Survive the Coming Bioterrorist Catastrophe

Urban Survival Guide

Discover How You Can Easily Have A Survival Plan Staying Right Where You Currently Live That's Better Than Having. A Fully Stocked Rural Retreat That You Can't Get To! Finally Revealed: Urban Survival Secrets For Surviving Terrorist Attacks, Natural Disasters And Pandemics! In The Real World, Most People Don't Have A Fully Stocked Retreat They Can Escape To. Even If You've Planned Ahead And You Do, There's No Guarantee That You'll Leave In Time Or That You'll Be Able To Make It There. Your First Plan Must Be To Survive In Place.

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Terrorism As A Threat

The principal goal of all terrorists is to undermine the existing structure of society so that it will be forced to accept their demands in order to avoid further destruction. Contrary to popular belief, acts of terrorism, particularly international terrorism, need not involve mass casualties similar to those resulting from wars between nations. Instead, terrorism bases its actions on swift, unpredictable assaults that force a target nation into a state of never-ending vigilance and redirection of its resources into sustained and costly counterterrorism measures that ultimately lead to prolonged economical and political turmoil. Destabilization of the national fabric of life will eventually lead to the introduction of countermeasures that place further burdens on the population may cause internal strife, and induce racial and ethnic tensions, that will continue the process of destabilization. The goal of continual and targeted terrorism is to induce sufficient uncertainty to cause...

General Factors Affecting Early Detection of Bioterrorism

Precautionary measures relevant to bioterrorism (or any other terrorist activity) involve operations based on a number of distinct but ultimately tightly interwoven plans. Clearly, the most important plan is prevention of the assault. It is also the most difficult aspect of activity because it has national and international ramifications. Development of appropriate intelligence resources, correlation of information gathered from a multiplicity of sources and agencies, creation of international intelligence collaboration and exchange, and ultimately the process of analysis of the available data are all essential aspects of the ability to predict the severity of a threat, its nature, and even the possible locations of the potential perpetrators of the terrorist act. Acquisition and analysis of intelligence data, while representing the most important proactive aspect of counterterrorism, remains the domain of agencies dedicated to intelligence gathering, military, and appropriate law...

Mental Health Response to Terrorism and Disaster

As disaster response systems have matured, they have increasingly included explicit attention to the mental health consequences of exposure to natural and technological disaster and terrorist attack. This development has accelerated as a result of the terrorist attacks of September 11, 2001 and heightened concern about future attacks. Historically, disaster mental health response has not included services explicitly informed by a cognitive-behavioral perspective. This state is now beginning to change (e.g., Walser et al., 2004), driven by increased interest in delivery of evidence-based interventions on the part of organizations charged with disaster mental health response (Gibson et al., in press). The terrorist attacks on the World Trade Center and Pentagon set into motion a number of initiatives to apply cognitive-behavioral methods of care for survivors (Neria, Suh, & Marshall, 2003 Levitt, Davis, Martin, & Cloitre, 2003). A cognitive-behavioral intervention (Hamblen et al.,...

Bioterrorism In History

Numerous allegations of the use of bacteriological warfare agents by the Western Powers, particularly the U.S., ensued during and after the Korean War. However, declassified documents obtained from both sides indicate beyond a doubt that the allegations were nothing but propaganda spread by the Eastern Bloc. In 1970, South Korea accused North Korea of preparing biological attacks. The charges, based on North Korea's large purchase of several biological agents, were ultimately abandoned, but the rumors about using such agents in wars in Southeast Asia persist. Yellow rain, a weaponized form of trichothecene myc-otoxin purportedly used by North Vietnamese forces in Laos, remains controversial. On the other hand, the use of antipersonnel traps containing sharpened, feces-covered sticks is a well documented form of biological warfare used by the Viet Cong. The nations of the Desert Storm Coalition (particularly the U.S. and Great Britain) attempted to interrupt the Iraqi program of...

Initial Patient Management

Bioterrorism field guide to disease identification and initial patient management Dag K.J.E. von Lubitz. 1. Bioterrorism Handbooks, manuals, etc. 2. Communicable diseases Prevention Handbooks, manuals, etc. 3. Emergency medical services Handbooks, manuals, etc. I. Title.

Exceptional External Agent

Disasters are often considered as events from the physical environment which are harmful for human beings and are caused by forces which are unfamiliar to them 8,9 . Disasters are normally unforeseen and catch the populations and administrations affected off-guard. However, there are disasters that repeat themselves, for example in areas affected by flooding, and others which are persistent, as in many forms of terrorism. In these cases a culture of adaptation and resignation to disasters develops.

The Nature Of The Agent

On other occasions, violence is due to terrorist attacks, assaults by rapists or similar events. This is an anonymous violence whose goal is to cause harm to whomever, something that prevents the people affected from developing any kind of defence. This kind of violence may affect any person, in any place of the world, at any time.

General Aspects Of Medical Management

Several factors make biological terrorism a particularly effective form of assault. The development of appropriate preparedness measures requires recognition of the fact that biological assault offers significant advantages to the terrorist compared to other forms of terrorist activity, for example It is imperative that all parties involved in responding to bioterrorism understand the characteristic aspects of infection caused by individual pathogens, pathologies that may accompany infections, and modes of transmission, diagnostics, and treatment. At the first indication of the probability of exposure to biological warfare agents, healthcare providers must consider vigorous implementation of several procedures dealing with patients The list of relevant diseases presented in this chapter is by no means complete. It is merely indicative of the variety of plausible agents. Moreover, medical personnel must bear in mind the possibility that the bacterial and viral pathogens involved in an...

Posttraumatic Stress Disorder

DSM-IV-TR classifies PTSD as an anxiety disorder with the major criteria of an extreme precipitating stressor, intrusive recollections, emotional numbing, and hyperarousal. Individuals at risk for PTSD include, but are not limited to, soldiers and victims of motor accidents, sexual abuse, violent crime, accidents, terrorist attacks, or natural disasters such as floods, earthquakes or hurricanes.7 PTSD has acute and chronic forms. In the general population, the lifetime prevalence of PTSD ranges from 1 to 12 and is frequently comorbid with anxiety disorders, major depressive disorder, and substance abuse disorders with a lifetime prevalence of comorbid disease ranging from 5 to 75 . PTSD is often a persistent and chronic disorder and a longitudinal study of adolescents and youth with PTSD showed that more than one-half of individuals with full DSM-IV-TR PTSD criteria at baseline remained symptomatic for more than 3 years and 50 of those individuals with subthreshold PTSD at baseline...

The Prevalence Of Disasters

The boundaries between the effects of war and those of disaster are becoming less easy to define, with the onset of more widespread terrorism that targets civilians. For example, the terrorist attacks in Israel, Palestine and Bali and in New York on September 11, 2001 could be considered as acts of war. Another perspective is that these are man-made disasters that are characterised by extreme malevolence. The argument for the latter categorisation is that the victims of these events had no anticipation of the events that unfolded, in contrast to the combatants in a more typical armed conflict.

Viral Hemorrhagic Fevers Vhfs

Viral hemorrhagic fevers are caused by a group of taxonomically different RNA viruses. All pose natural threats of infection, although the regions of where they are endemic may be confined to well-defined geographical territories. Under normal conditions, infection of humans occurs through contacts with infected animals or insect vectors. Four families, Arenaviri-dae, Bunyaviridae, Filoviridae, and Flaviviridae, although taxonomically diverse, are the primary causes of hemorrhagic fevers. The viruses are extremely pathogenic and, although relatively stable in aerosol form, are susceptible to detergents and household bleach. Their ability to replicate in cell cultures and their resulting yields make them potentially lethal as bioterrorist agents, particularly when introduced into ventilation systems.

Warding Warding Psychological Stability

Constant threat (especially that of terrorism) show a tendency to develop mechanisms like denial, which leads to the belief that the menace will never be effective or will not affect them directly. Based on this evidence, on the principles of somatic immunity and on the conviction that strong psychological and physical preparation helps people to accept reality, we developed the concept of ''mental immunity'', emphasizing the development of defenses so that attacks can be thought of as possible 7 . Mental immunity means that the individual can (a) recognize the menace and its characteristics (b) use psychological capacities to cope with threatening situations (c) take preventive and objective measures in case threat becomes a fact.

Staphylococcal Enterotoxin B

SEB has been extensively studied as a potential biological warfare agent. It can be aerosolized, it is stable, and it can induce considerable systemic damage including multiorgan failure, shock-like syndrome, and even death, particularly after high concentration exposures. Nonetheless, the consequences of SEB administered at even very low doses can be devastating. Some authors indicate that aerosol dispersion of SEB on a battlefield may produce up to 80 incapacitation. As a result of bioterrorism action, the numbers of affected populations would be significantly lower. In both cases, the major impact would arise from the incapacitating properties of the toxin rather than its lethality. Due to the duration of the illness, many daily activities within the affected community would be disrupted or cease entirely. A widespread panic reaction enhancing social destabilization would be a further consequence of a terrorist assault using SEB.

The Course Of Acute Stress Reactions

Most of these stress responses are transient. For example, whereas 94 of rape victims displayed sufficient PTSD symptoms 2 weeks posttrauma to meet DSM-IV criteria (excluding the 1 month time requirement American Psychiatric Association, 1994), this rate had dropped to 47 11 weeks later (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). In another study 70 of women and 50 of men were diagnosed with PTSD at an average of 19 days after an assault the rate of PTSD at 4-month follow-up had dropped to 21 for women and 0 for men (Riggs, Rothbaum, & Foa, 1995). Similarly, half of a sample of individuals who met criteria for PTSD shortly after a motor vehicle accident had remitted by 6 months, and two-thirds had remitted by 1-year posttrauma (Blanchard et al., 1996). There is also evidence that most stress responses after the terrorist attacks of September 11 may have been temporary reactions. Galea et al. (2002) surveyed residents of New York City to gauge their response to the terrorist...

What Type of Disaster

Technological and industrial disasters (train or plane crashes, sinking boats, explosions or fires in factories) are usually limited in space, which simplifies the organization of rescue operations. However, the Chernobyl radioactive cloud, in April 1986, threatened most of Europe. Disasters that are deliberately provoked by man (terrorist attacks, war bombings) are also usually limited in time and space, but the threat of recurrence may leave insecurity feelings in the population. Also, bombings of cities like Dresden, Tokyo, Hiroshima, and Nagasaki in World War II erased entire cities. Finally, society disasters, such as the panics in stadiums (Brussels, 29 April 1985 Sheffield, 15 April 1989) or at other places (the tunnel at Mecca, 1991) are generally limited in time and space. Whereas natural disasters can be attributed only to fate, destiny or the gods, man-made disasters involve questions of fault, cruelty, responsibility, which will complicate the psychological reaction to the...

Diagnostic Evaluation of Suspected Cutaneous Anthrax

Cutaneous anthrax in endemic areas is treated successfully with penicillin, given intravenously in cases of malignant edema (3,17). However, treatment of cutaneous anthrax in the setting of a bioterrorism attack as recommended by the Working Group on Civilian Biodefense includes ciprofloxacin 500 mg p.o. twice daily for 60 days, or doxycycline 100 mg p.o. twice daily for 60 days. Complete treatment recommendations are delineated by the Working Group and U.S. Centers for Disease Control (10,16). The rationale for extended treatment is to cover the likelihood of concomitant inhalation of anthrax spores, which may incubate for close to 60 days before resulting in clinical infection. Penicillin was not recommended in this treatment protocol because isolates from the 2001 anthrax attacks showed an inducible P-lactamase that degrades the antibiotic. The clinical significance is uncertain, but suggests the potential for rapid onset of penicillin resistance (10). No resistance to...

Portal of Entry Detection Clinical and Epidemiological Factors

Despite our best intentions, not every letter, water fountain, and ventilation duct can be checked and protected. Because of such limitations, healthcare workers (paramedics, nurses, ER physicians) and family members represent the first level of our existing and potential bioterrorism detection systems and the first contacts with victims of biological warfare. As a result most of our active bioterrorism countermeasures are essentially retroactive. Hence, our ability to rapidly and definitively identify the involved pathogen and to implement preexisting response plans is critically dependent on the appropriate performance at the entry portal level. In order to perform effectively as the most important early detection sensors of bioterrorism-related events, healthcare workers must be familiar with the essential clinical signs of the relevant diseases. Unfortunately, most bioterrorism-relevant agents initially induce largely nonspecific signs, e.g., flu-like symptoms. In some instances,...

Environments without Primary Contamination Cold Zone

With a few possible exceptions (anthrax spores, smallpox virus in detached scabs, T2 toxins, etc.), the environmental contamination with the pathogen may typically be significantly reduced or absent by the time the first victims of a bioterrorist assault reach healthcare workers. Thus, unless pathogen release precedes presentation at the healthcare facility by a very short time, or direct contact with the contaminant is confirmed by victims or witnesses (e.g., in assassination attempts or via aerosol release in confined spaces), or traces of contamination (powder or liquid residues on clothing or skin) are present, the contact with the patient's clothing or skin will not pose significant danger of secondary contamination. HOWEVER, PATIENTS PRESENTING WITH THE SIGNS OF PNEUMONIC PLAGUE, SMALLPOX, CRIMEAN-CONGO HEMORRHAGIC FEVER, AND EBOLA HEMORRHAGIC FEVER SHOULD BE CONSIDERED HAZARDOUS. of a bioterrorist attack. It is also recommended that the universal precautions be implemented as a...

Decontamination of Outdoor Environment

Highly unlikely in the context of a bioterrorist event. Terrain decontamination is costly and should be left to specialized decontamination units. If necessary, spraying with oily substances to prevent secondary aero-solization and the use of chlorine-calcium or lye may be considered.

Handling Of Deceased Victims

The problem of handling the bodies of victims of a bioterrorist attack represents a highly complicated arena involving ethical, legal, and religious issues. From the most simplistic point of view, the bodies of deceased victims found in a hot zone may present significant hazards, particularly if exposed to large concentrations of pathogens such as T2 toxins. Hence, the bodies may need to be treated as any other source of secondary contamination and as a threat to personnel and the rest of the population. The emotional impact of such an approach, particularly after the danger has been eliminated, may be very strong and incompatible with the rationalization implemented during the attack. While a thorough discussion of these highly complex problems is beyond the scope of the manual, this and other aspects of dealing with mass casualties after a chemical or biological terrorist attack demand very careful analysis and development of adequate plans in preparation for such events. Most...

Early Post Traumatic Stress Disorder and Clinical Treatment

Whilst many distressed survivors are evacuated to ERs, smaller but yet unknown numbers require clinical interventions and even fewer might require or be willing to attend formal therapy. Few Israeli hospitals provide systematic reaching out for traumatized survivors. Patient-initiated help-seeking is, therefore the key for receiving professional help in the aftermath of terrorist attacks (though help centers are regularly advertised). The NII offers a network of free consultations for identified direct survivors. On the basis of these data, and of clinical experience across the country, one can safely assume that a significant proportion of psychological casualties go undetected and might never come for formal therapy. Two community surveys (see below) indicate that much help is sought from other community resources (e.g., general practitioners, religious authorities) and most help is received within families. An estimate based on 7 years of ER admissions in Jerusalem shows that the...

Communities Under Stress

Beyond direct victims, terrorism affects communities at large. Published work by Bleich et al. 4 suggests that almost half of Israeli residents have been exposed to traumatic events emanating from terrorism, either directly or via friends and relatives (Table 15.2). About 60 felt that their lives were in danger and 58 disclosed being depressed. Nonetheless, and Table 15.2 Traumatic events emanating from terrorism telephone survey of a representative sample of 512 Israelis 4 The extent to which PTSD symptoms are the right identifiers of population in distress has been debated (e.g., 5). In the reality of continuous terrorism, many such symptoms represent normal and eventually protective responses (e.g., avoiding dangerous places and situations being emotionally reactive to reminders, vigilant and tuned). Additionally, PTSD assumes past trauma, whereas reactions under continuous terror comprise an element of anticipation. Nonetheless, PTSD symptoms have been used by most current studies...

Uncharted Yet Very Common Ways Of Coping

Empirical research into coping with terror falls short of providing sufficient explanations of the obvious discrepancy between the pervasiveness of the threat and the limited prevalence of mental disorders. Clearly, humans are more resilient than current risk-averse culture leads us to assume. Not that most humans are heroes, or otherwise extremely well trained for missions and fighting resilience is probably an attribute of ordinary people. Resilience of the normal type (as opposed to the often-depicted heroic resilience under combat-stress or during captivity) might be the best lesson we have learned from the response to terrorism in Israel. Yet this is an uncharted area. After 3 years of intense terrorism in Israel, several patterns of resilience emerge, which defy (or have escaped) systematic research. Following is a short comment on each. A frequent way of adjusting to terrorism has been to progressively shift expectations, in ways that have enabled most people to successfully...

General public may assist the authorities in preventing further spread of the disease

Equally important are the prophylactic measures providing the general public with adequate information on the nature of bioterrorism, the nature of the agents that may be potentially involved, and the most sensible prehospital responses to possible contamination, of which rapid and copious use of soap and water may be the most essential Such information should be presented in a manner devoid of all typical sensationalism and implementing all available dissemination media. In similarity to all other potential disasters that may involve large numbers of casualties (e.g., hurricanes, floods, or fires), engaging the broadest levels of the general public in clearly conceived countermeasures may be the most effective means of limiting the impact of a bioterrorist assault.

Psychological Support Measures

In similarity to the armed forces personnel in action, disaster recovery workers frequently suppress their own feelings and emotions, and concentrate on professional performance instead. Continuous activity in a highly stressful environment of multiple casualties, personal danger, and possible social tension will (also in similarity to the military personnel in combat) result in syndromes similar to battle fatigue or even combat shock. STRESS DEBRIEFING AND COUNSELING ARE MANDATORY ELEMENTS OF ALL ACTIVITIES BOTH DURING AND AFTER RECOVERY FOLLOWING A BIOTERRORIST ATTACK OR ANY OTHER LARGE-SCALE DISASTER EVENT. Although frequently neglected, plans for and subsequent efficient implementation of psychological support for the involved personnel (first responders, EMS personnel, hospital staffs) are essential to the success of all disaster recovery operations. Both at the time of bioterrorist attack and during its aftermath, implementation of effective community counseling and...

Domains Of Early Posttrauma Care

Established domains of early trauma care include efforts to serve individuals seeking emergency medical care (e.g., as a result of motor vehicle accidents or violent assault), survivors of disaster and terrorist attacks, survivors of sexual assault, and those traumatized during military deployment (e.g., combat, peacekeeping). In the past, cognitive-behavioral theory and intervention methods have had relatively little impact on development of these response services. More recently, however, cognitive-behavioral practitioners have become increasingly active in these settings, cognitive-behavioral interventions are being applied, and demonstration projects are being developed and evaluated.

Federal And State Agency Reports

GAO Report, Combating Terrorism, November 2000 http new.items d0114.pdf Public Health Response to Biological and Chemical Terrorism, Interim Planning Guidance for State Public Health Officials, CDC, July 2001 Domestic Terrorism Concept of Operations Plan Biological and Chemical Terrorism Strategic Plan for Preparedness and Response, Recommendations of the CDC Strategic Planning Workgroup, April 21, 2000 Patient Handling Precautions for BT agents (WRAMC) OSHA, Workplace Guidance for Anthrax Issues Maryland Department of Health Bioterrorism Article Compendium

Ensuring Utilization of Services

Concepts of normalization should also include normalization of help-seeking behavior, because research suggests that many individuals with significant levels of posttraumatic stress symptoms do not use mental health services, even when they are available. For example, following terrorist attacks, this nonutilization of services appears to be the case with direct survivors (Delisi et al., 2003), family members who lose loved ones (Smith, Kilpatrick, Falsetti, & Best, 2002), emergency workers (e.g., North et al., 2002), and medical staff (e.g., Luce & Firth-Cozens, 2002). Indeed, 3-6 months after the World Trade Center attacks in New York City, only 27 of those reporting severe psychiatric symptoms had obtained mental health treatment (Delisi et al., 2003). This reluctance to use services may characterize many trauma populations. Hoge et al. (2004) found that only 23-40 of those recently returned from combat duty in Iraq or Afghanistan, who met screening criteria for a mental...

Return to Functional Roles and Reinforcing Activities

One piece of coping advice that is often given to survivors of disaster terrorism is to, at the appropriate time, resume involvement in important personal work, school, and family roles. Similarly, combat and operational stress-control doctrine emphasizes the importance of preventing military personnel from adopting a sick role and instead keeping them actively engaged in work activities. Wagner (2003) has described an ongoing project that uses a cognitive-behavioral approach to achieving similar goals. in this work, behavioral activation, a component of cognitive-behavioral treatments for depression, has been modified to be used in the prevention of PTSD and depression in injured trauma survivors. Behavioral activation includes a review of daily activities, identification of personal values and goals, selection of personally meaningful and enjoyable activities, and activity scheduling. it focuses on blocking avoidance and withdrawal in trauma survivors and increasing involvement in...

Early Intervention Contexts Involving Continued Threat

Interventions designed for the treatment of PTSD are almost always applied under conditions of relative safety, in which threat of continued harm is minimal. In some environments (e.g., war zones, terrorist threat situations), however, these conditions do not apply. Realistic threats of ongoing exposure to continued attacks may form part of the environment in which traumatic stress reactions must be managed. Shalev et al. (2003) described modifications in delivery of cognitive-behavioral treatment for terrorism-related PTSD in Israel, designed to reflect these changed circumstances. During in vivo exposure assignments, survivors were encouraged to expose themselves to situations that were clearly safe, but not to those widely considered dangerous and avoided by most of the populace (e.g., city centers where repeated bombings had occurred). Their appropriate avoidance was characterized as positive safety behaviors and their goal as achieving normal fear. Cognitive therapy was applied...

Cost Effective Delivery

In most posttrauma environments, resource limitations inhibit the delivery of individual assessment and intervention to all survivors who might benefit. This limitation is especially apparent in situations involving large numbers of affected persons (e.g., terrorist attacks, large-scale disaster). It is also true in countries or communities with few available mental health resources. But it is also a limitation in hospital emergency medicine, in which staffing levels do not encourage routine screening and brief intervention with those showing high levels of acute traumatic stress (Zatzick et al., 2000). Telephone delivery represents another potential way of reaching early trauma survivors. in New York after the 9 11 attacks, a LifeNet hotline established as part of Project Liberty received heavy use it provided 24-hour mental health counseling, information, and referral, offering assistance in multiple languages. A study by Gidron et al. (2001) reported on an innovative effort to use...

Host response to viral infection and determinants of disease outcome

Smallpox was one of the biggest human scourges, resulting in mortality rates of up to 40 in some populations. However, a significant subset of the infected population recovered. The basis of susceptibility and resistance, and the immune parameters associated with recovery, is not known as the virus was eradicated more than 25 years ago. Despite the success of the smallpox eradication program, there remains considerable fear that variola virus (VARV), the causative agent of smallpox, or other related pathogenic poxviruses such as monkeypox (MPXV) could re-emerge and spread disease in the human population. The increased interest in understanding protective immunity to smallpox is due not only because of the potential threat of a bioterrorist attack (Henderson et al 1999) but it is the only disease known to humankind that has been successfully eradicated with a live virus vaccine. As such, very useful information on immunity and resistance to disease may be gleaned from the study of...

Electronic Personalized Health Records

A complex national network will take several years to take shape, but this eventual integrated system will do more than just enable people to share their health records with doctors and hospitals. Such a global, information-rich, real-time system of health data can serve as an aid in identifying health trends, providing an early-warning indication of drug complications arising from concomitant medications or perhaps signaling the advent of pandemics (such as avian flu) or bioterrorism. In a TCC-commissioned study, 86 percent of US physicians surveyed said that a health care system that adopted information technology such as electronic health records would improve the overall quality of health care received by patients.

Table 24 Properties of drug candidates to consider when contemplating fullscale development

While many companies have exited research on agents for infectious disease, new biodefense initiatives are bringing such work back into vogue.458 This renewed interest may yield drug candidates of use both for terrorist attacks and for the more traditional community-acquired infections, bacterial, fungal, or viral, including flu pandemics and the like.

Psychiatric Disorders Related To Trauma And Disaster

PTSD has been widely studied following both natural and human-made disasters (for review, see 51). PTSD is not uncommon following many traumatic events, from terrorism to motor vehicle accidents to industrial explosions. In its acute form, PTSD may be more like the common cold, experienced at some time in one's life by nearly all. If it persists, it can be debilitating and require psychotherapeutic and or pharmacological intervention. Recognizing that traumatic stressors are all too often a part of everyday life, DSM-IV 52 deleted the DSM-III-R 50 requirement that the stressor be ''outside the range of usual human experience''. An essential feature for ASD and PTSD in the DSM-IV is development of ''intense fear, helplessness, or horror'' after exposure to a traumatic event that does not need to be outside the normal range of human experience (Criterion A) 43 (see Tables 2.1 and 2.2). Exposure can involve direct experience or witnessing or learning about a traumatic event that caused...

Equine Encephalomyelitis

Laboratory manipulations (including genetic changes) of alphaviruses are relatively easy and alphaviruses have served frequently as models in studies of viral biology. Moreover, production of large quantities of these viruses does not require highly sophisticated facilities because they replicate rapidly, store easily, readily adapt to dissimilar hosts, and can be aerosolized with little difficulty. They can be used readily as bioterrorist weapons, especially because their environmental concentrations that produce significant infection rates need not be as high as those of many other pathogens. Aerosol release would be the most likely form of a bioterrorist attack employing an equine encephalitis virus (EEV). Equine encephalitis is usually nonlethal (< 1 overall mortality), and an epidemic resulting from a bioterrorist attack has the potential of causing a large-scale disease outbreak. Significant psychological stress of the population, interruption of normal activities, and severe...


This zoonotic disease (transmissible from animals to humans under normal conditions) is caused by Bacillus anthracis, a Gram-positive rod-shaped bacterium. The typical route of infection is via contact with infected animals (cattle, sheep, goats, horses) or contaminated animal products (hides, wool, hair, flesh, blood, or excreta). Under natural conditions, infection with anthrax manifests as a skin lesion. When used as a bioterrorist or warfare agent, anthrax is dispersed as an aerosol or as spore dust. Spores are stable and resistant to sunlight for relatively long periods. Sudden worsening and or deaths of patients originally presenting with flu-like symptoms indicate possible anthrax infection and demand immediate precautionary measures.


This disease is caused by Vibrio cholera, a Gram-negative, slightly curved bacillus whose motility is provided by a single polar flagellum. Vibrio species, including V. cholera and many noncholera species that can produce disease in humans, are among the most common organisms in surface waters and can be found in both fresh and salt water habitats. Although large-scale epidemic outbreaks of cholera were reported in the 1990s in South and Central America and in Asia, the incidence of the disease in the U.S. is low and most cases are related to foreign travel. Humans acquire the disease through ingestion of water or food contaminated with the bacilli. The most likely use of cholera bacteria in the context of biological warfare or bioterrorism is by contaminating water or food supplies. Dissemination in aerosol form is unlikely. Noncholera Vibrio infections have been reported in Alabama, Florida, Louisiana, and Texas. Septicemia is caused by food ingestion (primarily uncooked or...


A large number of patients presenting with similar systemic illness and nonproductive pneumonia within a short time (7 to 14 days) may be indicators of a bioterrorist event. A streptomycin-resistant strain of F. tularensis represents the potential choice for bioterrorist applications. It is sensitive to gen-tamycin. Compared to streptomycin, gentamycin affects a broader spec

Ricin Toxin

Although ricin oil manufacture ceased in the U.S., nearly 1 million tons of castor beans are processed for oil worldwide. The toxin remains in the waste mash and can be extracted via a simple chemical process. Because it is readily available, ricin found lethal application during the Cold War when the Bulgarian intelligence service Drazven Sigurnost and the Soviet KGB assassinated Georgi Markov, a Bulgarian dissident living in London, in 1978. Several other cases of the use of ricin as an assassination weapon were reported in the late 1970s and early 1980s. In the U.S., attempts to employ ricin as a bioterrorist weapon or as an instrument of murder led to convictions of the implicated individuals.

Hermetic packaging

An implant can fail in a number of ways.29 Lead wire insulation failure, encapsulation failure, failure at the interface between materials, substrate corrosion, surface dielectric corrosion, MOS gate contamination, P-N junction contamination, and failure of metal and polysilicon interconnects can be reasons for failure. The failure mechanism can be chemical attack, dissolution of coating into the body fluid, condensation of water, mobile ions and other biochemicals along interfacial planes, electrochemical reactions to insulators leading to dissolution into body fluids, and electrochemical corrosion of the silicon substrate. Careful accelerated testing of the packing should be done. Many chemical reactions are possible for packaging degradation. The dominant chemical reaction and dominant mechanism for a particular reaction may change with elevated temperatures. The properties of the packing material may also change with temperature increase.


Although saxitoxin can be isolated from contaminated mollusks or manufactured as a synthetic product, its applications as a large-scale bioterrorist weapon are limited. Production is difficult and requires significant knowledge and complex equipment. Moreover, since saxitoxin is among Schedule 1 agents cited by the Chemical Weapons Convention its distribution, even for research purposes, is under strict control. The most likely bioterrorist use of saxitoxin would be target-specific and predominantly for assassination. Aero-solization and limited contamination are remote possibilities.


No prophylactic measure is effective in the context of bioterrorism activity. Under other circumstances, avoidance of consumption of shellfish harvested outside regularly surveyed areas or harvested during periods associated with dinoflagellate blooms (red tides) is the only effective step. Antitoxin therapy has been successfully tested in animals but clinical efficacy studies have not been performed. No vaccine against saxitoxin has been developed.

Ongoing Stressors

It is important to note that there are important limitations to the current evidence for the effective use of CBT shortly after trauma exposure. First, although CBT does lead to significant reductions in recently traumatized people who complete treatment, a significant proportion of participants do drop out of treatment. For example, 20 of participants dropped out of both the Bryant et al. (1999) and Bryant et al. (2005) studies. That is, intent-to-treat analyses in these studies indicate modest benefits of CBT (Bryant et al., 1999, in press). This pattern clearly points to the need for interventions that are efficacious and manageable for more recently traumatized people. For example, providing nonexposure-based therapies (such as cognitive therapy) may be better tolerated by some patients. Alternately, teaching coping skills prior to exposure may help some patients cope with the exposure more effectively (Cloitre, Koenen, Cohen, Han, 2002). Second, most early intervention treatment...

Lessons Learned

In the Nairobi case there was initially great solidarity and courage demonstrated, with many pledges of help. Anger and harsh loud words blaming others were also notable. Chaos and confusion, especially in the early stages, were there in plenty. Terrorism destroys the sense of cohesion and safety and creates terror in the individual, in communities and in nations. Anger gripped the people of Kenya, at first directed at Muslims, Arabs and any other groups thought to be even remotely connected with the terrorists. The Americans were the next ''obvious'' targets, firstly for being there, and secondly for their insensitivity to the Kenyans' needs and feeling in the face of the attacks. These are ''normal'' reactions to terrorism as the community searches for a scapegoat to heap its anger and frustration on. In the ideal world, researchers would have had to wait until survivors had finished with vital traditional activities like funeral rites. The...

Cognitive Maps

A Islamic Fundamentalism, B Soviet Imperialism, C Syrian Control on Lebanon, D Strength of Lebanese Government, E PLO Terrorism, F Arab Radicalism A Islamic Fundamentalism, B Soviet Imperialism, C Syrian Control on Lebanon, D Strength of Lebanese Government, E PLO Terrorism, F Arab Radicalism


The question of research following a major disaster is complex as it involves both moral and scientific considerations. Delay in initiating data collection limits opportunities to obtain early information needed to understand mental health effects of disaster. Secondly, if researchers do not act quickly, important data may be lost forever. It is for these reasons that we decided to put in place a research and documentation team, which among other things developed a 57-item self-administered questionnaire, capable of generating the DSM-IV diagnosis of PTSD. In so doing we were fully cognizant of the fact that conducting methodologically solid investigations of mental health is extraordinarily difficult in the chaotic and complex settings of disasters, particularly those associated with terrorism. Some might disagree.

Anthrax Toxin

Anthrax toxin is the major virulent factor of Bacillus anthracis. Owing to its high mortality when the infection is untreated, and its ability to exist in an aerosol form, it poses a threat to public health as a potential reagent for biological warfare and terrorism. The toxin consists of three proteins, lethal factor (LF),edema factor (EF), and protective antigen (PA). Among them, the lethal factor appears to be a protease that targets the mitogen-activated protein kinase kinase (MAPKK) family of pro-teins.edema factor is an adenylate cyclase and PA forms a membrane pore-like transporter once activated by furin-like cellular proteases. The crystal structures of all three factors have been solved (Table 17.1.17 Petosa et al., 1997 Pannifer et al., 2001 Drum et al., 2002 Shen et al., 2002).

Warm Zone

Bypassing field decontamination sites, the effective warm zone will shift to a hospital, clinic, or other designated treatment location. Such a situation will be typical in the event of a bioterrorism event involving a large area (e.g., dispersion of a pathogen from an aircraft). If such an event is strongly suspected or confirmed, personnel in direct contact with the contaminated victims must wear respiratory protection. Since the pathogens likely involved in such attack (with the exception of mycotoxins) will pose little or no danger of skin penetration, dermal protection by means of self-contained suits will not be necessary. Secondary aerosolization of residues left on the skin, hair, or clothes of victims will be insignificant under these circumstances.


Triage of victims is frequently an inherent element of activities following a mass casualty incident. An act of bioterrorism may necessitate implementation of effective triage as well. Several standard approaches based on victim tagging have been developed. The most common approach is color tagging

Patient Transport

The majority of infections relevant to bioterrorism cannot be transmitted from person to person. However, standard precautions should be maintained while transporting patients suspected of being exposed to or diagnosed with anthrax, smallpox, plague, botulism, and tularemia. It is also recommended, particularly during ambulance transport, that patients infected with smallpox, plague, and hemorrhagic fevers be provided with surgical face masks to reduce the danger of droplet dispersal. As a rule, the movement of patients with bioterrorism-related infections should be limited as much as possible and be dictated only by the necessities of patient decontamination and care. Movement within healthcare facilities should take place along predetermined routes that will eliminate the possibility of accidental contamination of cold zones and of unaffected patients.

Network Of Care

Medical care in Israel is free of charge. Additionally, the National Insurance Institute of Israel (NII), a government agency responsible for most types of disabilities, supports the medical, financial and rehabilitation costs related to trauma emanating from terror. The NII provides extensive coverage, including medical care, disability compensation, dependants benefits, vocational rehabilitation and other forms of assistance (e.g., loans and grants for housing). These benefits extend to psychiatric casualties indeed, the NII has been very active in reaching out for casualties following major acts of terror, and has provided psychological debriefing sessions to groups of survivors. The NII also follows widows and dependants, starting from the first days of grief and escorting some individuals for years. Despite individual complaints about red tape and the slow process of recognition, the NII provides a safety network for all physical and psychological casualties of terrorism, so that...

Personnel Issues

In similarity to all other disasters, acts of bioterrorism will amplify inadequacies stemming from poor preparedness. However, bioterrorism involves an assault with the most elusive and invisible weapons that inflict damage in a seemingly sudden and random manner. The fear induced by biological weapons is compounded by the fact that, based on widely accessible information provided by the media, a relatively innocuous sickness occurring during a period of declared attack threat will appear to a lay person as a very lethal disease caused by the pathogen introduced by bioterrorist. Hence, the news or even a rumor of a bioterrorist attack will cause a rapid and substantial increase in the number of visits to healthcare facilities by patients with essentially insignificant complaints, or those simply requiring psychological support and reassurance from medical personnel. The explosive growth in the patient overload (that is already typical of the majority of emergency departments and...

Responder Impact

Independent of the scale of a bioterrorist attack, the psychological pressures imposed upon first responders and prehospital and hospital healthcare providers will be significant. Because they represent the first level of contact with the victims, personnel of these services face the greatest possibility of contamination and infection. The need for constant vigilance, realization of the probable dangers, and concerns about personal safety may ultimately lead to the deterioration of individual psychological barriers and result in absenteeism. The occurrence of the latter will be most likely more prevalent among the workers unused to personal danger and the execution of their duties under life-threatening circumstances. Consequently, there is a possibility that certain aspects of medical care delivery may be impaired, especially if the threat persists over a long period of time. Another likely effect of prolonged, high-intensity operations consequent to a major bioterrorism event will...

Laboratory Premises

Laboratories must have good stable work surfaces. Ideally, these should be totally resistant to all likely disinfectants (hypochlorites, phenolics, aldehydes, alcohols and detergents), acids, alkalis and solvents. The best surfaces are special laminates that are resistant to chemical attack and heat, and sufficiently scratch-resistant (kitchen work surfaces are rarely adequate). However, in the basic laboratories used in emergencies it is more common to find wooden tables or benches in use. Polished surfaces do not resist chemicals and solvents well and may trap microorganisms. Any gaps in the table surface should be filled and levelled before the surface is varnished.

Training Issues

Both national and state plans have been or are in the process of development outlining the nature and scope of responses to the threat or bioterrorist attack. Ultimately, all these plans are based on the ability of the base units local hospitals, EMS, law enforcement, etc. to perform in a manner that will allow rapid detection, characterization, containment, and elimination of a bioterrorism-related disease outbreak. Assuming that all other elements of readiness are in place (appropriate materiel, facilities, supplies, and knowledge), operational training is the most critical ingredient that will assure efficiency and success during real-life emergencies. Train as you fight, and fight as you train is the daily mantra of the armed forces whose almost religious practice assures the success in the field. The ever-present threat of a chemical or biological terrorism attack must impose the same rule upon the healthcare system and also upon the law enforcement, fire fighting, and other...

Group Interventions

In many posttrauma environments, group-administered early intervention activities are a staple element of care. This is especially true when (1) large numbers of persons are exposed to the same traumatic event (e.g., terrorist attacks, industrial accidents, mass violence, community disasters), (2) preexisting groups are exposed to trauma (e.g., a workplace exposed to a violent assault), and (3) workgroups are exposed to trauma as part of their job duties (e.g., military personnel, emergency response workers, police, forensic investigators). Groups would appear to be well-suited to challenging common distressing perceptions of survivors (e.g., feeling alone, different, misunderstood by those around them), reducing social isolation, and providing social support and may also be useful in helping survivors address the worries associated with traumas that are particularly difficult to talk about with family and friends (e.g., sexual assault), due to perceived social stigma, embarrassment...


Based treatments may be applied in flexible ways that allow providers to adapt treatments to their own delivery preferences and situational constraints. Providers were permitted to adjust the dose by repeating protocol sessions, as needed, to eliminate sessions perceived as inappropriate, and to spend time attending to issues that were not the focus of the manualized intervention. In Israel, also in a terrorism context, Somer et al. (2005) demonstrated the feasibility of training paraprofessional hotline counselors in a telephone-administered anxiety reduction intervention via a single 5-hour training workshop.