings are not specific for saxitoxin poisoning. Cardiac conduction disturbances may develop;
however, these electrocardiographic findings are nonspecific. The differential diagnosis of saxitoxin
poisoning includes ciguatoxin (ciguatera) and tetrodotoxin ingestion. Ciguatoxin occurs following ingestion
of large finned reef fish, and in contrast to saxitoxin, will result in more severe GI symptoms (nausea,
vomiting, diarrhea), and in a peculiar reversal of temperature sensationhot feels cold, cold feels hot.
4-35. Treatment
a. Triage Categories. Triage categories vary according to the severity of the disease and
availability of resources. Following aerosol delivery or toxic projectile, patients may be considered
candidates for the Immediate category for airway and ventilatory support, if available; or candidates for the
Expectant category in remote, isolated locations.
b. Medical Management. Supportive care is essential. Airway management and mechanical
respiratory support is required for severe intoxication. Standard management of poison ingestion, including
superactivated charcoal, should be used following oral ingestion.
c.
Prognosis. Prognosis following an aerosol challenge is poor.
4-36. Control of Patients, Contacts, and Treatment Areas
Apply Standard Precautions in patient care. Saxitoxin is not transmitted person to person.
4-37. Medical Evacuation
Patients may be evacuated. Apply Standard Precautions during evacuation.
Section VI. STAPHYLOCOCCAL ENTEROTOXIN B
4-38. General
a. Etiologic Agent. Staphylococcal enterotoxin B is one of numerous exotoxins produced by
Staphylococcus (S.) aureus. Up to one-half of all clinical isolates of S. aureus produce exotoxins; related
toxins include toxic shock syndrome toxin-1 (TSST-1) and exfoliative toxins. The SEB toxin is heat-stable
and is the second most common source of outbreaks of food poisoning.
b. Reservoir. The reservoir of S. aureus is humans (especially, food handlers with infected cuts
on their hands, abscesses, acne eruptions, nasal discharges, or on occasion, from normal appearing skin)
and contaminated milk or milk products. The SEB is usually produced in foods contaminated with S. aureus.
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c.
Transmission. Ingestion of food, milk, or milk products containing preformed toxin.
d. Endemic Disease. Staphylococcal food poisoning features the acute onset of fever, nausea,
vomiting, and diarrhea within hours of intoxication. The toxin increases intestinal peristalsis; severe nausea
and vomiting may be due to stimulation of the CNS. The staphylococcal enterotoxins belong to a class of
potent immune stimulants known as bacterial superantigens. Superantigens bind to monocytes at major
histocompatibility complex type II receptors rather than the usual antigen binding receptors. This leads to
the direct stimulation of large populations of T-helper cells while bypassing the usual antigen processing and
presentation. This results in a brisk cascade of pro-inflammatory cytokines and recruitment of other
immune effector cells, and a relatively deficient activation of counter-regulatory negative feedback loops.
This results in an intense inflammatory response that can injure host tissues.
4-39. Biological Warfare Agent Delivery
The primary threat is SEB aerosol release. The SEB may also be employed by sabotage contamination of
food and/or water supplies.
4-40. Environmental Detection
The NBC reconnaissance teams collect aerosol samples for supporting laboratory identification. Preventive
medicine/PHS/BEE personnel collect suspect contaminated water samples for laboratory identification.
Veterinary/PVNTMED/PHS personnel collect suspect contaminated food samples. Veterinary personnel
collect specimens from government-owned animals for supporting laboratory identification. Medical
treatment personnel collect specimens from patients presenting with signs and symptoms for laboratory
identification. The supporting laboratory performs toxin assay of epidemiologically implicated food or
water. The laboratory can also perform toxin assay of environmental samples following an aerosol attack.
4-41. Prevention
a. Pre-exposure Prophylaxis. Currently, there is no pre-exposure prophylaxis available.
Protecting food and water supplies from contamination and avoiding potentially contaminated food and
water will protect individuals from the effects of ingested toxins.
b. Post-exposure Prophylaxis. Currently post-exposure prophylaxis is not available; however,
passive immunization (immunoglobulin) can attenuate experimental disease in experimental animals if given
within 4 to 8 hours post-exposure. There are no human data or practice guidelines.
4-42. Biological Warfare Clinical Presentation
a. Incubation. Variable.
4 to 10 hours for GI illness.
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b. Signs and Symptoms. Illness due to poisoning of food or water supplies will present as acute
GI illness (see endemic disease, paragraph 4-38). Illness due to inhalation will result in respiratory tract
disease not encountered in the endemic disease. This is due to the activation of pro-inflammatory
cytochylema cascades in the lungs, leading to pulmonary capillary leak and pulmonary edema. Symptoms
include fever, headache, myalgia, nonproductive cough, and in severe cases, dyspnea. Gastrointestinal
symptoms may also occur due to inadvertent swallowing of SEB delivered via aerosol and deposited in the
upper aero-digestive tract, or coughed following mucociliary clearance. Severe cases may result in acute
pulmonary edema and respiratory failure.
4-43. Diagnosis
Diagnosis includes performing toxin assay (antigen detection) of implicated food or water and on
environmental samples collected following a suspect BW attack. Clinical specimens that could be sent for
toxin assay include serum and respiratory secretions. However, the toxin may not be detectable before the
onset of symptoms. Acute and convalescent sera for antibody tests will confirm the diagnosis. Nonspecific
findings may include leukocytosis, elevated sedimentation rate, and in severe cases, chest x-ray abnormalities
featuring pulmonary edema. Differential diagnosis include pneumonia due to viruses, mycoplasmas,
Chlamydia pneumoniae, Coxiella burnetii, Hantavirus pulmonary syndrome, CW agent inhalation injury (mustard,
phosgene), and in severe cases, other diverse causes of noncardiogenic pulmonary edema and ARDS.
4-44. Treatment
a. Triage Categories. Triage categories will vary with conditions and available resources.
Patients with acute respiratory distress should be placed in the Immediate category to obtain respiratory
support. Patients without respiratory distress should be placed in the Delayed category.
b.
Medical Management. Medical management is primarily supportive care; symptomatic relief
may be provided by the use of acetaminophen and cough suppressants. Severe cases will require intensive
care including respiratory support, hemodynamic monitoring, and possibly diuretics and vasopressors.
c.
Prognosis. Staphylococcal enterotoxin B is considered an incapacitating agent; most patients
may be expected to make a full recovery, although most patients will be unfit for duty for 1 to 2 weeks.
Patients with pulmonary edema and respiratory failure will be at risk for mortality.
4-45. Control of Patients, Contacts, and Treatment Areas
Apply Standard Precautions in patient care. Staphylococcal enterotoxin B is not communicable person to person.
4-46. Medical Evacuation
Patients may be evacuated. Observe Standard Precautions in patient movement.
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Section VII. TRICHOTHECENE MYCOTOXINS
4-47. General
a. Etiologic Agent. Trichothecene (T2) mycotoxins are a diverse group of over 40 compounds
produced by molds of the genus Fusarium. These toxins inhibit protein and DNA synthesis, mitochondrial
respiration, and alter cell membrane structure and function. Naturally occurring mycotoxicosis occurs in
livestock following ingestion of grains contaminated with molds.
b. Reservoir. Moldy grain.
c.
Transmission. Ingestion of moldy grains.
d. Endemic Disease. While there have been no laboratory-confirmed cases of human disease due
to T2 mycotoxins, these toxins are thought to have caused an epidemic of foodborne illness (alimentary
toxic aleukia) in Russia during World War II due to the ingestion of foods prepared from moldy grain.
4-48. Biological Warfare Agent Delivery
The toxin may be delivered by aerosol release or through contamination of food and water supplies. These
toxins are the agents allegedly delivered via aerosol during the Yellow Rain attacks in Afghanistan and
Southeast Asia during the 1970s and 1980s. The T2 mycotoxins are the only potential BW agents that can
harm and be absorbed through intact skin.
4-49. Environmental Detection
The NBC reconnaissance teams collect aerosol samples for supporting laboratory identification. Preventive
medicine/PHS/BEE personnel collect suspect contaminated water samples for laboratory identification.
Veterinary/PVNTMED/PHS personnel collect suspect contaminated food samples. Veterinary personnel
collect specimens from government-owned animals for supporting laboratory identification. Medical
treatment personnel collect specimens from patients presenting with signs and symptoms for laboratory
identification. The supporting laboratory performs toxin assay of epidemiologically implicated food or
water. The laboratory can also perform gas-liquid and high-pressure liquid chromatography of
environmental samples.
4-50. Prevention
a. Pre-exposure Prophylaxis. As a pre-exposure prophylaxis, the use of topical antivesicant
cream or ointment may provide limited protection of skin surfaces. Food and water contaminated with
mycotoxins must not be consumed.
b. Post-exposure Prophylaxis. There is no post-exposure prophylaxis.
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4-51. Biological Warfare Clinical Presentation
a. Incubation. The incubation period is minutes after exposure.
b. Signs and Symptoms. The BW disease presentation will vary according to the portal of entry
and delivered dose. Mycotoxins are highly cytotoxic and may be viewed as radiomimetic agents, or
having effects similar to vesicants, especially mustard agents. Delivery to the skin may cause a burning skin
pain, redness, tenderness, blistering, and progression to skin necrosis with eschar formation and sloughing.
Respiratory exposure may result in nasal itching with pain, rhinorrhea, sneezing, epistaxis, dyspnea,
wheezing, and cough. Exposure of the conjunctivae and other mucosal surfaces may result in local burning
pain and redness, followed by necrosis. Gastrointestinal exposure would be expected to result in nausea,
vomiting, crampy abdominal pain, and watery or bloody diarrhea. Systemic absorption may follow
delivery via any route and would result in late toxicity of decreased blood cell counts, predisposing to
bleeding and sepsis.
4-52. Diagnosis
Serum and urine should be sent for antigen detection. The parent toxin and metabolites (50 to 75 percent)
are eliminated in urine and feces within 24 hours; however, metabolites can be detected as late as 28 days
after exposure.
4-53. Treatment
a. Triage Categories. The triage category varies with the stage and severity of illness and
available resources.
b. Medical Management. Following oral ingestion, standard therapy for poison ingestion
including the use of superactivated charcoal is indicated. Other measures of supportive care depend upon
the organ system involved (for examples, respiratory support for respiratory involvement and standard burn
care for cutaneous involvement). All medical interventions are supportive; there are no antidotes or other
specific therapies available.
c.
Prognosis. Prognosis following the development of symptoms is poor.
4-54. Control of Patients, Contacts, and Treatment Areas
Apply Standard Precautions in patient care. Mycotoxins are not transmitted person to person.
4-55. Medical Evacuation
Patients may be evacuated. Observe Standard Precautions during evacuation.
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APPENDIX A
RECOGNITION OF A
BIOLOGICAL WARFARE AGENT CASUALTY
A-1. General
a. Medical personnel must be familiar with the signs and symptoms of BW agent casualties.
With current technology, it is likely that a BW attack will be completed before the local commander, or his
medical advisor, is aware that it has taken place. The medical officer must attempt to distinguish between
an epidemic of natural origin and a BW attack.
b. Medical and tactical intelligence channels should communicate with each other as early as
possible. Threat information on potential enemy force use of BW weapons/agents is important for planning
and executing HSS operations. Once BW agents have been used, identification of agents will be important
to medical intelligence channels for operational purposes.
c.
Medical units should rely on information not only from detectors and intelligence sources, but
also from the casualties themselves. This applies particularly to BW weapons/agents since at present there
are no rapid methods of detection or identification. Some of the problems in the recognition and diagnosis
of casualties suffering from the effects of BW operations are discussed here. Medical personnel must
remember that the signs and symptoms of most BW agents are identical to or similar to those of endemic
and epidemic diseases. The nature and timing of symptoms will vary with the route of exposure. Although
most BW agents require days to manifest, some agents produce their effects in minutes to a few hours. It is
important that the fullest and earliest information be given to medical units when the enemy has used BW
weapons/agents. This information is used to facilitate the diagnosis of individual cases, to initiate immediate
treatment, and to permit the arrangement for the reception of casualties.
A-2. Types of Casualties
On the BW battlefield, the following types of casualties may be seen:
a. Conventional Casualties.
(1) Conventional casualties with no BW injury and with no contamination of their clothing
and equipment.
(2) Conventional casualties with no BW injury but with contamination of their clothing and
equipment.
b. Direct Biological Warfare Casualties.
(1) Biological warfare agent casualties with no other injury.
(2) Mixed casualties with conventional and BW injuries. Since BW munitions often include
burst charges, such injuries may occur as part of a BW agent attack. They may also be present when the
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BW injury and conventional injury occur at different times. Other types of mixed casualties may be from
nuclear or chemical weapons used as well as the biological weapons. Also, mixed casualties may result
when biological injuries are combined with natural illnesses (infectious disease still accounts for the majority
of casualties in conventional warfare).
c.
Indirect Biological Warfare Casualties.
(1) Casualties suffering combat stress reaction occur often in warfare, but may be more
frequent where NBC threats exist. The service member will have the additional stress of isolation from
wearing the chemical protective ensemble; additional fatigue when wearing the protective garments; and
fear of NBC agents. See FM 8-51, FM 22-51, and MCRP 6-11c for additional information on combat
stress control.
(2) Some BW agent treatments can have undesirable side effects when taken inappropriately,
or in large enough quantities. Antibiotics kill desirable bacteria in the digestive tract, causing abdominal
pain and frequent bowel movements. Medical personnel must be alert for their appearance.
(3) Wearing the protective ensemble makes dissipation of excess body heat more difficult.
Wearing the mask also makes water intake difficult. Both will increase the probability of heat injury (heat
exhaustion or heat stroke).
(4) Indirect BW casualties will most likely be the largest group requiring treatment.
A-3. Recognize Biological Casualties
a. It is unlikely that BW agents will produce single casualties under field conditions. Also, a BW
attack should be suspected with any sudden increase in the numbers of unexplained casualties presenting
with the same signs and symptoms. If BW operations are unlikely, and if relatively few service members
are affected, an endemic or epidemic disease may be more probable (for example, Salmonella food
poisoning). If the number of cases continue to present over an extended period, as opposed to a large
number presenting in one or two days, a naturally occurring epidemic is suspected.
b. Under operational conditions, the psychological effects may complicate the medical situation.
To determine if a BW agent has caused the casualty, the medical officer should ask questions along the
following lines:
Was the casualty wearing full MOPP at the time of the exposure?
Was there any aircraft or artillery bombardment in the area at the time of the attack?
Was there anyone in the area dispersing a suspicious spray or vapor from portable or
vehicle-mounted devices?
Were there any suspicious persons around the unit water supply or in the unit food
service area?
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Was there any evidence of spray, liquid droplets, or suspicious persons in the area?
Was anyone else affected and if so, what effects?
c.
To recognize a BW attack, the identity of the agent must be determined.
(1) The medical officer should consider the following:
Groups of patients from a specific unit/area presenting with the same illness signs
and symptoms in a short period of time (hours to days).
Signs and symptoms not associated with any known endemic diseases in the AO.
(2) Also, question the patient about the delay or rapidity of the onset of symptoms. Was
there any delay between exposure or contamination and the onset of effects? If so, how long was the delay?
Did the effects persist after adjustment of the protective mask?
Has the casualty used any self-injection device or did anyone else use any injection
devices on the casualty? If so, did the symptoms improve or deteriorate?
Is the casualtys behavior normal?
d. To assess the dose of the agent received by the patient, determine the following:
Was the casualty exercising or at rest?
Was the casualty in the open or under cover?
How long was the suspect BW agent inhaled?
How long was the interval between suspected contamination and decontamination?
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APPENDIX B
MEDICAL MANAGEMENT AND TREATMENT
IN BIOLOGICAL WARFARE OPERATIONS
Section I. US ARMY MEDICAL TREATMENT FACILITIES
B-1. General
All US Army MTFs must be prepared to receive mass casualties caused by exposure to BW agents. A mass
casualty situation exists when the number and type of casualties exceed the local medical support capabilities
for their care. If the unit follows conventional operational standing operating procedures, an overwhelming
backlog of work will rapidly accumulate. Such backlogs can result in unnecessary loss of life and limb with
suffering. Therefore, all HSS planners must prepare plans for mass casualty situations and all units must be
trained and equipped for these plans. The unit must be ready to operate with minimal confusion. Medical
units must provide medical treatment to these casualties and supervise their decontamination. Normally,
individual service members are responsible for their own decontamination. For casualties who are injured
and unable to decontaminate themselves, this process has to be performed by buddy aid, by unit personnel
at a decontamination site, or at an MTF by nonmedical personnel from the supported units.
a. At US Army Levels I and II (unit, division, and nondivisional) units, the supported unit
commander must provide at least 8 nonmedical personnel to perform patient decontamination. At US Army
Levels III and IV (corps and echelons above corps) hospitals, a 20-man patient decontamination augmentation
team or 20 nonmedical personnel must be provided to perform patient decontamination. The base cluster
commander or units within the geographical area of the hospital must provide the 20 nonmedical personnel.
b. Medical personnel must supervise patient decontamination personnel to ensure patient
conditions are not aggravated by decontamination process. Supervising medical personnel must make the
final determination on the completeness of patient decontamination.
c.
If the supported units do not have the necessary resources to provide nonmedical personnel,
the units (not the medical services) must address this issue with higher headquarters.
B-2. Objectives of Health Service Support in Biological Warfare Operations
The objectives of HSS in BW operations are to
a. Return to duty the maximum number of personnel as soon as possible.
b. Manage casualties so that BW agent injuries are minimized and any other injuries or illnesses
are not aggravated.
c.
Protect persons handling contaminated casualties or working in contaminated areas.
d. Avoid spreading contamination in ambulances, other evacuation vehicles and aircraft, MTFs,
and adjoining areas.
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e.
Continue the MTFs operations to maintain normal services unrelated to the medical treatment
of BW agent illnesses and injuries.
B-3. Planning for the Management and Treatment of Biologically Contaminated Casualties
The initial management and treatment of casualties contaminated with a BW agent will vary with the tactical
situation and the nature of the contaminant. Therefore, each MTF must have a plan and put it into effect
immediately, then modify it to meet each specific situation. Patient decontamination sites are collocated
with an MTF. This ensures that medical supervision of patient decontamination is available. Specifics on
management of BW-contaminated patients at the MTF are found in FM 8-10-7. Each MTF has identical
medical equipment sets (MES) for chemical agent patient decontamination and treatment. The numbers of
each type of MES vary, depending on the level of care. For example, the battalion aid station (BAS) has
one chemical agent patient decontamination MES and two chemical agent patient treatment MES. The
patient decontamination MES provides sufficient supplies to decontaminate 60 patients. Each chemical
agent patient treatment MES provides sufficient medical supplies to treat 30 patients. The chemical agent
patient treatment MES contains the patient protective wraps
(PPWs) that are needed to transport
decontaminated litter patients to the next level MTF. Each MTF must be prepared to treat
Biological warfare agent casualties generated within the geographical area of the MTF.
Patients received from a forward and, in some cases, a lateral MTF.
Patients suffering from a combination of injuries/illnesses (such as BW and conventional, BW
and chemical agent, and BW and endemic disease.)
Patient suffering from battle injuries and DNBIs that have not been exposed to any NBC agents.
Enemy prisoners of war, detained persons, and noncombatants, when directed.
B-4. Emergency Medical Treatment of Biologically Contaminated Casualties
a. Biological warfare agent casualties received at an MTF may also have traumatic wounds or
illnesses due to other causes. Management of these patients must minimize the BW agent injuries without
aggravating their traumatic wounds or illnesses.
b. Triage of arriving casualties is extremely important. A decision is made whether EMT or
decontamination of the casualty requires priority. Airway management and/or control of hemorrhage may
be equal to or more urgent than treatment for BW agent poisoning. Therefore, EMT measures may have to
be performed in rapid sequence with decontamination or by simultaneous team actions.
c.
For contaminated casualties who have traumatic injuries or other illnesses, decontamination
should be accomplished as soon as the situation permits. Lifesaving measures for a traumatic injury or
some illnesses must be given priority over immediate decontamination, although the delay may increase the
BW agent illness or injury.
B-2
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
d. When a contaminated casualty has another injury or illness resulting in respiratory difficulty,
hemorrhage, or shock, the order of priority for emergency action is as follows:
(1) Control respiratory failure (provide assisted ventilation) and/or massive hemorrhage.
(2) Decontaminate the casualty.
(3) Administer additional EMT for shock, wounds, and illnesses so severe that delay may be
life or limb threatening.
(4) Evacuate the casualty as soon as possible, if necessary.
B-5. Patient Decontamination Methods
a. Patient decontamination serves two purposes
(1) It prevents the patients system from absorbing additional contaminants.
(2) It also protects medical personnel treating the patient and other patients from
contamination. Accumulated contamination in the MTF is a serious threat to medical personnel and
patients. Accumulated contamination may also impose a serious medical logistical burden on the unit. The
effectiveness of decontamination is strongly influenced by the time lapse between initial contamination and
decontamination. In many cases, the patient may have absorbed dangerous quantities of a contaminant
before arriving at the MTF.
b. Each service member is trained in immediate decontamination procedures and is equipped to
do so. However, any patient arriving at an MTF from a BW-contaminated area is considered contaminated,
unless there is positive proof to the contrary.
c.
A decontamination area is established on the downwind side of the MTF. It is provided with
overhead protection such as plastic sheeting, trailer covers, ponchos, tarpaulins, or tents. Only those
patients requiring treatment at a forward MTF will have their protective overgarments and other clothing
removed. Needless removal of protective clothing only increases the patients vulnerability to liquid agent
exposure which results in increased injury. Also, forward MTFs do not have replacement protective
overgarments. Any ambulatory patient decontaminated by clothing removal becomes a litter patient; he
must be placed in a PPW for protection from BW agents during evacuation. Patients not requiring
treatment at a forward MTF, but requiring evacuation to the next level MTF must have their MOPP gear
and equipment spot decontaminated. Spot decontamination will remove gross contamination, reducing the
hazard to the casualty and evacuation personnel.
d. Every person entering the decontamination area (including patients) must be wearing a
protective mask or have other respiratory tract protection in place. Most contaminants are removed by
carefully removing all clothing.
B-3
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
WARNING
Do not remove the patients protective mask. Remove the
mask hood, overgarments, booties and boots, the BDU, and
undergarments. For step-by-step procedures in performing
patient decontamination, see FM 8-10-7.
e.
After patients have been decontaminated, exercise rigid control to prevent exposing their
unprotected skin to a liquid BW agent. After treatment in the clean treatment area or collective protection
shelter (CPS), the patient is placed in a PPW (to protect them during evacuation) and taken to the evacuation
point to await evacuation. Medical personnel must monitor patients at the evacuation point to ensure that
their condition remains stable; if their condition changes, additional treatment may have to be provided
before evacuation.
f.
Ambulatory patients may be able to decontaminate themselves and assist with the
decontamination of other ambulatory patients. Their overgarments are not removed unless they must enter
the clean treatment area or CPS for treatment. For patients not entering the clean treatment area or CPS,
spot decontaminate the overgarment to remove gross contamination. When possible, have them proceed as
groups of two or three to facilitate control. Ambulatory patients require constant observation and periodic
assistance during the decontamination process. The aidman at the decontamination point removes all
bandages from patients that will be treated at the MTF. Bandages are not replaced unless needed to control
bleeding. After decontamination, each patient goes through the shuffle pit to the clean treatment area where
wounds are treated and if possible, protective covering is restored. Restore protective covering by taping
holes or tears in the protective overgarment. Patients are then returned to duty or go to the evacuation
point, as their medical conditions dictate. Ambulatory patients with injuries that do not require immediate
attention but require treatment at a higher level MTF are evacuated in their MOPP ensemble. For example,
a patient with a broken arm has a stabilizing splint on. This individual does not require treatment at the
BAS; however, his MOPP gear must be spot decontaminated to remove gross contamination before
evacuation to the Level II MTF.
NOTE
At forward MTFs (Levels I and II), only patients that cannot survive
evacuation to the next level MTF will be completely decontaminated
(have their clothing removed) and treated at the lower level of care
facility. Patients that are stable but require evacuation to a higher
level MTF should have their overgarments spot decontaminated before
evacuation. The patients must be completely decontaminated at the
MTF where essential medical care is provided.
B-4
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
B-6. Logistics
a. Provisions must be made to ensure that medical personnel are supplied and equipped to
manage and treat contaminated casualties. Also, supplies and equipment must be provided for the protection
of personnel manning the contaminated areas. Medical supplies are stored or stocked in a manner that
reduces potential loss from BW contamination.
b. Patient protective wraps must be available for casualties whose injuries require decontamination
(clothing removal) for treatment in the clean treatment area. After treatment, decontaminated patients must
be placed in PPWs before they are moved to the evacuation point (paragraph B-5e above).
B-7. Training
Commanders must ensure that medical personnel and decontamination team members (provided by the
supported unit) are trained to manage, decontaminate, and treat BW agent casualties. Personnel must be
trained to protect themselves from BW agent injuries. In addition, provisions must be made for practice
exercises to enable them to accomplish their responsibilities with speed and accuracy. Example:
Decontaminating a casualty with speed is achieved through practice. Training emphasis should be placed on
Employing individual protection.
Practicing immediate decontamination procedures.
Providing EMT.
Performing casualty decontamination.
Evacuating decontaminated casualties.
Evacuating contaminated casualties.
Sorting and receiving contaminated casualties into a system designed for the treatment of both
contaminated and uncontaminated casualties.
Techniques for patient lifting and litter transfer.
Using the chemical agent monitor (CAM) and chemical agent detection paper to monitor for
and detect chemical agents, if employment in conjunction with BW agents is suspected.
B-8. Casualty Evacuation
a. Contaminated casualties should be decontaminated as close to the areas where they were
contaminated as possible. Their MOPP gear and clothing should not be removed until they arrive at an MTF.
Evacuation by ground ambulance must not be delayed for completion of decontamination. Upon arrival at
the MTF where treatment will be provided, all contaminated clothing and equipment (except the protective
B-5
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
mask) are removed and the skin and protective mask are decontaminated; spot decontaminate the skin.
Decontaminated patients continue to be a hazard to persons handling, treating, or transporting them.
Therefore, appropriate precautions for the suspected disease must be applied. After decontamination at the
field MTF, the patient is placed in the clean holding area to await admission into the CPS or clean treatment
area. They must be protected from recontamination. Patients will keep their protective mask on until they
are in the clean treatment area (away from the hotline) or are in the air lock of the CPS (see FM 8-10-7).
(1) Once treated, the patient is placed in a PPW before movement to the evacuation pickup
point. The PPW protects the individual from further contamination. Individuals inside the PPW no longer
have to wear the protective mask and are evacuated as clean. A plastic window in the PPW permits patient
observation. A patient in a PPW and left in a sunny area is subject to heat build up. The protective mask
remains with the patient during evacuation even though it may not be worn.
(2) If a BW attack occurs, medical units in the evacuation system can expect to receive
contaminated casualties because of the need for hasty evacuation. Therefore, extreme care must be taken to
avoid spreading the contamination.
b. Before contaminated casualties are evacuated by Army aircraft or landing craft, they should be
decontaminated. Otherwise, the BW agent may endanger the crew and other personnel, as ventilation is
poor in aircraft compartments and other enclosed spaces. If casualties cannot be decontaminated before
evacuation, they should be evacuated by ground ambulance. These casualties should wear their protective
masks. The hazards of the BW agent to other persons can be further minimized by
Preparing each litter by placing an impermeable cover over it and an open blanket on top
of the cover.
Placing the casualties on the prepared litters and folding the sides of the blankets over
them. Although this measure helps protect other persons, it increases the casualties exposure to the
contaminant and increases the possibility of heat injuries.
Providing as much ventilation during transport as the weather and other conditions permit.
Removing the impermeable covers and blankets with the casualties when they are
removed from the vehicles. Litters that have not been protected with impermeable covers must be handled
as contaminated.
c.
Patients being evacuated by USAF AE aircraft should be decontaminated prior to evacuation.
See FM 8-10-6 and FM 8-10-7 for procedures on patient evacuation by USAF aircraft.
Section II. US AIR FORCE MEDICAL TREATMENT FACILITIES
B-9. General
a. The USAF recognizes five levels of care.
B-6
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
(1) Level I includes self-aid and buddy care, examination and emergency lifesaving measures
such as maintenance of airway, control of bleeding, prevention and control of shock, and prevention of
further injury. Medical treatment is administered by independent duty medical personnel.
(2) Level II care is administered at the Air Transportable Clinic which assumes AE
availability. Patients are stabilized for AE. There is limited outpatient clinical services, initial trauma
response, and no patient holding capability.
(3) Level III care is provided by the Air Transportable Hospital (ATH). There are 10-bed,
25-bed, and 50-bed ATH packages. Normally, individual service members who were exposed to a BW
agent and are in need of medical care are assisted by the WMDT in the decontamination process. For
casualties who are injured and unable to decontaminate themselves, this process has to be performed by the
WMDT. (Public health technicians on the WMDTs also have a secondary mission to provide technical
guidance on food decontamination.)
(4) Level IV care provides definitive therapy for patients in the recovery phase. If rehabili-
tation cannot be accomplished within a pre-determined holding period, patients are evacuated to Level V.
(5) Level V care is convalescent, restorative, and rehabilitative. Level V care is normally
provided by military, Department of Veterans Affairs, or civilian hospitals in CONUS.
b. Military personnel exposed to sufficient BW agents without personal protective equipment and
without immunity or prophylaxis will become medical casualties when
75 percent incapacitated.
Commanders must be aware that military personnel who become BW medical casualties will require
medical treatment for more than 7 days and it is unlikely that they will be recovered to 75 percent capacity
to permit return to duty until after a lengthy convalescent period. In-theater commanders must make
arrangements for medical evacuation of BW casualties and arrangement for replacement personnel.
Continental US commanders must prepare for at least a 10-day forecast of patient loads from theater
commanders and identify resources for treatment and recovery of BW patients. Special resources and
transportation requirements will be required for casualties exposed to IQDs; see paragraph 1-21.
B-10. Detection of Biological Agents
a. For information on the employment, physical properties, infectivity, detection, and control of
biological agents, see AFJMAN 32-4009 and AFVA 32-4011. Basically, protection consists of denying
access of the agent to the respiratory and digestive systems and immunization of individuals. Skin and
wound contamination is of secondary importance.
b. If a real-time field detection/identification capability is not present, recognition of BW agents
must be based on epidemiology and symptoms. Once illness begins to appear, the presence of an airborne
BW agent should be relatively obvious because of the large numbers of casualties and the absence of a
common exposure source such as food or water. However, food and/or water may also serve as a vehicle
of transmission. If the situation is not readily apparent, the attack will not have been effective. Some
indications of an attack are
B-7
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Point-source epidemiology with a record number of sick and dying patients presenting
within a short period of time (within 12 to 48 hours).
Very high attack rates (60 to 90 percent of personnel are affected/symptomatic).
A high incidence of pulmonary involvement signaling an aerosol route of infection. This
would apply to such agents as plague, tularemia, anthrax, and Q fever where the usual form of infection is
not pulmonary.
Impossible epidemiology. If CCVHF occurred in Alaska or New York, or VEE in
England, a man-made epidemic would be extremely likely.
Record fatality rates would be expected for many agents, since a large number of victims
would receive doses of organisms far beyond what could possibly occur in nature. This is especially true of
an aerosol attack.
Localized areas of disease epidemics might occur in an area or sector downwind from the
point of attack.
Multiple infections at a single site with unusual pathogens.
Increased numbers of dead animals of all species, such as rats for plague, or horses with
equine encephalitis viruses.
Protection of those working in indoor environments or environments with filtered air at
the time of the attack.
The near simultaneous outbreak of similar or different epidemics at the same site or at
different sites in a TO or at military installations around the world.
Direct evidence of an attack, such as finding an unexploded munitions or a contaminated
exploded munitions; admission by hostile forces or terrorists that BW weapons are being used; witnessing
an attack; or intelligence information reporting use of BW agents by hostile forces from covert agents
working within those hostile forces.
B-11. Identification
The MTF should attempt to identify the agent using whatever laboratory resources are available. The MTF
should collect and transport appropriate environmental samples and biological specimens to more capable
medical laboratory facilities, such as the Forward Naval Laboratory or the Area Medical Laboratory.
B-12. Decontamination
Normally, only life-saving medical treatment can be provided prior to decontamination, as described in
AFJMAN 44-149. Decontamination of casualties is normally done by the 19-member WMDT (Unit Type
B-8
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Code [UTC] FFGLB) using the equipment package UTC FFGLA. Decontamination is performed prior to
the delivery of definitive care in MTFs. Supplies are sufficient to perform complete body skin
decontamination of 500 casualties, but should be reviewed and modified to support local wartime tasking
and types of decontamination (DECON) facilities. For example the DECON facility can be connected to
the chemically hardened ATH via air locks at one end of the emergency room/triage area. Decontamination
is performed to arrest the action of the contaminant on the patient and prevent further contamination of
patients, medical personnel (who may work without protective equipment to maintain full patient care
capabilities) and medical assets. Decontamination does not imply absolute removal of contaminants. The
outer layer of clothing is removed and contaminated skin is washed with germicidal soap or 0.5 percent
hypochlorite and warm water. The clothing removal step in the decontamination process offers the greatest
opportunity for contaminant removal. Removal of the BDO normally decontaminates approximately 90 to
94 percent of the BW agent. If removal of the BDO adequately decontaminates the patient, the rest of the
clothing is not removed. Masks are not removed from patients until they have been transferred out of the
liquid and vapor hazard areas. Exception: The mask can be removed from the patient for emergency
airway management or resuscitation by the EMT trained personnel assigned to the WMDT. The resuscitation
device, individual chemical (RDIC) must be used to prevent exposing the patient to secondary aerosolization
hazards.
(See FM 8-10-7 and USAF WMDT CONOPS for complete details on patient decontamination.)
Section III. US NAVY MEDICAL TREATMENT FACILITIES
B-13. General
For purposes of this publication, US Navy Level I MTFs include battle dressing stations and medical
departments of US naval vessels, and BASs in support of the Fleet Marine Forces, regardless of the
presence of a physician. Where this manual differs from Navy and Marine Corps doctrine, such doctrine
shall have precedence.
a. Although the decontamination of naval personnel is considered a nonmedical function, it is
accepted that the potential scenario exists in which contaminated personnel might arrive at an MTF.
Therefore, all arriving casualties should be considered contaminated until proven otherwise, and all levels
should be prepared to receive such casualties.
b. Because of the variation in supported units, readers are referred to unit and higher level
medical policy in determining assignment of necessary decontamination personnel.
c.
No casualty will be denied medical treatment to the degree necessary, given overall medical
condition, local resources, other casualty demands, availability of evacuation, and proximity to higher
levels of care, solely due to casualty contamination. This is not to be construed, however, as to preclude
triaging a contaminated patient to the Expectant category. Such Expectant category patients should still be
provided minimal care, comfort, pain relief, and other measures as available.
B-9
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FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
REFERENCES
Joint Publications
Joint Pub 4-02. Doctrine for Health Service Support in Joint Operations.
26 April 1995.
Joint Pub 4-02.2. Joint Tactics, Techniques, and Procedures for Patient Movement in Joint Operations.
30 December 1996.
NATO STANAGs
2002. Marking of Contaminated or Dangerous Land Areas, Complete Equipments, Supplies and Stores
(NBC). 6th Edition.
7 November 1978.
2103. Chemical Hazard Prediction.
5th Edition.
1 July 1983.
2104. First Aid and Hygiene Training in NBC Operations. 2d Edition.
10 November 1989.
QSTAG
187. Reporting Nuclear Detonations, Biological and Chemical Attacks, and Predicting and Warning of
Associated Hazards and Hazard Areas.
21 May 1998.
Multiservice Publications
FM 3-3. Chemical and Biological Contamination Avoidance. FMFM 11-17. 16 November 1992. (Change 1,
29 September 1994).
FM 3-4. NBC Protection. FMFM 11-9. 29 May 1992. (Change 2, 21 February 1996).
FM 3-5. NBC Decontamination. FMFM 11-10. 17 November 1993.
FM 3-6. Field Behavior of NBC Agents (Including Smoke and Incendiaries). AFM 105-7; FMFM 7-11-H.
3 November 1986.
FM 8-9. NATO Handbook on the Medical Aspects of NBC Defensive Operations. AMedP-6 (B). NAVMED
P-5059; AFJMAN 44-151. 1 February 1996.
FM 8-33. Control of Communicable Diseases Manual. 16th Edition. NAVMED P-5038.
9 April 1996.
US Army Field Manuals
FM 3-101-4. Biological Detection Platoon Operations, Tactics, Techniques, and Procedures. 9 June 1997.
(Change 1, 15 August 1997).
FM 3-101-6. Biological Defense Operations Corps/Company, Tactics, Techniques, and Procedures.
19 March 1999.
FM 8-10-6. Medical Evacuation in a Theater of Operations, Tactics, Techniques, and Procedures.
31 October 1991.
(Change 1, 8 March 1994).
FM 8-10-7. Health Service Support in a Nuclear, Biological, and Chemical Environment. 22 April 1993.
(Change 1, 26 November 1996).
FM 8-42. Combat Health Support in Stability Operations and Support Operations.
27 October 1997.
US Air Force Publication
AFVA 32-4011. USAF Standardized Alarm Signals for Areas Subject to NBCC Attack. 1 December 1998.
References-1
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Civilian Reference Material
Books
Butler, T. Plague and Other Yersinia Infections. New York, NY: Plenum Medical Book Company, 1983.
Eitzen, E., Pavlin, J., Cieslak, T., Christopher, G., Culpepper, R. Medical Management of Biological
Casualties Handbook.
3d Edition. Fort Detrick, Frederick, MD: U.S. Army Medical Research
Institute of Infectious Diseases, 1998.
Fenner, F., Henderson, D.A., Arita, I., Jezek, Z., Ladnyi, I.D. Smallpox and Its Eradication. Geneva,
Switzerland: World Health Organization, 1988.
Fields, B.N., Knipe, D.M., Howley, P.M., et al. Fields Virology.
3d Edition. Philadelphia, PA:
Lippincott-Raven, 1996.
Mandell, G.L., Bennett, J.E., Dolin, R. Principles and Practice of Infectious Diseases. 4th Edition. New
York, NY: Churchill Livingstone, 1995.
Sidell, F.R., Takafuji, E.T., Franz, D.R. Medical Aspects of Chemical and Biological Warfare. (Textbook
of Military Medicine Series, Part I, Warfare, Weaponry, and the Casualty.) Office of The Surgeon
General, Textbook of Military Medicine Publications, Borden Institute, Washington, DC, 1997.
Strickland, Thomas G. Hunters Tropical Medicine.
7th Edition. Philadelphia, PA: W.B. Saunders
Company, 1991.
World Health Organization Group of Consultants: Health Aspects of Chemical and Biological Weapons.
Geneva, Switzerland: World Health Organization, 1970.
Journal Articles
Abramova, F.A., Grinberg, L.M., Yampolskaya, O.V., Walker, D.H. Pathology of Inhalational Anthrax
in 42 Cases from the Sverdlovsk Outbreak of 1979. Proceedings of the National Academy of
Sciences, USA (1993), 90:2291-4.
Centers for Disease Control and Prevention. Bioterrorism Alleging Use of Anthrax and Interim Guidelines
for Management-United States, 1998. Morbidity and Mortality Weekly Report (1999), 48:69-74.
Centers for Disease Control and Prevention. Management of Patients with Suspected Viral Hemorrhagic
Fever. Morbidity and Mortality Weekly Report (1988), 37:1-15.
Centers for Disease Control and Prevention. Prevention of Plague. Recommendations of the Advisory
Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (1996),
45:RR-14 (Suppl).
Centers for Disease Control and Prevention. Update: Management of Patients with Suspected Viral
Hemorrhagic Fever-United States. Morbidity and Mortality Weekly Report (1995), 44:475-9.
Centers for Disease Control and Prevention. Vaccinia (Smallpox) Vaccine: Recommendations of the ACIP.
Morbidity and Mortality Weekly Report (1991), 40:RR-14 (Suppl).
Christopher, G.W., Cieslak, T.J., Pavlin, J.A., Eitzen, E.M. Jr. Biological Warfare: A Historical
Perspective. Journal of American Medical Association (1997), 278:412-417.
Farrar, E.W. Anthrax: Virulence and Vaccines. Annals of Internal Medicine (1994), 121:379-80.
Franz, D.R., Jahrling, P.B., Friedlander, A.M., McClain, D.J., Hoover, D.L., Byrne, W.R., Pavlin,
J.A., Christopher, G.W., Eitzen, E.M. Jr. Clinical Recognition and Management of Patients
Exposed to Biological Warfare Agents. Journal of American Medical Association (1997),
278:399-411.
References-2
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Friedlander, A.M., Welkos, S.L.L., Pitt, M.L.M., et al. Postexposure Prophylaxis Against Experimental
Inhalation Anthrax. Journal of Infectious Diseases (1993), 167:1239-42.
Garner, J.S. Hospital Infection Control Practices Advisory Committee. Guidelines for Isolation Precautions
in Hospitals. Infection Control Hospital, Epidemiology (1996), 17:53-80, and American Journal of
Infection Control (1996), 24:24-52.
Jackson, P.J., Hugh-Jones, M.E., Adair, D.M., et al. Polymerase Chain Reaction Analysis of Tissue
Samples from the 1979 Sverdlovsk Anthrax Victims: The Presence of Multiple Bacillus Anthracis
Strains in Different Victims. Proceedings of the National Academy of Sciences, USA (1998),
95:1224-9.
McGovern, T.W., Christopher, G.W., Eitzen, E.M. Jr. Cutaneous Manifestations of Biological Warfare
and Related Threat Agents. Arch Dermatol (1999), 135:311-322.
Meselson, M., Guillemin, J.G., Hugh-Jones, M., et al. The Sverdlovsk Anthrax Outbreak of 1979. Science
(1994), 266:1202-1207.
Pile, J.C., Malone, J.D., Eitzen, E.M., Friedlander, A.M. Anthrax as a Potential Biological Warfare
Agent. Archives of Internal Medicine (1998), 158:429-34.
Pomerantsev, A.P., Staritsin, N.A., Mockov, Y.V., Marinin, L.I. Expression of Cereolysine AB Genes in
Bacillus Anthracis Vaccine Strain Ensures Protection Against Experimental Hemolytic Anthrax
Infection. Vaccine (1997), 15:1846-1850.
Turnbull, P.C.B. Anthrax Vaccines: Past, Present, and Future. Vaccine (1991), 533-9.
References-3
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