Bioterrorism: A Guide for Hospital Preparedness

by Masci; Joseph R.

• ISBN13: 9780849316609
• ISBN10: 084931660X
• Edition: 1st
• Format: Hardcover
• Copyright: 2004-12-28
• Publisher: CRC Press

Summary

In the battle against bioterrorism, one of the greatest challenges is finding the ideal balance between complacency and overreaction. The goal is to be so well prepared that we can prevent catastrophic outcomes in the event of a bioterrorist attack, while strengthening our ability to prevent and treat naturally-occurring infectious diseases.Bioterrorism: A Guide for Hospital Preparedness provides critical guidelines for health providers on effectively preparing for bioterrorism. The book presents information on all aspects of dealing with bioterrorism including the likeliest biological agents to be used, means of determining that an attack is taking place, diagnosis and management of specific diseases, and mechanisms of reporting to public health authorities. The text reviews cooperative planning for private practitioners, methods for protecting hospital and office staff and other patients in the event of an attack, approaches to handling the psychological effects of terrorism, special considerations concerning the care of children, and strategies for answering questions posed by the public and the media. It also includes data from national and regional exercises in assessing preparedness, with suggestions for implementing lessons learned from these exercises.With bioterrorism on the fine line between risk and reality, it is essential for health care providers to be properly equipped for every situation. This comprehensive guide features solid strategies for establishing and maintaining an attainable level of preparation in the ever-present risk of bioterrorism.

Table of Contents

SECTION I The Scope of the Problem	1	(46)
The Historical and Political Context of Bioterrorism Concerns	3	(26)
Introduction	3	(2)
Ease of Use of Biological Agents	5	(2)
The Case of Aum Shinrikyo	6	(1)
Difficulty in Containing Infectious Disease Outbreaks	7	(1)
Potential Destructiveness of Biological Weapons	8	(4)
Projections of Destructive Power	9	(2)
Tests of Biological Agents or Simulants	11	(1)
The Sverdlovsk Accident	11	(1)
Social and Economic Burdens of Bioterrorism	12	(4)
Costs of the Anthrax Incidents of 2001	13	(3)
Potential Perpetrators	16	(5)
Nations with Suspected Biological Weapons Programs	16	(1)
Potential Proliferation of National Research	16	(1)
The Soviet Union	16	(1)
South Africa	17	(1)
Iraq	18	(1)
Terrorist Groups	18	(1)
International Terrorists	19	(1)
U.S. Domestic Extremists	20	(1)
Trends in Terrorism	21	(2)
References	23	(6)
Bioterrorism and the Public Health System	29	(18)
Introduction	29	(1)
The Public Health System at the Time of the 2001 Anthrax Attacks	30	(6)
Recent Enhancements	30	(1)
Warnings of Weaknesses	30	(1)
TOPOFF	30	(1)
Dark Winter	31	(1)
The Gilmore Commission Report of 2001	31	(2)
Other Surveys	33	(1)
The Anthrax Experience	34	(2)
The Current State of Preparedness in U.S. Public Health Systems	36	(1)
The Results of TOPOFF 2	37	(1)
Major Obstacles to Preparing the Public Health System for Bioterrorism	37	(3)
Accurately Assessing the Hazard	37	(1)
Unpredictable Needs for Crisis Response	38	(1)
Lack of Standards for Preparedness	39	(1)
Ongoing Responsibilities of Public Health Officials	39	(1)
Funding at the Local Level	39	(1)
Issues of Public Health Infrastructure	40	(5)
Syndromic Surveillance	40	(2)
Drills and Exercises	42	(1)
The Use of Quarantine Measures	43	(1)
Interagency Communication	43	(1)
The Health Alert Network	43	(1)
Epi-X	44	(1)
The Smallpox Vaccination Campaign	44	(1)
The Strategic National Stockpile	44	(1)
Summary	45	(1)
References	45	(2)
SECTION II Improving Hospital Readiness and Response	47	(120)
Hospital Preparations and Needs	49	(28)
Introduction	49	(2)
A Framework for Hospital Emergency Planning	51	(2)
Mitigation	51	(1)
Preparedness	52	(1)
Response	52	(1)
Recovery	53	(1)
The Emergency Management Plan	53	(2)
JCAHO Standards	54	(1)
The Hospital Emergency Incident Command System (HEICS)	55	(1)
Infection Control	56	(11)
Contagious Potential of Specific Biological Agents	56	(2)
General Elements of Infection Control	58	(1)
Levels of Precaution	58	(1)
Personal Protective Equipment	59	(2)
Isolation of Patients Known To Be Infected	61	(1)
Laboratory Roles and Safety Levels	62	(2)
Special Infection Control Issues in Bioterrorism	64	(1)
Need To Intensively Educate Staff	64	(1)
Expedited Triage in the Emergency Department	64	(1)
Decontamination of Victims	65	(1)
Unaccustomed Legal Issues	66	(1)
Home Quarantine	67	(1)
Protection of Visitors	67	(1)
Coordination with Other Facilities and Organizations	67	(1)
Establishing Surge Capacity	67	(7)
Mobilizing Additional Staff	68	(1)
The Needs and Contributions of Nonclinical Departments	69	(1)
Making Space for an Influx of Patients	70	(1)
Clearing the Emergency Room	70	(1)
Making More Beds Available	70	(1)
Cohorting	71	(1)
Designating Contagion Hospitals	71	(1)
Using Regional Networks	72	(1)
Creating New Space	72	(1)
Making Room for the Worried Well	72	(1)
Diverting Potential Patients	73	(1)
Ensuring Adequate Supplies and Equipment	73	(1)
How Can Hospitals Ensure They Have Necessary Medications?	73	(1)
Communications Equipment	74	(1)
References	74	(3)
Targeting Staff Education	77	(10)
Introduction	77	(1)
Strategies for Educating and Preparing Hospital Staff	78	(6)
Establishing the Educational Mission	78	(2)
Elements of the Curriculum	80	(4)
Suggested Categorization of Staff by Educational Requirements	84	(1)
Educational Strategies and Formats	85	(1)
Reference	85	(2)
Psychological Factors in Patients and the Public	87	(24)
Introduction	87	(3)
Overview of Likely Reactions	88	(1)
The Need for Planning and Training	88	(1)
The Fundamentals of Response	89	(1)
Potential Short-Term Adverse Effects	90	(4)
Psychological Distress Following Disaster	90	(1)
Psychological Distress Linked to Illness	90	(1)
Examples from the 2003 SARS Outbreak	91	(2)
The ``Worried Well'' and Somatic Symptoms	93	(1)
A Note on Terminology	93	(1)
Outbreaks of Medically Unexplained Symptoms	93	(1)
Mass Panic	94	(1)
Potential Delayed Adverse Effects	94	(5)
Lingering Effects on the Anthrax Survivors	94	(1)
Posttraumatic Stress Disorder	95	(1)
Risk among Individuals Directly Affected by Trauma	95	(1)
Risk to the General Population	96	(1)
Risk Factors for PTSD	97	(2)
Early Intervention Measures	99	(4)
Reasons for Caution on Interventions	99	(1)
Psychological First Aid	99	(2)
Psychological Debriefing	101	(1)
Recent Recommendations on Early Intervention	102	(1)
Longer-Term Treatment	103	(1)
Cognitive--Behavioral Therapy	103	(1)
Pharmacological Treatment	103	(1)
Features of a Hospital Psychological Preparedness Plan	104	(1)
Before the Event	104	(1)
During the Event	104	(1)
After the Event	105	(1)
References	105	(6)
Managing Stress on Hospital Staff	111	(12)
Introduction	111	(1)
The 2003 SARS Experience	112	(3)
Recurring Problems	113	(2)
Measures To Deal with the Impact	115	(1)
Normal Reactions	115	(1)
Minimizing Distress among Hospital Staff	116	(4)
Measures To Take before the Event	116	(1)
Training and Equipment	116	(1)
Family and Professional Responsibilities	117	(1)
Resilience and Coping	117	(1)
Measures To Take During the Event	117	(1)
Prompt and Accurate Communication	118	(1)
Countring Fatigue and Isolation	118	(1)
Practical and Emotional Support	119	(1)
After the Event	119	(1)
References	120	(3)
Communicating through the Media	123	(28)
Introduction	123	(2)
Lessons of the Anthrax Crisis	124	(1)
Efforts To Improve Communication	125	(1)
The Role of the Media	125	(6)
Media Behavior in a Crisis	126	(1)
Trying To Find Out if Something Newsworthy Is Happening	127	(1)
Covering the Story	128	(1)
Assessing Performance	129	(1)
How the Media Can Help	129	(1)
Serving as an Early Warning System	129	(1)
Providing a Backup Communications Network	130	(1)
Serving as a Conduit for Official Information and Direction	130	(1)
The Role of Hospitals in Crisis Communication	131	(2)
The Importance of Local Experts	132	(1)
Creating a Crisis Media Plan	133	(5)
Assign Responsibility	133	(1)
Plan To Ensure Accuracy	134	(1)
Make Physical and Technical Arrangements	134	(1)
Get To Know the Media	134	(1)
Plan Ways To Distribute Information	135	(2)
Plan To Track the Media	137	(1)
Reach Non-English Speakers	137	(1)
Practice during Peaceful Times	137	(1)
Prepare Materials	138	(1)
Applying Principles of Risk Communication	138	(4)
Trust and Reassurance	138	(2)
Fear and Panic	140	(1)
Outrage Factors	140	(1)
Panic	141	(1)
Selected Media Issues	142	(4)
Meet the Media's Technical Needs	142	(1)
Stick to What You Know	142	(1)
Speaking ``Off the Record''	143	(1)
Speaking To Be Understood	144	(1)
Correcting Media Errors	145	(1)
References	146	(5)
Frequently Asked Questions	151	(16)
Introduction	151	(1)
Questions of Concern to the Public, Including Health Care Workers	151	(10)
How Likely Is a Bioterrorism Attack?	151	(1)
What Are the Most Likely Agents To Be Used in an Attack?	152	(1)
Why Are These Considered Likely?	152	(1)
How Can I Best Protect Myself and My Family?	152	(1)
Should I Own a Gas Mask or Other Type of Personal Protective Equipment?	152	(1)
Should I Designate a ``Safe Room'' in My House?	153	(1)
What General Supplies Would Be Appropriate for Me To Keep at Home?	153	(1)
Under What Circumstances Might Quarantine Be Imposed?	153	(2)
Under What Circumstances Might Travel Restrictions Be Imposed?	155	(1)
What Is the Most Reliable Source of Information during an Attack?	155	(1)
What Do the Various National Levels of Alert (the Colors) Mean and What Should My Family Do if the Alert Status Is Raised?	155	(2)
Should I Discuss Bioterrorism with My Children? If So, How Should I Do This?	157	(1)
How Afraid Should I Be? How Can I Deal with My Fears?	158	(1)
What Changes in My Lifestyle Should I Consider?	158	(1)
What Has the Government Done since 9/11 To Protect U.S. Citizens from Biological Attack?	159	(1)
What Have Local Governments Done?	160	(1)
To Whom Should I Express Any Concerns I Have about Bioterrorism?	160	(1)
How Can I Get Further Information?	161	(1)
Besides the Anthrax Letters in 2001, What Other Bioterrorism Attacks Have Taken Place in the U.S. or Abroad?	161	(1)
Questions Specific to Health Care Workers	161	(5)
How Would Health Care Personnel Learn of an Attack?	161	(1)
What Would Be the Most Appropriate Course of Action for a Health Care Worker Who Is at Home When an Attack Is Announced?	161	(1)
What Strategies Have Been Suggested To Protect Health Care Workers in the Event of an Attack?	162	(1)
What Are the Earliest Signs of Each of the Category A Agents?	162	(1)
Smallpox	162	(1)
Anthrax	163	(1)
Plague	163	(1)
Botulism	163	(1)
Tularemia	164	(1)
Viral Hemorrhagic Fever	164	(1)
What Health Care Jobs Put Me at the Greatest Risk of Coming into Contact with a Bioterrorism Agent?	164	(1)
What Workplace Safety Issues Should Be of Concern?	165	(1)
What Are My Responsibilities in General in Preparing for the Possibility of an Attack?	165	(1)
Should I Be Immunized to Smallpox? To Anthrax?	165	(1)
References	166	(1)
SECTION III Prevention, Diagnosis, and Treatment of Likely Biological Agents	167	(110)
Likely Agents of Biological Attack	169	(22)
Introduction	169	(1)
Classification of Potential Agents of Bioterrorism	169	(1)
Category A Agents	170	(18)
Smallpox	170	(1)
Why It Is Considered Likely	170	(3)
Availability	173	(1)
Means of Weaponizing	174	(1)
Potential Consequences of an Attack	175	(1)
Historical Information	175	(1)
Insights Gained from Exercises and Mock Drills	176	(1)
Anthrax	176	(1)
Why It Is Considered Likely	176	(1)
Means of Weaponizing	177	(1)
Potential Consequences of Attack	177	(1)
Historical Information	178	(1)
Insights Gained from Exercises and Mock Drills	179	(1)
Plague	179	(1)
Why It Is Considered Likely	179	(1)
Availability	180	(1)
Means of Weaponizing	180	(1)
Potential Consequences of Attack	180	(1)
Historical Information	181	(1)
Insights Gained from Exercises and Mock Drills	181	(1)
Tularemia	182	(1)
Why It Is Considered Likely	182	(1)
Availability	182	(1)
Means of Weaponizing	182	(1)
Potential Consequences of Attack	182	(1)
Historical Information	183	(1)
Insights Gained from Exercises and Mock Drills	183	(1)
Botulism	183	(1)
Why It Is Considered Likely	183	(1)
Availability	184	(1)
Means of Weaponizing	184	(1)
Potential Consequences of Attack	184	(1)
Historical Information	184	(1)
Insights Gained from Exercises and Mock Drills	185	(1)
Hemorrhagic Fever Viruses	185	(1)
Why They Are Considered Likely	185	(1)
Availability	185	(1)
Means of Weaponizing	185	(1)
Potential Consequences of Attack	185	(1)
Historical Information	186	(1)
Insights Gained from Exercises	186	(1)
Other Key Pathogens and Biological Agents	186	(1)
Foodborne Pathogens	186	(1)
Ricin	187	(1)
Why It Is Considered Likely	187	(1)
Means of Weaponizing	187	(1)
Potential Consequences of an Attack	188	(1)
Availability	188	(1)
Historical Information	188	(1)
Insights Gained from Exercises and Mock Attacks	188	(1)
References	188	(3)
Diagnosis and Management of Agents of Bioterrorism	191	(36)
Introduction	191	(1)
Smallpox	191	(5)
Causative Organism	191	(2)
Route of Transmission	193	(1)
Incubation Period	193	(1)
Symptoms	193	(1)
Physical and Laboratory Findings	193	(1)
Laboratory Diagnosis	193	(1)
Containment Measures	194	(1)
Therapy	195	(1)
Prevention	195	(1)
Special Considerations	195	(1)
Differential Diagnosis	195	(1)
How the Early Stages of a Smallpox Attack Might Appear	196	(1)
Anthrax	196	(5)
Causative Organism	197	(1)
Route of Transmission	197	(1)
Incubation Period	197	(1)
Symptoms	197	(1)
Inhalational Anthrax	197	(1)
Cutaneous Anthrax	198	(1)
Gastrointestinal Anthrax	198	(1)
Laboratory Diagnosis	198	(1)
Containment Measures	199	(1)
Therapy	199	(1)
Prevention	199	(1)
Anthrax Vaccine	199	(1)
Antibiotic Prophylaxis	200	(1)
Special Considerations	200	(1)
Differential Diagnosis and Look-Alikes	200	(1)
How the Early Stages of an Anthrax Attack Might Appear	201	(1)
Plague	201	(3)
Causative Organism	201	(1)
Route of Transmission	201	(1)
Incubation Period	202	(1)
Symptoms	202	(1)
Pneumonic Plague	202	(1)
Bubonic Plague	202	(1)
Physical and Laboratory Features	203	(1)
Laboratory Diagnosis	203	(1)
Containment Measures	203	(1)
Therapy	203	(1)
Prevention	203	(1)
Special Considerations	203	(1)
Differential Diagnosis and Look-Alikes	203	(1)
How the Early Stages of a Plague Attack Might Appear	204	(1)
Tularemia	204	(3)
Causative Organism	204	(1)
Route of Transmission	204	(1)
Incubation Period	205	(1)
Symptoms	205	(1)
Physical and Laboratory Features	205	(1)
Laboratory Diagnosis	206	(1)
Containment Measures	206	(1)
Therapy	206	(1)
Prevention	206	(1)
Special Considerations	206	(1)
How the Early Stages of a Tularemia Attack Might Appear	206	(1)
Botulism	207	(2)
Causative Organism	207	(1)
Route of Transmission	207	(1)
Incubation Period	207	(1)
Symptoms	208	(1)
Physical and Laboratory Features	208	(1)
Laboratory Diagnosis	208	(1)
Containment Measures	208	(1)
Therapy	208	(1)
Prevention	208	(1)
Special Considerations	208	(1)
Differential Diagnosis and Look-Alikes	208	(1)
How the Early Stages of a Botulism Attack Might Appear	209	(1)
Viral Hemorrhagic Fevers	209	(3)
Causative Organisms	209	(1)
Clinical Features	210	(1)
Route of Transmission	210	(1)
Incubation	210	(1)
Symptoms	210	(1)
Physical and Laboratory Features	211	(1)
Laboratory Diagnosis	211	(1)
Containment Measures	211	(1)
Therapy	211	(1)
Prevention	211	(1)
How the Early Stages of a Hemorrhagic Fever Virus Attack Might Appear	211	(1)
Foodborne Bacterial Infections	212	(7)
Salmonellosis	212	(1)
Clinical Features	212	(1)
Route of Transmission	212	(1)
Incubation Period	212	(1)
Symptoms	212	(1)
Physical and Laboratory Features	213	(1)
Laboratory Diagnosis	213	(1)
Containment Measures	213	(1)
Therapy	213	(1)
Prevention	214	(1)
Shigellosis	214	(1)
Route of Transmission	214	(1)
Incubation Period	214	(1)
Symptoms	214	(1)
Physical and Laboratory Features	215	(1)
Laboratory Diagnosis	215	(1)
Containment Measures	215	(1)
Therapy	215	(1)
Prevention	215	(1)
Escherichia coli	215	(1)
Clinical Features	216	(1)
Route of Transmission	216	(1)
Incubation Period	216	(1)
Symptoms	216	(1)
Physical and Laboratory Features	216	(1)
Laboratory Diagnosis	216	(1)
Containment Measures	216	(1)
Therapy	217	(1)
Prevention	217	(1)
Brucellosis	217	(1)
Causative Organisms	217	(1)
Clinical Features	217	(1)
Route of Transmission	217	(1)
Incubation Period	218	(1)
Symptoms	218	(1)
Physical and Laboratory Features	218	(1)
Laboratory Diagnosis	218	(1)
Containment Measures	218	(1)
Therapy	218	(1)
Prevention	218	(1)
Special Considerations	219	(1)
Selected Other Pathogens of Concern	219	(3)
Melioidosis and Glanders	219	(1)
Causative Organisms	219	(1)
Route of Transmission	219	(1)
Incubation Period	219	(1)
Symptoms	219	(1)
Physical and Laboratory Features	220	(1)
Laboratory Diagnosis	220	(1)
Containment Measures	220	(1)
Therapy	220	(1)
Prevention	220	(1)
Special Considerations	220	(1)
Q Fever	221	(1)
Causative Organism	221	(1)
Route of Transmission	221	(1)
Incubation Period	221	(1)
Symptoms	221	(1)
Physical and Laboratory Features	221	(1)
Laboratory Diagnosis	221	(1)
Containment Measures	222	(1)
Therapy	222	(1)
Prevention	222	(1)
Ricin Poisoning	222	(2)
Clinical Features	222	(1)
Route of Transmission	222	(1)
Incubation Period	222	(1)
Symptoms	222	(1)
Physical and Laboratory Features	223	(1)
Laboratory Diagnosis	223	(1)
Containment Measures	223	(1)
Therapy	223	(1)
Prevention	224	(1)
Special Considerations	224	(1)
References	224	(3)
Meeting the Needs of Children	227	(14)
Introduction	227	(1)
Children's Susceptibility to Biological Agents	228	(1)
Physiological Vulnerability	228	(1)
Differences in the Clinical Course of Diseases	229	(1)
Anthrax	229	(1)
Venezuelan Equine Encephalitis	230	(1)
Melioidosis (Burkholderia pseudomallei)	230	(1)
Children's Psychological Needs	230	(7)
Factors Affecting Children's Responses	231	(2)
Lack of Child-Oriented Resources	233	(1)
Triage of Children in a Mass Casualty Situation	234	(1)
Need for a Triage System	234	(1)
Jump START	234	(1)
Triage Training	235	(1)
Other Special Provisions for Children	235	(1)
Recent Recommendations of Expert Panels	235	(1)
Consensus Conference (2003)	235	(1)
National Advisory Committee on Children and Terrorism (2003)	236	(1)
References	237	(4)
The Role of Clinicians in Private Practice or Clinic Settings in Responding to a Biological Attack	241	(6)
Introduction	241	(1)
The Role of Clinicians in Recognizing a Bioterrorist Attack	242	(1)
When To Suspect an Infection Related to Bioterrorism	243	(1)
How To Report Suspicions	243	(1)
Other Steps To Be Taken	243	(1)
How To Educate Paraprofessional Staff about Bioterrorism	244	(1)
How To Protect Office Staff in the Event of an Attack	244	(1)
Likely Obstacles To Be Confronted by Non-Hospital-Based Providers in the Event of an Actual Attack	245	(1)
References	245	(2)
Internet Sources of Information	247	(30)
Introduction	247	(1)
Internet Resources by Topic	248	(12)
Hospital Preparedness Planning	248	(1)
Templates and Models for Hospital Plans	248	(3)
Hospital Compacts for Mutual Aid	251	(1)
Preparedness Overviews	252	(1)
Building Protection and Maintenance	252	(1)
Clinical Information on Potential Biological Agents	253	(1)
Websites with Clinical Information	253	(1)
Consensus Statements on Category A Biological Agents	254	(1)
Online Books and Manuals	255	(1)
Public Health Notification	256	(1)
Information Networks and Other Information Sources	256	(1)
Protocols: Interim Recommended Notification Procedures for Local and State Public Health Department Leaders in the Event of a Bioterrorist Incident	256	(1)
Public Health Resources: State Health Departments	256	(1)
State Public Health	257	(1)
FBI Field Divisions	257	(1)
Emergencies and Disasters, Planning and Prevention, State Homeland Security	257	(1)
E-mail Networks	257	(1)
Real-Time Alert Services	257	(1)
Medline Alert Services	257	(1)
Other Federal Update Services	258	(1)
Sites for Patients and the Public	258	(1)
American Academy of Pediatrics	258	(1)
American Red Cross	258	(1)
Centers for Disease Control and Prevention (CDC)	258	(1)
Department of Homeland Security Public Readiness Site	259	(1)
Kidshealth.org	259	(1)
Medline Plus	259	(1)
The RAND Corporation	259	(1)
Biological Weapons and Terrorism Policy Issues	259	(1)
Federation of American Scientists	259	(1)
Center for Nonproliferation Studies of the Monterey Institute of International Studies	259	(1)
Henry L. Stimson Center	259	(1)
Carnegie Endowment for International Peace	260	(1)
Chemical and Biological Arms Control Institute	260	(1)
National Memorial Institute for the Prevention of Terrorism (MIPT)	260	(1)
Alphabetical Listing of Websites	260	(16)
Agency for Health Research and Qualify (AHRQ)	260	(1)
American Association of Blood Banks	260	(1)
American Academy of Pediatrics (AAP)	260	(1)
American College of Emergency Physicians (ACEP)	261	(1)
American College of Physicians-American Society of Internal Medicine (ACP--ASIM)	261	(1)
American Hospital Association (AHA)	261	(1)
American Medical Association (AMA)	262	(1)
American Psychiatric Association	263	(1)
American Psychological Association	263	(1)
American Public Health Association	263	(1)
American Red Cross	263	(1)
American Society of Microbiology	263	(1)
Armed Forces Institute of Pathology	264	(1)
Association for Professionals in Infection Control (APIC)	264	(1)
Center for Biosecurity of the University of Pittsburgh Medical Center	265	(1)
Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota	265	(1)
Center for Nonproliferation Studies of the Monterey Institute of International Studies	266	(1)
Center for the Study of Bioterrorism and Emerging Infections, Saint Louis University School of Public Health	266	(1)
Centers for Disease Control and Prevention (CDC)	267	(1)
Department of Homeland Security (DHS)	268	(1)
Emerging Infectious Diseases	268	(1)
Food and Drug Administration (FDA)	269	(1)
General Accounting Office (GAO)	269	(1)
Health Resources and Services Administration (HRSA)	270	(1)
The Infectious Diseases Society of America (IDSA)	270	(1)
Joint Commission on the Accreditation of Healthcare Facilities (JCAHO)	270	(1)
Kidshealth.org	271	(1)
MedlinePlus	271	(1)
Morbidity and Mortality Weekly Report (MMWR)	272	(1)
National Bioterrorism Civilian Medical Response Center (CiMeRC)	272	(1)
The National Center for PTSD (Posttraumatic Stress Disorder)	273	(1)
National Guideline Clearinghouse	273	(1)
National Memorial Institute for the Prevention of Terrorism (MIPT)	273	(1)
National Institute for Occupational Safety and Health (NIOSH)	274	(1)
The National Mental Health Information Center	274	(1)
Premier Safety Institute	274	(1)
The RAND Corporation	275	(1)
Stanford University Medical Center	275	(1)
USAMRIID (The U.S. Army Medical Research Institute of Infectious Diseases)	275	(1)
References	276	(1)
SECTION IV Tabletop Exercises	277	(36)
Educating Hospital Staff and Maintaining Preparedness for Bioterrorism	279	(2)
References	281	(2)
Tabletop Exercise: Plague	283	(6)
Tabletop Exercise: Smallpox	289	(6)
Tabletop Exercise: Anthrax	295	(6)
Tabletop Exercise: Ricin	301	(4)
Tabletop Exercise: Hemorrhagic Fever	305	(4)
Tabletop Exercise: Botulism	309	(4)
SECTION V Appendices	313	(32)
Appendix A: Drug and Vaccine Compendium	315	(8)
Appendix B: Smallpox Vaccination	323	(12)
Appendix C: The Lessons of National Readiness Exercises	335	(10)
Index	345