Biological Agents in the Mail Center - Introduction

We can never predict how or when a terrorist attack using biological
agents might occur, but we do know that the threat is real.

One possible scenario involves mailing a biological agent that would be
intentionally distributed through the postal system to the target,
causing death and infection and requiring a coordinated response
including the addressee, law enforcement, public health and emergency
response.

Another possible scenario involves hoax letters that, although they do
not contain an actual biological agent, generate fear and panic in all
involved. Such \"hoaxes\" also have an economic effect and drain
resources for all involved.

Both these scenarios can best be dealt with by having a more thorough
understanding and knowledge base of biological agents. This course is
designed to increase your ability to assess and respond to a possible
biological agent in a federal mail center, but may also be applied to
various other business environments. Certainly the threat of biological
agents being used against U.S. targets is broader and more likely than
at any other point in our history. Therefore, awareness of this
potential threat and education of our federal employees on how to manage
it are crucial.

#### [Purpose]{.underline}

The purpose of this training is to provide an overview and quick
reference for assessing and managing biological threats in federal mail
centers. It is not intended as a definitive text on the medical
management of biological agents. The course was developed by an
interagency working group. Its members are listed in Appendix A.

#### [Objective]{.underline}

The objectives of this course are:

-   To develop the ability to define and understand what a biological
    agent is; To identify 6 of the most likely biological agents to be
    used and their characteristics;

-   To know the incubation period, symptoms, and treatment for these
    agents;

-   To prepare for briefing others in the workplace on biological
    agents.

#### [What is a Biological Agent?]{.underline}

A **biological agent** is any microorganism capable of causing disease
or a toxin derived from a living organism that is deliberately used to
produce death or disease in humans, animals or plants. A **biological
threat** is any biological material capable of causing:

-   Death, disease, or any other biological malfunction in a human, an
    animal, a plant or another living organism;

-   Deterioration of food, water, equipment, supplies or material of any
    kind;

-   Harmful alteration of the environment.

Biological agents are fundamentally different from other weapons of mass
destruction - nuclear and radiological devices, conventional explosives,
or chemical weapons. Biological agents are sometimes called the \"silent
killers\" because you can\'t see, smell or taste it. Biological agents
can take days or weeks for symptoms to appear. The first sign of a
biological attack may well be a patient in an emergency room or
doctor\'s office. Since early detection, by those screening and opening
the mail for example, may create the opportunity for successful
prevention or treatment of the illness.

#### [There Is A Difference Between Living In Fear And Being Prepared.]{.underline}

#### [Why Now?]{.underline}

Since we as a nation are vulnerable to BioTerrorism, the best way to
minimize our own vulnerabilities is to understand how bacteria and
viruses might be used against us. A little bit of information goes a
long way in changing anxiety into resolve. Prior to 1990, most people
could not have named a biological warfare agent. Based on the tremendous
media exposure during the Gulf War and the anthrax events in 2001, many
people are familiar with \"anthrax.\" By understanding the nature of
biological agents, symptoms of exposure, how they would be deployed and
symptoms, we can reduce the threat and potentially mitigate an attack or
hoax.

#### [Overview of Bacteria]{.underline}

Bacteria are microscopic organisms that are present in our everyday
life. Some bacteria cause illness and are called pathogens. Biological
agents are divided into 3 main categories:

-   **Bacterial Agents**

-   **Viral Agents**

-   **Biological Toxins**

The Centers for Disease Control and Prevention (CDC) officials have
evaluated the biological agents and ranked them into three categories
according to a risk matrix analysis. The first group, Category A,
contains agents considered the greatest threat in terms of producing
casualties or socio-economic disruption and the need for stockpiling
antibiotics and vaccines. These threats include:

-   **[Anthrax](http://159.142.144.141/Portal/content/offerings_content.jsp?contentOID=123822&contentType=1004&PMTM=1&S=1)**

-   **[Smallpox](http://159.142.144.141/Portal/content/offerings_content.jsp?contentOID=123827&contentType=1004&P=1&S=1)**

-   **[Plague](http://159.142.144.141/Portal/content/offerings_content.jsp?contentOID=123824&contentType=1004&P=1&S=1)**

-   **[Tularemia](http://159.142.144.141/Portal/content/offerings_content.jsp?contentOID=123826&contentType=1004&PMTM=1&S=1)**

-   **[Botulinum
    toxin](http://159.142.144.141/Portal/content/offerings_content.jsp?contentOID=123832&contentType=1004&PMTA=1&S=1)**

-   **[Viral hemorrhagic
    fevers](http://159.142.144.141/Portal/content/offerings_content.jsp?contentOID=123828&contentType=1004&P=1&S=1)**

Biological Agents in the Mail Center - Overview of Bacterial Agents

Bacteria are unicellular organisms. They vary in shape and size from
spherical cells (cocci) with a diameter less than a micrometer to
rod-shaped organisms (bacilli), which may be larger.

The shape of the bacterial cell is determined by the rigid cell wall.
Under special circumstances some types of bacteria can transform into
spores. The spore of bacterial cells are more resistant to adverse
conditions e.g. cold, heat, drying, chemicals and radiation, than the
vegetative bacterium itself.

Bacteria generally cause disease in human beings by one of two ways:

-   By invading host tissues

-   By producing toxins

Many pathogenic bacteria utilize both mechanisms. The diseases they
cause often respond to specific therapy with antibiotics. Many of these
biological agents also have an \"incubation period\" or time before
symptoms become apparent. This time can be used effectively to
specifically pin-point the biological agent in a laboratory and treat
exposed individuals with antibiotics or antitoxins.

The name of the disease and the causative agent are often different. It
is important to distinguish the name of the causative agent from the
disease it produces. Examples of bacterial agents and the diseases
include:

+---------------------+------------------------------------------------+
| #### [D             | #### [Causative Agent]{.underline}             |
| isease]{.underline} |                                                |
+---------------------+------------------------------------------------+
| Anthrax             | *Bacillus anthracis*                           |
+---------------------+------------------------------------------------+
| Plague              | *Yersinia pestis*                              |
+---------------------+------------------------------------------------+
| Tularemia           | *Francisella tularensis*                       |
+---------------------+------------------------------------------------+
| Smallpox            | *Variola virus*                                |
+---------------------+------------------------------------------------+
| Botulism            | *Clostridium botulinum*                        |
+---------------------+------------------------------------------------+

Biological Agents in the Mail Center - Overview Viral Agents

Viruses are the simplest microorganisms and consist of a protein coat
surrounding genetic material, either RNA or DNA.

Viruses are much smaller than bacteria and lack a system for their own
metabolism. This means that viruses, unlike bacteria, cannot be
cultivated in culture media, but must invade/infect living cells in
order to multiply. Every virus requires its own special type of host
cell for multiplication because of a complicated interaction between the
cell and virus. The host cells can be from humans, animals, plants, or
even bacteria, but this range is specific to the various viruses. The
cultivation of viruses is generally expensive and time-consuming. Types
of viruses which could potentially be used as biological agents are:

-   Variola Virus - Smallpox

-   Viral Hemorrhagic Fevers (VHF) - Ebola, filoviruses, arenaviruses,
    yellow fever and dengue.

Biological Agents in the Mail Center - Overview of Biological Toxins

Biological toxins are harmful substances produced by living organisms
that disrupt normal cellular functions, thus causing illness or death.

Toxins are generally more toxic per weight than chemical agents. The
toxins considered to be among the most likely to be used as biological
agents include:

-   Botulinum toxin - produced by the bacteria *Clostridium botulinum*

-   Ricin toxin - an extract of castor bean

-   Staphylococcal enterotoxin B (SEB) - food poisoning.

Toxins are non-volatile, which makes them unlikely to produce either
secondary or person-to-person exposures or a persistent environmental
hazard.

Biological Agents in the Mail Center - History of BioTerrorism

History of BioTerrorism

Before the era of modern microbiology brought the prospect of germ
warfare to the world of the 21st century, ancient armies used filth,
cadavers, animal carcasses and contagion as weapons against each other.
They knew that fear of infectious diseases could rapidly demoralize and
dismantle enemy forces.

During the North American colonization, British forces purposely spread
smallpox among the native Indian population by sending smallpox-infested
blankets as \"gifts\"; to Indian tribes who resisted British authority.

A chilling, low-tech, example of BioTerrorism in the U.S. happened in
1984 in a small town in Oregon, when members of the Rajneeshee religious
group used Salmonella poisoning to contaminate 10 salad bars in the
local area. This affected over 750 restaurant customers who had food
poisoning resulting in 45 hospitalizations. The attack was tied to a
failed plan to influence the outcome of a local election. This event
went undetected until the perpetrators were arrested on different
charges some months later and informed local officials about their
conspiracy.

**Biological Agents in the Mail Center - Anthrax (Bacillus anthracis)**

Anthrax is one of the oldest diseases known to man and is associated
with agricultural areas and farm life. The U.S. Postal Service was
utilized to disseminate potentially lethal letters containing Bacillus
anthracis (anthrax) in September, 2001, causing fear, panic, and five
deaths in the U.S. population.

In fact, terrorists sent seven letters (4 known and 3 suspect)
containing anthrax. This attack resulted in five deaths and illness to
eighteen others. A great deal was learned about the various forms of
disease since these incidences, and many health care professionals and
people are now more familiar with this disease.

  ---------------------------------------------------- -----------------------------------------------------
  ![](media/image1.png){width="0.9895833333333334in"   ![](media/image2.jpeg){width="1.2083333333333333in"
  height="0.6666666666666666in"}                       height="1.78125in"}

  B. anthracis, Gram stain demonstrating spores        Anthrax - Edema and typical lesions
  ---------------------------------------------------- -----------------------------------------------------

Anthrax is an infectious disease caused by the bacterium *Bacillus
anthracis*. These bacteria alternate between two states, the actively
growing or vegetative state and the dormant state. In the dormant state
the bacterium encases itself in a thick shell called a spore. The spores
are highly resistant to sunlight, heat and disinfectants and can survive
in this state for decades in the soil. It is this feature that makes it
highly effective as a terrorist agent.

Anthrax can produce three distinct forms of the illness. Except by
contact with open sores, it is not contagious from person to person.
Symptoms of the disease depend on how the organism enters the body. The
forms are:

-   **Cutaneous**

-   **Gastrointestinal**

-   **Inhalational**

[Cutaneous anthrax]{.underline} usually begins as an itchy area that
resembles an insect bite. Within a day or two it grows into a round,
fluid filled ulcer about the size of a dime. The characteristic feature
of the disease is a painless black scab that forms in the middle. The
word anthracis is derived from the Latin *attratus*, which means covered
in black. The scab loosens and falls off within 1-2 weeks, leaving
minimal scarring. It is rarely painful but can have associated swelling
in the lymph glands in the affected area. With proper treatment with
antibiotics, the survival rate is very high. If untreated the infection
can spread and cause blood poisoning.

  ---------------------------------------------------- ----------------------------------------- -----------------------------------------------------
  ![](media/image3.png){width="0.9791666666666666in"   ![](media/image4.png){width="0.96875in"   ![](media/image5.jpeg){width="1.5104166666666667in"
  height="0.8229166666666666in"}                       height="0.8229166666666666in"}            height="1.0729166666666667in"}

  Picture of Cutaneous Anthrax Day 2                   Picture of Cutaneous Anthrax Day 4        Picture of Cutaneous Anthrax Day 15, Eschar of the
                                                                                                 neck, typical of the last day of lesion.
  ---------------------------------------------------- ----------------------------------------- -----------------------------------------------------

[Gastrointestinal Anthrax]{.underline} occurs when the bacterium is
swallowed and may follow the consumption of contaminated meat. It is
rare and at the outset resembles a severe case of food poisoning.
Initial symptoms include nausea, loss of appetite, vomiting and fever.
These are quickly followed by abdominal pain, vomiting of blood and
severe diarrhea. If left untreated, about 33% of the patients will die
from the infection.

[Inhalational Anthrax]{.underline} is the most deadly form of the
disease and the most likely one a terrorist would try to exploit. For
the inhalational form to occur, the bacterium must be breathed into the
lungs. For anthrax to be inhaled and enter the lungs, it must be
\"aerosolized\" into particles between 0.4 and 2/10,000ths of an inch,
smaller than a red blood cell.

The first symptoms present as flu-like with fever, chills, headache,
nausea, vomiting, muscle aches and fatigue. Some people then experience
what appears to be a brief recovery and then the disease moves into the
second more severe stage. This is characterized by high fever, fluid in
the lungs and severe breathing problems.

  ------------------------------------------ ---------------------------------------
  ![](media/image6.jpeg){width="2.53125in"   ![](media/image7.jpeg){width="2.25in"
  height="2.0833333333333335in"}             height="2.0520833333333335in"}

  Inhalational Anthrax - Mediastinal         Inhalation Anthrax - Mediastinal
  widening with inhalational anthrax\        widening and pleural effusion on Chest
  (*JAMA* 1999:281:1735-1745)                X-Ray in inhalational anthrax
  ------------------------------------------ ---------------------------------------

There is an anthrax vaccine available that, if used after exposure but
before symptoms appear, may greatly reduce the number of illnesses and
deaths. The U.S. vaccine consists of a purified toxin component
(Protective Antigen) and is not infectious. The vaccination series
consists of 6 doses followed by yearly boosters.

**Biological Agents in the Mail Center - Plague (Yersinia Pestis)**

The very name means literally to strike or hit and conjures deep-routed
fears that date back for centuries. There is no wonder why. Many of us
remember reading about the Black Death in the fourteenth century that
was responsible for killing a greater number of the world\'s population
than any other disease or war in history.

Today it is an unlikely, although possible, BioTerrorist threat. The
bacterium that causes plague can be found on every populated continent
except Australia. Over the last 50 years, an average of 1,700 cases were
reported annually worldwide.

There are three forms of plague, but they are all caused by a bacterium
called Yersinia pestis. Plague is *transmitted to humans by the bite of
a flea that has fed on an infected rodent*. A single fleabite can
introduce thousands of microorganisms into the skin where they
immediately proceed to the closest lymph node. What happens next
determines the form of plague a person will manifest. Plague normally
appears in one of three forms in humans: bubonic (lymphatic infection),
septicemic (blood infection), and pneumonic (lung infection). It is
thought that the pneumonic plague would be the most likely form of a
biological attack.

  ----------------------------------------------------- -----------------------------------------------------
  ![](media/image8.jpeg){width="1.3020833333333333in"   ![](media/image9.jpeg){width="1.0833333333333333in"
  height="0.8645833333333334in"}                        height="1.03125in"}

  *Yersinia pestis* - Male *Xenopsylla cheopis*         Seen here are small hemorrhages on the skin of a
  (oriental rat flea) engorged with blood.\             plague victim.
  This flea is the primary vector of plague in most     
  large plague epidemics in Asia, Africa, and South     
  America. Both male and female fleas can transmit the  
  infection.                                            
  ----------------------------------------------------- -----------------------------------------------------

***Bubonic plague*** is the most commonly occurring form of the disease.
The bubonic form begins after an incubation period of 2-10 days with
acute and non-specific symptoms including high fever, malaise, headache,
sometimes nausea and vomiting. Shortly after these symptoms, the lymph
nodes become swollen and painful. The swollen lymph nodes are called
buboes and usually are seen in the groin and armpits as the arms and
legs are the most commonly flea-bitten part of the adult body. Bubonic
and septicemic plague are only spread through bites from infected fleas,
so person to person contagion is not an issue.

In cases where the bacteria are not contained by the lymph nodes, they
enter the bloodstream, where they can affect many different organ
systems. This is known as ***septicemic plague***. In those that do
progress to secondary septicemia, as well as those with primary
septicemias, the symptoms are high fever, chills, malaise, hypotension,
nausea, vomiting and diarrhea.

***Pneumonic plague*** is an infection of the lungs, which may be due to
either inhalation of the organisms or spread to the lungs from
septicemia. Following an aerosol or inhalational exposure, the disease
progresses very quickly. The incubation period can range from one to six
days. Onset is acute and progresses rapidly. The first signs include
high fever, chills, headache, and malaise followed within 24 hours by a
cough with bloody sputum. ***Pneumonic plague*** is highly contagious.
Bubonic and septicemic plague are spread only through bites from
infected fleas, so people who develop this form of the disease are not
contagious to others.

+-----------------------------------------------------------------------+
| ![](media/image10.jpeg){width="3.467361111111111in"                   |
| height="1.0194444444444444in"}                                        |
+-----------------------------------------------------------------------+
| \(A\) Cervical bubo in patient with bubonic plague;\                  |
| (B) Petechial and ecchymotic bleeding into the skin in patient with   |
| septicemic plague;\                                                   |
| (C) Gangrene of the digits during the recovery phase of illness of    |
| patient shown in B. In plague following the use of a biological       |
| weapon, presence of cervical bubo is rare; purpuric skin lesions and  |
| necrotic digits occur only in advanced disease and would not be       |
| helpful in diagnosing the disease in the early stages of illness when |
| antibiotic treatment can be lifesaving.                               |
|                                                                       |
| Pictures from Centers for Disease Control and Prevention, Division of |
| Vector-Borne Infectious Diseases, Fort Collins, CO.                   |
+-----------------------------------------------------------------------+

The earlier plague is diagnosed and treated, the more likely the
infection can be controlled and the potential for an epidemic minimized.
Pneumonic plague is highly contagious and infected patients should be
placed in respiratory isolation. Any diagnosed cases must be reported to
the local and state health departments so that community monitoring can
begin immediately to determine if the case is part of a larger outbreak.
The mortality rate for untreated pneumonic plague is nearly 100% and
survival is unlikely if treatment is delayed beyond 18 hours of
infection. The mortality of untreated bulbonic plague is about 60% and
can be reduced to 5% with prompt treatment with antibiotics.

There is no vaccine available to protect against pneumonic plague.
Historically, difficulties in sustaining the organism\'s virulence and
its lack of stability have been obstacles to the weaponization of this
bacterium.

**Biological Agents in the Mail Center - Tularemia (Francisella
Tularensis)**

Tularemia is caused by Francisella tularensis and occurs naturally in
mice, squirrels and rabbits. Humans can acquire tularemia after skin or
mucous membrane contact with infected animals or from bites of infected
ticks, deerflies, or mosquitoes.

Inhalation of contaminated dusts or ingestion of contaminated food or
water may also produce the disease. The bacterium can remain viable for
weeks in water or soil or in cold, moist conditions. It is resistant to
temperatures of freezing or below. It is easily killed by heat and
disinfectants. As few as 10-50 organisms are sufficient to cause disease
if inhaled or inoculated into the skin.

  ------------------------------------------------------ -------------------------------------------
  ![](media/image11.jpeg){width="2.2291666666666665in"   ![](media/image12.jpeg){width="1.46875in"
  height="1.8333333333333333in"}                         height="2.09375in"}

   Cutaneous ulcer of tularemia                           Tularemia
  ------------------------------------------------------ -------------------------------------------

Tularemia was developed as a bioweapon by Japan, the United States, and
the Soviet Union during World War II, and the Soviets reportedly
developed antibiotic and vaccine resistant strains during the 1980\'s.
It has prominence among biological weapons because it\'s one of the most
infectious diseases on earth. The bacterium is generally unstable, and
it is killed by mild heat and disinfectants.  But it can survive in
cold, moist conditions.  If released in aerosol form, it could remain
effective in the air for up to two hours if weather conditions are
right.  The disease is not spread person to person. The mortality rate
without treatment is from 5 % for the ulceroglandular form and 35% for
the typhoidal form.

The incubation period is short and varies from 1 to 21 days (average is
3 to 5 days) with an acute onset. The way the disease attacks the body
depends on how it\'s contracted. The initial symptoms are sudden onset
of fever, chills, headaches, aches and pains in the muscles and joints,
a dry cough and progressive weakness. If the bacteria are inhaled the
disease progresses rapidly to pneumonia, chest pain, difficulty
breathing, bloody sputum and if untreated, respiratory failure and
death.

In rare cases, \"Typhodial tularemia\" may be delivered via aerosol
attack. This form is a severe blood infection that affects the entire
body and can result in organ failure and respiratory failure if not
diagnosed and treated in time. It manifests as fever, weight loss,
respiratory symptoms and cough.

Tularemia can be treated with antibiotics if started early, such drugs
as Streptomycin, Gentamicin, or Doxycycline are effective. A vaccine was
developed for the lab people who routinely work with tularemia bacteria
but this vaccine would not be fully effective against the inhaled form
of the disease. It also requires 14 days after exposure for the
protection, so it would not be a consideration after people are exposed.

**Biological Agents in the Mail Center - Smallpox (Variola)**

Smallpox has not been seen in the world for the last 25 years, but the
increasing concern of potential Bio Terrorist outbreaks is cause to
revisit its signs, symptoms and treatment.

Smallpox claimed the lives of five hundred million people in the last
century alone. In probably the most successful public health effort
ever, naturally occurring smallpox disease was eradicated from the face
of the earth.

In 1967, the World Health Organization (WHO) launched a program to wipe
out smallpox. Mass vaccination campaigns were carried out throughout the
world and outbreaks were contained. In 1980 the WHO declared that
smallpox had been eradicated and recommended a worldwide end to
vaccinations. In 1972 vaccinations in the U.S. were stopped. The
potential weaponization of the smallpox virus continues to pose a threat
because of the aerosol infectivity of the virus and the development of
susceptible populations. While the odds are remote that it could happen,
we must be prepared.

Smallpox is an infection caused by the variola virus: variola major and
the milder form, variola minor. The U.S. stopped vaccinating its
military population in 1989 and civilians in the early 1980\'s so these
populations are now susceptible to smallpox, although recruits immunized
in 1989 may retain some degree of immunity.

Smallpox, variola major, is released by respiratory droplets from
infected patients, but can live on linens and clothing, causing contact
transmission. Persons with smallpox are most infectious during the first
week of illness, because that is when the largest amount of virus is
present in saliva. The incubation period is 7 to 17 days, (although the
average is 12 days) following exposure. The first symptoms are high
fever, fatigue, headache, physical collapse and backache. When the first
signs and symptoms occur, the incubation period has ended and the
individual is contagious.

![](media/image13.jpeg){width="2.1875in" height="1.75in"}

The rash first develops as tiny pink spots in the throat and mouth and
typically spreads to the face and forearms, then to the trunk and legs.
The rash is densest on the face and extremities. A distinctive
characteristic of smallpox is that the rash occurs on the palms of the
hands and soles of the feet. The rash grows into vesicles, or small
raised bumps that usually contain fluid and within several days become
filled with pus. The lesions can be extremely painful. About eight or
nine days after the rash first appears, scabs start to form. Once the
scabs fall off, people are often left with pitted scarring, especially
on the face.

Smallpox caused by variola minor tends to be less severe with fewer skin
lesions and milder symptoms. Individuals with some residual immunity
from past vaccinations may have milder symptoms and may recover more
quickly.

Unusual forms of smallpox can occur. Occasionally, hemorrhagic or
malignant smallpox may develop. In the hemorrhagic form, bleeding into
the skin and from mucous membranes happens. In the malignant form, the
rash remains flat and does not develop into the pus-filled form. Both of
these forms are usually fatal.

![](media/image14.jpeg){width="3.1354166666666665in"
height="0.8020833333333334in"}

The variola vaccine, a live vaccinia virus preparation called DryVac,
can be administered up to five days post-exposure to greatly reduce
severity of smallpox and reduce mortality rate. Antiviral drugs may be
effective against the variola virus and are being tested. The key to
containing any outbreak is to isolate those infected. Before the disease
was eradicated in the last century, about 30% of those who caught the
most severe form of smallpox, variola major, died. Getting exposed
people vaccinated within five days following exposure to the virus will
prevent many infections and at least decrease the likelihood of a
life-threatening illness.

**Biological Agents in the Mail Center - Viral Hemorrhagic Fevers
(VHF)**

The name viral hemorrhagic fevers (VHF) actually tells you a great deal
about this illness. The infections cause high fever and widespread,
uncontrollable bleeding.

The term \"hemorrhagic\" refers to one of VHF\'s characteristics: in its
most severe form, infection causes bleeding under the skin, in internal
organs, and from the mouth, nose, ears, eyes or other body openings.

The viral hemorrhagic fevers are a diverse group of illnesses caused by
RNA viruses from four viral families:

-   Arenaviridae (include Lassa fever)

-   Bunyaviridae (include Congo-Crimean hemorrhagic fever)

-   Filoviridae (include E-bola)

-   Flaviviridae (include dengue or West Nile)

All of the VHF agents (except for dengue virus) are infectious by
aerosol in the laboratory. These viruses could conceivably be used by an
adversary as biological warfare agents, in view of their aerosol
infectivity and high lethality.

These VHF viruses normally rely on animals or insects as disease
carriers. Once an outbreak begins, the virus can be spread from person
to person through direct contact with blood or body fluids. Of the four
viral families that cause VHFs, the one most likely to be used by
BioTerrorists is the filoviruses, which include Ebola and Marburg
hemorrhagic fevers and arenaviruses which include Lassa and South
American VHF. VHF agents are unstable and tend to rapidly become
inactive in the environment.

**The Filoviruses**

When examined in a microscope, filoviruses appear long and stringy, or
filamentous and were named for the distinctive appearance. The first
virus, **Marburg virus**, was discovered in 1967 in Marburg, Germany,
and Yugoslavia, when laboratory workers developed hemorrhagic fever
after handling tissues from African green monkeys. In 1975, a traveler
was exposed to the virus in Zimbabwe, South Africa and passed it to
others. Marburg epidemics have occurred on six occasions: five times in
Africa and once in Europe. The natural reservoirs of the filoviruses are
unknown.

  -----------------------------------------------------------------------
  ![](media/image15.jpeg){width="2.4583333333333335in"
  height="0.9583333333333334in"}

   VHF - Maculopapular Rash in Marburg Disease
  -----------------------------------------------------------------------

After a 5 to 7 day incubation period, the virus produces headaches,
fever, muscle pain, vomiting, diarrhea, hemorrhagic areas under the
skin, skin rash and jaundice. Fatalities occur in about 25 per cent of
cases. Marburg is considered a high priority as a BW agent. It is highly
infectious by the aerosol route and was actually weaponized in the
former Soviet BW program.

**The Ebola virus** was named for the river valley in Zaire (now the
Democratic Republic of the Congo) where the first outbreak occurred in
the mid 1970\'s. Ebola virus is one of the most pathogenic viruses known
to science, causing death in 50 to 90 per cent of all clinically ill
cases. The Ebola virus is transmitted through direct contact with blood,
secretions, organs or semen of infected persons. Health care workers
have proved especially vulnerable. Ebola comes in four different
strains; the two strains that were responsible for outbreaks are named
Ebola-Zaire and Ebola-Sudan. This virus killed 90 per cent of the people
in the Zaire outbreak and half of those infected in Sudan.

  -----------------------------------------------------------------------
  ![](media/image16.jpeg){width="1.3645833333333333in"
  height="0.6979166666666666in"}

   VHF - Ebola virus antigen in skin
  -----------------------------------------------------------------------

The virus has an incubation period of 2 to 21 days. It is characterized
by sudden onset of fever, weakness, muscle pain, headache and sore
throat. This is followed by vomiting, diarrhea, rash, limited kidney and
liver functions, and both internal and external bleeding. The
hemorrhagic symptoms begin on about the fifth day. There is no treatment
for Ebola virus. Symptomatic treatment is initiated by balancing fluid
and electrolytes, maintaining oxygen levels and blood pressure, giving
blood transfusions, and treating any complicating infections. Not all
infected persons develop VHF. There is both divergence and uncertainty
about which host factors and viral strain characteristics might be
responsible for the mechanisms of disease.

Although there has never been a case of the Ebola VHF in humans in the
U.S., it must be considered a high priority as a candidate for
biological warfare as it can be aerosolized.  It was given a high
priority in the offensive BW program of the former Soviet Union.

**The Arenaviruses**

The arenaviruses are a much larger family than the filoviruses and their
natural hosts are known: rodents. We know a lot more about arenaviruses
than we do about filoviruses. The arenaviruses are passed from
generation to generation through the rodents that carry them. Similar to
Ebola virus infections, humans are not a natural host for Lassa or the
South American viruses. Humans contract the disease by direct contact
with infected rodents or their urine or droppings. This can happen in a
variety of ways, including eating contaminated food.

The incubation period is from 1 to 3 weeks. In general, Lassa fever is
not as severe as the others. The symptoms are similar to those of Ebola
and Marburg and may involve hearing loss, tremors and inflammation of
the brain or encephalitis, and severe breathing problems. Overall, the
death rate is less than 1 per cent of those infected. The most severe
form has a death rate as high as 20 per cent. Pregnant women are more at
risk for the severe disease.

An antiviral drug called ribavirin has been successful in treating Lassa
fever and is most effective if used early in the illness. The drug is
not approved in the US for this virus and there is no vaccine.

**Biological Agents in the Mail Center - Botulism (Clostridium
Botulinum)**

Botulinum toxin is produced by the bacterium, Clostridium botulinum, the
most poisonous substance known to science. The toxins are usually formed
in canned foods and eaten, but can be spread by aerosol and inhalation.

Growth and toxic formation occurs under anaerobic conditions, such as in
non-acidic meat samples or inside vegetable cans. While the bacteria
reproduce by anaerobic fermentation, the toxin does not self-reproduce
or multiply once inside the body. Botulism poisoning takes place because
of the lethality of the already-produced toxin.

The toxin can cure as well as kill. It is the first biological toxin to
be licensed for treatment of human disease. It is used to treat eye
conditions, migraine headache, low back pain and under the trade name,
Botox TM, it is now used by cosmetic surgeons to remove wrinkles.

Botulism is a rare, paralyzing muscle disease. There are at least seven
recognized types of the toxin and each acts with the same mechanism. The
toxins are designated by the letters A through G. Only four cause
illness in humans.

Botulism occurs naturally in three forms: foodborne, infant and wound.
The names are indicative of each type. On average, 110 cases of botulism
are reported in the U.S. each year. Botulism is not contagious person to
person and you can\'t catch it through the skin unless there\'s a wound.
The toxins produce similar effects when inhaled or ingested, although
the time course may vary depending on the route of exposure and the dose
received. Although an aerosol attack is the most likely scenario for the
use of botulinum toxins, the agent could be used to sabotage food
supplies.

The onset of symptoms of inhalational botulism usually occurs from 12 to
36 hours following exposure. A shorter time is typical following eating
or swallowing the toxin or inhalation of stronger doses. Progression
from onset of symptoms to respiratory failure has occurred in as little
as 24 hours in cases of severe foodborn botulism.

The first symptoms are double vision, blurred vision, drooping eyelids,
slurred speech, difficulty swallowing, dry mouth and muscle weakness.
Botulism always begins in the muscles of the head, face and neck. If
untreated, the disease will work its way down the body, paralyzing the
arms, legs, trunk and respiratory muscles.

The fatality rate is about 60 percent in normal circumstances following
ingestion. The most common cause of death used to be respiratory
failure. With intensive medical care, especially the use of ventilators
to help them breathe, the patients can recover. The vaccine that has
been in use for thirty years is still considered experimental. It has
been used to immunize lab workers in many countries. The vaccine is
scarce and takes several months to build up immunity. It is also very
painful to receive.

There is an anti-toxin horse serum kept by the CDC that is used to treat
botulism. Physicians report any botulism cases to the CDC through the
state health department. Monitoring cases is essential, because if
someone contracts botulism from contaminated food, it\'s possible there
are other cases. The CDC is ready to ship the antitoxin anywhere
immediately, twenty-four hours a day. The serum blocks the toxin from
circulating in the blood. It can stop the disease from worsening but it
cannot reverse the paralysis that has already occurred.

**Biological Agents in the Mail Center - Ricin (Ricinus Communis)**

Ricin is a potent toxin made from the mash left over after processing
castor beans for oil. Castor bean processing is a worldwide activity and
the raw materials for making Ricin are easily available.

Ricin is easy to produce and is stable. The toxin is extremely toxic by
several routes of exposure, including the respiratory route. Ricin has a
high terrorist potential due to its ready availability, relative ease of
extraction and effective deployment.

Ricin can be prepared in liquid or crystalline form, or made into a dry
powder. It could be disseminated as an aerosol, injected into a target,
or used to contaminate food or water on a small scale. The usual route
of entry is inhalation, although it may be ingested through food or
water that was sabotaged. The disease is not transmissible from person
to person.

Ricin is very toxic to cells and the symptoms appear from 1 to 8 hours
after inhalational exposure. The symptoms include fever, chest
tightness, cough, difficulty breathing, nausea and muscle aches. This
progresses to severe inflammation of the lungs and airways, increased
difficulty breathing, cyanosis and death within 36-48 hours.

Ingestion of Ricin would be expected to cause nausea, vomiting, internal
bleeding of the stomach and intestines, failure of the liver, spleen and
kidneys and death by collapse of the circulatory vessels.

Currently there is no vaccine or prophylactic antitoxin available for
human use. The U.S. is conducting research on developing such a vaccine.
The only treatment available involves management of the effects based on
the method of exposure to the toxin. If Ricin is inhaled, oxygen may be
given with drugs to reduce inflammation and support the function of the
heart and circulatory system. Ingestion of Ricin would be treated by
pumping the stomach.

**Biological Agents in the Mail Center - Conclusion**

One of the lessons learned from September 11 is that we must prepare as
best we can for the unthinkable.

The threat for mail managers is not that someone will release a
biological agent into the air from a plane, it\'s that the agent will be
mailed in a letter or package. The difference between living in fear and
being prepared can mean the difference in human lives if an actual event
occurs. Learning about the biological agents and understanding them can
help in developing an appropriate response plan and is the first step in
minimizing the impact. Knowledge is power when we think about protecting
the health and safety of federal employees.

Biological Agents in the Mail Center - Frequently Asked Questions

**Frequently Asked Questions**

**Q. Would there be enough antibiotics available if many people were
exposed to a biological agent at one time?**

A. The CDC\'s National Pharmaceutical Stockpile Program (NPSP) was
established to ensure the availability of life saving pharmaceuticals,
antibiotics, chemical interventions, as well as medical, surgical and
patient support supplies and equipment for prompt delivery to the site
of a disaster, including a possible biological event anywhere in the
U.S. The NPSP also has vaccine available to address smallpox threats.
The components of the NPSP include 12-hour Push Packages for immediate
response and Vendor Managed Inventory (VMI). The 12-hour Push Packages
are designed for immediate deployment to reach any affected area within
12 hours of the federal decision to treat the exposed population. The
VMI is for those situations requiring a larger response and are expected
to arrive within 24-36 hours.

**Q. Is the smallpox vaccine effective if the disease has been
contracted?**

A. In the case of those who may have been exposed to smallpox, the
vaccine can lessen the severity of or even prevent illness if given
within 4 days after exposure. Vaccine against smallpox contains another
live virus called vaccinia. The vaccine does not contain smallpox virus.

**Q. If I was vaccinated against smallpox before 1972, will I get
smallpox if exposed?**

A. It\'s uncertain how much immunity would be present after a period of
years has gone by. Some experts estimate that a single dose of smallpox
vaccine offers protection for about three to five years and not more
than ten years. Since routine vaccinations ended in the U.S. in 1972
that means our entire population must be considered highly vulnerable.
It is possible that a revaccination for someone who was immunized as a
child might boost immunity faster than a first time vaccination.

**Q. What laws are in place concerning biological agents?**

A. [The Patriot Act (2001) and the Public Health Security and
BioTerrorism Preparedness and Response Act (2002)]{.underline} are
examples of laws in place to help in preventing biological agents from
being used inappropriately. Section 817 of the Patriot Act criminalizes
possession of biological agents unless justified by a \"prophylactic,
protective, bona fide research, or other peaceful purpose.\" It also
prohibits the possession, transport, and receipt of selected agents by
convicted felons, foreign nationals from terrorism-sponsoring nations,
individuals dishonorably discharged from the Armed Services, and
unlawful users of controlled substances.

The Public Health Security and BioTerrorism Preparedness and Response
Act requires that the Secretary of Health and Human Services maintain a
list of select agents; requires research facilities possessing select
agents to register their possession to the CDC, requires background
checks of those in possession of select agents to ensure they are not
convicted felons, etc.; and requires the \"Establishment of safeguard
and security measures to prevent access for such agents and toxins for
use in domestic or international terrorism or for any other criminal
purpose.\"

**Q. What is the difference between a chemical and a biological attack
agent?**

A. Unlike a chemical agent attack, which would cause an almost immediate
reaction, a biological attack would not cause a reaction until after an
incubation period. It might take from 24 to 48 hours before people would
start showing what often are non-specific, flu-like symptoms which would
then progress to whatever symptoms the specific agent would normally
cause.

**Q. How do you defend yourself against an attack you don\'t even know
has happened?**

A. The best defense comes from using a combination of awareness and
education to rapidly detect, warn, and report any incident. Knowing what
the characteristics of a suspicious letter or package are is a good line
of defense. The individual does not need to know immediately whether it
is anthrax or plague. They need to know how to report any suspicious
incident and how to work with a certified laboratory. The Federal Bureau
of Investigation (FBI) is the lead agency for any incident, which
includes biological agents or Weapons of Mass Destructions (WMD).

**Q. What is important to a mail manager about biological agents?**

A. While it may be laborious to plan an attack using aerosol release of
biological agents in an airplane or crowd, it is easier to mail the
agent in a letter or package. The agent may be mailed in powder or
aerosol form and would offer a clue to the dissemination. By being aware
of these substances, a mail manager may be the first to protect others
from serious consequences.

**Q. What are some considerations I might make if I think an event has
occurred?**

A. If you think you might have been exposed to a biological agent, after
calling the appropriate first responder, consider the following:

-   Identify those who were exposed. Document names, addresses,
    telephone numbers of all individuals entering the area of agent
    release after the time of release; document where individuals were
    located in relation to the point of agent release.

-   Maintain the scene by treating the area of release as a crime scene.
    All items contained within the area of release may be considered as
    evidence, including the clothes of individuals exposed.

-   Be aware of the potential for time lag and remind others so they do
    not panic. Victims of a biological weapons attack may not exhibit
    symptoms until many days after the attack occurred; you probably
    have time for a coordinated response with public health officials.

-   Stay calm and help reassure others, exposure may not necessarily
    indicate the need for decontamination or isolation, it depends on
    the agent.

Biological Agents in the Mail Center - Quick Reference Chart

The chart listed below was developed as a quick reference to give you an
overall view of the biological agents discussed in this course.

Like all terror attacks, BioTerrorism depends most of all on surprise.
The best defense against any disease is to know how diseases operate in
populations, and what lines of defense we have to stop them. The
following chart outlines key information i.e. availability, incubation
period, symptoms, and treatment of the biological agents listed in this
course.

# 

+----------+----------+----------+-----------+-------------+----------+
| **D      | **Incu   | *        | **Avail   | **Deliv     | **Tre    |
| isease** | bation** | *Early** | ability** | erability** | atment** |
|          |          |          |           |             |          |
|          | **       | **Sy     | **of      | **of        |          |
|          | Period** | mptoms** | Agent**   | Agent**     |          |
+----------+----------+----------+-----------+-------------+----------+
| **Inha   | 1-7 days | Non-s    | **High**. | **Medium**. | Anti     |
| lational |          | pecific, | Anthrax   | It takes    | biotics. |
| A        |          | Fever,   | grows     | technical   | Best if  |
| nthrax** |          | Malaise, | naturally | skills to   | given    |
|          |          | Cough,   | t         | refine      | early in |
|          |          | Chest    | hroughout | Anthrax to  | the      |
|          |          | Pains    | the       | the sized   | course   |
|          |          |          | world.    | required to | of the   |
|          |          |          | Hostile   | get into    | illness. |
|          |          |          | foreign   | the lungs.  | CDC      |
|          |          |          | nations   | More skill  | re       |
|          |          |          | have      | to          | commends |
|          |          |          | large     | manufacture | t        |
|          |          |          | supplies  | for aerosol | reatment |
|          |          |          |           | release.    | for 60   |
|          |          |          |           |             | days.    |
+----------+----------+----------+-----------+-------------+----------+
| **       | 1-6 days | Non-s    | **        | **Medium**. | Ant      |
| Plague** |          | pecific, | Medium**. | It has been | ibiotics |
| (Pn      |          | high     | The       | d           | must be  |
| eumonic) |          | fever,   | bacteria  | emonstrated | given 24 |
|          |          | cough,   | is stored | that the    | hours    |
|          |          | chills,  | in        | bacteria    | after    |
|          |          | dyspnea, | microbe   | could be    | symptoms |
|          |          | nausea,  | banks     | mass        | first    |
|          |          | v        | around    | produced as | appear   |
|          |          | omiting, | the       | a potential | for best |
|          |          | he       | world.    | weapon, but | of       |
|          |          | moptysis | S         | requires a  | survival |
|          |          |          | afeguards | high degree |          |
|          |          |          | make it   | of          |          |
|          |          |          | difficult | technical   |          |
|          |          |          | to        | skill.      |          |
|          |          |          | acquire a |             |          |
|          |          |          | powerful  |             |          |
|          |          |          | strain.   |             |          |
+----------+----------+----------+-----------+-------------+----------+
| #### T   | 3-5 days | Non-s    | **        | **Medium**. | Ant      |
| ularemia |          | pecific, | Medium**. | Bacterium   | ibiotics |
|          |          | fever,   | Bacterium | is          | started  |
|          |          | fatigue, | occurs    | difficult   | early    |
|          |          | chills,  | naturally | to process  | are very |
|          |          | cough,   | in mice,  | and harder  | ef       |
|          |          | malaise, | squirrels | to make     | fective. |
|          |          | GI       | and       | stable      |          |
|          |          | symptoms | rabbits.  | enough to   |          |
|          |          |          |           | cause mass  |          |
|          |          |          |           | casualties. |          |
|          |          |          |           | It is one   |          |
|          |          |          |           | of the most |          |
|          |          |          |           | infectious  |          |
|          |          |          |           | bacterium   |          |
|          |          |          |           | known.      |          |
+----------+----------+----------+-----------+-------------+----------+
| #### S   | 7-17     | First    | **Very    | **Medium**. | V        |
| mall Pox | days     | s        | Low**.    | It would be | accinate |
|          |          | ymptoms: | The       | difficult   | within 4 |
|          |          | fever,   | a         | to process  | days of  |
|          |          | malaise, | uthorized | and         | e        |
|          |          | h        | stores    | aerosolize  | xposure. |
|          |          | eadache, | are in    | release,    |          |
|          |          | dis      | two labs: | but it      |          |
|          |          | tinctive | in Russia | could be    |          |
|          |          | rash or  | and U.S.  | done.       |          |
|          |          | pox      | It is     |             |          |
|          |          | breaks   | suspected |             |          |
|          |          | out      | that      |             |          |
|          |          | later.   | other     |             |          |
|          |          |          | nations   |             |          |
|          |          |          | have      |             |          |
|          |          |          | illegal   |             |          |
|          |          |          | supplies. |             |          |
+----------+----------+----------+-----------+-------------+----------+

+----------+----------+----------+-----------+-------------+---------+
| **D      | **Incu   | *        | **Avail   | **Deliv     | **Trea  |
| isease** | bation** | *Early** | ability** | erability** | tment** |
|          |          |          |           |             |         |
|          | **       | **Sy     | **of      | **of        |         |
|          | Period** | mptoms** | Agent**   | Agent**     |         |
+----------+----------+----------+-----------+-------------+---------+
| **Viral  | 2-21     | Fever,   | **        | **Low**.    | ##      |
| Hem      | days;    | easy     | Medium**. | Technology  | ## None |
| orrhagic | varies   | b        | It would  | required to |         |
| Fevers** | among    | leeding, | be        | produced to |         |
| (VHF)    | viruses  | pe       | difficult | VHF is not  |         |
|          |          | techiae, | to obtain | considered  |         |
|          |          | red      | a strain  | to be       |         |
|          |          | itchy    | of Ebola, | highly      |         |
|          |          | eyes,    | but would | advanced    |         |
|          |          | hem      | be easier |             |         |
|          |          | atemesis | to obtain |             |         |
|          |          |          | strains   |             |         |
|          |          |          | of        |             |         |
|          |          |          | Are       |             |         |
|          |          |          | naviruses |             |         |
|          |          |          | from      |             |         |
|          |          |          | rodents.  |             |         |
+----------+----------+----------+-----------+-------------+---------+
| ####     | **Food   | None     | **High**. | **Medium**. | There   |
| Botulism | borne**: |          | Toxin is  | It is hard  | is an   |
|          | 12-72    | **Food   | widely    | to          | an      |
|          | hours    | borne**: | a         | weaponize   | titoxin |
|          |          | nausea,  | vailable, | to be       | horse   |
|          | *        | vomiting | but the   | released as | serum   |
|          | *Inhalat | a        | more      | an aerosol, | kept by |
|          | ional**: | bdominal | deadly    | but it      | the CDC |
|          | 18-80    | cramps,  | form is   | could be    | ready   |
|          | hours    | d        | more      | put into    | to ship |
|          |          | iarrhea. | difficult | uncooked    | imme    |
|          |          |          | to        | food, such  | diately |
|          |          | *        | obtain.   | as a salad  | 24      |
|          |          | *Inhalat | Rogue     | bar or      | hours a |
|          |          | ional**: | nations   | beverage.   | day.    |
|          |          | de       | are       |             |         |
|          |          | scending | believed  |             |         |
|          |          | p        | to have   |             |         |
|          |          | aralysis | it.       |             |         |
|          |          | progress |           |             |         |
|          |          | to       |           |             |         |
|          |          | airway   |           |             |         |
|          |          | obst     |           |             |         |
|          |          | ruction. |           |             |         |
+----------+----------+----------+-----------+-------------+---------+
| ####     | 4-8      | Inha     | **High**. | **Medium**. | ##      |
| Ricin (t | hours    | lational | Castor    |             | ## None |
| oxin fro | after    | fever,   | beans are |             |         |
| m castor | inha     | w        | commonly  |             |         |
|  beans ) | lational | eakness, | a         |             |         |
|          | exposure | cough,   | vailable. |             |         |
|          |          | hypo     |           |             |         |
|          |          | thermia, |           |             |         |
|          |          | cardiac  |           |             |         |
|          |          | c        |           |             |         |
|          |          | ollapse. |           |             |         |
+----------+----------+----------+-----------+-------------+---------+

**Biological Agents in the Mail Center - Resources**

The following information was Appendix A to the oral presentation of
this course.

The following List of Federal and State Agencies participating in
development of this course:

-   CBCCOM

-   Department of Homeland Security

-   Federal Bureau of Investigation

-   Federal Protective Service

-   General Services Administration

-   New York State Department of Health

-   U.S. Postal Inspection Service

**Biological Agents in the Mail Center - Glossary**

The following terms are intended to assist you with understanding the
terms used in this course.

**Active immunization** - the act of artificially stimulating the body
to develop antibodies against infectious disease by the administration
of vaccines or toxoids.

**Anaerobic** - living, active, or occurring in the absence of free
oxygen.

**Antitoxin** - An antibody formed in response to and capable of
naturalizing a biological poison; an animal serum containing antitoxins.

**Cutaneous** - relating to the skin.

**Cyanosis** - a bluish or purplish coloration of the skin and mucous
membrane due to deficient oxygenation of the blood.

**Dyspnea** - shortness of breath associated with disease of the heart
or lungs.

**Hematemesis** - vomiting of blood.

**Hemoptysis** - coughing up blood from the lungs or bronchial tubes as
a result of pulmonary or bronchial hemorrhage.

**Incubation period** - the interval between exposure and the
development of symptoms.

**Malaise** - an indefinite feeling of debility or lack of health often
indicative of the onset of an illness; a vague sense of mental or
physical ill being.

**Petechiae** - minute hemorrhagic spots in the skin, which does not
blanch by, pressure.

**Vaccine** - a suspension of attenuated live or killed microorganisms
(bacteria, viruses, or rickettsiae), or fractions thereof, administered
to induce immunity and thereby prevent infectious disease.

Biological Agents in the Mail Center - References

The following references were used to assist in writing and researching
this course. The following information was Appendix C to the oral
presentation of this course.

#### References

#### U.S. Government Publications

Army FM 8-284, *Treatment of Biological Warfare Agent Casualties*, 17
July 2000.

Interagency OPSEC Support Staff, *Terrorism Threat Handbook*
Unclassified/for Official Use Only, June 2001.

USAMRIID\'s, *Medical Management of Biological Casualties Handbook*, 17
July 2000.

U.S. Army Medical Research Institute of Infectious Diseases, *Medical
Management of Biological Casualties Handbook*, Fort Detrick, Frederick,
Maryland. July 1998.

U.S. Department of State, *Patterns of Global Terrorism 2000*, April
2001.

#### Civilian Reference Material

#### Books

Frist, Senator Bill, M.D. *When Every Moment Counts*. Lanham, Maryland.
Rowman & Littlefield Publishers, Inc. 2002.

Lesser, Ian O., Hoffman, Bruce, Arquilla, John, Ronfeldt, David, Zanini,
Michele. *Countering the New Terrorism*. Santa Monica, CA. Rand. 1999.

Mangold, Tom and Goldberg, Jeff. *Plague Wars: The Terrifying Reality of
Biological Warfare*. New York, NY. St. Martin\'s Press. 1999.

Miller, Judith, Engelberg, Stephen, Broad, William. *Germs*. New York,
NY. Simon & Schuster. 2001.

Osterholm, Michael T., Ph.D., M.P.H. and Schwartz, John. *Living
Terrors*. New York, New York. Delacorte Press. 2000.

Sidell, Frederick R., M.D., Patrick, William C. III, and Dashiell,
Thomas R., Alibek, Ken, MD, Layne, Scott, MD. *Jane\'s Chem-Bio
Handbook.Second Edition*. Alexandria, Virginia. Jane\'s Information
Group. 2002.

The Parents\' Committee for Public Awareness. *Anthrax: A Practical
Guide for Citizens*. Boston, MA. Harvard Perspective Press. 2001.

#### Articles

Kozaryn, Linda D. *Defending Against Invisible Killers: Biological
Agents*. American Forces Press Service.
[www.defenselink.mil](http://www.defenselink.mil/). February 7, 2003.

Kwik, Gigi, Fitzgerald, Joe, Inglesby, Thomas V and O\'Toole, Tara.
*Biosecurity: Responsible Stewardship of Bioscience in an Age of
Catastrophic Terrorism*. Biosecurity and Bioterrorism: Biodefense
Strategy, Science and Practice. Volume 1, Number 1, 2003. Mary Ann
Liebert, Inc.

Simons, Lewis M. *Weapons of Mass Destruction*. National Geographic.
November 2002. pp4-35.

#### References

#### U.S. Government Publications

Army FM 8-284 *Treatment of Biological Warfare Agent Casualties* 17 July
2000.

Interagency OPSEC Support Staff *Terrorism Threat Handbook*
Unclassified/for Official Use Only June 2001.

USAMRIID\'s *Medical Management of Biological Casualties Handbook* 17
July 2000.

U.S. Army Medical Research Institute of Infectious Diseases *Medical
Management of Biological Casualties Handbook* Fort Detrick. Frederick,
Maryland. July 1998.

U.S. Department of State *Patterns of Global Terrorism 2000*. April
2001.

**Biological Agents in the Mail Center - Web Sites**

The following web sites are intended to assist you with further insight
and guidance.

#### Federal Emergency Management

For the most comprehensive guide to personal emergency preparedness
published by the Federal Emergency Management Agency (FEMA), [Are You
Ready? A Guide to Citizen Preparedness]{.underline}, will help
individuals prepare themselves and their families for disasters. To
download a copy of this most useful survival information, visit FEMA\'s
web site at: <http://www.fema.gov/areyouready>.

#### State Assistance

The following links to non-Federal organizations are provided only as a
courtesy to our users. We do not endorse these organizations or their
programs and we are not responsible for the content of the individual
organizations or the state programs. No endorsement should be inferred.
For information on state and local health departments:\
<http://www.cdc.gov/other.htm#states> or Health Agency contact
directories:
[http://www.statepublichealth.org](http://www.statepublichealth.org/).

#### Biological Agents

Early detection of and response to biological terrorism are crucial.
Without special preparation a large-scale attack with variola virus,
aerosolized anthrax spores, or a food borne biological agent could
threaten the security of your mail center. The following web sites will
provide you with current information.

A list of biological diseases/agents can be found at:\
http://www.bt.cdc.gov/Agent/agentlist.asp

This presentation by the CDC will assist you in recognizing agents that
could be used for BioTerrorism and advise you on bio safety practices if
you should come in contact with one of these dangerous specimens. Please
point your browser to:
http://www.bt.cdc.gov/documents/PPTResponse/agentsglenfinal.pdf

Detailed information about a clinical diagnosis related to a rare or
unusual infectious disease outbreak associated with the release of a
biological agent.\
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a2.htm

United States Army Medical Research Institute of Infectious Diseases
(USAMRIID)\'s Medical Management Of Biological Casualties Handbook
*Fourth Edition February 2001*
http://www.usamriid.army.mil/education/bluebook.html

John Hopkins Medicine, Center for Civilian Biodefense Strategies, a web
based Communications system, which lists news articles, resources and
events related to BW Agents can be found at:\
http://www.hopkins-biodefense.org

#### Anthrax

For interesting reading of a possible case history, point your browser
to:\
http://www.cdc.gov/ncidod/EID/vol5no4/inglesby.htm

#### Smallpox

Interesting reading of a possible attack scenario can be found at:\
http://www.cdc.gov/ncidod/EID/vol5no4/otoole.htm

Frequently asked questions on smallpox from the Department of Homeland
Security (DHS) at:\
http://www.dhs.gov/dhspublic/display?theme=34&content=62

#### Terrorism

Written in a question and answer format, all the answers are carefully
researched, reported, written, and updated by the experts and
nonpartisan staff of the Council on Foreign Relations, in consultation
with a wide group of outside experts at:\
http://www.terrorismanswers.com/home/

#### Coping with Terrorism

The American Psychological Association \-- Coping with Terrorism, Tips
for helping you cope after a terrorist attack.\
http://www.helping.apa.org/daily/terrorism.html

American Medical Association - Fear and anxiety are normal human
reactions to a perceived threat or danger. Uncertainty is manageable if
people keep the threat of fear in perspective. \"Knowledge and
information based on fact can help us manage our anxieties\", says
Richard K. Harding, M.D., APA President Read more at:
http://www.psych.org/disaster/copingnationaltragedy-main92501.cfm

American Psychiatric Association - Psychosocial, Post Traumatic Stress
Resources, as well as resources for helping children cope.\
http://www.psych.org/disaster/copingnationaltragedy-main92501.cfm

The Red Cross has information available on how citizens can prepare for
a terrorist attack. For more information visit
http://www.redcross.org/services/disaster/keepsafe/unexpected.html