A Reference Guide for Media

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

TERRORISM AND OTHER 

PUBLIC HEALTH EMERGENCIES
A Message from the Office of the Assistant Secretary for Public Affairs

U.S. Department of Health and Human Services

The U.S. Department of Health and Human Services (HHS) created this guide to provide

information for media professionals throughout the nation. An abbreviated version of the most

essential information from this guide is available in “Terrorism and Other Public Health

Emergencies: A Field Guide for Media,” a compact guide designed to fit in a glove compartment,

briefcase, or purse.

Both publications are available online at http://www.hhs.gov/emergency. The Office of the

Assistant Secretary for Public Affairs at HHS will keep the online versions updated with new

information on agents, treatments, new learning, and any evolutions in the organization of public

health emergency response. We urge you to refer to the Web versions for the latest information.

You can order a copy of this guide or the field guide by calling (240) 629-3161 or online at

http://www.hhs.gov/emergency. If you have any questions or comments about the guide itself,

please contact the HHS Public Affairs Office at (202) 690-6343.

Please note: All Web sites were checked and available during the final editing (September 2005) of this manual.
OFFICE OF THE ASSISTANT SECRETARY FOR PUBLIC AFFAIRS

U.S. Department of Health and Human Services • Washington, D.C.

http://www.hhs.gov/emergency September 2005

A Reference Guide for Media

TERRORISM AND OTHER 

PUBLIC HEALTH EMERGENCIES
ii Terrorism and Other Public Health Emergencies: A Reference Guide for Media

ACKNOWLEDGMENTS

This guide was produced by the Office of the Assistant Secretary for Public Affairs and the Office of Public Health

Emergency Preparedness at the U.S. Department of Health and Human Services (HHS) with the support of the American

Institutes for Research.

The following agencies, organizations, and individuals provided expert guidance and review for this guide.

Federal Government Agencies

U.S. Department of Health and Human Services

> Centers for Disease Control and Prevention

> Food and Drug Administration

> Health Resources and Services Administration

> National Institutes of Health

> Substance Abuse and Mental Health Services Administration

U.S. Department of Agriculture

U.S. Department of Energy

U.S. Department of Homeland Security

U.S. Environmental Protection Agency

Nuclear Regulatory Commission

Additional Contributors and Reviewers

American Institutes for Research, Health Program, Washington, DC; Silver Spring, MD; Frederick, MD; Chapel Hill, NC; 

and Atlanta, GA

Center for Emergency Preparedness, The George Washington University Medical Center, Washington, DC

Vincent Covello, Ph.D., Center for Risk Communication, New York, NY

D.A. Henderson, M.D., M.P.H., The Center for Biosecurity, University of Pittsburgh Medical Center, Baltimore, MD

Gerard A. Jacobs, Ph.D., Disaster Mental Health Institute, The University of South Dakota, Vermillion, SD

National Public Health Information Coalition, Marietta, GA

David Ropeik, M.S., Harvard Center for Risk Analysis, Harvard School of Public Health, Boston, MA

Peter Sandman, Ph.D., Risk Communication Consultant, Princeton, NJ

Tim Tinker, Dr.P.H., M.P.H., Widmeyer Communications, Washington, DC

Virginia Department of Health, Office of Epidemiology, Richmond, VA

HHS also wishes to thank the professional media organizations that provided initial analysis of the concept for this guide

as well as several independent reviewers whose knowledge of journalism, the media, health care, science, government,

and ethics was an important source of insight into the information this guide should provide.
U.S. Department of Health and Human Services iii

CONTENTS

01 INTRODUCTION 1

02 PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH 5

03 BIOLOGICAL AGENTS 39

04 CHEMICAL AGENTS 95

05 RADIATION EMERGENCIES 115

06 TERRORISM AND THE FOOD SUPPLY 127

07 ENVIRONMENTAL SAFETY AND TESTING 135

08 THE ROLE OF THE FEDERAL GOVERNMENT 141

09 SELF-CARE FOR MEDIA 157

10 RANGE OF PUBLIC REACTIONS 169

11 RISK COMMUNICATIONS DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY 183

12 HISTORY OF BIOLOGICAL, CHEMICAL, AND RADIATION EMERGENCIES 195

13 MEDIA CONTACTS 205

APPENDICES 223

INDEX 253

Appendix A. Acronyms 224

Appendix B. Selected Web Sites 226

Appendix C.Epidemiology Glossary 232

Appendix D. Descriptions of Selected Sections of Acts Related to Public Health Emergencies 234

Appendix E. Family Disaster Planning—Five Steps to Safety 239

Appendix F. Disaster Supplies Kit 241

Appendix G.Personal Workplace Disaster Supplies Kit 243

Appendix H. Self-Monitoring Checklist 245

Appendix I. Reducing Stress and Renewing Energy 246

Appendix J. Helping Children and Adolescents Cope with Violence and Disasters 247

v

The information in this guide is a result of the best knowledge available at the

time of publication. In the sections describing terrorist agents, an effort has

been made to identify issues that are not yet understood or where disagreement

exists among experts. We urge you to refer to the Web version of this guide at

http://www.hhs.gov/emergency for the latest information.

01INTRODUCTION
INTRODUCTION

2 01. INTRODUCTION Terrorism and Other Public Health Emergencies: A Reference Guide for Media

his guide is for the people who write the words, who

take the pictures, and who tell the stories about the

events in our world—both ordinary and extraordinary.

It is intended to provide information about how the public

health system is preparing for and will respond to previously

unthinkable events, such as September 11. More specifically,

the guide’s intent is to offer the best possible information about

the worst-case scenarios.

The efforts of public health agencies at the federal, state, and

local levels to prepare for what could happen in the future are

largely invisible until there is an emerging threat, such as the

recent SARS outbreak, or a dramatic event, such as the

anthrax attacks of 2001. Through this effort, the U.S.

Department of Health and Human Services (HHS) intends to

provide the best available and most essential up-to-date

health-related facts and background information that will be

needed in the event of a terrorist attack or public health 

emergency. In addition, HHS hopes to reveal the commitment

and often hidden complexity of the public health domain to

news people who live in the world of here and now. The goal

of this guide is not to tell you how to report or what to think

but to serve as a resource at the time of an event and 

to provide guidance about what may be some of the most

important stories ever written.

As ambitious as this enterprise is, it has limits. No one volume

can contain everything the media need to know about reporting

on terrorism and public health emergencies. While this guide

is the product of some of the best available expertise inside

and, in some cases, outside of the government, no one would

claim this is the final word on the subject. It is a work in

progress and will be updated online as new information

becomes available.

Some may look at this volume skeptically as the product 

of a government agency with an agenda or a bureaucratic

mindset. Others may view this guide for reporting on possible

apocalyptic events as advancing a kind of doomsday mentality.

The intention is neither.

The intention is to meet the need for credible source material

on terrorism and other very real public health threats. 

The reports and images that would shape people’s view of 

a possible terror attack or other health crisis would have an

extraordinary impact not only on the readers, listeners, and

viewers but also the writers of those stories. The burden is

great for those who follow, or in some cases lead, first

responders into the unknown and are then asked to emerge

calmly with the facts.

While there is a difference between the roles of the public health

professional and the journalist, there are also similarities.

Both face dangers, both seek the truth, and both see 

communication as a primary goal. However, the intent here is

not to merge these two disciplines or even suggest that one

serve as a conduit for the other. Often, the media and government

are adversaries due to the nature of their functions in society.

Yet, the hope is that this guide will help to foster transparency

and understanding between government health officials and

journalists and to build a bridge that many will need to cross,

if the time comes.

This tool will be most useful in the early phase of a terrorism

event or major public health emergency but also has relevance

for other public health events, such as disease outbreaks. It is

not meant to supplant other works from either private or 

governmental sources but rather, to provide a different and

complementary perspective. What is different here is that this

guide assembles a wide variety of resources and filters them

through the lens of public health action immediately following

a major public health event. In addition to collecting extensive

background information on possible terror weapons and

agents, there is source material on how public health agencies

and professionals function in an emergency.

There is also a chapter on the risk communication approach

used by many public health officials. Communicating risk in

the most responsible and accurate way during an emergency

will be an ongoing challenge for the government—and the media.

Here, the media and public health officials share the same goal—

quickly providing the public with accurate information.

Achieving this goal is critical to saving lives.

T
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 3

More than a year in the making, this guide has been extensively

reviewed for accuracy by government scientists and experts in

HHS and other federal agencies. Factually, the book represents

the best current understanding of the problems as seen 

by HHS. In addition, several veteran journalists provided their

insights and comments about what worked and what didn’t in

the guide from a media perspective. Their input has been

incorporated and responded to whenever possible.

Some of the key topics addressed in this work are:

> Information about the most likely biological, chemical, 

and radiological weapons that could be used by terrorists. 

> Unanswered questions and conflicting opinions about certain

terrorist agents.

> The emotional impact of disaster on the public and how that

is likely to affect people’s reactions.

> How public health does its job in an emergency. For example,

how does a disease detective track down the cause of an 

outbreak? When can quarantine be declared? 

> What are the emotional consequences for journalists who

spend a sustained period of time covering a disaster? What

can be done to help reporters shield themselves from stress

and other dangers that can affect their lives and their work?

This guide was written to be a helpful companion that can help

inform your best work while trying to keep you safe. In every

page of this book, there is that hope and that commitment.

REFERENCE

Sesno, F. (2004, September). Covering terrorism: 

New challenges in a new era. Testimony before the 

House Select Committee on Homeland Security.

Some say that this ‘new normal’ requires a new arrangement. They say the news media and government should pursue a

‘partnership’ to get the job done. That is neither practical nor wise. And it won’t happen. The news media have a job to do

that requires them to stand aside. They should inform. They should investigate. They should hold responsible officials to

account. To do this they must remain independent from those they cover, even against the grim backdrop of terrorism.

That is not to say, however, that there are not common interests and even common responsibilities.

Frank Sesno, university professor of public policy and communication at 

George Mason University and former Washington, D.C. bureau chief for CNN

Testimony before the House Select Committee on Homeland Security, September 2004

“

JOURNALISTS AND GOVERNMENT OFFICIALS BOTH SERVE THE PUBLIC.

BOTH NEED TO BE SURE THE INFORMATION THEY DISSEMINATE IS ACCURATE,

CREDIBLE, TIMELY, AND RELEVANT. BOTH MUST KNOW THAT THEY WILL PAY A

PRICE IF THEY FAIL TO DO THEIR JOBS WELL.

“
02Preparation and Response in Public Health PLANNING FOR THE UNTHINKABLE:
PLANNING FOR THE UNTHINKABLE:

Preparation and Response in Public Health

6 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

housands of public health professionals work to

promote health and prevent disease and disability

across the nation in every community every day.

Although this guide primarily focuses on the federal public

health response to terrorism and other public health

emergencies, understanding how public health works at the

local and state levels is critical to understanding how a public

health response to an emergency event will take place in a

given community.

The backbone of the nation’s public health system is at the

local (typically county, township, or city) level. Providing 

low-cost health care services in communities is what many

people think of when they hear the term “public health,” 

but those services are only a small fraction of public health

activities. Public health also includes the following functions,

many of which are relevant to a public health emergency:

> Preventing and controlling epidemics and the spread of 

disease

> Protecting against environmental hazards

> Preventing injuries and disabilities

> Promoting and encouraging healthy behaviors (e.g., exercise,

good nutrition) and mental health

> Responding to disasters and assisting communities in

recovery

> Assuring the quality and accessibility of health services

> Ensuring safe and effective medical products

> Ensuring the safety of food, blood, and biologics (vaccines)

(Harrell & Baker 2004)

In a terrorist attack, epidemic, natural disaster, or major 

accident, state and federal public officials provide help, 

but local public health is in the forefront during the first critical

minutes and hours after a major incident has occurred. 

In addition, even after federal assistance arrives, the public

health response will be implemented and managed locally. 

For example, decisions about where a mass vaccination 

clinic should be held would be made by local health officials.

While many health departments were preparing for handling a

major incident in their communities before September 11, the

tragic events of that day focused new attention and resources

on emergency preparedness and response.

This guide does not go into detail about how local and state

health departments will function in a public health emergency

because every state and locality does things differently.

Although all public health departments share similar functions

and a philosophy about serving the public, the federal

government does not mandate how state and local health

departments are structured. All states have a state health

department, but the exact services that are offered and 

how they are administered vary greatly across the country. For

example, in South Carolina, the state agency is centralized and

the state provides services in each of the state’s 46 counties,

whereas in Idaho, local public health districts are completely

independent from the state health department.

These differences allow states and localities to focus 

specifically on the needs of their citizens in a way that makes

sense for them. For example, the needs of people in New York

City—a densely packed urban community where residents

DEFEATING DISEASES: THE CASES OF SMALLPOX AND POLIO

For many centuries, smallpox was a feared disease that killed many.

In 1796, Edward Jenner conducted the first successful smallpox 

“vaccination” with cowpox virus, a virus related to smallpox. Through

vaccination, particularly through the successful technique of “ring

vaccination” (described later in this section), smallpox was controlled.

Vaccine development techniques improved over the years and by the

1940s, a stable, freeze-dried vaccine was perfected and used

throughout the world. The last case of smallpox in the United States

was in 1949, and the last case in the world was in Somalia in 1977. 

In 1980, the disease was considered eradicated—the first time that

mankind had successfully eliminated a disease.

Polio was one of the most feared childhood diseases of the early- to

mid-20th century. The first polio outbreak occurred in 1916 and

resulted in more than 27,000 reported cases and 7,000 deaths. 

The disease peaked in 1952, with about 60,000 new cases and 3,000

deaths. The polio epidemic effectively ended in 1955 with the

introduction of the Salk vaccine. The incidence of polio decreased by

85–90 percent between 1955 and 1957. With the introduction of a

second vaccine that had been developed by Albert Sabin, by 1962, the 

incidence of polio had declined by 95 percent and was effectively

eradicated in the Americas.

T
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 7

speak scores of different languages—will vary greatly from 

the needs of people in a mostly rural state, like South Dakota.

How these places structure their service delivery will be

understandably different. Therefore, in order to understand

how immediate response to an emergency will occur in a given

community, one must know how the local health department

functions in that area.

The main goal of the remainder of this section is to provide an

overview of how federal government public health agencies

would function in an emergency and, when applicable, how

their actions would relate to those of state and local

governments and to the private medical system. This section

appears in the beginning of this guide to provide a framework

and context that are critical to understanding the “big picture”

as well as many of the programs and processes discussed later

in this guide. For example, in order to understand how 

a smallpox attack could unfold, the “Biological Agents” section

is a key resource, but it is also important to understand how a

smallpox attack would be discovered, how it would be

reported, how it might be contained, and how vaccines would

be delivered to communities. These are the kinds of issues

discussed in this section. Some of the specific topics covered

here include:

> Syndromic surveillance systems

> The role of epidemiology

> Laboratory testing 

> Information sharing in public health

> Strategic National Stockpile

> Vaccination strategies

> Isolation and quarantine

> National Disaster Medical System

> The threats of emerging infectious diseases and influenza

pandemics

THE IMPACT OF PUBLIC HEALTH

During the 20th century, the lifespan of the average American increased

by more than 30 years. Much of this increase can be attributed to

improvements in public health. In 1999, the U.S. Department of Health

and Human Services’ (HHS) Centers for Disease Control and Prevention

(CDC) compiled the following list of the 10 greatest public health

achievements of the 20th century (not in order of importance):

> Vaccination—Vaccine use assisted in the eradication of smallpox

worldwide and the elimination of polio in the Americas

> Motor-vehicle safety—Engineering advances and changes in

behaviors, such as the use of seatbelts and child safety seats, have

reduced death and injury rates

> Safer workplaces—Changes have reduced injuries and deaths related

to many industries, such as mining, manufacturing, and construction

> Prevention and control of infectious diseases—Improved sanitation

has reduced cholera and typhoid, while the advent of antibiotics has

helped to combat tuberculosis and other diseases

> Decline in deaths from coronary heart disease and stroke—

Decreases in smoking and better blood pressure control have

reduced death rates from coronary heart disease and stroke

> Safer and healthier foods—Decreases in food contamination and

fortification of foods with nutrients to protect against rickets, 

goiters, and other diseases have resulted in fewer deaths and 

illnesses related to food and nutrition

> Healthier mothers and their babies—Better hygiene and nutrition,

antibiotics, and technological advances have reduced death and illness

> Family planning—Access to family planning and contraceptives has

resulted in fewer maternal and child deaths

> Fluoridation of drinking water—Addition of fluoride to water has

resulted in less tooth decay

> Recognition of tobacco use as a health hazard—Understanding the

risks of smoking has led many smokers to stop, which has reduced

deaths from smoking

UNDERSTANDING HOW PUBLIC HEALTH WORKS

at the local and state levels is critical to understanding how a public health

response to an emergency event will take place in a given community.
8 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

ACRONYM LIST

ATSDR Agency of Toxic Substances and Disease Registry

BSL Biosafety Level

CDC Centers for Disease Control and Prevention

DHS U.S. Department of Homeland Security

Epi-X Epidemic Intelligence Exchange

FBI Federal Bureau of Investigation

HAN Health Alert Network

HHS U.S. Department of Health and Human Services

LRN Laboratory Response Network

NDMS National Disaster Medical System

NEDSS National Electronic Disease Surveillance System

NIAID National Institute of Allergy and Infectious Diseases

NIH National Institutes of Health

RRR Rapid Response Registry

SNS Strategic National Stockpile; formerly NPS

WHO World Health Organization

You may find it helpful to refer to the following list of acronyms as you read this section.

PUBLIC HEALTH RESPONSE TO TERRORISM

After the September 11 and anthrax attacks in 2001,

strengthening the public health infrastructure, particularly in

relation to terrorism, became a heightened national priority. In

the past several years, HHS and the U.S. Department of

Homeland Security (DHS) have substantially increased funding

(primarily to local and state governments) to build capacity 

to prepare for and respond to future terrorism events and/or

other potential public health emergencies (e.g., a SARS or

major influenza epidemic).

The remainder of this section will be organized by three stages

that are typical of any public health response to a healthrelated emergency, including one caused by terrorist activity:

> Detection

> Response

> Containment

DETECTION

It is likely that the initial recognition of a possible terrorism

incident will be at the local level. Incidents may be:

> Overt or immediately obvious (e.g., a bomb, an envelope

containing a suspicious powder along with a message 

saying the powder is a deadly substance)

> Covert or quietly conducted without an obvious beginning (e.g.,

transmitting a disease, like smallpox, to people without any

distinct signals)

How each type of attack would unfold is quite different. 

An overt attack would be obvious and would immediately be

responded to by local, state, and national law enforcement and

public health officials. A covert attack would unfold more

slowly and be harder to identify. It could be hours or days

before officials would have any indication of the need for a

response to such an attack.

Keeping Track of the Status of the Nation’s Health

Domestic Systems

A covert attack is likely to be identified by the routine

monitoring and analysis of data, called syndromic surveillance,

on disease patterns and deaths that are performed in the

public health and medical communities. As a result of

concerns over the increased threat of terrorism and an increase

in the use of electronic health information programs, health

professionals can track and analyze data more easily and more

quickly than ever before. The rapid availability of data

increases the ability of public health officials to identify a largescale terror attack in its early stages. For example, in late

2001, the New York City Department of Health and Mental

Hygiene established a syndromic surveillance system to monitor
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 9

emergency room visits. Symptoms, such as respiratory difficulties,

fever, diarrhea, and vomiting, are tracked and information is

transmitted electronically to the health department daily to be

analyzed for unusual patterns that would warrant further

investigation (Heffernan et al. 2004).

CDC and individual states have numerous surveillance policies

and networks, some of which are fairly broad in scope and

others which are focused on the tracking of specific diseases.

Reporting at the local health department level is often 

electronic but is still done via paper forms in some places.

Although data are entered into electronic systems, the transfer

of the data is not always seamless or in real time. To address

this issue, CDC is in the process of developing the National

Electronic Disease Surveillance System (NEDSS) (http://www.

cdc.gov/nedss/index.htm). NEDSS will create standards for the

collection, management, transmission, analysis, access, and

dissemination of data. The goal is to get data as close to real

time as possible. Several pilot versions of NEDSS have been

completed and are being used in some states, but the system

is not yet fully operational.

CDC believes that NEDSS will offer significant improvements

in the way public health surveillance is conducted at the local,

state, and federal levels. The long-term vision for NEDSS is

that of complementary Internet-based electronic information

systems that:

> Gather health data automatically from a variety of sources on

a real-time basis

> Facilitate the monitoring of the health of communities

> Assist in the ongoing analysis of trends and detection of

emerging public health concerns

> Provide information for setting public policy

The data fed into the local systems are often the result of alert

health care professionals. The following types of professionals

may notice unusual disease patterns and deaths that will

require further investigation:

> Doctors, nurses, and others working in health care institutions

and clinics

> Veterinarians and animal control personnel

> Medical examiners

> Pharmacists

> Laboratory scientists

> Epidemiologists

When health care professionals see atypical diseases, unusual

patterns of diseases (e.g., large numbers of cases of disease

not commonly seen in that part of the nation), larger than

normal death rates from a disease, unusual rises or patterns in

purchases of drugs, or uncommon test results, they contact

FIGURE 2–1: FLOW OF INFORMATION

Local health care

professionals and

veterinarians

Local health department State health department HHS/CDC
10 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

local public health officials. These officials

will start investigating and may contact

state and federal officials, as well as law

enforcement, depending on the situation.

Figure 2–1 illustrates how information flows

from individual health care professionals

through the system to local, state, and

federal officials.

For example, in August of 1999, an

infectious disease specialist contacted the

New York City Department of Health

about two patients with encephalitis in

Queens. Preliminary investigations at

nearby hospitals identified six additional

cases. After talking to the patients’ 

families, it became clear that all of the

patients had participated in outdoor

activities around their homes in the

evenings, such as gardening. Mosquito

breeding sites and larvae were also found

in their area. Medical professionals

believed at first that the disease was St.

Louis encephalitis. However, 4 weeks

after the outbreak in humans, a flavivirus,

later identified as West Nile virus, was

isolated from specimens from crows and

a flamingo nearby and was determined to

be the source of the outbreak for both

animals and humans. These were the first

cases of West Nile virus ever seen in the

Western Hemisphere (Nash et al. 2001).

Another example, with a different

outcome, occurred in the winter of 2003

when a state medical examiner in Virginia

noticed an unusual pattern of childhood

(ages 2–7) deaths over a short time

period from what appeared to be a flu-like

illness in one region of the state. 

This observation prompted a full-scale

investigation to quickly identify the exact

cause of the deaths and determine if all of

the children died of the same cause. 

In the end, health officials learned that the

children had died of a variety of causes,

including the flu, and although the deaths

had occurred in a short timeframe, the

total number of deaths was not unusual

for a given flu season (Commonwealth of

Virginia Department of Health 2003).

BioSense

Late in 2003, CDC began operating a

high-tech bioterrorism detection program,

known as BioSense. BioSense monitors

and rapidly picks up on any possible

health emergencies by constantly

scanning medical information from

hospital emergency rooms and pharmacies

(http://www.syndromic.org/pdf/work3

-JL-BioSense.pdf). BioSense also scans

environmental data from Project

BioWatch, which is described in detail

in the “Environmental Safety and

Testing” (see p. 135).

BioSense monitors enormous databases

to find groups of common symptoms,

such as fever, rash, diarrhea, and nausea.

The system can assess whether there are

any sudden increases in the number of

visits to emergency rooms or whether

there are sharp increases of prescription

and over-the-counter medication

purchases in any given location. By

comparing these increases with the

normal number of visits and medication

purchases, analysts can determine

whether there might be a cluster of

symptoms or an unusual pattern of

symptoms that could signal a terrorist

attack or other unusual public health

problem that could be brewing (e.g.,

SARS). Eventually, BioSense will expand

to include information from ambulance

dispatches, clinics, doctors’ offices,

school-based clinics, and worksites.

BioSense scans data from hospitals, pharmacies,

and BioWatch for:

• Common symptoms

• Increased medical visits

• Increased drug purchases

FIGURE 2–2: HOW BIOSENSE WORKS

1.

BioSense identifies clusters or patterns of 

suspicious activity that could signal a possible

emergency.

2.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 11

International Systems

In our modern world, where international travel is common

and rapid, a disease can spread around the globe very quickly.

On an international level, the World Health Organization (WHO)

has developed and monitored International Health Regulations

(with origins in the mid-19th century) to help prevent

epidemics from spreading worldwide. The regulations are

being revised to address bioterrorism as well as chemical and

radiological threats.

In 1997, WHO established a mechanism to identify, verify,

and respond to public health emergencies that may be of

international concern, working closely with government 

agencies and other partners throughout the world. Reports of

current outbreaks that are thought to have international

significance are included in a weekly e-mail service that is

distributed to public health professionals and partners

worldwide. This information is also available to the public on

the Internet at http://www.who.int/csr/don/en.

In 2000, WHO also created the Global Outbreak Alert and

Response Network to help its member states better identify

and manage outbreaks that are unintentional as well as

intentional. The network is a collaboration of 120 international

partners, including scientific institutions, laboratories, United

Nations organizations, and humanitarian organizations as well

as many others. The main goals of the network are to:

> Combat the international spread of outbreaks

> Ensure that appropriate technical assistance reaches affected

areas rapidly

> Contribute to long-term epidemic preparedness and capacity

building

In 2004, the Global Public Health Information Network, an

electronic surveillance system developed and maintained by

Health Canada for WHO, was expanded and enhanced. The

system uses powerful search engines to actively trawl the

World Wide Web looking for reports of communicable diseases

in electronic discussion groups, on news wires, and elsewhere

on the Web. The system also disseminates preliminary reports

on public health threats on a “real-time, 24/7” basis. The

Global Public Health Information Network now provides early

warning in all official United Nations languages—Arabic,

Chinese, English, French, Russian, and Spanish—allowing for

speedier screening and sharing of information on both natural

and manmade threats.

Additionally in 2004, WHO’s Strategic Health Operations Center

(SHOC) opened. SHOC features a communications system that

allows the staff to closely monitor international public health

response activities around the world. SHOC health experts,

technical advisors, and logistics planners watch and assist their

colleagues on the ground as they deal with crises ranging from

SARS or Ebola outbreaks to tropical storms and tsunamis.

More information on the role of the WHO in international 

surveillance, preparedness, and response can be found at

WHO’s Communicable Disease Surveillance and Response

program Web site (http://www.who.int/csr/en).

The Role of Epidemiology

This section provides an overview of the role of epidemiology,

or disease investigation, in a public health emergency. The

science of epidemiology is quite complex and epidemiologists

often use highly technical language to explain their findings.

Epidemiologists at the local, state, and federal levels conduct

investigations of suspected or confirmed disease or injury

outbreaks. In some cases, an epidemiologist may even be the

person who spots the outbreak by noticing unusual patterns 

for a disease in routine surveillance data (as described

previously). Once a problem is identified through surveillance,

epidemiologists will launch a more comprehensive investigation.

Their findings are used to determine the source of an illness and

make recommendations to guide public health intervention.

Steps for Investigating an Outbreak

Epidemiological investigations evolve through three phases:

the preliminary phase, the analytic study phase, and the control

and followup phase. Epidemiologists complete several steps

within each of these phases to help them systematically 

collect information, test hypotheses, and communicate findings.

Although these steps often occur simultaneously, they may be

repeated as new information becomes available. The entire

A glossary of some commonly used epidemiology terms is included in appendix C of this

guide as a reference.
12 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

investigation process is methodical but

also needs to be rapid and responsive to

stop the spread of the disease and treat

those affected as soon as possible.

Preliminary Phase

> Work with lab data and disease tracking

data to confirm the outbreak.

> Research the symptoms, causes, and

routes of transmission of the disease.

> Assemble a multidisciplinary investigation

team that includes experts in clinical

medicine, environmental health,

microbiology, behavioral science, and

health education.

> Define what a case of the disease

looks like so that cases can be

accurately identified.

> Investigate medical records and

conduct patient interviews to identify

related cases.

> Summarize collected data by time,

person, and place and tabulate.

> Take immediate control measures if an

obvious source of illness is identified.

Analytic Study Phase

> Develop hypotheses about the cause

of the outbreak, based on knowledge

about the microbiology of a disease,

background research, and patient

interviews.

> Test hypotheses analytically with

existing data.

Outbreak Control and Followup Phase

> Implement prevention and control

measures to stop additional outbreaks

by collaborating with government,

industry, and health officials.

> Prepare health promotion messages

for the public.

> Select a spokesperson to share health

promotion messages with the media.

> Evaluate the short- and long-term

effects of the investigation.

> Prepare a detailed summary of the

investigation and recommendations

for participants (FOCUS Workgroup

2003).

Interviewing and Contact Tracing

One of the key methods used to

investigate an outbreak is the interviewing

of patients. These interviews provide

epidemiologists with some of the data

needed to map the spread of an outbreak

(i.e., where it came from and where it

might be going). For example, by talking

to patients, epidemiologists may learn

that all of the patients attended the same

event, which provides clues about how

the outbreak started. Interviews may

allow the epidemiologists to determine

the index case (the first known case),

which may be critical to determining the

origin of the outbreak. Epidemiologists

also use interviews to identify the close

contacts of each patient (called contact

tracing). Close contacts are those people

who spend a lot of time in close, physical

proximity to the patient (e.g., family

members, office mates, significant others).

In the case of a contagious disease, these

people must be found and treated or

isolated to prevent the spread of the

illness.

Possible Indications of a

Bioterrorism Event

Health professionals, including

epidemiologists, will use the same

methods to investigate a bioterror event

that they would use to investigate any

other outbreak. In many cases today,

bioterrorism may be considered as the

possible cause of an outbreak unless

THE BASIC STEPS OF AN OUTBREAK

INVESTIGATION

1. Verify the diagnosis and confirm the

outbreak.

2. Define a case and search for cases.

3. Tabulate and orient data: time, place,

person.

4. Take immediate control measures.

5. Formulate and test hypotheses for the

cause of the outbreak.

6. Plan and execute additional studies, 

as needed.

7. Implement and evaluate control measures.

8. Communicate findings.

EPIDEMIOLOGY IS THE STUDY OF PATTERNS OF DISEASE: “

who has the disease, how much disease they have, and why they have it.

Daniel Wartenberg, “Epidemiology for Journalists”

“
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 13

proven otherwise. In some cases, an

attack may be suspected either because

there is evidence of the agent (e.g.,

anthrax powder) or because of

intelligence or claims of responsibility.

In less obvious cases, there are also a

few characteristics (see box on the right

side of this page) that may indicate that

an outbreak is intentional, particularly if

several of these characteristics are true

of the outbreak.

Even though these characteristics may

point to bioterrorism, many of them

may also be true in new and emerging

naturally caused infectious diseases,

like SARS or West Nile virus. Over the

past 30 years, CDC has been involved

in the discovery of many emerging

naturally occurring infectious diseases

that have the characteristics described

here. For example, in 1993, there was

an outbreak of Hantavirus Pulmonary

Syndrome in the Southwestern United

States. This severe pneumonia of

unknown origin, which affected healthy

adults, had never been seen in the

United States before, which made 

the outbreak suspicious. Outbreaks of

avian flu—bird flu not previously seen in

humans—in China since 1997 are also

examples of unusual but naturally

occurring outbreaks. (More information

on avian flu and animal diseases that

may affect humans can be found at the

end of this section.) Therefore, although

the question of “Is it bioterrorism?” is

likely to be asked in unusual situations,

public officials will be careful not to

prematurely assume that bioterrorism is

the cause of an outbreak (Reynolds

2002).

CHARACTERISTICS OF OUTBREAKS

THAT MAY INDICATE POSSIBLE

BIOTERRORISM

> A large number of cases appearing at the

same time, particularly in a discrete

population (e.g., people from the same

town, people who attended the same event)

> A large number of cases of a rare disease

or one considered a bioterrorism threat

(e.g., plague, tularemia)

> More severe cases than typical for a

given disease and/or an unusual route of

exposure

> A disease that is unusual in a given place

or is out of season (e.g., a flu outbreak in

the summer in the United States)

> Multiple simultaneous outbreaks of the

same disease or different diseases

> A disease that affects animals as well as

humans

> Unusual disease strains or uncommon

antibiotic resistance to an organism

RESPONSE

Laboratory Testing

Once a potential attack is identified, the

public health response will immediately

begin. Law enforcement, the Federal

Bureau of Investigation (FBI), and local

and state health and emergency officials

will typically work together to determine

if a suspicious outbreak is related to

terrorism. Law enforcement and forensic

scientists may actually begin work at

any stage of the public health process,

depending on the situation. If possible,

the FBI will arrange for samples of the

agent to be sent to a special laboratory

for testing. It is likely that this lab would

be a local or state lab that is a part of

the national Laboratory Response

Network (LRN), which is described in

detail later in this section.

A positive result from an initial

screening test, however, does not

provide confirmation. Initial field testing

(onsite) is considered presumptive,

which means that additional tests must

be performed to confirm the original test

result (CDC 2004b). If a specific agent is

suspected, tests may also be used that

are specific to that agent (if any exist).

For example, if anthrax is suspected,

nasal swabbing may be done on people

who were present in the environment

where the suspected anthrax release took

place. (However, it is important to note

that nasal swabs are not used for

diagnostic purposes; rather, they may

provide information on whether a given

environment has been contaminated.

They do not indicate who will get anthrax

illness.) If a chemical agent is suspected,

blood or urine samples can be collected

from people with suspected exposures.

Although initial positive test results may

begin the process of emergency and public

health response (e.g., determining who

may have been exposed, deciding who

will need treatment), it can take up to a

few days in some cases to confirm

which agent is at work. Some of the

time is needed to make sure that

samples are collected properly and

transported to labs with the ability to do

the needed testing. More detailed

information on diagnostic testing for

specific biological agents can be found

in the “Biological Agents” section (see

p. 39).
14 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Laboratory Response Network

To make it easier for laboratories across the country to work

together in the case of an act of terrorism or other public

health emergency and to facilitate rapid identification of a

bioterrorism agent, CDC, the Association of Public Health

Laboratories (http://www.aphl.org), and the FBI formed the

Laboratory Response Network (LRN) in 1999 (http://www.bt.cdc.

gov/lrn/pdf/lrnfactsheet.pdf). The LRN currently has two major

components: a well-developed network of public health

laboratories dealing with biological agents and a newer

network of public health laboratories dealing with chemical

agents.

Bio-LRN

The Bio-LRN is a network of about 120 labs in all 50 states

that include local, state, and federal public health labs as well

as international, veterinary diagnostic, military, and other

specialized labs that test environmental samples, animals, and

food. The network is made up of three levels of labs that handle

progressively more complex testing:

Sentinel Labs

> Private and hospital labs that routinely process patient tests.

> May be the labs to first test and/or recognize a suspicious

organism.

> Conduct tests to “rule out” less harmful organisms.

> Refer samples to a reference lab, if they cannot rule out that

the sample is a bioterror agent.

Reference Labs

> Have specialized equipment and trained personnel.

> Perform tests to detect and confirm the presence of a bioterror

agent.

> Are capable of producing conclusive, confirmatory results.

> Include local, state, and federal labs.

National Labs

> Include CDC, the U.S. Army Medical Research Institute for

Infectious Diseases in Maryland, and the Naval Medical

Research Center, also in Maryland.

> Perform highly specialized testing to identify specific disease

strains and other characteristics of an investigated agent.

> Test certain highly infectious agents that require special

handling.

The Bio-LRN has been involved in a number of major testing

operations since it was established in 1999. In the 2001

anthrax attacks, Bio-LRN labs tested more than 125,000

samples by the time the investigation was completed. Bio-LRN

labs are also involved in BioWatch, a program in selected

American cities that uses air samplers to test for bioterrorism

agents. (More information on BioWatch can be found in the

“Environmental Safety and Testing” section [see p. 135].) BioLRN labs were also involved in developing tests and materials

to support the DNA sequencing of the SARS virus, which was

identified at the CDC (CDC 2004a).

Source: Association of Public Health Laboratories. (2003). State public health laboratory bioterrorism

capacity. Public health laboratory issues in brief: Bioterrorism capacity, 1–6.

http://www.aphl.org/programs/emergency_preparedness/files/BT_Brief_2003--

corrected.pdf.

definitive characterization

confirmatory testing

recognize, 

rule-out, refer

FIGURE 2–3: THE BIO-LRN
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 15

BSL-1 LABS

These labs are used to study agents not known to consistently cause 

disease in healthy adults (e.g., E. coli). Researchers follow basic safety

procedures and require no special equipment or design features.

BSL-2 LABS

These labs are used to study agents that pose a danger if accidentally

inhaled, swallowed, or exposed to the skin (e.g., plague). However,

diseases related to these agents can be treated through available

antibiotics or prevented through immunization. Safety measures include

the use of gloves, eyewear, and lab coats as well as hand washing sinks,

methods of waste decontamination, and safety equipment.

BSL-3 LABS

These labs are used to study agents that can be transmitted through the air

and cause potentially lethal infection (e.g., West Nile virus). Researchers

perform lab manipulations in a gas-tight enclosure. Other safety features

include personal protective equipment, clothing decontamination, sealed

windows, and specialized ventilation systems.

BSL-4 LABS

These labs are used to study agents that pose a high risk of life-threatening

disease for which no vaccine or therapy is available (e.g., Ebola). Lab

personnel are required to wear full-body, air-supplied suits and to shower

when exiting the facility. The labs incorporate all BSL-2 and BSL-3 features. In

addition, BSL-4 laboratories are negative-pressure rooms that are completely

sealed and isolated to prevent release of viable agents into the environment

(National Institute of Allergy and Infectious Diseases 2004a; Richmond 2000).

All labs participating in the Bio-LRN are BSL-3 or BSL-4 labs.

Chem-LRN

The Chem-LRN is a network of 61 laboratories in all states

and some territories and municipalities that test for chemical

agents in human samples, such as urine or blood. The ChemLRN member laboratories have three levels of activities. Each

level builds on the activities of the preceding level.

> Every network member participates in Level 1 activities.

These Level 1 laboratories work with hospitals in their

jurisdiction and maintain competency in clinical specimen 

collection, storage, and shipment.

> Forty-one laboratories also participate in Level 2 activities,

meaning that the laboratories are trained to detect exposure

to a limited number of toxic chemical agents.

> Five laboratories participate in Level 3 activities. These

laboratories are able to detect exposure to an expanded

number of chemicals, including those analyzed by Level 2

laboratories, as well as analyses for mustard agents, nerve

agents, and ricin.

Responding to an Event

> At the onset of an event, a state may request CDC’s 

assistance. CDC may then deploy a Rapid Response Team to

the affected state to assist with specimen collection,

packaging, storage, and shipment.

> Representative samples from people who are suspected to be

highly exposed, moderately exposed, and those thought to

have low exposure are sent to CDC for analysis through the

Rapid Toxic Screen, which can analyze people’s blood or

urine for a large number of chemical agents likely to be used

by terrorists.

> Data produced from the Rapid Toxic Screen and the health

implications associated with those exposures will be

communicated in a secure, electronic manner to the affected

state.

> Hospitals and laboratories may be dealing with many people

concerned about exposure. There will be a need to respond to

these concerns and determine whether an individual has been

exposed and at what level. CDC will contact the appropriate

LRN labs to help participate in the response.

Biosafety Level Classifications

All labs in the United States are rated according to a biosafety

level (BSL) classification system. Levels range from 1 to 4.

Biosafety levels are used to determine the types of agents 

scientists can work with in their labs. Scientists use a

combination of critical principles, practices, and safety devices

to work with infectious materials safely and effectively. Biosafety

level classifications are designed not only to protect researchers

and technicians from laboratory-acquired infection but also to

prevent microorganisms from entering the environment. 

Many microorganisms may be studied at more than one level,

depending on what kinds of activities are involved.

The four BSLs define proper laboratory techniques, safety

equipment, and design, as described below:
16 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Expansion of the Current Laboratory System

The National Institute for Allergy and Infectious Diseases

(NIAID), of HHS’ National Institutes of Health (NIH), is funding

extensive research on new and improved medical

countermeasures—diagnostic tests, drugs, and vaccines to

detect, treat, and prevent illness from potential agents of

bioterror. Much of the research to develop medical

countermeasures for potential agents of bioterror needs to be

conducted in BSL-3 or BSL-4 laboratories. Many institutions

and companies with infectious disease research programs

have BSL-3 laboratories, but many are small, need

modernization, or are dedicated to a specific use. There is

currently a limited number of BSL-4 labs operating in the

United States in the following locations:

> CDC in Atlanta, GA

> U.S. Army Medical Research Institute of Infectious Diseases

at Fort Detrick, near Frederick, MD

> Southwest Foundation for Biomedical Research in San

Antonio, TX

> University of Texas at Galveston, TX

NIAID is funding the construction of four new laboratories that

will have BSL-2 to BSL-4 capabilities as well as the 

construction or renovation of some facilities with BSL-2 and

BSL-3 capabilities. In addition to advancing research, these

labs may also expand the LRN and/or supplement the current

LRN labs in responding to a public health emergency. The four

new laboratories include facilities at the following locations:

> NIH headquarters in Bethesda, MD

> NIAID at Fort Detrick, near Frederick, MD

> NIAID’s Rocky Mountain Laboratories in Hamilton, MT

> University of Texas Medical Branch at Galveston, TX

More information on the new laboratories can be found on the

NIAID Web site (http://www.niaid.nih.gov/factsheets/facility_

construction.htm).

It should be noted that HHS is not funding research on

bioweapons. Such research is prohibited by international law.

To identify treatments and ways to prevent epidemics,

however, scientists sometimes need to work with small

quantities of the actual microbes or toxins in extremely wellcontrolled protected facilities.

HHS Support for Hospital Preparedness

To strengthen local response, in 2002, HHS’ Health Resources

and Services Administration started the National Bioterrorism

Hospital Preparedness Program. The program is helping to

improve hospital capabilities and surge capacity (the ability of

a hospital to handle a large influx of patients at one time, often

requiring specialized medical equipment and treatment), staff

training, and the building of specialized facilities, such as

decontamination areas.

To receive funding through the program, states must enter into

cooperative agreements with the Health Resources and

Services Administration, agreeing to use the funds for certain

activities. In 2002, activities focused on needs assessments

and planning for state agencies, hospitals, and other health

care facilities, such as outpatient centers, emergency medical

services, and poison control centers. All states were required

to make plans with their hospitals for dealing with an epidemic

involving 500 or more patients in their state or region. Other

topics that the response plans cover include:

SELECT AGENT PROGRAM

As a safeguard against the accidental or intentional exposure of

dangerous agents outside of laboratories, CDC developed the Select

Agent Program in 1996 to control the possession, packaging, labeling,

and transport of certain agents that are capable of causing

substantial harm to human health and safety. The program requires

that facilities that work with such agents, including government

agencies, universities, research institutions, and commercial entities,

register with CDC. In addition to tracking and safeguarding the use of

these agents, the Select Agent Program established systems for

alerting authorities if unauthorized attempts are made to acquire

these agents by terrorists or others. These requirements are outlined

in the Select Agent Regulation, which was officially published in 2002.

The regulation includes a list of dozens of agents to which it applies,

including viral hemorrhagic fevers (like Ebola), smallpox, plague,

ricin, anthrax, and avian flu. More detailed information on the Select

Agent Program and the Select Agent Regulation can be obtained on the

program’s Web site (http://www.cdc.gov/od/sap/index.htm).
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 17

HOW ONE STATE’S HEALTH AND HUMAN SERVICES SYSTEM

USES HAN

States have taken many different approaches to creating their own

HANs. One state developed a HAN home page on its HHS Web site. 

In the future, health professionals will be able to register online to be

a part of the state HAN network and gain access to secure Web pages. 

The state’s HHS Web site provides links to the HAN, emergency 

contact numbers, and other terrorism information. It also has a link to

a list of news releases on HAN-related issues. The state also has special

emergency Web pages ready to activate in the event of a public health

emergency.

These messages can be viewed over the Internet on the HAN

Web site (http://www.phppo.cdc.gov/HAN/Index.asp).

HEALTH UPDATE

Provides updated information regarding an incident or situation; 

unlikely to require immediate action.

HEALTH ADVISORY

Provides important information for a specific incident or situation; 

may not require immediate action.

HEALTH ALERT

Conveys the highest level of importance; warrants immediate action 

or attention.

> Communication between hospitals and emergency responders

> Procedures for receipt and distribution of vaccines, antibiotics,

and supplies from federal sources (like the Strategic National

Stockpile)

> Quarantine, isolation, and decontamination

> Hospital lab capacity

> Personal protective equipment

> Emergency drills

> Personnel training

Local and state governments are actively working with their

hospitals to implement the elements outlined in the plans to

enhance local preparedness.

Information Sharing In the Public Health Community

Once lab tests confirm the presence of a terrorism agent,

information will need to be distributed throughout the medical

community quickly to facilitate identification of additional

patients and advise health care providers about treatment.

Over the past several years, CDC has been developing several

national networks to encourage and facilitate the sharing of

information within the public health community. The networks

are designed to help health officials and hospitals around the

country share information both before and during public health

emergencies.

Health Alert Network

The Health Alert Network (HAN) (http://www.phppo.cdc.gov/

HAN/Index.asp), which was introduced by CDC in 1998, 

is a nationwide, integrated electronic information and

communications system for the distribution of health alerts,

prevention guidelines, national disease surveillance, and

laboratory reporting. HAN is a collaboration between CDC,

local and state health agencies, and national public health

organizations. It allows for the sharing of information between

state, local, and federal health agencies as well as hospitals,

laboratories, and community health providers. There is also a

distance-learning component to allow network users to

continually increase their knowledge of bioterrorist threats via

satellite and the Internet.

HAN is designed to assist public health and emergency

response during a terrorism event as well as any public health

emergency. It provides early warnings by broadcast fax and 

e-mail to alert officials at all levels about urgent health threats

and appropriate actions. There are three categories of HAN

messages:
18 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

In addition to the national HAN network that is led by CDC,

CDC has encouraged states to develop their own HAN

networks and is providing funding and technical assistance in

conjunction with other health organizations, such as the

National Association of County and City Health Officials and

the Association of State and Territorial Health Officials.

Epidemic Information Exchange

The Epidemic Information Exchange (Epi-X) is a secure, 

Web-based communication network that was created in 2000

to connect CDC and other federal health agencies, state and

local health departments, poison control centers, laboratories,

and other public health professionals in the United States and

neighboring countries. Since 2000, Epi-X (http://www.cdc.

gov/mmwr/epix/epix.html) has posted over 4,000 reports of

disease outbreaks and other health threats, and has grown to

include more than 3,000 public health professionals

nationwide. To protect health on the U.S. border, senior health

officials in Mexico and Canada also share information on Epi-X.

In contrast to the fairly open membership structure of HAN,

health agencies authorize certain officials to participate on EpiX and share provisional technical information. Peers contribute

information to CDC, monitor the network 24 hours a day, 

and typically post reports within minutes to hours of 

submission. Epi-X staff also send out daily e-mails to users

about new reports and events. Staff can also notify users

immediately by e-mail, pager, and telephone if a situation is

deemed an emergency. In addition to near daily use during the

response to routine disease outbreaks, Epi-X has been used for

a number of major public health crises, including the outbreaks

of West Nile virus, SARS, and monkeypox. Figure 2–4 illustrates

the operation of Epi-X in both normal and emergency situations.

CONTAINMENT

Once an attack has been confirmed, public health officials may

use a variety of tactics to control its effects, ranging from

distributing antibiotics to using quarantine strategies. This

section describes several methods that might be used for

containment.

Strategic National Stockpile

What SNS Is

The Strategic National Stockpile (SNS) (formerly the National

Pharmaceutical Stockpile) (http://www.bt.cdc.gov/stockpile/

index.asp) is a national repository of critical medical supplies

designed to supplement and resupply state and local public

health agencies in the event of a national emergency anywhere

and at anytime within the United States or its territories. The

goal of the SNS program is to provide rapid delivery of SNS

lifesaving pharmaceuticals to any location within all U.S.

states and territories within 12 hours or less from the federal

decision to deploy. The SNS program is managed by CDC and

is carried out in conjunction with state and local communities

who have responsibility for developing their own local plans for

the receipt and distribution of SNS supplies. SNS distributes

medical supplies and provides technical assistance to states in

their planning efforts related to the receipt and distribution of

SNS assets. SNS only distributes medical supplies—it does

not operate mass casualty centers or clinics.

What SNS Includes

Items included in SNS are based upon current terror threats,

the vulnerability of the U.S. civilian population, and availability

and ease of distribution of supplies. SNS contains multiple

caches of medical supplies stored in warehouses in different

regions across the country. These caches include antibiotics,

chemical antidotes, antitoxins, life-support medications,

intravenous (IV) administration, airway maintenance supplies,

and medical/surgical items.

How SNS Is Activated

> The affected state’s Governor’s office requests SNS materials

from HHS or CDC.

> HHS assesses the situation and determines prompt and

appropriate action. This assessment could include consultation

with other federal agencies and entities (e.g., DHS).

> Supplies are sent in what are called “12-hour Push

Packages,” which contain a broad range of products that may

be needed in the early hours of an emergency and are ready

to be loaded on trucks or aircrafts. These supplies would go

directly to predesignated sites, depending on the situation

and the plans made by the affected community.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 19

State health agencies select Epi-X members.

FIGURE 2–4: EPI-X NORMAL OPERATION

EPI-X EMERGENCY OPERATION

1.

Members send important information to Epi-X staff.

2.

Epi-X staff edit and post information from 

members on discussion board.

3.

Epi-X members can access discussion board to

get information.

4.

Epi-X staff also send out daily e-mails to users

about new reports and events.

5.

Epi-X staff notifies members immediately via 

e-mail, pager or telephone.

1.
20 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

FIGURE 2–5: SNS ACTIVATION

1.

Either the state requests SNS supplies or the 

federal government determines there is a need.

2.

SNS supplies arrive within 12 hours anywhere in

the United States or its territories.

3.

State and local officials distribute supplies 

according to their SNS distribution plans.

4.

Additional supplies may be sent directly from

Vendor Managed Inventory or Stockpile Managed

Inventory, or in lieu of Push Packages.

5.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 21

HOW A VACCINATION CLINIC OR SNS DISTRIBUTION SITE

MIGHT FUNCTION

Although most communities have done advance planning in terms of

where clinics and dispensing sites may be held and how they will

work, the exact location and setup will be incident specific. As a

result, the local media would be heavily relied on to get information

out about who should go to one of these sites and where and when

they will be open.

HHS has also recommended that, if a clinic or dispensing site needs to

be used, the center should be open for the local media to tour before

it is officially opened so that local media can provide information to the

public about what to expect when they arrive at the site.

Public health officials will request that people bring the following

information to receive appropriate treatment:

> Photo identification (driver’s license, military ID, company badge)

> Medical records, including previous immunizations, current

medications, and allergies

> Current age and weight of children

It is helpful for people to gather this information before the emergency

and keep in a safe, but easily accessible, place.

This information would be requested strictly for medical reasons.

Anyone who needs treatment will be able to get treatment free of

charge and regardless of immigration and residency status.

> If an incident requires additional pharmaceuticals and/or

medical supplies, additional shipments of supplies through

Vendor Managed Inventory and Stockpile Managed Inventory

will be shipped to arrive within 24–36 hours. These

shipments can be tailored to provide pharmaceuticals,

supplies, and/or products specific to the suspected or

confirmed agent(s) in addition to or instead of the 12-hour

Push Packages.

> CDC is also funding the Cities Readiness Initiative, a pilot

program to direct funding to targeted cities to increase their

capacity to deliver medicines and medical supplies during a

large-scale public health emergency. This program helps

ensure state and local partners have effective plans for

receiving, storing, and dispensing medication to large

populations when needed.

How SNS Is Managed

> The SNS program helps support state and local

governments, health care providers, and first responders in

the development of plans and capabilities to receive, secure,

distribute, and dispense SNS supplies. With SNS program

assistance, state and local officials develop, train, and

exercise state-specific plans for utilizing SNS.

> Local and state officials are responsible for the distribution of

SNS supplies once they arrive at agreed upon receiving sites.

> While SNS supplies are being transported, the SNS program

will deploy its Technical Advisory Response Unit. The unit’s

staff will coordinate with state and local officials so that SNS

supplies can be efficiently received and distributed upon

arrival at the site.

> The SNS program ensures that medical supplies are rotated

and kept within potency shelf life limits. This involves

quarterly quality assurance/quality control checks on all 

12-hour Push Packages; a full inventory conducted annually

of 12-hour Push Package items; and inspections of

environmental conditions, security, and overall package

maintenance.

Figure 2–5 illustrates how SNS is activated.

Vaccination Strategies

One method that public health officials may use to control 

an outbreak of some diseases caused by bioterrorism is 

vaccination. Vaccines cause the body to produce antibodies,

which protect the body against later infection by a particular

agent. However, vaccines are not available for many diseases

and not all vaccines work the same way. Smallpox vaccine, for

example, provides almost immediate immunity and can be

beneficial even if someone is vaccinated a few days after

exposure. Other vaccines, such as the anthrax vaccine, may

require a number of doses over time before the recipient builds

up immunity. Therefore, vaccines may or may not be helpful in

a sudden outbreak, depending on the disease and incident.
22 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Scientists are currently doing research on vaccines to combat

various bioterror agents, but currently, the only major bioterror

agents for which vaccines are available in case of an attack are

smallpox and anthrax. Although these vaccines may be used

in case of an attack, they are not currently available to the

general public due to potential vaccine side effects and other

issues. However, these vaccines may become available in the

case of an attack. In fact, in October 2004, HHS awarded a

contract to VaxGen, Inc., to produce 75 million doses of a new

anthrax vaccine for the SNS. Additional details on vaccines

can be found in the “Biological Agents” section (see p. 39) and

on NIAID’s Web site (http://www2.niaid.nih.gov/biodefense).

Smallpox Vaccination

Although vaccination before a smallpox event has been a hotly

debated topic over the past several years due to potential side

effects of the vaccine, in the case of a smallpox “outbreak,” it

is likely that public health officials would turn to vaccination

because the risks associated with the smallpox illness would

be much higher than the risks of the possible vaccine side

effects. There are two main ways to conduct vaccination for

smallpox:

> Ring vaccination

> Mass vaccination

Ring Vaccination

Ring vaccination was the primary strategy that was used to

control smallpox outbreaks and led to the complete eradication

of the disease worldwide by 1980. It involves finding and

vaccinating the contacts of smallpox patients. First line

contacts are those who have had face-to-face contact (6 feet

or less; for example, at school or the workplace) and those

living in the same household as the person who has smallpox.

Then, close contacts of the first line contacts are vaccinated to

make sure to break the chain of transmission. For the contacts

of contacts, those who have what are called contraindications

(medical conditions that may cause adverse reactions to the

vaccine; for example, eczema or immune deficiencies) are not

typically vaccinated. 

Ring vaccination is typically effective if the outbreak appears

to be small and contacts can be identified quickly. It minimizes

the number of people who will need to be vaccinated and who

may have reactions to a vaccine. (Note: Someone cannot

contract smallpox from the smallpox vaccine.)

Mass Vaccination

Depending on the nature of the outbreak, public health officials

may decide to use a mass vaccination strategy. Some reasons

that a mass vaccination may be used include: if the number of

cases is high, if outbreaks occur in a number of locations,

and/or if the outbreaks continue to grow despite the use of ring

vaccination. Since routine vaccination for smallpox in the

United States ended for the general public in 1972 and there

are large numbers of Americans who are susceptible to the

virus, mass vaccination would be strongly considered for a

smallpox outbreak. If mass vaccination were indicated, supplies

from SNS would be used, and it is planned that vaccine clinics

would be set up to vaccinate people quickly and efficiently.

Patient(s)

First line contacts of patient(s)

Contacts of first line contacts

FIGURE 2–6: RING VACCINATION

Source: CDC & WHO. (2003). Course: “Smallpox: Disease, prevention, and intervention.”

Day 2, Module 4: Vaccination strategies to contain an outbreak. PowerPoint

presentation. http://www.bt.cdc.gov/agent/smallpox/training/overview.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 23

FIGURE 2–7: BIOSHIELD

Project BioShield

Project BioShield was signed into law in July 2004. The

program is designed to provide incentives for the

pharmaceutical and medical technology industries to develop

and make available modern, effective drugs and vaccines to

protect the population against attack by biological and chemical

weapons or other dangerous toxins (http://www.hhs.gov/news/

press/2004pres/20040721b.html). Many existing medications,

such as vaccines or other drugs, are 20 or 30 years old and

are available in limited supply or may have significant side

effects (e.g., smallpox vaccines). Recommended decontamination

procedures and other treatments for chemical and radiation

exposure have not changed much since the 1970s (National

Memorial Institute for the Prevention of Terrorism 2004). For

many biological and chemical agents, no specific vaccines or

treatments have been developed yet, based in part on the

absence of a market and thus reduced financial incentives for

industry to develop new products and devices (Gottron 2003)

as well as a variety of liability concerns.

Project BioShield allows the federal government to buy improved

vaccines and other drugs for smallpox, anthrax, and botulinum

toxin for SNS. It will also speed up the product development and

approval cycle for new countermeasures against other dangerous

pathogens, such as Ebola and plague, as soon as scientists verify

their safety and effectiveness, by authorizing HHS and DHS to

buy drugs, vaccines, medical devices, and other supplies up to 5

years before the products would normally be expected to come to

market. To help make new treatments available to the public in

an emergency, a new law guarantees a government market for

otherwise experimental drugs and medical treatments.

How BioShield Works

Project BioShield has three main components:

> Ensuring that resources are available to pay for vaccines and

other drugs

> Speeding up NIH research and development by authorizing

NIAID to accelerate the normal contracting, scientific peer

review, and approval processes

> Providing new emergency-use authorization for the Food and

Drug Administration (FDA) for medical treatments that have

not been formally approved and licensed

HHS will have new funding authority to identify and include

medical countermeasures in SNS. Products in development

include new smallpox vaccines as well as treatments for

botulism, plague, Ebola, and other diseases. HHS would

coordinate SNS purchasing decisions with DHS and the Office

of Management and Budget.

The HHS Secretary will play a critical role in authorizing the

use of not yet approved and unlicensed products and

technologies in an emergency. The routine development and

approval processes for drugs, devices, and biological products

are designed to provide safe and effective products to protect

and enhance the public health. However, conducting thorough

safety and effectiveness studies for submission to HHS and the

Food and Drug Administration often takes the industry several

years—too long for emergency situations. If the need arises,

the HHS Secretary could issue an emergency authorization to

use an investigational treatment after determining that there

were no other alternatives available and that the known or

potential benefits would outweigh the known or potential risks.

Isolation and Quarantine

To protect the public in the case of an outbreak of a highly

contagious infectious disease, such as smallpox or plague,

public health officials may decide to employ quarantine and

isolation strategies, separately or together, depending on the 

situation. These practices can reduce the public’s exposure to 

an illness by separating and restricting the movements of 

persons known to be infected or who are suspected of infection. 

Both practices may be carried out voluntarily, but, ultimately,

government officials have the authority to impose quarantine and

isolation, if necessary, to protect the public welfare.

Money to pay for

vaccines and drugs

Accelerating research

and development

through NIH

FDA emergency-use

authorization
24 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Isolation removes people who are ill with contagious diseases

from the general public and restricts their activities to stop the

spread of a disease. Isolation is not required for patients with

noncontagious diseases, such as anthrax. Isolation:

> Confines infected persons to their homes, hospitals, or

designated health facilities

> Allows health care providers to provide infected persons with

specialized care

> Is commonly used in hospitals for people with certain 

diseases, such as tuberculosis 

> Is initiated mostly on a volunteer basis, but government officials

at all levels have the authority to enforce it (CDC 2004c)

Quarantine separates people who have been potentially exposed

to a contagious disease and may be infected but are not yet ill to

stop the spread of that disease. Quarantine:

> Confines persons to their homes or community-based facilities

> Can apply to a group that has been exposed at a public gathering

> Can apply to persons who are believed to have been exposed

while traveling, particularly overseas

> Can apply to an entire geographic area, in which case a

community may be closed off by sealing its borders or by a

barricade, known as a “cordon sanitaire”

> Is enforced at the state level and/or by CDC’s Division of Global

Migration and Quarantine

Although quarantine and isolation policies are commonly put into

emergency plans, public health and government officials have not

needed to use widespread quarantine and isolation measures in

recent years in the United States. The last large-scale quarantine

measures that were imposed in this country were used in the

early 20th century to contain outbreaks of plague, yellow fever,

and smallpox. Other countries have successfully used quarantine

measures recently to control SARS. However, how quarantine is

managed is unique to each country.

Legal Authority Related to Isolation and Quarantine

All levels of government have the legal authority to issue orders

for isolation and quarantine. Generally, however, if an outbreak

of an infectious disease occurs in a specific location, the

authority for quarantine falls to the local authorities that

govern that area. If the outbreak affects more than one

community or has the potential to cross local boundaries,

authority is passed on to the state. The federal government is

primarily responsible for preventing diseases from being

introduced and spread in the United States from foreign

countries as well as interstate and national outbreaks.

The Division of Global Migration and Quarantine at CDC

(http://www.cdc.gov/ncidod/dq/mission.htm) enforces regulations

that are intended to prevent the introduction, transmission,

and/or spread of communicable diseases from foreign

countries into the United States. They operate eight full-staffed

Quarantine Stations in international airports in the United

States. These stations are responsible for monitoring all ports,

seaports, and international airports for a given region. Officers

at these stations also train immigration, customs, and

agriculture inspectors to watch for ill persons and imported

items that may have public health significance. During the

SARS epidemic in 2003, quarantine officers took a number of

actions to protect the health of the public, ranging from

distributing health notices to air travelers with information

about SARS to boarding planes to see if ill travelers had

symptoms of SARS.

More detail on the legal authority related to isolation and

quarantine can be found in “The Role of the Federal

Government” section under the “Public Health Sources of

Authority” heading (see p. 153).

National Disaster Medical System

The National Disaster Medical System (NDMS) is a federally

coordinated system that provides medical services to help

local and state agencies respond to major emergencies 

and disasters, including acts of terrorism. This system is 

made up of medical professionals who are specially trained

and volunteer their services in case of an emergency as a

supplement to local hospital systems. Some people describe

the system as the “National Guard for Medicine.”

NDMS (http://ndms.dhhs.gov) operates as a part of DHS, 

in partnership with HHS, the U.S. Department of Defense, and

the U.S. Department of Veterans Affairs. The system is made

up of specialized teams and a network of hospitals. In addition
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 25

to assisting communities in disasters, NDMS also supports

military medical systems and U.S. Department of Veterans

Affairs facilities in caring for casualties that are evacuated back

to the United States from overseas conflicts. NDMS is

operational in two situations: (1) if a National Emergency is

declared, or (2) at the request of a state or local government.

The five types of NDMS teams are:

> Disaster Medical Assistance Teams

> Disaster Mortuary Operational Response Teams

> Veterinary Medical Assistance Teams

> National Nursing Response Teams

> National Pharmacy Response Teams

Each of these teams will be described in turn.

Disaster Medical Assistance Teams

> Eighty teams across the country comprised of local

professional and paraprofessional medical personnel and

logistical staff.

> Include four National Medical Response Teams, which are

especially equipped and trained to deal with Weapons of

Mass Destruction, and other specialized teams available to

handle specific medical needs, such as burn and mental

health emergencies.

> Designed as rapid-response units to supplement local services

(e.g., triage, emergency care) until a situation is resolved or

until additional resources—federal or private—can be

activated.

> Deployed to affected areas with enough supplies to last 72

hours.

> May work at fixed or temporary medical sites.

> Each team managed by a sponsoring organization, such as a

public health agency or a nonprofit group, that operates under

a Memorandum of Agreement with DHS.

> Sponsor recruitment and organization of team members,

arrange training, and coordinate the deployment of the team.

> Although designed to supplement services at the local, state,

or regional level, may be used on a national basis.

Disaster Mortuary Operational Response Teams

> Ten regional teams formed to provide help to local officials in

tasks relating to the recovery, identification, and burial of

victims.

> One national team is specially trained to handle events

involving Weapons of Mass Destruction.

> Members are private citizens with specialized expertise.

> Examples of types of team members include: funeral directors,

medical examiners, coroners, and pathologists.

> Include two Disaster Portable Morgue Units, which are

complete morgues that can be deployed to an affected site.

Veterinary Medical Assistance Teams

> Five nationally deployable teams of private citizens who provide

veterinary care following major emergencies.

> Examples of tasks include the following:

- Medical treatment for rescue animals, farm animals, and pets

- Tracking and assessment of disease in animals

- Animal decontamination

> Examples of types of team members include:

- Clinical veterinarians

- Veterinary pathologists

- Veterinary technicians

- Microbiologist/virologists

- Epidemiologists

- Toxicologists

National Nurse Response Teams

These teams are currently being formed to assist with mass

vaccinations and provide specialized services in case the

nation’s supply of nurses is overwhelmed during a major

emergency. There will be 10 regional teams, which will 

each consist of approximately 200 civilian nurses.
26 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

National Pharmacy Response Teams

Ten regional teams are being formed to help with emergency

situations that may require the assistance of large numbers of

pharmacy professionals, such as mass vaccination. Members

will be sponsored by the Joint Commission of Pharmacist

Practitioners and work in partnership with DHS.

Administration of Teams

When activated, members of NDMS teams are considered

federal employees and are paid for their service. They are

required to maintain the appropriate licensures for their 

disciplines, and some are required to stay current in treatment

recommendations for diseases related to Weapons of Mass

Destruction and to complete Web-based training in disaster

and terrorism response.

Federal Coordinating Centers

In addition to the five types of teams, NDMS also coordinates a

network of approximately 2,000 hospitals to assist in a disaster.

NDMS relies on the voluntary assistance of accredited

hospitals across the country—usually those with more than

100 beds and located in large metropolitan areas. Federal

Coordinating Centers recruit these hospitals to commit a

number of their acute-care beds for NDMS patients, if needed.

If a hospital admits NDMS patients in an emergency, it is

guaranteed reimbursement by the federal government.

In the case of a major disaster, the Federal Coordinating

Centers may coordinate the evacuation or transport of patients

to NDMS network hospitals in unaffected areas. These

activities are coordinated with the U.S. Department of

Defense, which would be responsible for transporting patients

over long distances.

Other Supplementary Personnel and Resources

In response to a public health emergency, the federal government

may dispatch personnel from the Epidemic Intelligence Service

(EIS), the Commissioned Corps Readiness Force, or the

Medical Reserve Corps.

EIS (http://www.cdc.gov/eis) is a 2-year postgraduate program 

of service and on-the-job training for health professionals

interested in epidemiology. EIS, which is managed by HHS/CDC,

was developed more than 50 years ago to defend the nation

against biological warfare but also provides surveillance and

response units for all types of outbreaks. Medical doctors,

researchers, and scientists work in a range of subject areas,

including infectious diseases, and are supervised by

experienced epidemiologists at CDC and local and state health

departments.

The Commissioned Corps of the U.S. Public Health Service

(http://www.usphs.gov) is a uniformed service with a number

of programs to help promote the health of the nation. It

includes a variety of health professionals, including physicians,

dentists, pharmacists, nurses, veterinarians, and other

scientists and professionals. The Commissioned Corps

Readiness Force is a subset of the Commissioned Corps that

may be sent to respond to public health emergencies.

The Medical Reserve Corps (http://www.medicalreservecorps.gov)

are teams of local volunteer medical and public health

professionals who have offered to contribute their skills and

expertise during times of community need. The Medical

Reserve Corps program office is within the HHS Office of the

Surgeon General, but the volunteer teams are operated out of

local Citizen Corps, a national network of volunteers concerned

with preparing their communities for disasters of all kinds.

RAPID RESPONSE REGISTRY

As part of the response to an emergency event, CDC’s Agency for Toxic

Substances Disease Registry (ATSDR) may establish and maintain a

Rapid Response Registry (RRR) of people exposed to a terrorist or other

emergency event affecting public health within the United States and its

territories. RRR will follow up with registrants over time to determine if

there are any health problems that can be linked to the event.

ATSDR has been identified as the lead agency in establishing an

event-related registry of victims and exposed population and will

initiate RRR within 8–12 hours after an event. ATSDR will deploy field

supervisors and data collection teams to the site of the event, and

begin enrolling on an urgent basis all people who were exposed or

potentially exposed. RRR can respond to any size and type of agent.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 27

Red Cross

The Red Cross (http://www.redcross.org) is another key player

in responding to a public health emergency. The Red Cross is

a nonprofit humanitarian organization led mostly by volunteers

and has been providing disaster recovery assistance to

Americans since the 1880s. Although not a government

organization, the Red Cross was given authority through 

a Congressional Charter in 1905 to provide assistance in

disasters, both domestically and internationally. As a result,

Red Cross Chapters work closely with federal, state, and local

governments to respond to disasters. The following are some

of the services offered by the Red Cross in a disaster:

> Emergency first aid

> Health care for minor injuries and illnesses in mass-care

shelters or other sites

> Supportive counseling for victims and those affected by the

event

> Personnel to assist in the temporary infirmaries, immunization

clinics, morgues, hospitals, and nursing homes

> Assistance with meeting basic needs (e.g., food, shelter)

> Provision of blood products

THE THREAT OF EMERGING INFECTIOUS DISEASES

With the development of antibiotics, other drugs and vaccines,

vastly improved sanitation, and better control of insects and

other animals that can harbor and spread disease, great strides

have been made in public health over the last century. In the

1960s, it was even thought that the long era in which

infectious diseases inflicted high mortality might be drawing to

a close. But increases in international travel, the number of

people living in urban areas, and the adaptability of microbes

have given cause for increased concern in recent years.

Also of increasing concern to scientists and the medical

community are infectious diseases that have previously

infected only animals but are now infecting humans. Because

such diseases are relatively unstudied in humans, these

species-jumping or zoonotic infections have the potential to

become serious problems quite rapidly. In addition, it is

difficult to predict when or where such a disease might emerge.

Many factors may cause these jumps, including contact between

animals and humans, mutations of a microbe, and changes in

the environment. The recent increase of these sorts of infections

may be due to many factors, including that increasingly larger

numbers of people and animals are coming into contact with

each other and that modern transportation allows people to

quickly travel around the globe and rapidly spread infections

widely (Murphy 1998). As mentioned previously, many of

these outbreaks have characteristics similar to bioterror

attacks and may be investigated as such in their beginning

stages.

The following emerging diseases (all of which are thought to

have animal origins) are among those that the public health

community continues to try to understand and manage.

EBOLA (A VIRAL HEMORRHAGIC FEVER)

Ebola is highly contagious and usually fatal. Most cases have

occurred in Central Africa. The first Ebola epidemics occurred

in Zaire and Sudan in 1976 and outbreaks have occurred in

the last decade in Cote d’Ivoire, Zaire, Gabon, Uganda, the

Congo, and Sudan. According to WHO, 257 deaths were

reported between December 2002 and 2003. Outbreaks are

thought to begin with human contact with an infected animal.

Once the first person is infected, the disease can then be spread

from person to person through infected blood or secretions, 

or via contaminated objects, such as needles. Researchers

continue to try to pinpoint which animals act as hosts to 

this virus. Knowledge about the host and about how Ebola

spreads will help prevent future outbreaks. Researchers are

alsocurrently working on developing a vaccine and possible

antiviral drug treatments for Ebola. 

In 2001, at the time of an active Ebola outbreak in Uganda,

Africa, there was a “false alarm” concerning a suspected viral

hemorrhagic fever case in Ontario, Canada. A patient who had

traveled from Africa by plane was hospitalized with an

infectious disease that had symptoms consistent with those of

a viral hemorrhagic fever. If this diagnosis had been confirmed,

this would have been the first viral hemorrhagic fever case ever

seen in North America. Health Canada and CDC worked together

on the case and quickly coordinated their public health

messages and recommendations. Fortunately, the test results

were negative for any viral hemorrhagic fever, but this case

illustrates the potential global threat of newly emerging

infectious diseases.
28 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

More detailed information on viral hemorrhagic fevers, like Ebola,

can be found in the “Biological Agents” section (see p. 39).

SARS

SARS (severe acute respiratory syndrome) is a viral respiratory

illness caused by a coronavirus. The first confirmed cases

occurred in Guangdong Province in China in November 2002.

These 11 independent cases appear to have resulted from

human consumption of wild animals. The virus quickly evolved

to a form that could be transmitted among humans. In the

2003 outbreak, a total of 8,098 people worldwide contracted

SARS and 774 died. Most SARS cases were in Asia. There

were eight lab-confirmed cases of SARS in the United States,

but none of these individuals died from the disease. Those

affected had all traveled to parts of the world where SARS

outbreaks were occurring. By late July 2003, no new cases

were being reported and WHO declared that the global

outbreak was over. In April 2004, there were several cases of

SARS in China that were laboratory acquired infections. CDC

now has a plan in place to respond quickly if SARS recurs.

Tremendous progress has been made in the development of

experimental SARS vaccines. For more information on SARS,

including current information on SARS transmission throughout

the world, see CDC’s SARS Web site (http://www.cdc.

gov/ncidod/sars) or WHO’s SARS Web site (http://www.who.int/

csr/sars/en/).

WEST NILE VIRUS

West Nile virus (WNV) is transmitted by mosquitoes from birds

to humans or other animals. Humans, horses, and some

species of domestic and wild birds are susceptible to WNV.

The most serious form of the disease is viral encephalitis,

which is an inflammation of the brain. In 2003, 2.6 percent

of infected humans developed severe symptoms. No humanto-human transmission has been reported.

The first known occurrence of WNV in humans was in the

West Nile District in Uganda in 1937. There was an outbreak

among the elderly in Israel in 1957, and horses were stricken

in Egypt and France in the early 1960s. WNV first appeared

in North America in 1999. According to CDC, in 2003, 9,862

cases were documented in humans in the United States and

264 people died. Efforts are now underway to develop specific

treatments and different vaccine approaches to manage WNV.

In 2002 and 2003, a small number of cases of WNV were

acquired through blood transfusions. Tests were developed to

screen blood for WNV and as of July 2003, every blood bank

in the United States was screening donated blood for WNV. In

addition, blood banks started screening out donors with recent

possible symptoms of WNV (i.e., fever, headache). However,

since the current testing procedures cannot catch every

infected blood donation, scientists continue to work on better

tests and testing procedures.

More information on WNV can be found at http://www.cdc.gov/

ncidod/dvbid/westnile/index.htm.

BOVINE SPONGIFORM ENCEPHALOPATHY 

(“MAD COW” DISEASE)

Bovine spongiform encephalopathy (BSE), which is commonly

known as “mad cow” disease, was a concern in the United

States in the winter of 2003–2004 after the discovery of a

single dairy cow in Washington state with BSE. This cow’s

birth was traced to a farm in Alberta, Canada. BSE is a

progressive neurological disorder that is typically spread in 

cows when they eat animal feed containing neural tissue (e.g.,

spinal cords, brain tissue) of BSE-infected cows. Feed bans

were implemented in North America in 1997, which

prohibited the use of this kind of cattle feed. The majority of

BSE cases have appeared in Great Britain, peaking in the mid1990s. The concern about BSE is that it appears linked to a

neurological disease in humans called variant CreutzfeldtJackob disease (vCJD). It is thought that humans may be

exposed in a way similar to cows’ exposure—if they eat meat

products that contain contaminated bone, spinal cord, or brain

tissues. In a few cases, people have been infected by

contaminated blood transfusions or tissue or organ transplants.

The BSE risk to humans, particularly in the United States, 

is considered low. As of December 1, 2003, there had been

153 vCJD cases reported worldwide—143 of them in Great

Britain (CDC 2003a). CDC has increased surveillance, however,

to monitor for cases of vCJD in the United States and the 

U.S. Department of Agriculture has enhanced regulations,

inspections, and surveillance related to BSE.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 29

THE THREAT OF PANDEMIC INFLUENZA

Influenza or flu viruses routinely cause epidemics of disease

every winter that can cause illness in about 10–20 percent of

the population in the United States. Although these routine

influenza epidemics cause an average of 36,000 deaths and

200,000 hospitalizations per year in the United States, healthy

adults are usually not at high risk for complications. The groups

that are at risk for complications include the very young,

pregnant women, older adults, and those with chronic medical

conditions. Typically, flu shots are available and effective

against these types of influenza outbreaks that occur each

winter, although persuading people most at risk to get annual

vaccinations remains a challenge. Flu viruses are continually

circulating around the world and mutate or change over time.

This is the reason that the vaccine is updated to include current

viruses each year and that people who want to be protected

against the flu need to get a new flu shot each year.

Pandemics of influenza are explosive global events in which

most, if not all, persons worldwide are at risk for infection and

illness. In past pandemics, influenza viruses have spread

worldwide within months. With increased globalization, a new

pandemic could cross the globe within weeks or perhaps even

days. Pandemic viruses have historically infected one-third or

more of large populations and have led to tens of millions of

deaths.

Pandemics occur when there is a major change in an influenza

virus, resulting in a new strain that most of the world has never

been exposed to, therefore leaving most individuals susceptible

to infection. Unlike the gradual changes that occur in the

influenza viruses that appear each year during flu season, a

pandemic influenza virus is one that represents a major,

sudden shift in the virus’ structure that increases its ability to

cause illness in a large proportion of the population. This kind

of change is called an “antigenic shift.” 

There are two types of influenza viruses: type A and type B.

Type A viruses can be found in many types of animals, while

type B viruses circulate only among humans. While a routine

epidemic can involve either type of virus, antigenic shift can

only occur with influenza A viruses. One way that an antigenic

shift can occur is through pigs. Pigs can be infected with both

avian and human influenza viruses. If pigs are infected with

viruses from different species at the same time, it is possible

for the genes of these viruses to mix and create a new virus.

Humans would not have any immune protection to such a

virus and could be infected in large numbers (CDC 2004d)

The rare appearance of a flu pandemic virus would likely be

unaffected by currently available flu vaccines that are modified

each year to match the strains of the virus that are known to

be in circulation among humans around the world. 

During previous influenza pandemics, large numbers of people

were ill, sought medical care, were hospitalized, and died.

Three major influenza pandemics occurred during the 20th

century. The most deadly influenza pandemic outbreak was

the 1918 Spanish flu pandemic, which caused illness in

roughly 20–40 percent of the world’s population and more

than 50 million deaths worldwide. Between September 1918

and April 1919, approximately 675,000 deaths from the

Spanish flu occurred in the United States alone (HHS 2004a).

In 1957, the Asian flu pandemic resulted in about 70,000

deaths. The most recent influenza pandemic occurred in 1968

with the Hong Kong Flu outbreak, which resulted in nearly

34,000 deaths in the United States. Although the virus

involved in the 1968 outbreak was a dangerous virus, experts

believe that fewer deaths occurred in the United States than in

previous outbreaks for several reasons: 

> The virus was similar to the virus that appeared in the 1957

outbreak, and some people already had immunity

> The peak of the outbreak occurred during December when

children were out of school, so the virus was not widely

transmitted among school-aged children

> Medical care and available treatments for complications had

improved since the 1957 outbreak (HHS 2004b)

Although no one can predict when the next pandemic will

occur, public health scientists believe that the risk of an

influenza pandemic is greater now than it has been in decades. 

AVIAN INFLUENZA

One type of influenza A virus that is of concern to many 

public health officials is often called avian flu or bird flu. Both

the 1957 and 1968 pandemics are thought to have had avian

origins. Avian flu is caused by a group of influenza viruses that

circulate among birds. Avian flu is highly contagious among
30 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

birds, particularly domesticated birds, such as chickens. It is

thought that human cases have resulted from contact with

infected birds. In the past, quarantine and depopulation 

(or culling) and surveillance around affected flocks have

contained outbreaks. Among humans, symptoms range from

conjunctivitis to a flu-like illness that includes severe

respiratory distress and pneumonia. There has been no

evidence of sustained human-to-human transmission of avian

flu, although there have been a few isolated cases of

transmission between family members. However, because

influenza viruses have the potential to change and gain the

ability to spread easily between people, monitoring for human

infection and person-to-person transmission is important.

Several humans have been infected with avian flu since 1997.

The first documented human case was identified in 1997 in

Hong Kong. Both humans and chickens were infected.

Eighteen people were known to be infected and six died. 

To prevent further spread of the disease, public health

authorities killed more than a million chickens. A second

outbreak occurred in Hong Kong in 1999; two children were

infected but both recovered. Three outbreaks occurred during

2003. Two separate cases in Hong Kong and a third outbreak

occurred among poultry workers and their families in the

Netherlands. Eighty-four people were infected and one died.

Avian flu is a continuing threat. In early 2004, a new outbreak

of avian influenza occurred in humans in Thailand and

Vietnam. It also appears that cats may become infected from

infected birds and that those cats may then transmit the

disease to other cats. 

During 2004, avian flu cases were spread to unprecedented

levels in both poultry and humans in several countries in Asia.

The threat to the United States is considered uncertain at this

time. While poultry imports from Asia are limited (mostly

feathers or processed or cooked products, which are

considered to be low risk), it is possible that in the future an

individual infected with a new avian influenza virus that is able

to spread from person to person could travel to the United

States (Center for Emerging Issues 2004).

One important reason for the current heightened concern

about influenza viruses is that avian influenza has become

endemic in many species of birds throughout Asia. Therefore,

the threat of an avian flu pandemic is not diminishing.

Scientists will need to continue to carefully monitor avian flu

epidemics in Asia each year to make sure that they remain

contained and that the virus has not transformed into a virus

that can be easily transmitted from person to person.

Preparing for a Pandemic

Prepandemic planning is essential to minimize the effects

should an influenza pandemic occur. Although some of the

planning activities for terrorism and other public health

emergencies are relevant to an influenza pandemic (e.g.,

strengthening surveillance systems), planning is also

underway that is more specific to influenza. HHS’ current

Pandemic Influenza Preparedness and Response Plan

(http://www.hhs.gov/nvpo/pandemicplan) (HHS 2004c)

provides guidance to national, state, and local policymakers

and health departments for public health preparation and

response in the event of a pandemic influenza outbreak. 

At the federal level, health officials are also conducting a

number of other activities in preparation for the next pandemic,

including international surveillance activities, vaccine

development and research, and antiviral drug stockpiling and

research. Among other activities, resources are being allocated

to expand vaccine production as needed and add influenza

antiviral drugs to SNS. Research is also being conducted on

new influenza vaccines, more effective antiviral drugs, and

ways to rapidly sequence the genes of influenza viruses.

If a pandemic were to occur, the federal response activities

would depend to an extent on the stage of the pandemic. 

For example, the activities are different if scientists have 

discovered a new influenza strain in one person in another

country than if a number of people in the United States are ill

with a new strain of influenza. The kinds of activities that the

federal government might be involved in include:

> National and international surveillance to identify people

who have the virus and where outbreaks are occurring

> Rapid development, licensure, and production of new vaccines

> Implementing of programs to distribute and administer vaccine

> Determining how antiviral drugs could be used to combat the

current flu strain and target drug supplies
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 31

SOME DIFFERENCES BETWEEN TYPICAL INFLUENZA OUTBREAKS AND PANDEMIC INFLUENZA OUTBREAKS

TYPICAL INFLUENZA PANDEMIC INFLUENZA

Yearly occurrence. Rare occurrence (last one was in 1968).

Virus undergoes gradual change from previous years. Major, sudden virus shift in virus structure (antigenic shift).

Previous exposure to similar viruses may provide some protection. Little or no previous exposure in the population to similar viruses.

Healthy adults usually not at high risk for complications. Entire population may be at risk for complications.

Vaccines may be developed in advance to combat the virus. Vaccines cannot be developed until virus strain appears. Some antiviral medications

may be effective.

Approximately 5–20 percent of Americans get the flu each year and approximately

36,000 die from the disease.

Percentages of the population that would be infected by a pandemic influenza virus

and die from it are hard to predict ahead of time but would be significantly higher

than a typical flu season.

Symptoms include fever, cough, runny nose, and muscle pain. Symptoms could be more severe, including shortness of breath, acute respiratory 

distress, pneumonia, and organ failure.

> Implementing control measures to decrease the spread of 

the disease (e.g., infection control in hospitals, screening

travelers from affected areas)

> Communicating with the public, health care providers,

community leaders, and the media about the status of the

pandemic and the response

States are also expected to develop their own plans to deal

with the local aspects of planning for and response to a

potential influenza pandemic. Some examples of what these

plans would include are the state and local perspective on:

> Surveillance activities

> Vaccine management (distribution and administration)

> How to acquire and use antiviral agents

> How to implement community control measures (e.g., school

closings, isolation and quarantine)

> Emergency response (e.g., delivery of medical care, 

maintenance of essential community services)

Local preparedness will be an essential determinant of how

communities do in the early months of a pandemic.

Communities are encouraged to plan now for the crucial period

when a pandemic has stuck, but when there are not yet

adequate supplies of vaccines or antivirals. Three tasks should

be considered by communities in this process:

1. Reducing social contact to slow the spread of the virus

2. Treating those who become ill 

3. Sustaining civic life in the face of greatly increased 

morbidity, mortality, and fear

Examples of the many issues a community should consider

are: how to use volunteers, especially people who have

recovered and are, therefore, immune; how to educate 

children if schools were closed; and how essential businesses

would operate.

More detail on possible federal and state preparedness and

response activities can be found in HHS’ Pandemic Influenza

Preparedness and Response Plan (http://www.hhs.gov/nvpo/

pandemicplan).
32 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media ESSAY

Introduction

There are many ways to use numbers to help explain public

health risks. For example, numbers can be used to explain:

> Concentrations—such as parts per million or billion

> Probabilities—the likelihood of an event

> Quantities—such as how many spores of anthrax were 

in a letter

> Comparisons—such as comparing how dangerous something

is compared to something else (e.g., twice as deadly...)

But unfortunately, numbers can also be very confusing and can

sometimes be misinterpreted or presented in ways that

inadvertently raise levels of concern and alarm. For example, if

a substance is described as being “twice as deadly as cobra

venom,” that is not the same thing as “like being bitten by two

cobras.” Why not? Because the first comparison is about how

lethal or poisonous the substance is, and the second is about

the amount of poison someone might be exposed to.

Here are some other issues to be aware of when using

numbers to help describe public health risks.

Framing. The impact of a health risk number changes

depending on how the risk number is framed, or positioned.

For example, describing “lives lost” versus “lives saved” can

have a profound effect on how people respond to the

information. In one classic study, doctors were presented with

a hypothetical choice between two cancer therapies with

different probabilities of success and failure. Half were told

about the relative chances of dying while the rest had the same

information presented in terms of survival rates. The change in

framing—even though the results were the same—more than

doubled the number of doctors choosing one alternative.

Absolute Versus Relative Risk. Responses to risk messages—

especially when communicating increases or decreases in

risk—depend critically on whether probabilities are presented

in absolute terms (“the probability was 2 percent and is now 4

percent”) or relative terms (“the probability has doubled” or

“this group suffers twice the normal risk of ...”). The latter 

can be seriously misleading. Information about relative risks

can result in misperceptions if information about baseline

probabilities is not made clear.

Scale. Scales can also radically change perceptions of risk

numbers. For example, in communicating concentrations, 

the expression “6 parts per billion” sounds a great deal larger

than 0.006 parts per million, even though they are the same.

Scale is also a factor in communicating probabilities. 

For example, a risk agent that is expected to result in the death

of 1.4 people in 1,000 can equally be expressed as:

> The risk is 0.0014.

> The risk is 0.14 percent.

> In a community of a thousand people, we could expect 1.4

to die as a result of exposure.

Although these alternatives are equivalent, their meaning to,

and effect on, audiences are not. The first term may make the

risk seem smaller, whereas the last term may make the risk

seem larger. Confusion can often be avoided by embedding

risk numbers in words that help clarify their meaning or

translating the numbers into a comparison that people can

imagine. For example, “a risk of 0.047” is comprehensible to

only a few people. By comparison, it is much easier to

understand that roughly 5 people in an auditorium of 100

would be affected. This embedding process can also be

accomplished through visuals, including graphs, charts, 

animation, and pictures. But as mentioned earlier, embedding

must be done carefully so that appropriate and accurate

comparisons are made.

Estimates. Many risk numbers—for example, risk probabilities

and mortality rates—are estimates based on modeling and not

real life experience. Because they are based on models, many

risk numbers often have substantial uncertainties and margins

of error. In some cases, uncertainties in risk estimates arise

from the use of different assumptions and extrapolations. In

other cases, uncertainties arise because the risk is very low,

because data are still preliminary, because diagnosis is difficult,

or because measurement is difficult.

Because of uncertainties, one approach to communicating risk

numbers is to report the most likely estimate of risk. 

A JOURNALIST’S GUIDE

To Communicating Health Risk Numbers Effectively by Vincent T. Covello, Ph.D.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 33

A second approach is to report the upper-bound, “worst case,”

or maximum estimate of risk. A third, and more complete

approach, is to report the most likely estimate, along with the

highest and lowest estimates. For example:

“Our best estimate is a. Our cautious, worst-case estimate is b.

The highest estimate we have heard, from scientists at

University X, is c.”

Context. In presenting risk numbers, it is often useful to explain

how the risk numbers were obtained. For example, it is often

useful to explain how mortality rates and probabilities (1 in a

million) are calculated. Demystifying the risk assessment

process has several benefits. Perhaps most importantly, it

enables the presenter to make points that may be important

for people to understand. For example, it allows the presenter

to make the point that the presence of a risk agent does not

necessarily signify a significant health risk. This point is often

extremely difficult to communicate. For a risk agent to pose a

risk, an exposure must occur. There must be a way for the risk

agent to get from where it is to where people or the things they

value are.

A second critical point for the public to understand about risk

assessment is that after a route of exposure is established, the

next important question is the concentration of the risk agent that

may reach people. Concentration amounts of exposure are

typically far lower than the concentration amounts at the source.

Moreover, they often become even lower with the passage of time

and distance. Risk assessors consider not only whether a risk

agent is present but also how much is present.

Comparisons. Risk numbers are often communicated as part

of a comparison. The goal of comparisons is to make the

original risk number more meaningful by comparing it to other

numbers. For example, small probabilities are often 

difficult to conceptualize: just how small, really, is “1 in 10

million” or “a probability of 0.00015”?

Comparisons, although useful for putting numbers in

perspective, can create their own problems. For example, use 

of the concentration comparisons found in table 2 can lead to

disagreements. The statement that 1 part per million of a

contaminant is equal to one drop in an Olympic-size

swimming pool or one drop of vermouth in a million-gallon

martini is typically intended to help the reader understand

how “small” an amount exists. However, for some

individuals, such comparisons represent a subtle way of

trivializing the problem and prejudging acceptability.

Furthermore, concentration comparisons can sometimes be

misleading because risk agents vary widely in terms of the

amount of the agent needed to sicken or kill someone.

Risk Comparisons. Comparing one risky thing to another

helps people grasp how likely something is to cause harm

compared to something else. Probabilities are only one of

many kinds of information on which people base decisions

about risk acceptability. Risk numbers cannot preempt those

decisions. No explanation of a risk number will be

successful if it appears to be trying to settle the question

of whether a risk is acceptable.

Although more research is needed, the most effective 

comparisons appear to be:

> Comparisons of the same risk at two different times

> Comparisons with a regulatory standard

> Comparisons with different estimates of the same risk

> Comparisons of the risk of doing something versus not

doing it

> Comparisons of alternative solutions to the same problem

> Comparisons with the same risk as experienced in other

places

All of the types of comparisons have some claim to relevance

and legitimacy.

The least effective comparisons appear to be those that

disregard the risk perception and outrage factors that people

consider important in evaluating risks. The most important

of these include voluntary versus coerced, natural versus

human-made, familiar versus unfamiliar, not memorable

versus memorable, dreaded versus not dreaded, chronic

versus catastrophic, knowable versus unknowable, individually

controlled versus controlled by others, fair versus unfair,
34 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media ESSAY (cont.)

morally irrelevant versus morally relevant, trustworthy sources

versus untrustworthy sources, and responsive process versus

unresponsive process.

Conclusion

In conclusion, as with any information contained in a news

story, only health risk numbers that can be supported by

reliable data should be selected. Some of the data

manipulations discussed in this article are just simple

transformations of the same number. However, other

transformations can radically affect the way the audience

hears, understands, and remembers the number.

Vincent Covello, Ph.D., is the founder and director of the

Center for Risk Communication in New York City. He is a

nationally and internationally recognized trainer, researcher,

consultant, and expert in risk and crisis communication.

TABLE 2: CONCENTRATION COMPARISONS

UNIT 1 PART PER MILLION 1 PART PER BILLION 1 PART PER TRILLION

Length 1 in./16 mi. 1 in./16,000 mi. 1 in./16,000,000 mi. (a 6-in. leap on a journey to the sun)

Time 1 min./2 years 1 sec./32 years 1 sec./320 centuries (or 0.06 sec. since the birth of Jesus Christ)

Money 1 cent/$10,000 1 cent/$10,000,000 1 cent/$10,000,000,000

Weight 1 oz./31 tons 1 pinch salt/10 tons of potato chips 1 pinch salt/10,000 tons of potato chips

Volume 1 drop vermouth/80 “fifths”of gin 1 drop vermouth/500 barrels of gin 1 drop of vermouth in a pool of gin covering the area of a football field 43 ft. deep

Area 1 square ft./23 acres 1 square in./160-acre farm 1 square ft./the state of Indiana; or 1 large grain of sand on the surface of

Daytona Beach

Action 1 lob/1,200 tennis matches 1 lob/1,200,000 tennis matches 1 lob/1,200,000,000 tennis matches

Quality 1 bad apple/2,000 barrels 1 bad apple/2,000,000 barrels 1 bad apple/2,000,000,000 barrels

TABLE 1: VARIOUS ANNUAL AND LIFETIME RISKS 

(U.S. POPULATION ONLY)*

CAUSE OF DEATH OR HARM ANNUAL RISK LIFETIME RISK

Heart disease 1 in 4 1 in 300

Cancer (all forms) 1 in 7 1 in 510

Pneumonia 1 in 57 1 in 4,300

Plague 1 in 240,000 1 in 19,000,000

Anthrax (2001) 1 in 730,000 1 in 56,000,000

Suicide 1 in 120 1 in 9,200

Criminal homicide 1 in 240 1 in 18,000

Motor vehicle 1 in 88 1 in 6,700

Commercial aircraft 1 in 40,000 1 in 3,100,000

Passenger train 1 in 920,000 1 in 70,000,000 

On the job 1 in 620 1 in 48,000

Accidental electrocution 1 in 4,000 1 in 300,000

Lightning 1 in 39,000 1 in 3,000,000

Shark attack 1 in 3,700,000 1 in 280,000,000

Source: Rowe, W.D. & Hageman, F.J. (1984). Evaluation methods for environmental standards. Boca Raton, FL: CRC Press.

* These numbers vary from country to country. Individual risks vary.

Source: Ropeik, D. & Gray, G. (2002). Risk: A practical guide to what’s really safe and what’s

really dangerous in the world around you. Boston, MA: Houghton Mifflin. 
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 35

REFERENCES

APHIS Veterinary Services. (2001). Fact sheet—Questions and

answers: Bovine spongiform encephalopathy (BSE). http://www.aphis.

usda.gov/lpa/pubs/fsheet_faq_notice/faq_ahbse.pdf.

Association of Public Health Laboratories. (2003). State public health

laboratory bioterrorism capacity. Public health laboratory issues in

brief: Bioterrorism capacity, 1–6. http://www.aphl.org/programs/

emergency_preparedness/files/BT_Brief_2003--corrected.pdf.

Barbera, J., Macintyre, A., Gostin, L., Inglesby, T., O’Toole, T.,

DeAtley, C., et al. (2001). Large-scale quarantine following biological

terrorism in the United States: Scientific examination, logistic and

legal limits, and possible consequences. Journal of the American

Medical Association, 286, 2711–2717.

Buck, G. (2002). Preparing for biological terrorism: An emergency

services guide. Albany, NY: Delmar, Thomson Learning. 

Center for Emerging Issues. (2004). Highly pathogenic avian 

influenza, Asia outbreak summary, January 29, 2004: Impact worksheet.

http://www.aphis.usda.gov/vs/ceah/cei/IW_2004_files/hpai_asia_

summary_0104_files/hpai_asia_summary_0104.htm.

Centers for Disease Control and Prevention. (1999). Ten great public

health achievements United States, 1900–1999. Morbidity and

Mortality Weekly Report, 48, 241–243. http://www.cdc.gov/epo/

mmwr/preview/mmwrhtml/00056796.htm.

Centers for Disease Control and Prevention. (2000). National Vaccine

Program Office. FluAid home. http://www2a.cdc.gov/od/fluaid/

default.htm.

Centers for Disease Control and Prevention. (2001). The public

health response to biological and chemical terrorism: Interim planning

guidance for state public health officials. http://www.bt.cdc.gov/

documents/planning/planningguidance.pdf.

Centers for Disease Control and Prevention. (2003). Division of global

migration and quarantine: Mission. http://www.cdc.gov/ncidod/dq/

mission.htm.

Centers for Disease Control and Prevention. (2003). EPI-X: The 

epidemic information exchange. http://www.cdc.gov/mmwr/epix/epix.html.

Centers for Disease Control and Prevention. (2003a). Questions and

answers regarding bovine spongiform encephalopathy (BSE) and

creutzfeldt-jakob disease (CJD). http://www.cdc.gov/ncidod/diseases/

cjd/bse_cjd_qa.htm.

Centers for Disease Control and Prevention. (2003). Strategic national

stockpile. http://www.bt.cdc.gov/stockpile/index.asp.

Centers for Disease Control and Prevention. (2003). West Nile virus:

Background: Virus history and distribution. http://www.cdc.gov/

ncidod/dvbid/westnile/background.htm.

Centers for Disease Control and Prevention. (2004). Bird flu fact sheet.

http://www.cdc.gov/flu/avian/outbreak.htm.

Centers for Disease Control and Prevention. (2004). Fact sheet—

Influenza (flu): Basic information about avian influenza (bird flu).

http://www.bt.cdc.gov/documents/planning/planningguidance.pdf.

Centers for Disease Control and Prevention. (2004a). Fact sheet—

Laboratory preparedness for emergencies: Facts about the laboratory

response network. http://www.bt.cdc.gov/lrn/pdf/lrnfactsheet.pdf.

Centers for Disease Control and Prevention. (2004). Fact sheet—

Severe acute respiratory syndrome: Basic information about SARS.

http://www.cdc.gov/ncidod/sars/factsheet.htm.

Centers for Disease Control and Prevention. (2004). Frequently asked

questions about SARS. http://www.cdc.gov/ncidod/sars/faq.htm.

Centers for Disease Control and Prevention. (2004). Influenza (flu):

Questions and answers: The disease. http://www.cdc.gov/flu/about/

qa/disease.htm.

Centers for Disease Control and Prevention. (2004b). Laboratory 

preparedness for emergencies: CDC’s laboratory response to suspicious

substances. http://www.bt.cdc.gov/labissues/pdf/substanceresponse.pdf.

Centers for Disease Control and Prevention. (2004c). Severe acute

respiratory syndrome: Fact sheet on isolation and quarantine.

http://www.cdc.gov/ncidod/sars/pdf/isolationquarantine.pdf.

Centers for Disease Control and Prevention. (2004). Severe acute 

respiratory syndrome: Public health guidance for community-level

preparedness and response to severe acute respiratory syndrome

(SARS) version 2/3. http://www.cdc.gov/ncidod/sars/sarsprepplan.htm.

Centers for Disease Control and Prevention. (2004). Severe acute 

respiratory syndrome: The U.S. response to SARS: Role of CDC’s

Division of Global Migration and Quarantine. http://www.cdc.gov/

ncidod/dq/quarantine.pdf.
36 02. PLANNING FOR THE UNTHINKABLE: PREPARATION AND RESPONSE IN PUBLIC HEALTH Terrorism and Other Public Health Emergencies: A Reference Guide for Media

REFERENCES (cont.)

Centers for Disease Control and Prevention. (2004d). The influenza

(flu) viruses. http://www.cdc.gov/flu/about/fluviruses.htm.

Centers for Disease Control and Prevention. (2004). West Nile virus:

Questions and answers. http://www.cdc.gov/ncidod/dvbid/westnile/

qa/transfusion.htm.

Centers for Disease Control and Prevention, Office of Inspector

General, & HHS. (2002). 42 CFR Part 73, Office of the Inspector

General. 42 CFR Part 1003: Possession, use, and transfer of select

agents and toxins; Interim final rule. Federal Register, 240,

76886–76905. http://www.cdc.gov/od/sap/docs/42cfr73.pdf.

Centers for Disease Control and Prevention, & Public Health Practice

Program Office (PHPPO). (2002). Health alert network fact sheet.

http://www.phppo.cdc.gov/han/Documents/FactSheet/HANFactSheet4.pdf.

Centers for Disease Control and Prevention, & World Health

Organization. (2003). Course: “Smallpox: Disease, prevention, and

intervention.” Day 2, Module 4: Vaccination strategies to contain an

outbreak. PowerPoint presentation. http://www.bt.cdc.gov/agent/

smallpox/training/overview.

Centers for Disease Control and Prevention Epidemiology Program

Office. (2004). Epidemic intelligence service. http://www.cdc.gov/eis/.

Centers for Disease Control and Prevention Special Pathogens

Branch. (2003). Ebola hemorrhagic fever. http://www.cdc.gov/

ncidod/dvrd/spb/mnpages/dispages/ebola.htm.

Commonwealth of Virginia Department of Health. (2003). State

health department releases results in unexplained death investigation.

Press release, March 6, 2003. http://www.vdh.state.va.us/news/

PressReleases/PDFs/2003/030603UnexplainedDeaths.pdf.

Ember, L.R. (2001). Anthrax testing strains the system. Recent 

outbreak reveals deficiencies in public health labs’ ability to respond

to bioterror. Chemical & Engineering News, 79, 27–31.

FOCUS Workgroup. (2003). Overview of outbreak investigations.

FOCUS on Field Epidemiology, 1, 1–6. http://www.sph.unc.edu/

nccphp/focus/index.htm.

Gottron, F. (2003). CRS report for Congress: Project BioShield.

http://www.fas.org/irp/crs/RS21507.pdf.

Hall, B. (2003). Emergency response at the Department of Health

and Human Services. PowerPoint presentation. 

Harrell, J.A., & Baker, E.L. (2004). The essential services of public

health. http://www.apha.org/ppp/science/10ES.htm.

Heffernan, R., Mostashari, F., Das, D., Karpati, A., Kulldorff, M.,

& Weiss, D. (2004). Syndromic surveillance in public health practice,

New York City. Emerging Infectious Diseases, 10, 858–864.

http://www.cdc.gov/ncidod/eid/vol10no5/03-0646.htm.

Infoplease. (2004). Major U.S. epidemics. http://www.infoplease.com/

ipa/A0001460.html.

Lovgren, S. (2003). The mystery of the SARS virus: How is it spread?

http://news.nationalgeographic.com/news/2003/04/0409_030409_sars.html.

Lovgren, S. (2003). Where does ebola hide between epidemics?

http://news.nationalgeographic.com/news/2003/02/

0219_030219_ebolaorigin.html.

Marburger, J. BioSecurity 2003, October 20, 2003, Washington, DC:

Keynote address on national preparedness. http://www.ostp.gov/html/

10-20-03%20jhm%20BioSecurity%202003.pdf.

Murphy, F.A. (1998). Emerging zoonoses. Emerging Infectious Diseases,

4, 429–435. ftp://ftp.cdc.gov/pub/EID/vol4no3/adobe/murphy.pdf.

Nash, D., Mostashari, F., Fine, A., Miller, J., O’Leary, D., Murray, K., et

al. (2001). The outbreak of West Nile virus infection in the New York

City area in 1999. New England Journal of Medicine, 344,

1807–1814. http://content.nejm.org/cgi/content/full/344/24/1807.

National Institute of Allergy and Infectious Diseases. (2002). Strategic

plan for biodefense research. http://www2.niaid.nih.gov/NR/rdonlyres/

D75B6B83-6ACD-403D-B650-0A28F06CA9DC/0/strategic.pdf.

National Institute of Allergy and Infectious Diseases. (2003). West Nile

virus. http://www.niaid.nih.gov/newsroom/focuson/bugborne01/wnile.htm.

National Institute of Allergy and Infectious Diseases. (2004). The need

for biosafety laboratory facilities. NIAID fact sheet, February 2004.

http://www.niaid.nih.gov/factsheets/facility_construction.htm.

National Institute of Allergy and Infectious Diseases. (2004a). 

What are biosafety labs? http://www2.niaid.nih.gov/biodefense/

public/biolab.htm.

National Memorial Institute for the Prevention of Terrorism. (2004).

Fact sheet—President details Project BioShield. http://www.mipt.org/

projectbioshield.asp.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 37

REFERENCES (cont.)

Nebraska Health and Human Services System. (2003). Nebraska &

bioterrorism: Ready to respond. http://www.hhs.state.ne.us/aftermath/

NebraskaResponds.pdf.

Nebraska Health and Human Services System. (2004). Health alert

network. http://www.hhs.state.ne.us/han/hanindex.htm.

Pavlin, J.A. (1999). Epidemiology of bioterrorism. Emerging Infectious

Diseases, 5, 528–530.

Reynolds, B. (2002). Crisis and emergency risk communication.

Atlanta, GA: Centers for Disease Control and Prevention. 

Richmond, Y. Slide set presented at the 5th National Symposium on

Biosafety: Rational Basis for Biocontainment, February 6–9, 2000,

Atlanta, GA: The 1, 2, 3’s of biosafety levels. http://www.cdc.gov/

od/ohs/pdffiles/bsl123.pdf.

Ropeik, D., & Gray, G. (2002). Risk: A practical guide to what’s really

safe and what’s really dangerous in the world around you. Boston,

MA: Houghton Mifflin. 

Rowe, W.D., & Hageman, F.J. (1984). Evaluation methods for 

environmental standards. Boca Raton, FL: CRC Press. 

Smolinski, M.S., Hamburg, M.A., Lederberg, J., & Institute of

Medicine (U.S.) Committee on Emerging Microbial Threats to Health

in the 21st Century (Eds.). (2003). Microbial threats to health:

Emergence, detection, and response. Washington, DC: The National

Academies Press. 

Thompson, T.G. (2003). Testimony: Statement by Tommy G.

Thompson, Secretary of the Department of Health and Human

Services, on Project BioShield before the Committee on Energy and

Commerce Subcommittee on Health & Committee on Homeland

Security Subcommittee on Emergency Preparedness and Response.

http://www.hhs.gov/asl/testify/t030327.html.

U.S.Department of Health and Human Services. (2004). HHS buys

new anthrax vaccine for stockpile. News release. http://www.hhs.gov/

news/press/2004pres/20041104a.html.

U.S. Department of Health and Human Services. (2004). HHS fact

sheet—Biodefense preparedness: Record of accomplishment. News

release. http://www.hhs.gov/news/press/2004pres/20040428.html.

U.S. Department of Health and Human Services. (2004a). HHS

issues national pandemic influenza preparedness plan. News release.

http://www.hhs.gov/news/press/2004pres/20040826.html.

U.S. Department of Health and Human Services. (2004b). National

Vaccine Program Office: Pandemics and pandemic scares in the 20th

century. http://www.hhs.gov/nvpo/pandemics/flu3.htm.

U.S. Department of Health and Human Services. (2004). 

Pandemic flu fact sheet: Pandemic influenza. http://www.hhs.gov/

nvpo/pandemics/dhhs.html.

U.S. Department of Health and Human Services. (2004c). Pandemic

influenza response and preparedness plan. http://www.hhs.gov/

nvpo/pandemicplan.

U.S. Department of Health and Human Services, & Health Resources

and Services Administration. (2003). National bioterrorism hospital

preparedness program, cooperative agreement guidance.

http://www.wha.org/disasterPreparedness/pdf/2003hrsagrant.pdf.

U.S. Department of Homeland Security. (2004). National disaster

medical system. http://ndms.dhhs.gov/.

United Press International. (2004, January 30). Study shows how

SARS virus became lethal. Accessed March 16, 2004.

University of Pittsburgh. (2004). The shot heard ’round the world:

The development of the Salk polio vaccine 1947–1955. 

http://museum.pharmacy.pitt.edu/salk/.

Wartenberg, D. (2000). Epidemiology for journalists. http://www.facsnet.

org/tools/ref_tutor/epidem/index.php3.

World Health Organization. (2004). Avian influenza A(H5N1) update

32: Situation (human) in Thailand. http://www.who.int/csr/don/

2004_03_09/en/print.html.

World Health Organization. (2004). Avian influenza fact sheet.

http://www.who.int/csr/don/2004_01_15/en/print.html.

World Health Organization. (2004). Communicable disease 

surveillance and response. http://www.who.int/csr/en.

World Health Organization. (2004). Communicable disease 

surveillance and response (CSR): Avian influenza. http://www.who.int/

csr/disease/avian_influenza/en.

03BIOLOGICAL AGENTS
GOAL OF THIS SECTION

BIOLOGICAL AGENTS

40 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

To provide the best available scientific and medical 

information on selected biological agents that may be used

by terrorists as weapons. 

WHAT THIS SECTION INCLUDES AND WHY

> Category A agents, as classified by the U.S. Department

of Health and Human Services’ (HHS) Centers for Disease

Control and Prevention (CDC), are included because they

are of the highest concern as potential threats. They have

the potential for major public health impact and social

disruption and are also known to have been studied by

some countries for use in biological warfare.

> Category B agents, which are defined as a “second highest

priority” by CDC, are also included. Although these agents

are fairly easy to disseminate, they generally cause

moderate illness and low death rates.

WHAT THIS SECTION DOES NOT INCLUDE AND WHY

> Category C agents, which are considered to be “third

highest priority” by CDC, are not included because they

are currently not major bioterrorism threats. However,

these agents are emerging as infectious disease threats

that CDC believes could, in the future, be engineered 

to produce biological weapons. Examples of Category C

agents include yellow fever, drug-resistant tuberculosis,

and hantaviruses.

Please note: Information on the use of personal protective

equipment (e.g., biohazard suits and masks) can be found

in the “Self-Care for Media” section (see p. 157).

BIOLOGICAL AGENT OVERVIEW

> The threat from biological agents arises when naturally

occurring microbes are weaponized—harnessed and

modified to cause disease or even kill many people.

> Organisms can be used in their naturally occurring state 

or they may be able to be modified to increase virulence

and/or render the disease they cause resistant to treatment.

> To determine if an outbreak may be bioterrorism, scientists

will look for the following characteristics:

- A large number of cases appearing at the same time, 

particularly in a discrete population (e.g., people from the

same town, people who attended the same event)

- A large number of cases of a rare disease or one considered

a bioterrorism threat (e.g., plague, tularemia)

- More severe disease manifestation than typical for a given

disease and/or an unusual route of exposure

- A disease that is unusual in a given place or is out of

season (e.g., a flu outbreak in the summer in the 

United States)

- Multiple simultaneous outbreaks of the same disease or

different diseases

- A disease that affects animals as well as humans

- Unusual disease strains or uncommon antibiotic resistance

to an organism

Although some of these characteristics may be true of a

naturally occurring outbreak, they will generally signal that the

outbreak needs to be closely scrutinized.

UNDERSTANDING BIOLOGICAL AGENTS

The first step in understanding biological agents and 

how they affect the human body is a review of associated

terminology.

Infectious Diseases

> Infectious diseases are caused by the invasion of the body

by harmful microorganisms.

> Microorganisms multiply and make the person sick by

attacking organs or cells in the body.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 41

> These harmful microorganisms include viruses and bacteria,

as well as certain other microscopic organisms, and are

sometimes called pathogens.

> There is usually a lag time, called an incubation period,

between when a person is infected and when the symptoms

appear.

> People can become infected with these diseases in any

number of ways, including consuming contaminated water or

food, being bitten by insects or animals, or inhaling or

touching the microorganisms or their spores.

- Spores are produced by certain bacteria and plants. 

Like seeds, spores do not grow until the environment is

conducive for them to do so. They are highly resistant to

heat and other environmental factors.

> All of the diseases discussed in this section are considered

infectious diseases. Illnesses caused by chemical agents 

(see “Chemical Agents” section [p. 95]), by contrast, are not

infectious diseases.

Contagious Diseases

> A contagious disease is an infectious disease that can be

“caught” by a person who comes into contact with someone

who is infected. Not all infectious diseases are contagious.

> Exposure to a contagious disease usually happens through

contact with the infected person’s bodily fluids or secretions,

such as a sneeze.

> Depending on the disease, the level of contact required to

pass on the illness could be as casual as water droplets in

the air from a cough (e.g., smallpox).

> The level of contagiousness has nothing to do with how

serious the resulting disease may be. For example,

pneumonic plague and the common cold are both highly

contagious, but pneumonic plague is obviously a much more

serious disease.

> There are some infectious diseases that are not contagious at

all, no matter how close the contact with an infected person

(e.g., botulism, tularemia).

Toxins

> Toxins are the poisonous, usually protein-based, substances

produced by microorganisms (bacteria, mold, virus) in certain

infectious diseases.

> Microorganisms use these toxins as the specific weapons for

attacking organs or cells in the body.

> Antitoxins are medications that attempt to neutralize a toxin

without necessarily killing the bacteria, mold, or virus that is

producing the toxin.

> Many different types of antitoxins exist because a specific

antitoxin will usually only fight a particular kind of toxin.

> Although toxins are usually classified as being biologically

produced, common language often refers to the poisons

created by nonliving chemical agents as chemical toxins.

JOURNALISTS FROM LARGE CITIES TO SMALL TOWNS “

could wake up and be on the front lines of a new kind of warfare involving radiological, chemical,

or biological agents with all the associated hazards or responsibilities. There’s a whole new

dimension here that’s never existed before. “

Peter Van D. Emerson, Senior Associate

Harvard University’s John F. Kennedy School of Government

“Girding for Terror,” American Journalism Review, April 2003
42 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Bacteria and Viruses

> Both bacteria and viruses can cause infectious diseases.

Bacteria

> Bacteria are one-celled microorganisms that are capable 

of multiplying.

> Not all bacteria are harmful (e.g., bacteria turn milk into cheese).

> Antibiotics are medications that can be used to kill harmful

bacteria.

> Some bacteria can develop resistance to antibiotics, making the

medications less effective.

> Hospitals will typically have supplies of antibiotics known to be

effective against most Category A and B bacterial agents.

Viruses

> Viruses are simpler than bacteria, often made up merely of a

bit of deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)

that is surrounded by a protective coat of protein.

> Viruses are parasitic in nature and unable to multiply without

host cells—cells within a person’s body that the viruses

invade and use to multiply.

> Antibiotics are not effective against viruses.

> Some antiviral medications do exist, but many that might 

help against Category A agents are still in clinical trials.

Consult HHS’ National Institute of Health’s National Institute

for Allergy and Infectious Diseases’ (NIAID) Web site

(http://www2.niaid.nih.gov/biodefense) for ongoing research

in this area.

DELIVERY OF BIOLOGICAL AGENTS

The ability to successfully deliver a biological attack depends on:

> The type of agent or organism

> The method of dissemination

> The weather (e.g., wind speed, humidity, time of day,

precipitation, temperature):

- Wind speed affects how widely an agent can be spread

- Humidity can cause decomposition of an agent

- Precipitation can cause clumping, making fine particles

more difficult to inhale

Routes of Entry

Biological agents can enter the body through:

INFECTIOUS BUT NOT CONTAGIOUS INFECTIOUS AND CONTAGIOUS

FIGURE 3–1: INFECTIOUS DISEASE: SOMETIMES CONTAGIOUS, SOMETIMES NOT

MICROORGANISM

INFECTIOUS DISEASE

INFECTED PERSON

INFECTIOUS DISEASE 

THAT IS ALSO CONTAGIOUS

INFECTIOUS DISEASE 

THAT IS ALSO CONTAGIOUS

INFECTED PERSON

MICROORGANISM

INFECTIOUS DISEASE

INFECTED PERSON INFECTED PERSON
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 43

> Absorption

> Inhalation

> Ingestion

> Injection

Delivery Methods

Biological weapons can be prepared for delivery as a weapon

in wet or dry form:

> In dry form, agents are more stable and refinement is easier

> In liquid form, agents are less stable, require refrigeration,

and are difficult to refine to small particle sizes

Biological weapons can be delivered by:

> Wet or dry aerosol sprayers

> Explosive devices

> Transmission through insects, animals, or humans

> Introduction into food, water, or even medications

> In or on objects, in some cases (e.g., anthrax in envelopes)

Effectiveness of Release

The effectiveness of a biological release depends on:

> The particle size and its potency (for example, in an aerosol

release, the size must be between 1 and 5 microns to be

inhaled and cause illness) (Note: 1 micron is one millionth of

a meter. A strand of hair ranges between 20 and 200 microns

in width.)

> How well the agent survives in the environment

> Weather conditions

TESTING FOR BIOLOGICAL AGENTS

Quick diagnosis and treatment of a patient exposed to a

biological agent are key to saving that patient’s life. 

A biological attack may go unnoticed until large groups of

people begin exhibiting symptoms, which makes prompt

diagnosis even more critical. But getting a quick medical

answer is complicated by the fact that currently there is no

single test that can diagnose whether a person has been

exposed to biological agents. There are clinical trials under

way, however, on better testing methods.

To look for evidence of biological agents, physicians will take

blood or other samples to be tested at clinical laboratories. 

As the clock is ticking, the sample must be collected and sent

to the appropriate lab for analysis. However, it takes time 

to isolate the bacteria, toxin, or virus from the sample. 

This timeframe can stretch from hours to days, depending on the

agent, the amount of exposure, the proximity and capabilities

of the lab, and the time the test(s) take. The following list

provides descriptions of the types of tests that may be run:

> Environmental testing is examining a building or an area for

the presence of a biological or chemical agent. Testing is

usually a two-step process. Using anthrax as an example, 

if the sample contains a large amount of the bacteria

(Bacillus anthracis), a positive reading may come back

within minutes. However, this quick initial result from the

scene may be what is called a false positive result, so a more

reliable test must be done by a more sophisticated laboratory

to confirm the results. The confirmation test can take up to

72 hours depending on how fast the bacteria grow and can

be positively identified.

BACTERIA VIRUSES

• One-celled microorganisms that contain several components • Bits of DNA or RNA.

within the single cell.

• Some bacteria can also exist as spores that help them survive • Viruses need to infect living cells to survive and multiply.

harsh conditions. Spores can germinate to become full-fledged

bacteria; this is the case with anthrax.

• Antibiotics can be used to kill bacteria. • Antibiotics do not affect viruses; some antiviral medications exist.
44 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

SHOULD I KEEP SUPPLIES OF CIPRO AND KI IN MY MEDICINE

CABINET AT HOME?

After the anthrax attacks of 2001, many people wanted to obtain certain

medical supplies, such as Cipro (ciprofloxacin hydrochloride) or KI

(potassium iodide) tablets, to have on hand in case of an emergency.

Although people may feel comforted by keeping these supplies at

home, the truth is that personal stockpiling of such products can

actually do more harm than good. Because we do not know how a

future attack will unfold, it is impossible to know what type of medical

response will be best. Here are a few specific concerns that public

health officials have about the stockpiling of medical supplies:

> False sense of security. Believing that one has what he or she needs

at home can result in not getting necessary medications if they are

really needed. For example, Cipro is a prescription antibiotic that

was the drug of choice in the 2001 anthrax attacks. It may be useful

for combating some kinds of biological agents but may not be the

best drug to use for all bacteria. And, if the drug has been sitting in

a medicine cabinet for several years, it may no longer be potent.

> Some supplies may be ineffective against a given threat. KI, for

example, can protect the thyroid gland from exposure to radioactive

iodine, which may be released in some radiological incidents, but

this does not help protect against other forms of radioactivity that

may come with an attack. In addition, not all attacks will involve the

release of radioactive iodine. Some communities with nearby

nuclear reactors have made KI available to residents, but that 

doesn’t mean that maintaining a ready stock of KI is right for every

community and every family. If an attack with a dirty bomb or other

radiological device took place, KI may not be helpful, and people

may mistakenly think that they are protected.

> Side effects and adverse reactions. Certain medications, including

Cipro, can cause an allergic reaction or severe side effects in some

people. Taking these drugs without proper guidance can increase

the risk of possible side effects and adverse reactions.

Public health officials do recommend that people have other supplies

on hand, including food, water, medications taken routinely, and a 

battery-powered radio. A more detailed list of supplies can be found

in appendix F (see p. 242). In an emergency, public health officials will

let community members know through the media what is going on and

where they should go to obtain necessary medical supplies.

> A nasal swab is an environmental test that may be used 

to assist in a public health investigation to determine the

presence of a bioterrorism agent in an area or building. 

Nasal swabs are not used to determine if a person is infected

by a given agent.

> A culture is a method for growing an organism in the lab 

(for example, in a Petri dish). A culture can help in identifying

a bacteria or virus. Cultures are the most readily available

technology for clinical diagnosis of a suspected case of

bioterrorism but can be time consuming to complete.

> A blood culture is a test that looks for bacteria or viruses in

the blood. Blood is drawn from a patient, and the sample is

sent to a special laboratory for analysis. The sample is

incubated, or kept in a warm place, at a certain temperature,

and in this controlled environment, the bacteria grow and are

isolated from the blood for easier identification.

> “Media” are the nutrient mixes used to grow organisms in 

a lab. Selective media are used to identify an organism by

giving it or depriving it of certain nutrients. For example,

selective agents can be added or removed, which “poison”

some organisms while allowing others to grow.

> Gram staining uses dyes to make a bacterial cell stand out

for identification. A specimen is put on a slide and a four-part

staining procedure begins. This test may produce results in

less than an hour, but it is not specific enough to definitely

identify the organism, and a longer confirmation test is still

needed.

> Obtaining sputum involves getting a sample of a patient’s

phlegm by having him or her cough it up. Sputum samples

are usually ordered when a patient is exhibiting pneumonialike symptoms that could be an indicator of an inhalational

form of anthrax, plague, or tularemia. The sample is then

stained and viewed under a microscope to look for the

presence of certain bacteria. Part of the same sample is also

used for a culture.

There are also more sophisticated tests that are used to 

identify agents, such as:

> Immunoassays, which look for specific antigens or antibodies

and are useful in detecting the presence of toxins. However,

antibody production for identification can take time.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 45

> Gene amplification assays, such as a polymerase chain

reaction, which look at the DNA or RNA to identify an agent.

However, sample preparation can take a long time.

In general, detection and identification using any of these

methods is dependent on the sample quantity and quality and

the exactness of the processing. A combination of tests will

yield the most accurate results. In the absence of immediate

results, physicians who suspect bioterrorism may begin a

preliminary course of treatment until the lab results are in.

HOW LONG TESTING SHOULD TAKE

Unfortunately, there is no single answer to the question of how

long testing will take. The testing of biological agents 

is complicated by several factors, which can affect the time

that passes before the presence of an agent can be confirmed

or a diagnosis can be made. These factors include:

> Identifying the agent: Although bioterrorism is now a

household term, actual incidents of bioterrorism have been

rare, leaving today’s physicians with limited experience in

identifying these agents in the lab or treating affected

patients. This means that the first patients who become sick

may be mistaken for having other illnesses, thus causing a

delay in the effort to test for biological agents.

> Presumptive vs. confirmatory diagnoses: Not all tests are

conclusive. Some tests, such as Gram stains, can give a

presumptive diagnosis that an agent is present, but followup

tests are needed. In general, presumptive diagnosis of an

agent can usually be made in about a day. Confirmatory

diagnosis can take 2–3 days.

> Viral, bacterial, or toxin load: The “load” refers to how much

of the agent is present in a patient. If relatively large amounts

of an agent are present in a patient, cultures designed to

grow the bacteria or virus could take as little as a few hours. 

If smaller amounts of the agent are present in a patient, 

these same culture tests could take up to 2 or 3 days.

> Lab capabilities: Can the needed tests be done in local labs,

near a suspected attack, or do the samples need to 

be shipped out to more advanced labs, thus affecting the

overall timeline? Shipping samples to more advanced labs

can tack on an extra day or two to the wait time. CDC’s

Laboratory Response Network helps facilitate this process.

> The kind of test that is used: Numerous tests are employed

to detect the presence of bioterror agents. Blood cultures can

take up to 3 days, in some cases for example, but Gram

stains can be ready within an hour. However, some of these

quicker tests will only give preliminary information, which

must be confirmed with more comprehensive tests.

More information on the laboratory system in the United

States can be found in the “Planning for the Unthinkable:

Preparation and Response in Public Health” section (see p. 5).

WHAT WE DON’T KNOW ABOUT BIOLOGICAL WEAPONS 

OF MASS DESTRUCTION

> It is not known who is in possession of biological Weapons

of Mass Destruction.

> Medical experts do not know if bacteria have been

engineered to be resistant to antibiotics.

> Experts do not know how potent the strains will be in a

biological attack.

> Experts do not know if the illnesses caused by some of these

agents will be immediately recognizable.

> There is disagreement on how long some of these agents can

survive in the environment.

> Experts do not know if the diseases these agents cause will

be the same as past epidemics (e.g., is today’s smallpox the

same as the disease that was eradicated?).

THERE IS NO SINGLE ANSWER to the question of how long testing will take.

03BIOLOGICAL AGENTS

ACATEGORY A AGENTS

Category A agents are defined by CDC as the

“highest priority” of concern for potential

bioterrorist threats. Category A agents are given the

most consideration in this section because there are

many different kinds—each with a different effect

on the body—and because the natural origin of

these so-called bioweapons makes the building

blocks relatively easy for terrorists to acquire. 

In general, dissemination of any of the Category A

agents could strain the public health care system

and cause widespread concern.

Basic facts and scientific information for Category A

agents are provided; agents are treated alphabetically.
ANTHRAX

BASIC FACTS WHAT WE DON’T KNOW ABOUT ANTHRAX AS A

WEAPON

> Exactly how long the spores remain dangerous is unclear.

> Experts cannot say whether spores can become airborne

again after settling. This was one of the issues that made it

difficult to assess how the attacks on the U.S. mail system

would play out.

> Experts disagree on how many spores are necessary to infect

someone. Originally it was believed that it would take up to

10,000; but after the 2001 attacks, experts have revised

that number; some believe it takes only a few thousand. 

For immune compromised people, there is no safe lower limit.

IDENTIFYING AN ATTACK

> An anthrax attack will most likely go undetected until people

start becoming sick.

> Tests to confirm the presence of anthrax spores can be 

conducted on suspicious powder or residue.

> Environmental testing confirms the presence of spores in 

a building.

- Testing determines the extent of exposure in a building 

or site (whether anthrax spores are there and how many).

- Initial tests onsite are not as accurate as subsequent lab

tests and can sometimes generate false positive results.

- Initial tests may miss smaller quantities of spores.

- Samples must be sent to specialized laboratories for more

definitive tests.

- Receipt of conclusive results can take up to 72 hours 

due to the complexity of taking the sample (workers must

wear protective suits), transporting it to a specialized lab,

isolating the bacteria or spores, and producing a test result.

> Blood tests are more reliable in confirming individual cases

of anthrax disease.

> Nasal swabs can be a quick tool to confirm the presence of

anthrax spores in a given environment (but not to diagnose

illness). See the following “Diagnosis” section for more

information.

ANTHRAX SPORES AS A WEAPON

Historically, many nations have weaponized anthrax by turning

it into a concentrated powder or aerosol form. Generally, anthrax

spores tend to clump together and the body can defend itself

against them in that form. In a refined state, however, the

spores are very dangerous when inhaled.

> Anthrax bacteria are easy to grow in a lab but not easy to

refine as a weapon.

> Anthrax spores can be manipulated so they can float through

the air and disperse as widely as possible.

> Anthrax spores can be released into the air directly or through

a building’s heating and ventilation system.

> The 2001 anthrax attacks demonstrated that spores can even

be distributed through envelopes in the mail.

> Once aerosolized, anthrax spores cannot be seen by the naked

eye or smelled.

> Weaponized anthrax spores can remain in the environment for

long periods of time.

> Scientific name: Bacillus anthracis; rod-shaped bacteria

(not a virus).

> Anthrax is the disease that develops after exposure 

to spores produced by this bacteria.

> The spores can remain dormant for long periods but are

still capable of causing infection when someone comes

in contact with them by touching or breathing them in.

> Anthrax spores can cause three types of illness,

depending on how a person is exposed:

- Inhalational (respiratory)—most lethal

- Cutaneous (skin)

- Gastrointestinal (digestive)

> The anthrax illness is not contagious.

> Anthrax can be treated with antibiotics if diagnosed early.

> An anthrax vaccine exists but is not in widespread use.

48 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media
ANTHRAX ILLNESSES

Anthrax spores can induce three types

of illness, depending on how they make

contact with the human body.

INHALATIONAL ANTHRAX

Exposure

> Victims breathe in spores floating

through the air; the spores then lodge

in their lungs.

> Certain cells take the spores to the

lymph nodes surrounding the lung.

Once they enter the lymph nodes, the

spores germinate into bacteria and

cause inflammation and enlargement

of these lymph nodes.

> Anthrax bacteria then spread from the

lymph nodes to sites throughout the

body and produce a toxin that can be

destructive to organs and is difficult to

treat.

Symptoms

Symptoms can occur within 7 days of

infection or can take up to 42 days to

appear. These symptoms include:

> Fever (temperature greater than 

100 degrees Fahrenheit); may be

accompanied by chills or night sweats

> Flu-like symptoms

> Cough, usually a non-productive cough;

chest discomfort; shortness of breath;

fatigue; or muscle aches

> Sore throat, followed by difficulty

swallowing; enlarged lymph nodes;

headache; nausea; loss of appetite;

abdominal distress; vomiting; or diarrhea

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 49

Anthrax spores inhaled.

FIGURE 3–2: INHALATIONAL ANTHRAX

1.

Anthrax bacteria produce toxin that can destroy

organs.

Note: Antibiotics must be prescribed quickly to kill

the anthrax bacteria.

4.

Anthrax spores lodge in lungs where certain cells

take them to lymph nodes surrounding the lungs.

Once they enter the lymph nodes, the spores 

germinate into bacteria and cause inflammation

and enlargement of these lymph nodes.

2.

Anthrax bacteria spread from the lymph nodes

around the lungs and throughout the body.

3.
50 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Anthrax spores enter the body through an open

wound or cut, or even through microscopic 

breakdowns of the skin.

FIGURE 3–3: CUTANEOUS ANTHRAX

1.

Within 1–7 days, a small sore develops into a

blister that becomes a skin ulcer and ultimately

develops a black scab in the center.

2.

Recovery/Mortality Rate

> Cutaneous anthrax is the least deadly

form of anthrax.

> The survival rate is 80 percent without

treatment and more than 99 percent

with treatment.

GASTROINTESTINAL ANTHRAX

Exposure

Gastrointestinal anthrax occurs when

anthrax is ingested, usually through

meat from anthrax-infected animals.

Symptoms

> First signs of the infection appear

within 2–5 days of exposure.

> Initial symptoms include nausea and

loss of appetite.

> Later symptoms include bloody diarrhea,

fever, and severe stomach pain.

> Symptoms mirror those for stomach

flu, food poisoning, and appendicitis.

Recovery/Mortality Rate

If untreated, at least 25 percent of 

gastrointestinal anthrax cases lead to

death.

DIAGNOSIS

To treat someone with an anthrax illness

successfully, it must be diagnosed early.

Early diagnosis is complicated because

there is no single screening test to

confirm anthrax illness.

> Exposure is confirmed by isolating the

anthrax bacteria from the blood, skin

lesions, or respiratory secretions or by

measuring specific antibodies in the

blood.

> Blood tests to confirm an anthrax

infection can take up to 72 hours, since

it takes time to isolate a particular

bacterium in a blood sample. Some

circumstances may produce test results

much more quickly. For example, in a

severe inhalational case, there may be

Recovery/Mortality Rate

> Inhalational anthrax is the most lethal

form of an anthrax illness.

> Inhalational anthrax was the cause of

all five deaths in the 2001 U.S. postal

system attacks.

> Some patients treated with antibiotics

can have an initial recovery followed

by a relapse once antibiotic therapy

has been terminated.

> Inhalational anthrax, like most

diseases, is more deadly for people

with compromised immune systems.

> Untreated inhalational anthrax has 

a 90 percent mortality rate. 

> The survival rate for inhalational anthrax

victims depends on quick diagnosis

and treatment with antibiotics.

> The mortality rate is still approximately

75 percent, even with antibiotics.

CUTANEOUS ANTHRAX

Exposure

Anthrax spores enter the body through

an open wound or cut, or even through

microscopic breakdowns of the skin.

Symptoms

> Symptoms appear within 1–7 days

after exposure.

> A small sore quickly develops into a

blister.

> The blister becomes a skin ulcer, or

eschar, and ultimately develops a

black scab in the center.

> The sore, blister, and ulcer do not hurt

and initially look like a spider bite.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 51

a large concentration of bacteria in a sample, which may allow

technicians to obtain a result in a few hours.

> If inhalational anthrax is suspected, physicians typically obtain

a chest X-ray and a CAT scan to confirm their suspicions.

> Nasal swabs can detect the presence of spores but are not a

diagnostic tool. A positive swab does not mean a person will

develop an anthrax illness and a negative swab does not

mean a person will not develop an anthrax illness. 

A nasal swab is only an indicator of whether anthrax spores

are present in an area.

WHAT WE DON’T KNOW ABOUT ANTHRAX AS AN

ILLNESS

> No one knows for sure when treatment must begin to be

successful. Some believe antibiotics must start within hours,

others say days.

> Physicians do not know if children or specific ethnic groups

are more vulnerable to anthrax than the general population.

> There is still debate about how many spores are needed to

infect a person.

TREATMENT

All three types of anthrax can be treated with antibiotics.

Though ciprofloxacin was first used as a treatment for anthrax

during 2001, doxycycline is now the preferred antibiotic for

anthrax infection. The reason for this is to prevent other 

bacteria from developing resistance to ciprofloxacin.

> Antibiotics are prescribed for 60 days.

> Treatment must begin as soon as possible after exposure 

to be successful because the bacteria produce a toxin in the

body that poisons the system quickly and sometimes

irreversibly. Antibiotics kill the bacteria but cannot remove

the toxin or lessen the effects of any toxin already in the body.

There is no antitoxin for the anthrax toxin.

> Those with inhalational anthrax normally have to be hospitalized

and on a ventilator to help with breathing.

> Anthrax patients do not have to be isolated since the illness

cannot be passed from person to person.

> Which antibiotic is prescribed depends on a patient’s age

and health, the number of cases in the area being treated,

and what is available at the hospital and/or through the

Strategic National Stockpile. More information on the

Strategic National Stockpile can be found in the “Planning for

the Unthinkable: Preparation and Response in Public Health”

section (see p 5).

> Additional antibiotics for treatment of anthrax are being

studied in animal efficacy trials.

VACCINE

> The vaccine is used as a preventive measure for those in

high-risk populations, including:

- Lab workers

- Members of the armed forces deployed to countries 

suspected of having biological weapons programs

> The current anthrax vaccine is not available to the general

public but might be used if an anthrax attack occurs.

> The vaccine is given as a series—three shots administered 2

weeks apart.

> Subsequent injections are given at 6, 12, and 18 months;

annual boosters follow.

> The current vaccine can have side effects:

- Mild side effects may include soreness, itching, or a lump

where the shot was administered; muscle or joint aches;

fatigue; or headache

- Severe side effects may include a severe allergic reaction

(very rare)

- There is no evidence that the vaccine has long-term

adverse side effects

> In October 2004, HHS awarded a contract to VaxGen, Inc.,

for the manufacture of 75 million doses of a new anthrax

vaccine for the Strategic National Stockpile. Evidence from

laboratory and animal research has shown that the new

vaccine, which uses purified recombinant protective antigen,

is effective in providing protection against aerosol exposure to

anthrax spores (HHS 2004).

> For more information on the clinical trials for new anthrax

vaccines, anthrax diagnostic tests, and new antibiotics for

anthrax treatment, see NIAID’s Web site (http://www2.

niaid.nih.gov/biodefense).
52 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

PREVENTION

Although anthrax cannot be spread from person to person, the

spores can travel widely. Following are steps that can be taken

to minimize the risk to people who have come into contact

with anthrax spores:

> Wash skin with soap and water

> Start antibiotic treatment if exposure is suspected but not yet

confirmed

> Treat mail with low doses of radiation; irradiating mail kills

anthrax spores

> Use special mail handling procedures, such as wearing

gloves and masks, to prevent cutaneous anthrax

ANTHRAX HISTORICAL TIMELINE

Naturally occurring, anthrax has affected humans for centuries.

It was typically contracted by people, as well as animals, who

ate, handled, or inhaled spores from infected animals 

or animal products. Early cases of reported anthrax exposure,

however, were isolated and were among workers who handled

wool or leather products.

1876: Robert Koch isolates the bacteria that cause anthrax.

1880: First successful immunization against anthrax is 

performed on livestock.

1937: Japan starts biological warfare program in Manchuria,

including tests involving anthrax.

1942: The United Kingdom experiments with anthrax at

Gruinard Island off the coast of Scotland (which was only

recently decontaminated).

1943: The United States begins developing anthrax weapons.

1970: Anthrax vaccine is approved by the U.S. Food and Drug

Administration.

1972: At the Biological Weapons Convention, more than 100

nations agree not to produce or stockpile Weapons of Mass

Destruction (including the United States).

1979: Aerosolized anthrax spores are released accidentally at

a Soviet Union military facility, killing about 68 people.

1991: U.S. troops are vaccinated for anthrax in preparation for

the Gulf War.

1995: Iraq admits it produced 8,500 liters of concentrated

anthrax as part of its biological weapons program.

1998: U.S. Secretary of Defense William Cohen approves an

anthrax vaccination plan for all military service members.

2001: Letters containing anthrax powder are sent through the

U.S. Postal Service; 22 people become ill and 5 people die.

ASSESSING THE RISK

> Because it is a naturally occurring bacteria and is studied 

in thousands of labs, anthrax is readily available.

> Anthrax spores are highly stable and can survive in the

environment for decades.

> Terrorists would have to be highly skilled to mill weaponsgrade anthrax spores or distribute them effectively to inflict

mass casualties.

> Anthrax is highly lethal and may potentially be made more

so by engineering it to be resistant to antibiotics.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 53

THE CHALLENGE OF ACCEPTING AND COMMUNICATING UNCERTAINTY: IMPLICATIONS OF THE ANTHRAX ATTACKS

As with many of the naturally-occurring diseases that could be caused

by acts of terrorism, anthrax is a disease that is rare in America today.

Between 1989 and the anthrax attacks of 2001, only one case of anthrax

was reported in the United States. Earlier in the 20th century, there were

only 100 cases per year, and it is thought that the anthrax illness had

been largely prevented through an animal vaccination program.

Much of what was known about anthrax before the 2001 attacks was

based on these historical case records. CDC conducted 41 field

investigations from 1950 to 2001, which supplied information about how

anthrax can be contracted, how it affects the body, and the kinds of

decontamination procedures used. Most of these cases involved

agricultural workers who handled infected animals. The public health

community approached the 2001 attacks with this real-world, working

knowledge of anthrax. Unfortunately, the weaponized anthrax used in

2001 showed that what was true of naturally occurring anthrax did not

prove true for this new, weaponized form of the pathogen.

For example, the miniscule size of the weaponized anthrax spores

released in 2001 showed that the spore powder could actually escape

through the tiny pores in paper envelopes and infect people who handle

the envelopes—something naturally occurring spores could never do.

Officials are learning that what we “think we know” about these

pathogens may not hold true during a bioterror attack. And these

differences can change the way an illness is contracted, prevented,

treated, and decontaminated. Communication with the public will try to

explain that the ongoing investigation during the actual incident may

reveal characteristics of the pathogens that are new and unexpected.

Public health treatment and containment strategies will be based on the

best available knowledge at the time and may need to be adapted during

the crisis as new facts are brought to light. Former CDC Director Jeffrey

Koplan said it well in 2001: “No doubt there will be things we learn 2

weeks from now that we wish we would have known today.”

Sources:

Centers for Disease Control and Prevention. (2002). Epidemiologic response to anthrax

outbreaks: Field investigations, 1950–2001. Emerging Infectious Diseases, 8(10).

http://www.cdc.gov/ncidod/eid/vol8no10/02-0223.htm.

Centers for Disease Control and Prevention. (2002). Public health in the time of bioterrorism.

Emerging Infectious Diseases, 8(10). http://www.cdc.gov/ncidod/eid/vol8no10/02-0444.htm.

Centers for Disease Control and Prevention. (2003). Endemic, notifiable bioterrorism-related

diseases, United States, 1992–1999. Emerging Infectious Diseases, 9(5).

http://www.cdc.gov/ncidod/eid/vol9no5/02-0477.htm.
BOTULINUM TOXIN

BASIC FACTS

54 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

WHAT WE DON’T KNOW ABOUT BOTULINUM TOXIN 

AS A WEAPON

Experts believe that only a small amount of the toxin would

need to be inhaled to be deadly on a large-scale basis.

However, because there has never been a successful attack,

the exact amount needed is still a question.

IDENTIFYING AN ATTACK

> Because botulinum toxin is colorless, odorless, and tasteless,

a foodborne, waterborne, or aerosol attack would probably

go unnoticed until people exhibit symptoms.

> Existing public health surveillance is likely to rapidly identify a

large-scale attack once victims began seeking medical care.

BOTULINUM TOXIN ILLNESSES

FOODBORNE BOTULISM

Exposure

> This form of botulism is caused by eating improperly 

preserved or cooked food; contamination can be caused 

by improper canning or cooking of foods.

> Contaminated food may be discolored or have a bad odor 

or taste.

> In infants, botulism can occur when a large amount of the

spore is ingested through food products, such as honey and

corn syrup, normally tolerated by adults.

Symptoms

> Foodborne symptoms generally begin 18–36 hours after

eating contaminated food but can occur as early as 6 hours

or as late as 10 days after food consumption.

> Initial symptoms include blurred or double vision, slurred

speech, drooping eyelids, difficulty swallowing, dry mouth,

and muscle weakness.

> Botulism toxin spreads throughout the body and

predominantly affects the nervous system.

> Within hours, a facial paralysis begins and spreads to the

rest of the body.

> Botulism can result in respiratory failure.

BOTULINUM TOXIN AS A WEAPON

Clostridium botulinum bacteria produce a toxin. Terrorists

have tried to weaponize botulinum toxin by refining the toxin

and putting it into an aerosol form. Refined or crude

preparations of toxin could be used to poison food or beverages,

and refined toxin, with a sophisticated delivery system, could

be used to disseminate the toxin by air.

> Botulism toxin can be disseminated via the air, water, or food.

> Such contamination would be hard to detect because 

botulinum toxin is colorless, odorless, and tasteless.

> Poisoning the water supply would be difficult for terrorists

because:

- Large quantities of toxin would be needed to affect the

water system

- Chlorine in most water treatment facilities would destroy

the toxin

> Scientific name: Botulinum toxin. The toxin, or poison,

is produced by the bacterium Clostridium botulinum

(not a virus).

> Botulinum toxin is the most poisonous substance

known to science.

> Botulism is a muscle-paralyzing disease that develops

after a person is poisoned with botulinum toxin.

> The toxin is colorless, odorless, and tasteless.

> Clostridium botulinum exists naturally in the environment,

and the botulinum toxin it produces can cause two

types of illness:

- Foodborne botulism

> Infant botulism

- Wound botulism

> Inhalation botulism, caused by breathing botulinum

toxin, does not occur naturally but could happen as 

a result of deliberate dissemination of the toxin in the

air by a technologically sophisticated terrorist or as a

laboratory accident. 

> Botulism is not contagious.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 55

Botulinum toxin ingested through food or water.

FIGURE 3–4: FOODBORNE BOTULISM

1.

Initial symptoms include blurred or double vision,

drooping eyelids, and slurred speech.

4.

Within hours, a facial paralysis begins and

spreads through the body.

Note: Symptoms of inhalational botulism would 

be similar.

5.

Botulinum toxin absorbed.

2.

Botulinum toxin spreads throughout the body and

predominantly affects the nervous system.

3.
56 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

cases appear together, it is likely that the diagnosis would be

made quickly.

> There is no single test to detect botulinum poisoning.

> A blood test can detect traces of botulinum.

> A stool sample test may be useful in detecting foodborne 

or infant botulism.

> Suspected foods should also be tested for presence of the

botulinum toxin.

> Special tests (e.g., brain scan) may be needed to exclude

similar conditions from botulism.

TREATMENT

Prompt medical attention is the key to successful treatment for

a botulism illness.

> Treatment should begin as soon as botulism is suspected.

> Botulism antitoxin derived from horse serum is prescribed.

> This antitoxin reduces the spread of paralysis but will not

reverse paralysis that has already set in, so early treatment 

is critical.

> With treatment, most paralysis will eventually go away.

> In severe cases, patients may need long-term care, 

including a ventilator to help assist breathing.

VACCINE

A vaccine to protect against botulism is not available to the

general public.

> An experimental vaccine produced in the 1960s is given to

lab workers and military troops sent to high-risk areas.

> This experimental vaccine is not considered useful for the

general population because many months pass before a

vaccinated person builds full immunity and because repeated

vaccination is required to maintain this immunity.

> People who receive the experimental vaccine may not 

benefit from the medical uses of botulinum toxin, including

cosmetic surgery and treatment of vocal chord spasms.

Recovery/Mortality Rate

If treated, ingested botulism has a survival rate of more than

90 percent.

WOUND BOTULISM

Exposure

> This form of botulism is extremely rare.

> It occurs when someone gets the bacteria into an open cut.

> This illness is most often found in injection drug users.

Symptoms

Symptoms are similar to those for foodborne or inhaled 

botulism.

Recovery/Mortality Rate

The fatality rate for wound botulism is less than 3 percent.

INHALATIONAL BOTULISM

Exposure

> This form does not occur naturally and only three cases (from

a laboratory accident) have ever been reported.

> It would be caused if people inhaled refined botulinum toxin

disseminated through the air.

Symptoms

> Symptoms of inhaled botulinum toxin are similar to those 

of foodborne botulism.

> Symptoms may begin several hours to several days after an

airborne attack (e.g., studies with monkeys show that

symptoms begin 12–80 hours after exposure).

Recovery/Mortality Rate

Because there are so few recorded cases, it is unclear what the

fatality rate of inhalation botulism would be in an attack.

DIAGNOSIS

Botulism is a rare disease. Whether it is naturally occurring or

the result of terrorism, a single case of the illness may be

difficult for physicians to diagnose. However, if several or many
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 57

ASSESSING THE RISK

> Clostridium botulinum is a common, naturally occurring

bacteria, but the toxin is not easily available because one

has to have the laboratory knowledge to produce the toxin

from the bacteria.

> Botulinum toxin is only moderately stable because the

aerosol form can deteriorate in sunlight.

> Terrorists would have to be highly skilled to stabilize the

botulinum toxin for airborne release. A foodborne release

would be somewhat easier.

> An airborne attack could produce highly lethal results; 

a foodborne attack could also be lethal.

PREVENTION

Proper food handling and cooking is the best way to prevent

naturally occurring botulism poisoning.

> Do not eat food that has been left out for long periods 

of time.

> Practice proper home canning of food to reduce the risk 

of botulism.

> Boiling food for 10 minutes can destroy botulinum toxin if

there is concern that food has been contaminated.

BOTULINUM TOXIN HISTORICAL TIMELINE

World War II: Japan uses botulinum toxin to poison food of

Chinese prisoners.

Cold War Era: Various nations, including the Soviet Union 

and the United States, experiment with botulinum toxin as a

bioweapon.

1972: At the Biological Weapons Convention, more than 100

nations agree not to produce or stockpile Weapons of Mass

Destruction (including the United States).

1990: Japanese cult Aum Shinrikyo tries unsuccessfully to

produce an aerosol version of botulinum toxin.

Post-Cold War: Some nations in the Middle East are suspected

of having stockpiles of botulinum toxin; some former Soviet

Union stockpiles of botulinum toxin are unaccounted for.
PLAGUE

BASIC FACTS

> Scientific name: Yersinia pestis; a bacterium (not a

virus).

> Plague is the disease that develops after infection with

this bacterium.

> Humans contract plague by inhaling it or from the bite

of an infected flea.

> Plague infection takes three primary forms:

- Bubonic

- Pneumonic

- Septicemic

> Only pneumonic plague is contagious through respiratory

droplets with direct close contact (within 6 feet).

> Plague is highly lethal if untreated.

> Plague can be treated with antibiotics if caught early.

> Some plague infections occur naturally each year

(usually bubonic).

58 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

PLAGUE AS A WEAPON

Because pneumonic plague is highly lethal and contagious and

would quickly overwhelm communities and their health care

systems, countries with biological weapons programs have

explored using plague in aerosol form to infect large groups 

of people.

> A pneumonic plague outbreak would be difficult to contain.

> Treatment must be immediate (within 24 hours of first

symptoms) to be successful.

> Once refined, plague bacteria can be released into the air

undetected.

> Once released into the air, plague bacteria remain infectious

for up to an hour.

> Aerosolized plague bacteria can infect large groups of people

quickly.

> Plague bacteria degrade quickly in sunlight or heat.

WHAT WE DON’T KNOW ABOUT PLAGUE AS A WEAPON

Experts are uncertain as to how wide an area would be

affected by an aerosol release of plague bacteria or whether it

can be disseminated successfully through the mail, as was the

case with anthrax.

IDENTIFYING AN ATTACK

> A plague attack will likely go unnoticed until people exhibit

symptoms.

> Tests of powder or residue can identify the presence of

plague bacteria.

PLAGUE ILLNESSES

There are three common forms of illness caused by the plague

bacteria:

BUBONIC

Exposure

> Bubonic plague is caused when infected fleas bite humans.

> A person can also be infected through a break in the skin.

> This form of plague illness is not contagious.

Symptoms

> Bubonic plague infects the lymphatic system and causes

severe swelling.

> The first symptoms appear 2–6 days after infection and

include weakness, high fever, and chills.

> If bubonic plague is not treated, bacteria can spread through

the bloodstream, causing septicemic plague or a secondary

case of pneumonic plague.

> Later symptoms appear, such as muscular pain, swelling of

lymph glands, and seizures.

Recovery/Mortality Rate

If untreated, bubonic plague is fatal in more than 50 percent

of cases because of progression of the bacteria into the 

bloodstream.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 59

PNEUMONIC

Exposure

> This form of the disease infects the

lungs.

> It is caused by breathing in aerosolized

plague.

> This illness can be transmitted from

person to person through respiratory

droplets with direct close contact

(within 6 feet).

Symptoms

> Symptoms usually surface 2–4 days

(range of 1–6 days) after exposure.

> Initial symptoms include high fever,

cough, and chills, similar to the flu.

> Later symptoms include pneumonia and

bloody sputum (coughing up blood).

Recovery/Mortality Rate

> Without early detection and treatment,

the mortality rate from pneumonic

plague is nearly 100 percent.

> If treated, the mortality rate from

pneumonic plague is still 50 percent.

SEPTICEMIC

Exposure

> Septicemic plague may be a secondary

illness caused by complications from

bubonic or pneumonic plague, or it can

occur by itself.

> Plague bacteria enter the bloodstream.

> This form of the disease is not 

contagious.

Plague bacteria inhaled.

FIGURE 3–5: PNEUMONIC PLAGUE

1.

Plague may be transmitted to others through 

respiratory droplets (contagious).

4.

Pneumonia starts to develop within 1–6 days.

2.

Symptoms include coughing up blood.

3.
60 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Symptoms

> Symptoms appear 2–6 days after infection.

> Initial symptoms include nausea, vomiting, fever, and chills.

> Later symptoms include low blood pressure, abdominal pain,

shock, and, finally, internal bleeding.

Recovery/Mortality Rate

> Death occurs rapidly if this form of plague is untreated.

> Even with treatment, the recovery rate is only 50 percent.

DIAGNOSIS

Plague can be difficult to diagnose because its initial symptoms

are flu-like and the disease progresses so rapidly. Because it is

contagious in the inhaled form, a bioterror attack involving

plague could go undetected until large groups of people begin

exhibiting symptoms.

> If bubonic plague is suspected, physicians check for the

presence of a painful, swollen lymph node called a bubo,

which occurs no more than 24 hours after initial symptoms.

> Blood cultures, a sputum sample, or examination of a lymph

node sample can confirm plague.

> Physicians will ask for a travel history from the patient to see

if he or she has traveled to a known outbreak area.

TREATMENT

Treatment of plague with antibiotics must begin immediately

to be effective. Containing a plague outbreak involves isolation

and other precautions so that plague does not quickly spread

in communities and overwhelm the health care systems.

> Antibiotics, such as streptomycin, gentamicin, the tetracyclines,

and chloramphenicol, are all effective against plague.

> Determining which antibiotic to prescribe depends on patient

age, health, and availability of the drug, in addition to the

number of cases in an area.

> Antibiotic treatment for pneumonic plague must begin 

within 24 hours after the first symptoms to be successful.

> Patients with pneumonic plague should be isolated.

> Antibiotics are recommended for people exposed to someone

who has pneumonic plague.

> As a precaution, antibiotics may be administered to a person

before plague is diagnosed.

VACCINE

> There is currently no licensed plague vaccine available in the

United States.

> Clinical trials on a vaccine for pneumonic plague are

underway. For more information, see NIAID’s Web site

(http://www2.niaid.nih.gov/biodefense).

PREVENTION

> Preventing plague starts with controlling flea and rat 

populations, the two known carriers of plague.

> Insect repellants should be used to prevent flea bites.

> People traveling to an outbreak area may be given a 

3-week course of preventive antibiotics.

PLAGUE HISTORICAL TIMELINE

Middle Ages: Plague, sometimes called the “Black Death,”

kills millions in Europe; invading armies use plague corpses as

weapons.

World War II: Japanese army drops plague-infected fleas over

China; it is unclear how many people were infected.

Cold War: The United States and the Soviet Union study

plague as a biological weapon; the Soviet Union learns ways

to aerosolize plague.

1970: The United States suspends its program.

1972: At the Biological Weapons Convention, more than 100

nations agree not to produce or stockpile Weapons of Mass

Destruction (including the United States).

Post-Cold War: Stockpiles of plague are unaccounted for in the

former Soviet Union; laboratories around the world receive

plague samples for study.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 61

ASSESSING THE RISK

> Although plague bacteria are under study in many countries,

safeguards in these labs would make a potent strain 

minimally available to terrorists.

> Plague is moderately stable in the environment. It can

remain infectious for up to an hour after being released into

the air, but the organism will break down more quickly if

exposed to sunlight or heat.

> Terrorists would have to be highly skilled to refine plague into

an aerosol attack.

> Plague is highly lethal even with treatment.
SMALLPOX

BASIC FACTS

62 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Scientific name: Variola Major; a virus from the

Orthopoxvirus family.

- A closely related virus, Variola Minor, causes a less

severe form of illness with less than 1 percent 

fatality rate.

> Smallpox was a naturally occurring disease that killed

an estimated 300 million people in the 20th century.

> Officially eradicated in nature in 1980, smallpox has

more recently been of concern as a potential

bioterrorism threat.

> The smallpox virus is moderately contagious; direct,

face-to-face contact is usually required to spread the

disease. Smallpox can also be spread through direct

contact with infected body fluids or contaminated

objects (e.g., bedding).

> Characterized by skin lesions and high fever, smallpox

historically has killed approximately 30 percent of

those infected.

> Routine vaccinations in the United States ended in

1972. At present, a large portion of the population is

considered vulnerable to infection should a bioterrorism

incident occur.

SMALLPOX AS A WEAPON

Because it is contagious from person to person and could

potentially infect large groups of people, taxing the health care

systems of a community, smallpox would be an attractive

weapon for terrorists. It would most likely be delivered in an

aerosol form.

> The smallpox virus could be disseminated into the air as a fine

spray or powder and could infect large numbers of people.

> In aerosol form, the smallpox virus may be infectious for 24

hours before degrading. Heat and sunlight (UV exposure)

may destroy the virus within hours.

> Terrorists could possibly use smallpox virus samples to

intentionally infect a few people, possibly themselves, with

the intention of infecting others. However, it is doubtful that

any one individual would succeed in infecting more than a

few others. By the time that these individuals were

contagious, they would be very obviously seriously ill.

WHAT WE DON’T KNOW ABOUT SMALLPOX AS A

WEAPON

Experts do not know if the smallpox virus in a weaponized

form would be as contagious as the disease was before it was

eradicated.

IDENTIFYING AN ATTACK

Because smallpox has been eradicated worldwide, even one

case of smallpox would be considered a probable terrorist

attack.

> The first sign of an attack would likely be victims becoming

ill, usually between 7 to 17 days after exposure.

> A properly disseminated aerosol cloud of the smallpox virus

would be invisible, odorless, and extremely hard to detect.

SMALLPOX ILLNESS

EXPOSURE

> The incubation period is typically 7–17 days following

exposure.

> Infection usually occurs only when a susceptible person is in

face-to-face contact with someone who has the virus and is

ill with fever and a rash of round lesions.

> The virus is usually spread by droplets; however, having it

spread by aerosol or contaminated objects (e.g., bedding) 

is also possible.

> Smallpox is not known to be transmitted by insects or 

animals.

SYMPTOMS

> Initial symptoms of smallpox may include high fever, fatigue,

headache, and backache.

> Typically, people with smallpox are not contagious until

lesions start appearing and they are obviously ill.

> Two to 3 days after the onset of symptoms: A rash of round

lesions develops on the face, arms, and legs. At the same

time, lesions in the mouth are also present and release large

amounts of the virus into the saliva.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 63

Smallpox virus inhaled or transmitted through 

contaminated objects.

FIGURE 3–6: SMALLPOX

1.

Smallpox may be transmitted to others through

bodily fluids (contagious).

4.

Initial symptoms include headache, backache, 

and fever.

2.

Severe rash starts on face, arms and legs, and

spreads across the body.

3.

> Seven days after the onset of symptoms:

The lesions become small blisters and

by the seventh day are filled with pus. 

> Twelve days after the onset of symptoms:

Lesions begin to crust over. Severe

abdominal pain and delirium can

occur in the later stages of the

disease.

> Three to 4 weeks after the onset of

symptoms: Scabs develop and fall off.

A patient who survives is no longer

contagious after the final scab falls off.

RECOVERY/MORTALITY RATE

> Death is likely in one-third of all

smallpox cases, usually during the first

or second week of illness.

> Of those who recover, 65–85 percent

are marked with deep-pitted scars.

> Some who recover may be permanently

blind.

DIAGNOSIS

Physicians have not seen cases of

smallpox for more than 2 decades, and

making a diagnosis would require

familiarity with the disease and its history.

However, CDC has worked on educating

first responders and emergency room

personnel about the signs and symptoms

of smallpox.

> Smallpox is most commonly identified

by the distinctive rash it causes.

> The rash can sometimes be confused

initially with chicken pox.

> The smallpox lesions are painful 

(as opposed to chicken pox lesions).

> The distribution of smallpox lesions on

the body is different than chicken pox.
64 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Patients with smallpox are typically much sicker.

> Testing of the fluid from the lesions can confirm smallpox.

TREATMENT

There is little that physicians can do, other than supportive

care, to treat the illness itself; containing a smallpox outbreak

becomes the priority once a case is suspected or confirmed.

The public health community becomes involved to track down

and vaccinate those who may have been exposed to 

an infected patient and their close contacts (e.g., family). Strict

home or hospital isolation of cases is very important; close

contacts must be kept under close daily surveillance and

isolated if they develop fever.

> Antibiotics are not effective.

> There is no way to fight the virus once patients become sick.

> Patients with smallpox are isolated.

> Patients with smallpox may require intravenous (IV) fluids

and medication to control fever or pain.

> Secondary bacterial infections of the skin sometimes occur.

These can be treated with antibiotics.

> Research is currently underway on the use of the antiviral

drug cidofovir as a treatment for smallpox.

VACCINE

After the September 11 attacks, fears that terrorists would use

the smallpox virus as a biological weapon led to renewed

vaccine production. There is now enough vaccine available in

the Strategic National Stockpile for every American in case of

an attack.

> The vaccine contains a live virus (vaccinia) which is related

to the smallpox virus but entirely different from it; the vaccinia

virus is weaker so that people produce antibodies but usually

develop only the single pustule at the site of vaccination and,

sometimes, a low grade fever.

> The vaccine provides a high level of immunity from infection

for 3–5 years after vaccination and decreasing immunity

thereafter. It is unclear how long the vaccine provides some

protection against the disease. If a person is vaccinated again

later, immunity lasts even longer.

> However, if a person actually has had smallpox and survives,

he or she then has lifelong immunity.

> The vaccine prevents disease in 95 percent of those 

vaccinated.

> Given within 3 days after exposure to the smallpox virus, the

vaccine will prevent or significantly modify smallpox in the

majority of persons. Vaccination 4–7 days after exposure

likely offers some protection from disease or may modify the

severity of the disease.

> The smallpox vaccine is currently not administered to the

general public because:

- The likelihood of an attack is not known

- Vaccination can result in complications for several welldefined, but specific, groups of people with skin conditions,

such as eczema, as well as for people with HIV/AIDS and

others with compromised immune systems

- Pregnant women, infants under 1 year old, and those taking

steroids could also suffer complications

- Recent research indicates that people with certain heart

conditions should not receive the vaccine (at least until

further research is conducted)

> The vaccine is effective after one dose, so it could easily 

be given to many people if a smallpox event or outbreak

takes place.

> Vaccination of only those people who might have been

exposed to the smallpox virus and their contacts (ring 

vaccination) was used successfully in the past to eradicate

smallpox. However, mass vaccination might be necessary 

in the aftermath of a terrorist attack. More information on

vaccination strategies can be found in the “Planning for the

Unthinkable: Preparation and Response in Public Health”

section (see p. 5).

WHAT WE DON’T KNOW ABOUT THE SMALLPOX

VACCINE

Experts do not know how many of those vaccinated or

revaccinated for smallpox before 1972 can still get sick if

exposed today.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 65

PREVENTION

> Place smallpox patients in medical isolation so that they will

not spread the virus.

> Take special precautions to ensure that all bedding and

clothing of patients are cleaned using bleach and hot water.

> Clean contaminated surfaces with disinfectants, such as

bleach or ammonia.

> Within 3 days, vaccinate people who have come into direct

and prolonged face-to-face contact with smallpox patients.

Closely watch them for symptoms of smallpox.

> In an aerosol release, widespread decontamination is not

necessary, since the airborne virus rapidly blows away from

the area and particles die on their own within 1–2 days.

> Physicians typically use a “ring vaccination” approach, 

vaccinating the circle of people who may have come in

contact with a smallpox patient and the family contacts of

this group of people in order to provide a ring of protection

from further spread. This approach was successfully used in

the past to control outbreaks until smallpox was finally

eradicated.

SMALLPOX HISTORICAL TIMELINE

1700s: Smallpox is likely used as a biological weapon during

the French and Indian War when British soldiers distributed

blankets that had been used by smallpox patients to initiate

outbreaks among American Indians.

1796: Edward Jenner uses the milder cowpox virus to develop

a vaccine for smallpox.

1949: The last confirmed case of smallpox in the United

States occurs.

1972:

> Routine smallpox vaccination ends in the United States.

> At the Biological Weapons Convention, more than 100

nations agree not to produce or stockpile Weapons of Mass

Destruction (including the United States).

October 1977: An unvaccinated person in Somalia becomes

the last documented naturally occurring case of smallpox in

the world.

1980: The World Health Organization officially declares

smallpox eradicated.

1989: Vaccination of U.S. military personnel is discontinued.

2002: Amid new fears of smallpox being used as a weapon,

the Bush Administration announces a priority program to

produce enough smallpox vaccine to assure its availability for

every American. A voluntary program to vaccinate high risk

health care workers is announced. More than 600,000 

military personnel are vaccinated.

2003: Clinical trials are under way for a new vaccine; 

for more information, see NIAID’s Web site (http://www2.

niaid.nih.gov/biodefense).

ASSESSING THE RISK

> The smallpox virus has a low availability, as the only two

confirmed repositories for the virus are in high containment

laboratories in the United States and Russia. Still, there 

is concern that some countries may have secretly retained

their smallpox samples for bioweapons research and 

production.

> The smallpox virus is highly stable (can survive for 1–2 days)

in aerosol form.

> Terrorists would have to be moderately skilled to produce the

smallpox virus in aerosol form if they could acquire the virus. 

> Smallpox is highly lethal because it kills approximately 30

percent of those infected; it is quite contagious and spreads

from person to person.
TULAREMIA

BASIC FACTS

66 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Scientific name: Francisella tularensis; a bacterium

(not a virus).

> Tularemia is the disease caused by this bacterium; 

it is also known as Rabbit Fever or Deer Fly Fever.

> Tularemia spreads to humans from infected animal

tissue.

> The disease can be spread through contaminated food

and water.

> Tularemia is not contagious.

> A small amount of the bacteria can cause the disease.

> There are three types of tularemia:

- Ulceroglandular

- Inhalational

- Typhoidal

TULAREMIA AS A WEAPON

Weaponized tularemia bacteria would most likely be

disseminated through the air. But terrorists could also use the

bacteria to contaminate food or water.

> If released into the air, F. tularensis can remain potent for up

to 2 hours.

> The bacteria can survive at low temperatures in water, soil,

hay, or frozen animal carcasses.

> The bacteria quickly degrade in heat once released in the air.

WHAT WE DON’T KNOW ABOUT TULAREMIA AS A

WEAPON

Experts are not sure exactly how small an amount of bacteria

is needed to cause infection. According to CDC, as few as

10–50 bacteria could cause disease.

IDENTIFYING AN ATTACK

> An attack may go undetected until people start getting sick.

> Testing of powder or residue can confirm the presence of

tularemia bacteria.

> Environmental monitoring of air and water samples can

detect the presence of tularemia bacteria.

TULAREMIA ILLNESSES

The tularemia infection takes several forms, depending on the

strength of the bacteria and how they enter the body.

ULCEROGLANDULAR

Exposure

> People can contract this disease from the bite of an infected

tick or fly.

> People can also contract this disease when an open wound

comes in contact with infected meat.

Symptoms

> Symptoms typically appear between 3 to 5 days, but

sometimes as late as 14 days after exposure.

> Skin ulcers appear at the infection site.

> Lymph nodes in the area become swollen.

Recovery/Mortality Rate

> The disease is treatable with antibiotics.

> With treatment, fewer than 2 percent of victims die from this

form of tularemia.

INHALATIONAL

Exposure

The disease is contracted by inhaling the bacteria.

Symptoms

> Symptoms typically appear within 3–5 days but sometimes

as late as 14 days after exposure.

> Early symptoms include sudden fever, chills, coughing, 

joint pain, weakness, and headaches, similar to the flu.

> Later symptoms include inflamed eyes, oral ulcers, severe

pneumonia, chest pain, and respiratory failure.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 67

Recovery/Mortality Rate

> This form of the disease is treatable by

antibiotics.

> Inhalational tularemia has a 60 percent

fatality rate if untreated.

TYPHOIDAL

Exposure

This is a secondary form of tularemia

that develops after a victim has contracted

inhalational tularemia.

Symptoms

> This form of tularemia attacks the 

circulatory system as well as the 

respiratory system.

> Symptoms include fever, extreme

exhaustion, and weight loss.

Recovery/Mortality Rate

> This form of tularemia is treatable with

antibiotics.

> The recovery rate is similar to that for

inhalational tularemia.

DIAGNOSIS

All forms of tularemia are difficult to

diagnose because early symptoms

resemble those of the cold and flu.

> A rapid diagnostic test for tularemia

does not exist.

> A chest X-ray may confirm inhalational

tularemia.

> Blood tests can confirm the presence

of tularemia bacteria.

TREATMENT

> All forms of tularemia can be

successfully treated with antibiotics,

including streptomycin, gentamicin, or

doxycycline.

> The choice of antibiotics is determined

by the patient’s age and health and

the availability of the drug when

weighed against the number of cases

in an area.

> Physicians prefer the injection of

antibiotics for more effective results.

VACCINE

> An investigational vaccine for tularemia

was developed but is currently

unavailable. When it was in use, it

was in limited distribution, mainly to

lab workers.

> The vaccine is not useful for people

who have already been exposed to

tularemia.

> The current vaccine does not fully

protect against inhalational tularemia.

> Research continues on a nextgeneration vaccine for inhalational

tularemia; for more information, 

see NIAID’s Web site (http://www2.

niaid.nih.gov/biodefense).

Tularemia bacteria inhaled.

FIGURE 3–7: INHALATIONAL TULAREMIA

1.

Initial symptoms include sudden fever, chills,

coughing, and aches.

2.

Later symptoms include inflammation of the eyes,

pneumonia, and chest pain.

3.
68 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

PREVENTION

> Avoid contact with dead animals that may be infected.

> Decontaminate yourself with soap and water if you have

come into contact with the bacteria.

> Decontaminate surfaces using solutions that are a combination

of bleach and alcohol.

TULAREMIA HISTORICAL TIMELINE

1940s: The United States, the Soviet Union, and Japan study

tularemia as a biological weapon.

1970s: Reports indicate that Soviets develop strain of

tularemia resistant to antibiotics.

1972: At the Biological Weapons Convention, more than 100

nations agree not to produce or stockpile Weapons of Mass

Destruction (including the United States).

1990s: Mass quantities produced by the Soviet Union in

biowarfare program remain unaccounted for.

Summer 2000: An outbreak of pneumonic tularemia occurs

on Martha’s Vineyard, linked to brush and lawn cutting; 15

patients are successfully treated.

ASSESSING THE RISK

> Although the disease can occur naturally, it is rare, so the

bacteria are only moderately available.

> Tularemia bacteria are minimally stable, since even 

moderate heat and disinfectants can kill the organism.

> Terrorists would have to be highly skilled to use tularemia in

an attack because the bacteria are difficult to process and

stabilize into a form that can do great harm. A waterborne

attack would require too great of an amount of the bacteria

to poison the water, since chlorine added to most drinking

water would kill the bacteria.

> When treated with antibiotics, tularemia has a low lethality.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 69

EXAMINING TULAREMIA—IS IT TERRORISM OR A NATURALLY OCCURRING DISEASE?

Whenever a case of an illness caused by a potential bioterrorism agent

occurs, the media will ask, “Is this terrorism?” CDC’s disease detectives,

or epidemiologists, will also ask that question and will use what we know

about these illnesses, and what we know about the new cases, to help

answer the question. Since many of the Category A and B agents exist

naturally in the United States, it is important to look closely at individual

cases and outbreaks before jumping to any conclusions. Tularemia—

a disease which has been reported in every state except Hawaii—is 

an example.

During 1990–2000, a total of 1,368 cases of tularemia were reported 

to CDC from 44 states, averaging 124 cases per year. Although 

cases have appeared nationwide, four states accounted for 56 percent 

of all reported tularemia cases: Arkansas, Missouri, South Dakota, 

and Oklahoma.

In the United States, most persons with tularemia acquire the infection

from arthropod bites, particularly tick and deerfly bites, or from contact

with infected mammals, particularly rabbits. Fifty years ago, most cases

occurred during winter and were often related to rabbit hunting. Now,

most cases occur in the late spring and summer months, when tick bites

are most common. Outbreaks of tularemia in the United States have also

been associated with muskrat handling, deerfly bites, and lawnmowing

or cutting brush.

Although tularemia does occur in the United States, it is a rare disease,

so every case will be carefully observed. To answer the question

“Terrorism or nature?,” epidemiologists will ask whether the case and

patients follow the familiar patterns of the past. For example:

> Is the case in an area of the country where we usually see tularemia?

> Has the patient had contact with animals or been bitten by a tick or

other arthropod?

> Is this a time of year when we usually see tularemia in that geographic

area?

The CDC’s National Notifiable Diseases Surveillance System is used to

track data on cases of various diseases, including tularemia. From these

types of data, baseline patterns emerge for comparison purposes.

Outbreaks that do not fit the usual pattern may raise red flags. For

example, if cases occur in a person with no known risk factors, there is

an unusual pattern of symptoms, or a cluster of cases is seen in an

unusual area of the country, such as a major metropolitan area, then

concern about possible terrorism would be higher. A case of pneumonic

tularemia, particularly in low-incidence areas, would also be of concern.

Sources:

Centers for Disease Control and Prevention. (2002). Tularemia—United States, 1990–2000.

Morbidity and Mortality Weekly Report, 51(9), 182–184.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5109a1.htm.

Centers for Disease Control and Prevention. (2003). Endemic, notifiable bioterrorism-related

diseases, United States, 1992–1999. Emerging Infectious Diseases, 9(5).

http://www.cdc.gov/ncidod/eid/vol9no5/02-0477.htm.
VIRAL HEMORRHAGIC FEVERS (VHFs)

BASIC FACTS

70 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

VHF ILLNESSES

EBOLA

Of all the VHFs, Ebola is probably the best known due to

outbreaks in Africa.

Exposure

> Ebola can be passed to humans through infected animals.

> Once a person becomes ill, the virus can be transmitted to

others through exposure to blood or bodily fluids, including

airborne droplets from coughing.

> Outbreaks most often occur in areas where isolation of

patients is difficult.

Symptoms

> Patients usually become sick 4–6 days after exposure.

> The disease attacks blood vessels and organs, particularly

the liver, spleen, and kidneys, causing heavy bleeding.

> Symptoms include fever, vomiting, diarrhea, and heavy

bleeding from multiple sites.

Recovery/Mortality Rate

> The fatality rates range from 50–90 percent.

> Death usually occurs within 1–2 weeks of falling ill, 

most often from shock and blood loss.

DIAGNOSIS

> Specific laboratory tests do exist to detect the virus in a blood

sample.

> The handling of the virus is a biohazard, so tests need to be

performed in a biosafety level 4 laboratory.

> Diagnosis is usually made by monitoring symptoms and by

tracking a patient’s exposure to the virus.

TREATMENT

Physicians treat the patient with fluids to prevent dehydration

and try to control bleeding.

VHFs AS A WEAPON

> In aerosol form, any of these viruses could be highly lethal.

> Soviet scientists are known to have weaponized the Marburg

virus, a close cousin of Ebola.

> Many other VHFs have potential for aerosol dissemination or

weaponization.

IDENTIFYING AN ATTACK

> Evidence of an attack would most likely come when patients

fall ill.

> Because natural outbreaks of VHFs have been known to occur,

investigators would have to rule out nonterrorist causes.

Viral hemorrhagic fevers (VHFs) are a class of diseases,

contracted from viruses, that include:

> Ebola

> Marburg virus

> Other illnesses (e.g., Lassa, Machupo)

The following are general characteristics of VHFs:

> They are naturally occurring in mosquitoes, ticks,

rodents, and other animals

> They cause massive internal and external bleeding

> The fatality rate can be as high as 90 percent

> With the exception of yellow fever and Argentine 

hemorrhagic fever, for which vaccines have been

developed, no vaccines exists that can protect against

these diseases

> No drugs are available to combat the viruses that 

cause VHFs
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 71

VACCINE

> No vaccine currently exists for most

VHFs.

> Research continues on a possible

vaccine and antiviral drug treatments;

for more information on clinical trials,

see NIAID’s Web site (http://www2.

niaid.nih.gov/biodefense).

> Even under lab conditions, the virus 

is contagious, complicating vaccine

research.

PREVENTION

Due to the contagious nature of Ebola,

quick identification and isolation of 

victims is essential to containing the

spread of it and other VHF diseases.

While considered highly contagious,

Ebola is spread only by direct contact

with patients and their bodily fluids.

> Avoid infected animals or people.

> Isolate and monitor patients and 

people who have had close physical

contact with patients.

> Hospital workers and caregivers must

wear gowns, gloves, and masks and

practice extreme caution while treating

patients.

> Promptly bury or cremate patients

who die from the disease because a

corpse can be infectious for a period of

time after death.

WHAT WE DON’T KNOW ABOUT

EBOLA PREVENTION

> It is not known how long a person can

remain contagious after recovering.

> Some research suggests that those

patients who survive can continue to

pass the disease to others through

sexual contact for up to 7 weeks.

VHF HISTORICAL TIMELINE

1967: The Marburg virus is first

recognized in laboratory workers in

Marburg, Germany, and Belgrade,

Yugoslavia; the workers had been

exposed to tissues and blood from

African green monkeys imported from

Uganda.

1972: At the Biological Weapons

Convention, more than 100 nations

agree not to produce or stockpile

Weapons of Mass Destruction 

(including the United States).

1976: The Ebola virus first emerges in

two major disease outbreaks occurring

almost simultaneously in Zaire and

Sudan; more than 500 cases are

reported, with a mortality rate of 80

percent.

Ebola virus inhaled or transmitted through bodily

fluids from an infected person or animal.

FIGURE 3–8: EBOLA

1.

Symptoms include fever, vomiting, diarrhea, and

heavy bleeding.

2.

Ebola may be transmitted to others through bodily

fluids (contagious).

3.
72 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

1980s: Soviets weaponize the Marburg virus as an airborne

powder and experiment on blending Ebola with smallpox.

1989: Monkeys imported from Africa to Reston, Virginia, test

positive for Ebola, prompting an outbreak scare chronicled in

the book “The Hot Zone.”

1992: Japanese cult Aum Shinrikyo makes an unsuccessful

attempt to obtain Ebola in Zaire.

1995: Ebola breaks out in Zaire, killing 244 of the 315 

people infected.

1996: Ebola first surfaces in Gabon in the form of two

outbreaks in February and July.

2000: Ebola outbreak in northern Uganda kills 173 people.

2001: Ebola kills 53 people in Gabon.

2004: A Russian scientist at a former Soviet biological

weapons laboratory in Siberia dies after accidentally pricking

herself with a needle laced with Ebola (showing how

dangerous VHFs can be, even under lab conditions).

2005: Marburg outbreak confirmed in Angola, Africa. 

ASSESSING THE RISK

> The ingredients to weaponize VHFs are moderately available,

since naturally occurring outbreaks of Ebola could become a

source for a terrorist organization. Some less virulent VHF

viruses can be obtained from animals.

> VHFs are generally minimally stable, and few can be 

produced in aerosol form for widespread release.

> Terrorists would have to be highly skilled to weaponize 

VHFs since they are extremely dangerous to work with, even

in the lab.

> VHFs are highly lethal, especially because there are 

no known vaccines or treatments to protect against most 

of them.
03BIOLOGICAL AGENTS BCATEGORY B AGENTS

Category B agents are defined by CDC as “second

highest priority.” Although these agents are fairly

easy to disseminate, they generally cause moderate

illness and low death rates. In most cases,

scientists have experience with Category B agents

as naturally occurring infectious diseases but do not

know much about how they could be used as

weapons by terrorists. Examples of Category B

agents include Salmonella, E. coli O157:H7,

Staphylococcus enterotoxin B, and ricin. Ricin is

perhaps best known because it was sent through

the mail to U.S. Senate office buildings in early

2004.

Basic facts and scientific information for Category B

agents are provided; agents are treated alphabetically.

Some categories of detail that appear in the

Category A agents section do not appear here

because the information available on some of these

agents is limited.
BRUCELLOSIS

BASIC FACTS

> Brucellosis is an infectious disease caused by the 

bacteria Brucella species (not a virus).

> These bacteria are mainly transmitted among animals

(sheep, goats, cattle, deer, elk, pigs, dogs, and several

others).

> Humans can contract brucellosis by coming into 

contact with infected animals (and unpasteurized milk

from infected animals).

> Brucellosis is not very common in the United States.

> It is more common in countries where animal disease 

is high.

BRUCELLOSIS AS A WEAPON

Scientists expect that terrorists would refine brucellosis into

aerosol form for an open-air release.

WHAT WE DON’T KNOW ABOUT BRUCELLOSIS 

AS A WEAPON

Scientists are not sure if the bacteria that cause brucellosis can

be aerosolized into a form that can cause mass casualties in an

open-air or closed environment release.

BRUCELLOSIS ILLNESS

EXPOSURE

Humans can be infected three ways:

> Eating or drinking something contaminated with brucellosis

(most common)

> Inhaling the organism (most common in laboratories or in a

biological attack)

> Having the bacteria enter the body through open wounds

SYMPTOMS

> Human brucellosis symptoms include flu-like symptoms,

including fever, sweats, headaches, back pains, and physical

weakness.

> Severe infections to the central nervous system or lining of

the heart can occur.

> Chronic or long-lasting symptoms may include recurrent

fevers, joint pain, and fatigue.

RECOVERY/MORTALITY RATE

Recovery can vary from a few weeks to several months,

depending on the timing of treatment and severity of the 

illness.

DIAGNOSIS

> Laboratory blood or bone marrow testing can detect Brucella

organisms.

> A blood test can also be used to detect antibodies against the

bacteria. This method requires that two blood samples be

taken 2 weeks apart.

TREATMENT

The antibiotics doxycycline and rifampin are usually used in

combination for 6 weeks to prevent reoccurring infection.

VACCINE

> Vaccines are available for the animal forms of brucellosis.

> There is no vaccine available for humans.

PREVENTION

> If food products have not been pasteurized, they should not 

be eaten.

> When handling animal carcasses, rubber gloves should 

be worn.

74 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media
EPSILON TOXIN

BASIC FACTS

> Epsilon toxin is produced by the bacteria Clostridium

perfringens (not a virus).

> This toxin is a common cause of foodborne illness

attributed to improper cooking, cooling, or holding of

beef or chicken.

EPSILON TOXIN AS A WEAPON

Could be used to contaminate the food supply, but this is not

a toxin that could cause mass casualties.

WHAT WE DON’T KNOW ABOUT EPSILON TOXIN 

AS A WEAPON

Scientists do not know what concentrations would be needed

to cause severe illness if this toxin were put into the food

supply.

EPSILON TOXIN ILLNESS

EXPOSURE

People would most likely be exposed by eating tainted foods.

SYMPTOMS

Symptoms of the illness caused by epsilon toxin include severe

stomach pain, diarrhea, nausea, and vomiting.

RECOVERY/MORTALITY RATE

> Most people recover within days with or without treatment.

> The illness from epsilon toxin can be fatal in some cases—

for the elderly and those with compromised immune systems.

DIAGNOSIS

> Blood tests are used to determine the presence of the toxin.

> A stool sample test may help physicians make a diagnosis.

TREATMENT

The patient is given fluids to prevent dehydration.

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 75
FOOD SAFETY THREATS

OVERVIEW

ESCHERICHIA COLI O157:H7 BASIC FACTS

76 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

There are a variety of bacteria that can affect food safety. Harnessed by terrorists, these could be used to poison the food

supply and cause illness and death. Three examples are:

> E. coli O157:H7

> Salmonella

> Shigella

> E. coli O157:H7 is one of hundreds of strains of the

bacteria Escherichia coli (not a virus).

> Most strains of E. coli are harmless and are found in

healthy humans.

> E. coli O157:H7 is the most toxic of the strains and can

cause severe illness and, in some cases, death.

E. COLI ILLNESSES

EXPOSURE

> Eating raw or undercooked meat contaminated with E. coli

O157:H7, especially ground beef, can expose a person to the

bacteria.

> The bacteria can be passed by cows to milk and then to

humans if the milk is not pasteurized.

> Eating contaminated raw vegetables, unpasteurized milk and

juice, and swimming in or drinking sewage-contaminated

water can also infect a person.

> E. coli O157:H7 can spread if an infected person does not

wash his or her hands properly.

SYMPTOMS

> Symptoms appear from hours to days after exposure.

> The infection causes severely bloody diarrhea and abdominal

cramps.

> A slight fever may be present.

> In young children under age 5 and the elderly, severe cases

of O157:H7 may result in kidney failure. About 2–7 percent

of infections lead to this complication.

RECOVERY/MORTALITY RATE

Most cases recover without antibiotics or other treatment in

5–10 days.

DIAGNOSIS

> E. coli O157:H7 can be diagnosed by testing a stool sample.

> Any person who suddenly has bloody diarrhea should seek

medical attention.

TREATMENT

> Most cases of E. coli food poisoning are not O157:H7 and

require no medical treatment.

> There is no evidence that antibiotics improve the course of

this disease.

> Patients should not use over-the-counter medicines to combat

diarrhea because diarrhea expels the bacteria from the 

body. However, replacing fluids to prevent dehydration 

is very important.

> Blood transfusions and kidney dialysis are required in the

most severe cases of O157:H7.

VACCINE

There is no vaccine at this time.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 77

SALMONELLOSIS BASIC FACTS

> Salmonellosis is an infection from the bacteria called

Salmonella (not a virus).

> There are many different types of Salmonella bacteria.

PREVENTION

> Cook all ground beef and hamburger to an internal 

temperature of 160 degrees Fahrenheit.

> Keep raw meat away from ready-to-eat foods.

> Always wash hands, counters, and utensils that have

touched raw meat.

> Wash raw produce under running water.

> Drink water that has been treated with chlorine or other

disinfectants.

> Avoid swallowing lake or pool water while swimming.

> Wash hands to prevent the spread of the disease.

> People with diarrhea should avoid swimming in public pools

or lakes, sharing baths, and preparing food for others.

SALMONELLOSIS AS A WEAPON

> An attack would be carried out by using the bacteria to

contaminate the food supply.

> An attack would be identifiable if large numbers of people

began getting sick.

SALMONELLOSIS ILLNESS

EXPOSURE

> Salmonellosis is usually spread to humans by eating foods

contaminated with animal feces that contain the bacteria.

> Contaminated food usually looks and smells normal.

> Contaminated food is often meat, such as beef and poultry,

or milk or eggs, but any food can be contaminated.

SYMPTOMS

> Symptoms usually develop 12–72 hours after infection.

> Symptoms include diarrhea, fever, and abdominal cramps.

RECOVERY/MORTALITY RATE

> Most people recover.

> This illness can be dangerous for the elderly and young

children and those with compromised immune systems.

DIAGNOSIS

> A stool sample test can be used to detect salmonellosis 

(as with other bacterial infections).

> Once the test confirms salmonellosis, another test should be

conducted to identify the type of salmonellosis.

TREATMENT

> Patients are given intravenous (IV) fluids in extreme cases to

prevent dehydration.

> If the infection has spread from the intestines to other parts

of the body, the patient may be prescribed antibiotics, such

as ampicillin; gentamicin; trimethoprim/sulfamethoxazole

(TMP–SMX), an antibiotic commonly known by the brand

names of BactrimTM and SeptraTM; or ciprofloxacin.

> Once the type of salmonellosis has been identified, 

the doctor can prescribe the appropriate antibiotic.

VACCINE

There is no vaccine at this time.

PREVENTION

> Avoid eating raw or undercooked eggs, poultry, or beef.

> Cook poultry and beef to an internal temperature of 160

degrees Fahrenheit.

> Avoid eating or drinking unpasteurized dairy products.

> Thoroughly wash produce.

> Always wash hands, counters, and utensils that have touched

raw meat.
78 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

SHIGELLOSIS BASIC FACTS

> Shigellosis is an infection caused by the bacteria

Shigella (not a virus).

> Shigella is present in the diarrheal stools of infected

persons.

SHIGELLA AS A WEAPON

The bacteria would be used to infect food or water.

SHIGELLOSIS ILLNESS

EXPOSURE

> Shigella is ingested or enters the body through an open

wound.

> Most Shigella infections are the result of the bacterium

passing from stools or soiled fingers of one person to the

mouth of another person (i.e., if someone does not wash 

his or her hands properly after a bowel movement and

handles food).

> Flies can breed in infected feces and thus spread

contamination to food.

> People swimming in water contaminated by sewage runoff or

by a sick person can be exposed to the bacteria.

SYMPTOMS

> Symptoms usually occur 1–2 days after a person is exposed

to the bacteria.

> Symptoms include diarrhea (often bloody), fever, and

stomach cramps.

> A severe infection may include high fever and children

younger than 2 years old may experience seizures.

> In some cases, an infected person may experience no

symptoms but he or she can still spread the bacteria to

others (see “Exposure” section above).

RECOVERY/MORTALITY RATE

Shigellosis usually resolves in 5–7 days.

DIAGNOSIS

> A stool sample test can detect the presence of the bacteria.

> Another stool test can identify the type of strain so appropriate

medication can be prescribed.

TREATMENT

> A patient is given plenty of fluids to prevent dehydration. 

In severe cases, treatment is administered in the hospital.

> The following antibiotics are commonly used to treat shigellosis:

ampicillin; trimethoprim/sulfamethoxazole (TMP–SMX), 

an antibiotic commonly known by the brand names of

BactrimTM and SeptraTM; nalidixic acid; or ciprofloxacin.

> Medicine to control diarrhea can make the illness worse.

VACCINE

There is no vaccine at this time.

PREVENTION

> Wash hands with warm water and soap for at least 15 

seconds to stop the spread of shigellosis.

> Regularly disinfect diaper changing areas used for an 

infected child.

> Put diapers of an infected child in a closed-lid garbage can.
GLANDERS

BASIC FACTS

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 79

> Glanders is the disease caused by the bacterium

Burkholderia mallei (not a virus).

> Glanders primarily affects horses, mules, and donkeys

but can infect humans.

> Glanders is stable in the environment.

> Glanders is an extremely rare disease.

GLANDERS AS A WEAPON

> The bacteria are highly lethal in aerosol form.

> Only a few particles of the bacteria can make someone sick.

> The Germans used glanders in World War I against attacking

cavalry.

> Soviet bioscientists experimented with the bacteria.

WHAT WE DON’T KNOW ABOUT GLANDERS AS A

WEAPON

> Scientists know the bacteria that cause glanders can be put

in aerosol form but are not sure how long they would survive

in an outdoor release.

> Scientists do not know how long the bacteria would be

infectious in an indoor release.

GLANDERS ILLNESS

EXPOSURE

> People are exposed by breathing in an aerosolized form of 

the bacteria.

> The bacteria can also enter the body through an open cut.

> Glanders can be passed from person to person but is not

considered highly contagious.

> Because the disease is so rare, scientists are not sure 

how close the person-to-person contact needs to be to

spread the disease.

SYMPTOMS

> Symptoms begin 1–4 days after exposure.

> Symptoms include fever, headaches, muscle tightness, and

chest pain.

> Symptoms progress to swollen lymph nodes, watery eyes,

and sensitivity to light.

> If the bacteria enter the body through a cut, a pustular lesion

appears in 1–5 days.

> In severe cases, pneumonia develops.

RECOVERY/MORTALITY RATE

Glanders is highly lethal, killing 50 percent of those exposed.

DIAGNOSIS

> Symptoms of glanders resemble those for a cold or the flu.

> There is no single test to confirm glanders.

TREATMENT

> Glanders is treated with amoxicillin; tetracycline; and

trimethoprim/sulfamethoxazole (TMP–SMX), an antibiotic

commonly known by the brand names of BactrimTM and

Septra.TM

> Even with treatment, the mortality rate is high (roughly 

50 percent).

> No vaccine is available at this time.
MELIOIDOSIS

BASIC FACTS

80 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Melioidosis is an uncommon disease caused by the

bacterium Burkholderia (not a virus).

> Melioidosis is also called Whitmore disease.

> There is no evidence that melioidosis is contagious.

MELIOIDOSIS AS A WEAPON

> These bacteria would be most effective in aerosol form.

> The bacteria could also be used to poison the food or water

supply.

> The bacteria are found naturally in soil and water.

WHAT WE DON’T KNOW ABOUT MELIOIDOSIS AS A

WEAPON

> Scientists are not sure if any countries have experimented

with melioidosis as a biological weapon.

> Scientists are not sure how an aerosol version of the bacteria

might affect the population.

> Scientists are not sure if a waterborne attack can be prevented

by chlorination in the water or what amounts would have 

an impact.

MELIOIDOSIS ILLNESS

EXPOSURE

Victims breathe in or ingest the bacteria.

SYMPTOMS

> Symptoms of melioidosis include dry cough, fever, and

pneumonia.

> Later symptoms can include a fatal blood infection 

(septicemia).

RECOVERY/MORTALITY RATE

With treatment, patients can recover but some can suffer from

the after effects of the illness for up to 25 years after exposure.

DIAGNOSIS

> Blood tests can eventually confirm melioidosis.

> Physicians may suspect melioidosis if the patient has 

traveled to or lived in southeast Asia.

TREATMENT

> The most effective treatment for melioidosis is trimethoprim/

sulfamethoxazole (TMP–SMX), an antibiotic commonly

known by the brand names of BactrimTM and Septra.TM

> The antibiotics gentamicin and amoxicillin are also prescribed

to treat melioidosis.

> There is no vaccine for melioidosis.
PSITTACOSIS

BASIC FACTS

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 81

> Psittacosis is a disease caused by the microorganism

Chlamydia psittaci (not a virus)—different from the

Chlamydia species causing sexually transmitted 

disease.

> It is transmitted to humans from birds.

> It is most commonly referred to as parrot fever.

> Human-to-human transmission is rare.

PSITTACOSIS AS A WEAPON

> There is no evidence that countries with biological 

weapons programs have experimented with psittacosis in 

an aerosol form.

> In most cases, this disease is not fatal.

WHAT WE DON’T KNOW ABOUT PSITTACOSIS AS A

WEAPON

> Scientists do not know if an outbreak of this illness could be

engineered by terrorists.

> Scientists do not know if a more potent strain has been

harnessed to be effective as a bioweapon.

PSITTACOSIS ILLNESS

EXPOSURE

> People are exposed by inhaling respiratory secretions or dust

from dried droppings of infected birds.

> This disease is most common in pet shops, on farms, or at

slaughterhouses.

> People can be exposed by having an infected bird as a pet.

SYMPTOMS

> Symptoms can appear from 5 to 28 days after exposure.

> Most symptoms appear 10 days after exposure.

> Symptoms include fever, headache, chills, and muscle aches.

> In severe cases, a patient develops pneumonia.

RECOVERY/MORTALITY RATE

> The disease is usually mild in humans.

> The disease can be more severe in those with diabetes.

> The disease can be fatal in elderly people who do not receive

treatment.

DIAGNOSIS

> The disease is difficult to diagnose because it resembles

the flu.

> The diagnosis is most often confirmed by testing for antibodies.

TREATMENT

> Physicians should ask for a travel history and about exposure

to pet birds.

> Tetracycline or doxycycline are the preferred antibiotics.

PREVENTION

> Identifying and isolating an exposed bird is the key to

containment.

> Treatment of infected birds should be supervised by a

veterinarian.

> Strict import and quarantine laws keep rare birds in 

isolation so they cannot infect humans.
Q FEVER

BASIC FACTS

82 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Q fever is a disease caused by the bacteria Coxiella

burnetti (not a virus).

> The bacteria are resistant to heat and many common

disinfectants.

> The bacteria can survive for long periods of time in the

environment.

> Farm mammals, such as sheep, goats, and cattle, are

carriers of the bacteria that cause the Q fever illness.

The bacteria are present in urine, feces, and milk and

are shed in high numbers from amniotic fluid and 

placental tissue during birthing.

Q FEVER AS A WEAPON

> This is a highly infectious disease.

> Inhaled, the bacteria can be very dangerous to humans.

> One single organism can cause illness.

> It is possible to produce this in aerosol form for an 

airborne release.

> These bacteria are less likely to be used to infect the food or

water systems.

WHAT WE DON’T KNOW ABOUT Q FEVER AS A

WEAPON

Scientists are not sure how effective a foodborne release would

be or what quantities would be required for such a release to

be effective.

Q FEVER ILLNESS

EXPOSURE

> Humans are exposed by inhaling infected barnyard dust.

> People can be exposed during the birth of an animal.

> People can also be exposed by drinking contaminated milk.

> Sometimes infected ticks carry the bacteria and can transmit

the bacteria to humans, but ticks are not the principle means

of infection.

SYMPTOMS

> Symptoms occur 2–3 weeks after exposure.

> Symptoms include high fever (104–105 degrees Fahrenheit).

> Symptoms also include sore throat, headache, chills, general

aches, and sweats (similar to flu symptoms).

> Later symptoms may include diarrhea, vomiting, and 

chest pain.

RECOVERY/MORTALITY RATE

> The fever normally lasts up to 2 weeks.

> During this time, there is weight loss.

> Without treatment, only 1–2 percent of those infected die.

> Most people recover in several months.

> Complications include hepatitis and an inflammation around

the heart.

> A chronic form of the disease can last as long as 20 years

after the initial infection. Chronic Q fever affects the heart

and is often fatal; it most often strikes those with 

preexisting heart valve disease or a history of bypass surgery.

> Once a person has Q fever, he or she may maintain lifelong

immunity.

DIAGNOSIS

> There is no single test to diagnose Q fever.

> Doctors analyze blood tests to isolate the bacteria, their

DNA, or antibodies indicating an infection.

TREATMENT

> Doxycycline is the antibiotic of choice to treat acute Q fever.

> Chronic Q fever typically requires multiple antibiotics given

over a prolonged period of time.

> The antibiotic is most effective when given within 3 days of

the first symptoms and for 21 days thereafter.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 83

VACCINE

A vaccine is in limited use for researchers working with 

animals but it is not currently available in the United States.

PREVENTION

> Pasteurization of milk minimizes the risk of Q fever.

> Animal testing and quarantine can prevent transmission 

to humans.
RICIN TOXIN

BASIC FACTS

84 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Scientific name: Ricinus communis; a biological toxin.

> Ricin can be made from the waste left over from 

processing castor beans.

> Ricin can take powder, mist, or pellet form, or it can be

dissolved in water.

> Ricin has some potential medical uses, such as in bone

marrow transplants and cancer treatment.

> The illness resulting from ricin poisoning is not 

contagious.

Note: Ricin is classified by CDC as both a chemical and

a biological agent because it is a chemical toxin but has

a biological source (unlike other chemical agents, such

as sarin).

RICIN TOXIN AS A WEAPON

> Ricin can be processed into a powder that could then be

aerosolized.

> People would become sick after breathing in the substance.

> Pellets of ricin or ricin dissolved in a liquid can be injected

into people’s bodies.

> Ricin can also contaminate water or food and then be 

swallowed.

WHAT WE DON’T KNOW ABOUT RICIN TOXIN 

AS A WEAPON

Scientists are not sure how much ricin is needed in an aerosol

release to cause mass casualties or how long it remains viable

in the environment.

IDENTIFYING AN ATTACK

> Almost any ricin illness would be considered an attack, since

accidental ricin poisoning is extremely unlikely.

> Evidence of an attack would be numerous cases of illness by

people who have been in the same location or attended the

same event.

RICIN TOXIN ILLNESS

Ricin works by getting inside the cells of a person’s body 

and preventing the cells from making the proteins they need.

Without the proteins, cells die. Eventually this is harmful to the

whole body, and death may occur.

EXPOSURE

Ricin can be inhaled, ingested, or injected.

SYMPTOMS

Inhalation

> Initial symptoms occur within 8 hours of exposure and

include difficulty breathing, fever, cough, nausea, and tightness

in the chest.

> Later symptoms include heavy sweating and fluid buildup in

the lungs (making breathing even more difficult), and the

skin might turn blue. Low blood pressure and respiratory

failure may result, leading to death.

Ingestion

> Initial symptoms occur within 6 hours and include vomiting

and bloody diarrhea. Severe dehydration may result, 

followed by low blood pressure.

> Later symptoms may include hallucinations, seizures, and

blood in the urine. Within several days, the person’s liver,

spleen, and kidneys might stop working, and the person

could die.

Injection

> A tiny amount of ricin (the size of a pinhead) is enough to

cause death, such as in the 1978 case in London in which

ricin was used on the tip of an umbrella to assassinate a

Bulgarian exile.

> Ricin immediately kills the muscles and lymph nodes near

the site of the injection.

> Failure of the major organs and death usually follow within 

4 days.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 85

RECOVERY/MORTALITY RATE

> Chances of death depend on the method of exposure and

dose of toxin received.

> If the dose is sufficient, death from ricin poisoning could

occur within 36–72 hours of exposure.

> If death has not occurred in 3–5 days, the victim usually

recovers.

DIAGNOSIS

> No reliable test exists to confirm ricin exposure.

> Tracking symptoms of those suspected of being exposed

could lead to a diagnosis.

> An X-ray could confirm fluid in the lungs.

TREATMENT

> No antidote exists to counteract the effects of ricin poisoning.

> Victims are given intravenous (IV) fluids and assisted with

breathing, possibly with a ventilator.

> Medications to control low blood pressure and seizures may

also be administered.

> Those who have recently ingested ricin may have their

stomachs flushed with activated charcoal to keep the toxin

from being absorbed into the body.

> Eyes that come in contact with ricin should be flushed 

with water.

VACCINE

No vaccine exists to protect against ricin poisoning.

PREVENTION

> Leave the area of a known ricin release to prevent exposure.

> If exposed, remove clothing and shower thoroughly with soap

and water.
STAPHYLOCOCCAL ENTEROTOXIN B (SEB)

BASIC FACTS

86 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Staphyloccal enterotoxin B (SEB) is one of the toxins

linked to foodborne illness.

> SEB is produced naturally by the Staphylococcus aureus

bacteria (not a virus).

> SEB is not contagious.

SEB AS A WEAPON

> SEB is produced in aerosol form for easy dissemination 

in the air or in a building’s ventilation system.

> SEB can also be released in food or water.

WHAT WE DON’T KNOW ABOUT SEB AS A WEAPON

Scientists do not know how much of the toxin is needed 

in an aerosol release to inflict mass casualties.

SEB ILLNESS

EXPOSURE

SEB illness develops after the toxin is inhaled or ingested.

SYMPTOMS

> Symptoms appear 3–12 hours after exposure.

> Symptoms of inhaled exposure include fever, chills, 

and headache, similar to flu symptoms.

> Symptoms of ingested exposure include nausea, vomiting,

and diarrhea, similar to stomach virus symptoms.

RECOVERY/MORTALITY RATE

> Higher mortality rates of 50–80 percent occur after 

inhalation of the toxin.

> Most patients recover from ingested forms of the toxin.

> The progression of the disease depends on the route of

exposure and the dose of the toxin.

DIAGNOSIS

> Respiratory symptoms will signal when a patient may have

inhaled the toxin.

> Tests of respiratory secretions can detect the toxin.

> Evidence of the toxin can be found in blood and urine.

> SEB is quickly identified in food.

TREATMENT

> Patients with severe cases resulting from aerosol exposure

may require a ventilator.

> A vaccine is currently not available but is under

development. For more information, see NIAID’s Web site

(http://www2.niaid.nih.gov/biodefense).
TYPHUS FEVER (EPIDEMIC OR LOUSE-BORNE TYPHUS)

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 87

BASIC FACTS

> Caused by the bacterium Rickettsia prowazekii

(not a virus).

> The disease is spread from person to person by body

lice. (Not to be confused with typhoid fever, which is

spread by unrelated bacteria.)

WHAT WE DON’T KNOW ABOUT TYPHUS FEVER AS A

WEAPON

It is not known to what extent scientists have explored the use

of typhus in other forms that would be more deadly for use in

a mass casualty event.

TYPHUS FEVER ILLNESS

EXPOSURE

> People are infected when exposed to body lice from other

infected individuals.

> A less severe disease, murine typhus, is spread via fleas from

infected mice, rats, and some other animals. Murine typhus

is caused by different but related bacterium, Rickettsia typhi.

> This Louse-borne typhus is not contagious except as spread

by lice.

SYMPTOMS

> Symptoms appear 1–2 weeks after exposure.

> Symptoms include fever, headache, chills, and general pains.

> Initial symptoms are followed by a body rash, typically

beginning around the armpits or upper trunk and spreading

outward.

> The rash typically does not appear on the face, the palms of

the hands, or the soles of the feet.

RECOVERY/MORTALITY RATE

> The recovery rate is good (except in high outbreak areas) 

if antibiotic treatment begins quickly.

> Left untreated, the disease kills up to 40 percent of infected

individuals; those who recover typically undergo a 2–3 month

convalescence.

> In some individuals, typhus may arise spontaneously many

years after recovery from an infection. This illness, called

Brill-Zinsser disease, appears to be caused by reactivation 

of a dormant infection and is typically milder than the 

initial disease.

DIAGNOSIS

Typhus is diagnosed by a variety of blood tests.

TREATMENT

Doxycycline is the most prescribed antibiotic of choice for

typhus illness. Some other antibiotics are also effective.

PREVENTION

> Typhus can be prevented by delousing and improved hygiene.

> There is no U.S. Food and Drug Administration-approved

vaccine for epidemic typhus.
VIRAL ENCEPHALITIS

BASIC FACTS

88 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> The majority of cases of “encephalitis” are caused by

viruses (not bacteria).

> Several different types or families of viruses can cause

encephalitis.

> The term “encephalitis” only refers to inflammation of

the brain. “Encephalomyelitis,” which refers to

inflammation of the brain and spinal cord, is a term that

may also be used since most cases of viral encephalitis

also involve the spinal cord. These illnesses are

different than “meningitis,” which refers to

inflammation of the covering (meninges) of the brain.

> Many “encephalitis viruses” are arthropod-borne

viruses (arboviruses), typically transmitted to humans

and animals via the bits of mosquitoes, ticks, and

sandflies. However, many other infectious agents, such

as mumps, measles, adenoviruses, enteroviruses,

herpesvirus, and rabies, can also cause encephalitis.

These agents will not be discussed here.

> Many outbreaks of viral encephalitis, particularly those

associated with mosquito transmission, occur naturally

and have a seasonal pattern (often more cases in late

summer when more vectors [e.g., insects] are present). 

> The most common mosquito-borne viral encephalitis

infections are:

- Alphaviruses—Eastern equine encephalitis (EEE),

Venezuelan equine encephalitis (VEE), and Western

equine encephalitis

- Flaviviruses—St. Louis encephalitis, West Nile virus

encephalitis, Japanese encephalitis, tick-borne

encephalitis, and dengue encephalitis

- Bunyavirus—Rift Valley encephalitis

VIRAL ENCEPHALITIS AS A WEAPON 

> Viral agents causing encephalitis could be weaponized 

relatively easily. Many encephalitic viruses, such as VEE, can

be aerosolized. 

> VEE and EEE are two examples of viruses that are thought to

have been weaponized. 

> Viral agents causing encephalitis may be attractive as

weapons because they are available in nature and could

cause disease outbreaks initially indistinguishable from 

naturally occurring outbreaks. If aerosolized viral agents 

were introduced into areas where there are insects 

capable of transmitting disease, there could be a secondary

transmission of the disease (i.e., an insect first bites an

infected person and then bites another person, thereby

spreading the disease).

> These viruses are zoonotic—capable of causing infection in

humans and animals, such as horses.

WHAT WE DON’T KNOW ABOUT VIRAL ENCEPHALITIS 

AS A WEAPON

We have limited intelligence information on the current

weaponization of specific agents causing viral encephalitis.

VIRAL ENCEPHALITIS ILLNESSES 

(CAUSED BY AN ARBOVIRUS)

EXPOSURE

> Under natural conditions, an individual would be bitten 

by an insect, which could introduce the virus into the body.

If there are a large number of vectors (e.g., insects) that carry

the virus and are capable of transmitting it to people, there

is a greater likelihood of an outbreak of the disease.

> For laboratory workers working with such viruses, the

aerosolization of infectious virus particles is a concern and

lab safety and personal protective safeguards are necessary.

> In a bioterrorist scenario where the viral agents are

aerosolized, the impact of the attack will probably be

dependent on the number of people exposed, the amount of

virus they are exposed to, and any preexisting immunity of

the population.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 89

SYMPTOMS

> Depending on the specific virus, the amount of virus

introduced into the body, and the individual’s state of

immunity, symptoms may vary from none to drowsiness,

headaches, stiff neck, confusion, seizures, coma, and death.

Depending on the specific agent, the incubation period may

vary from 2 to 3 weeks. 

> In many cases of naturally occurring infection, the body’s

immune system fights off the infection. In many cases, there

may be only mild symptoms, such as fever or headache or

malaise, and the diagnosis is often missed. Individuals with

compromised immune systems, such as infants and the

elderly, may be at greater risk of developing complications.

RECOVERY/MORTALITY RATE

> Severity of disease and mortality rate are dependent on the

particular virus infection. For example, EEE has been

associated with a high mortality rate (50–80 percent) in

older populations.

> Recovery is usually gradual, but residual effects of the

infection may occur. These include disturbances in cognitive

function, restlessness, recurring seizures, and personality

changes.

DIAGNOSIS

> Viral encephalitis can be diagnosed through blood tests, viral

cultures, and a spinal tap.

> An MRI or CAT scan may also be used for diagnosis.

TREATMENT

> Unlike bacteria, viral infections cannot be specifically treated

with antibiotics. 

> There are no licensed therapies for arboviral infections at 

this time, although certain drugs and therapies under Food

and Drug Administration investigational use may be

available, if needed.

> Treatment for arboviral encephalitis is supportive care 

(hospitalization, intravenous fluids, respiratory support, 

prevention of secondary infections, etc.).

> Various chemical compounds are being evaluated for possible

antiviral activity against arboviruses.

VACCINE

> A licensed vaccine for Japanese Encephalitis is currently

available in the United States.

> Vaccines against EEE, Western equine encephalitis, VEE,

and Rift Valley encephalitis were developed by the U.S.

Department of Defense and are available under specific

investigational drug protocols through the U.S. Army Medical

Research Institute of Infectious Diseases at Fort Detrick,

Maryland.

> No licensed vaccines are available in the United States 

for viruses causing encephalitis, with the exception of rabies,

mumps, and measles vaccines. Vaccines are under

development against several arboviruses (EEE, Western

equine encephalitis, VEE, tick-borne encephalitis, and West

Nile virus).

PREVENTION

> In a bioterrorist attack, it is unlikely that the virus 

could survive very long (more than a few hours) outside of

the body.

> Vector control measures (e.g., elimination of insect breeding

sites) will reduce the risk of mosquito-borne disease. 

> Personal protective measures, such as the use of insect

repellents and appropriate clothing (e.g., shirts with long

sleeves), will reduce the risk of bites.
WATER SAFETY THREATS

90 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

OVERVIEW

WATER SAFETY THREATS BASIC FACTS

While not all are discussed in this guide, some examples of water-borne contaminants that pose threats include:

> Cholera

> Giardiasis

> Cryptosporidiosis

> There are several bacteria or parasitic organisms that

can contaminate the water and make people sick.

> Diagnosis would most likely occur after large numbers

of people begin getting sick with intestinal symptoms,

including nausea and diarrhea.

> Symptoms usually occur within hours or days of exposure.

Community water systems that do not filter their water

or that inadequately disinfect drinking water are more

likely to transmit disease-causing organisms.

> The most well-known of these diseases is cholera.

CHOLERA BASIC FACTS

> Cholera is an acute, diarrheal illness caused by 

infection of the intestine with the bacterium Vibrio

cholerae (not a virus).

> Cholera can be highly lethal if untreated, but the 

mortality rate is low with treatment.

> The disease can spread rapidly in areas with inadequate

treatment of sewage and drinking water.

> Cholera bacteria can also live in brackish rivers and

coastal waters.

> Cholera is unstable in fresh water but remains vibrant

in salt water.

WHAT WE DON’T KNOW ABOUT CHOLERA AS A

WEAPON

In most areas, chlorination and aeration of water kills the

bacteria that can make people sick. Scientists do not know 

if terrorists have experimented with ways to infect the water

systems that can withstand the chlorine treatment to inflict

mass illnesses.

CHOLERA ILLNESS

EXPOSURE

> A person can become infected by drinking water or eating

food contaminated with the cholera bacteria.

> In an epidemic, the source of contamination is usually the

feces of an infected person contaminating the water supply.

SYMPTOMS

> Infection is often mild and no symptoms may occur.

> Approximately 1 in 20 infected people has a severe case,

which is characterized by profuse watery diarrhea, vomiting,

and leg cramps.

> In severe cases, the rapid loss of bodily fluids leads to

dehydration and shock.

RECOVERY/MORTALITY RATE

> Without treatment, death can occur within hours.

> With prompt rehydration, fewer than 1 percent of cholera

patients die.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 91

DIAGNOSIS

> Physicians ask for a travel history from the patient to see if

he or she has traveled to a known outbreak area.

> A stool sample test can confirm cholera.

TREATMENT

> Patients are treated with fluids to replace those lost due 

to diarrhea.

> Most patients are given large amounts of a water, sugar, and

salt mixture to drink.

> More severe cases also require administration of intravenous

(IV) fluids.

> Antibiotics shorten the course and diminish the severity of

the illness, but they are not as important as rehydration.

VACCINE

There is no cholera vaccine currently available in the United

States. However, there are vaccines widely available in

countries where cholera is a major public health problem.

PREVENTION

Travelers to areas where cholera has occurred should observe

the following recommendations:

> Drink only water that you have boiled or treated with 

chlorine or iodine; other safe beverages include tea and

coffee made with boiled water and carbonated, bottled

beverages with no ice

> Eat only foods that have been thoroughly cooked and are still

hot or fruit that you have peeled yourself

> Avoid undercooked or raw fish or shellfish, including ceviche

(raw fish salad)

> Make sure all vegetables are cooked; avoid salads

> Avoid foods and beverages from street vendors

> Do not bring perishable seafood back to the United States
REFERENCES

2000 Emergency response guidebook: A guidebook for first

responders during the initial phase of a dangerous goods/

hazardous materials incident. (2000). Washington, DC: The

Office of Hazardous Materials Safety, U.S. Department of

Transportation. 

Battlebook Project Team, USACHPPM, & OSG. (2000). 

The medical NBC battle book USACHPPM tech guide 244.

Aberdeen Proving Ground, MD: United States Army Research

Institute of Medical Defense. 

Bevelacqua, A., & Stilp, R. (1998). Hazardous materials field

guide. Albany, NY: Delmar Publications. 

Bevelacqua, A., & Stilp, R. (2004). Terrorism handbook for 

operational responders. Clifton Park, NY: Delmar Thomson Learning.

Centers for Disease Control and Prevention. (2001). 

Emergency preparedness and response: Facts about botulism.

http://www.bt.cdc.gov/agent/botulism/factsheet.asp.

Centers for Disease Control and Prevention. (2002). Emergency

preparedness and response: Frequently asked questions (FAQ)

about plague. http://www.bt.cdc.gov/agent/plague/faq.asp.

Centers for Disease Control and Prevention. (2002). Emergency

preparedness and response: Smallpox: Frequently asked questions

about smallpox. http://www.bt.cdc.gov/agent/smallpox/

disease/faq.asp.

Centers for Disease Control and Prevention. (2002). Emergency

preparedness and response: Smallpox: Smallpox disease overview.

http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp.

Centers for Disease Control and Prevention. (2002). Epidemiologic

response to anthrax outbreaks: Field investigations, 1950–2001.

Emerging Infectious Diseases, 8(10). http://www.cdc.gov/ncidod/

eid/vol8no10/02-0223.htm.

Centers for Disease Control and Prevention. (2002). Public health

in the time of bioterrorism. Emerging Infectious Diseases, 8(10).

http://www.cdc.gov/ncidod/eid/vol8no10/02-0444.htm.

Centers for Disease Control and Prevention. (2002). Tularemia—

United States, 1990–2000. Morbidity and Mortality Weekly

Report, 51(9), 182–184. http://www.cdc.gov/mmwr/preview/

mmwrhtml/mm5109a1.htm.

Centers for Disease Control and Prevention. (2003). Anthrax Q & A:

Laboratory testing. http://www.bt.cdc.gov/agent/anthrax/faq/

labtesting.asp.

Centers for Disease Control and Prevention. (2003). Disease

information: Shigellosis. http://www.cdc.gov/ncidod/dbmd/

diseaseinfo/shigellosis_g.htm.

Centers for Disease Control and Prevention. (2003). Emergency

preparedness and response: Anthrax: What you need to know.

http://www.bt.cdc.gov/agent/anthrax/needtoknow.asp.

Centers for Disease Control and Prevention. (2003). Emergency

preparedness and response: Key facts about tularemia.

http://www.bt.cdc.gov/agent/tularemia/facts.asp.

Centers for Disease Control and Prevention. (2003). Endemic,

notifiable bioterrorism-related diseases, United States,

1992–1999. Emerging Infectious Diseases, 9(5).

http://www.cdc.gov/ncidod/eid/vol9no5/02-0477.htm.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Radiation emergencies: Potassium iodide (KI).

http://www.bt.cdc.gov/radiation/pdf/ki.pdf.

Centers for Disease Control and Prevention. (2003). Viral and

Rickettsial Zoonoses Branch: Q fever. http://www.cdc.gov/

ncidod/dvrd/qfever/index.htm.

Centers for Disease Control and Prevention. (2004). Disease

information: Botulism. http://www.cdc.gov/ncidod/dbmd/

diseaseinfo/botulism_g.htm.

Centers for Disease Control and Prevention. (2004). Disease

information: Brucellosis. http://www.cdc.gov/ncidod/dbmd/

diseaseinfo/brucellosis_g.htm.

Centers for Disease Control and Prevention. (2004). Disease

information: Cholera. http://www.cdc.gov/ncidod/dbmd/

diseaseinfo/cholera_g.htm.

Centers for Disease Control and Prevention. (2004). Disease

information: Escherichia coli O157:H7. http://www.cdc.gov/

ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm.

Centers for Disease Control and Prevention. (2004). Disease

information: Salmonellosis. http://www.cdc.gov/ncidod/dbmd/

diseaseinfo/salmonellosis_g.htm.

92 03. BIOLOGICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media
REFERENCES (cont.)

Centers for Disease Control and Prevention. (2004). 

Emergency preparedness and response: Facts about ricin.

http://www.bt.cdc.gov/agent/ricin/facts.asp.

Centers for Disease Control and Prevention. (2004). Emergency

preparedness and response: Plague. http://www.bt.cdc.gov/

agent/plague/trainingmodule/index.asp.

Centers for Disease Control and Prevention. (2004). Emergency

preparedness and response: Questions and answers about

anthrax. http://www.bt.cdc.gov/agent/anthrax/faq/index.asp.

Centers for Disease Control and Prevention. (2004). Emergency

preparedness and response: Questions and answers about ricin.

http://www.bt.cdc.gov/agent/ricin/qa.asp.

Centers for Disease Control and Prevention. (2004). Special

Pathogens Branch: Ebola Hemorrhagic Fever. http://www.cdc.gov/

ncidod/dvrd/spb/mnpages/dispages/ebola.htm.

Centers for Disease Control and Prevention, Office of Inspector

General, & HHS. (2002). 42 CFR Part 73, Office of the Inspector

General. 42 CFR Part 1003: Possession, use, and transfer of

select agents and toxins; Interim final rule. Federal Register, 240,

76886–76905. http://www.cdc.gov/od/sap/docs/42cfr73.pdf.

Davis, L.E., LaTourrette, T., Mosher, D., Davis, L., & Howell, D.

(2003). Individual preparedness and response to chemical, 

radiological, nuclear, and biological terrorist attacks. 

Santa Monica, CA: Rand Corporation. 

Encyclopedia.com. (2004). Polymerase chain reaction.

http://www.encyclopedia.com/printable.asp?url=/ssi/p1/polychn.html.

Federal Emergency Management Agency. (2000). Emergency

response to terrorism: Job aid. Washington, DC: FEMA, U.S. 

Fire Administration, National Fire Academy: U.S. Department 

of Justice, Office of Justice Programs. 

Harville, D., & Williams, C. (2003). The WMD handbook: 

A guide to Weapons of Mass Destruction. New York: 

First Responder Inc. 

Keller, J.J. (1998). Hazardous materials compliance manual.

Neenah, WI: J.J. Keller & Associates. 

Mayer, T.A., Bersoff-Matcha, S., Murphy, C., Earls, J., Harper, S.,

Pauze, D., et al. (2001). Clinical presentation of inhalational

anthrax following bioterrorism exposure: Report of 2 surviving

patients. Journal of the American Medical Association, 286,

2549–2553.

MEdIC. (2004). Gram-staining procedure. http://medic.med.uth.

tmc.edu/path/grampro.htm.

Pavlin, J.A., Gilchrist, M.J., Oweiler, G.D., & Woollen, N.E.

(2002). Diagnostic analyses of biological agent-caused 

syndromes: Laboratory and technical assistance. Emergency

Medicine Clinics of North America, 20, 331–350.

Sidell, F.R., Patrick, W.C., Dashiell, T.R., & Alibek, K. (2002).

Jane’s chem-bio handbook. (2nd ed.). Alexandria, VA: Jane’s

Information Group. 

Smolkin, R. (2003). Girding for terror. American Journalism

Review. http://www.ajr.org/Article.asp?id=2885.

The Harvard Medical School Family Health Guide. (2003).

Diagnostic tests: Sputum evaluation (and sputum induction).

http://www.health.harvard.edu/fhg/diagnostics/sputumEval/

sputumEvalWhat.shtml.

U.S. Army Medical Research Institute of Infectious Disease.

(2001). Medical management of biological casualties handbook.

(4th ed.). Fort Detrick, MD: U.S. Army Medical Research Institute

of Infectious Diseases. 

U.S. Department of Health and Human Services. (2004). HHS

buys new anthrax vaccine for stockpile. News release.

http://www.hhs.gov/news/press/2004pres/20041104a.html.

University of Wisconsin-Madison. (2004). Department of

Bacteriology, Microbiology Textbook. http://www.bact.wisc.edu/

Microtextbook/modules.php?op=modload&name=Sections&file=

index&req=viewarticle&artid=5.

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 93

04CHEMICAL AGENTS
GOAL OF THIS SECTION

CHEMICAL AGENTS

96 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

To provide details on chemical agents that could be used

by terrorists.

WHAT THIS SECTION INCLUDES

> Categories of agents are provided with examples from

each category. The U.S. Department of Health and

Human Services’ (HHS) Centers for Disease Control and

Prevention (CDC) use the impact that chemical agents

have on the human body to categorize them. For example,

nerve agents affect the central nervous system, 

while choking agents affect breathing.

WHAT THIS SECTION DOES NOT INCLUDE AND WHY

> All possible chemical agents that could be used in an

attack are not included here. This section provides one or

two examples of four major types of chemical agents. A

detailed description of more chemical agents can be

found on CDC’s Web site, (http://www.bt.cdc.gov/agent/

agentlistchem.asp).

> This section will not focus on the specific amounts of 

an agent that will make people sick. There are too many

variables in how a chemical weapon could be delivered.

However, this section will address exposure and

treatment in more general terms. 

> Detailed information on toxic industrial chemicals are not

included. Though a terrorist may use toxic industrial

chemicals in an attack (e.g., by causing a truck

containing toxic chemicals to explode, or by attacking a

chemical plant), any one of thousands of industrial

chemicals could be used in this way. However, the federal

response to an attack or accident involving industrial

chemicals will be similar to the federal response to the

chemical agents as described in this guide (see p. 141).

> Ricin and other biological toxins are not covered in this

section. Ricin is classified as a chemical agent, as well as

a biological agent, because it is a toxin but it has a

biological source (unlike sarin or other chemical agents).

Details on ricin can be found in the “Biological Agents”

section (see p. 39).

Please note: Information on the use of personal protective

equipment (e.g., biohazard suits and masks) can be found

in the “Self-Care for Media” section (see p. 157).

BASIC FACTS

This section discusses four major types of chemical agents,

grouped according to how they affect the human body: 

> Blister (e.g., mustards)

> Blood (e.g., cyanides)

> Choking (e.g., chlorine)

> Nerve (e.g., sarin, VX agents)

Other categories of chemicals include:

> Biotoxins

> Caustics (acids)

> Incapacitating agents

> Long-acting anticoagulants

> Metals

> Organic solvents

> Riot control agents/tear gas

> Toxic alcohols

> Vomiting agents

For more information on these other chemical categories,

please see http://www.bt.cdc.gov.

> Chemical agents can come in the form of poisonous gases,

liquids, or solids.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 97

> These agents are usually fast acting and toxic to people,

animals, or plants. (Note: A major exception is mustard agents

for which symptoms appear several hours after exposure.)

> Poisoning by chemicals is not contagious. However, if

residual chemical agents or vapors are on the skin, clothing,

hair, or in biologic fluids (such as vomit), others can be

exposed and affected. Once the agent is removed (e.g., by

removing clothing and showering), the illness caused by a

chemical agent cannot be spread.

CHEMICAL AGENT HISTORIC TIMELINE

1914–1918 (World War I): Mustard gas, phosgene, and

chlorine are introduced for chemical warfare.

1939–1945 (World War II): Germans use hydrogen cyanide

as a genocidal agent. Germans use chlorine in World War II as

a chemical weapon.

1980s: Iraq uses cyanide against Kurds in Northern Iraq.

1981–1988: Iraq uses mustard gas and nerve agents in the

Iran-Iraq war.

1995: Aum Shinrikyo cult in Japan releases sarin in Tokyo subway.

ASSESSING THE RISK

> Because certain chemical agents are used in industry and

household products, they are highly available.

> After an outdoor release, the dangers associated with many

chemical agents decrease over time because the chemical

gets diluted as it spreads over a given area.

> Terrorists could be minimally skilled to launch a limited

chemical attack. A more widespread attack would require

more expertise.

> How lethal an attack is depends on several factors, including

amount and type of agent used, route of exposure, time

elapsed before decontamination, and access to medical care.

CHEMICAL AGENTS AS WEAPONS

> Sufficient quantities must be used for chemical weapons to

be effective.

> Weather factors have an impact on the effectiveness of an

open-air release. These factors include:

- Temperature

- Wind speed and direction

- Humidity and air stability

> Chemical agents are typically more deadly in confined or

crowded areas, such as buildings, subways, or battlefields,

where evacuation options are limited.

> Chemical agents can be deployed in five ways:

- Spraying the chemical with wet or dry aerosol sprayers

(e.g., crop dusters, handheld spraying devices)

- Using a heat source to vaporize the chemical for release

- Using an explosive device to disperse the chemical

- Pouring the chemical on a specific site (e.g., building floor,

sidewalk, subway platform)

- Contamination of food, water, or pharmaceuticals (such as

the 1982 intentional contamination of acetaminophen

products with cyanide)

IDENTIFYING AN ATTACK

> A chemical release may result in environmental clues, including:

- Dead plants, animals, or insects

- Pungent odor

- Unusual clouds, vapors, or droplets

- Discoloration of surfaces

> Some common immediate physical symptoms from an

airborne attack may include:

- Tightness in chest and difficulty breathing

- Nausea and vomiting

- Watery eyes and blurry vision

> A chemical attack is different from a biological attack in the

following ways:

- It is often an easily identifiable incident (e.g., chemical release

from a fire at an industrial manufacturing facility)

- Signs and symptoms appear rapidly after exposure (usually

within minutes)

- Victims are not contagious, although rescue workers can

become ill if there is still residual chemical on the patient’s

clothes or skin, or in biologic fluids, and they are exposed to

these agents without proper personal protective equipment

(e.g., gloves and masks)
98 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

SHELTER-IN-PLACE* SUPPLY LIST

(Maintain enough for 3 days; check

supplies every 6 months)

> Food

> Bottled water (1 gallon per day per

person, plus water for pets)

> Change of clothing (including

undergarments)

> Shoes

> First aid kit

> Paper goods and plastic utensils

> Plastic garbage bags

> Bedding

> Battery-operated radio

> Batteries

> Flashlight

> Medicines

> Toiletries

> Telephone (hard-wired phones are best)

> Emergency-contact phone list

> Extra eyeglasses or contact lenses

> Baby formula

> Pet food

> Plastic sheeting

> Duct tape

* More extensive emergency supply checklists

can be found in appendices F and G (see pp.

241–244).

LESSENING THE IMPACT OF EXPOSURE 

(TO CHEMICAL AGENTS IN GENERAL)

> Follow the instructions of emergency

workers, if possible.

> Move away from the site of release (if

known) during an outdoor release or

go indoors.

> Shelter-in-place if indoors near an

outdoor release.

> Evacuate the affected building during

an indoor release.

> If exposed, remove contaminated

clothing and place in a plastic bag.

> Wash with soap and water (when

appropriate).

> Flush eyes with water (when

appropriate).

> Seek medical attention if you have

breathed in chemical fumes or if

chemicals have touched your skin. 

> Patients should be decontaminated if

they have chemicals on their clothes

and/or skin (when appropriate).

> If medically indicated and available, get

appropriate antidote(s).

> Consider using protective masks and

clothing to minimize exposure.

> Whenever possible, get emergency

personnel in protective gear to assist in

the removal of contaminated clothing.

INSTRUCTIONS TO SHELTER-IN-PLACE

AND SEAL THE ROOM DUE TO

CHEMICAL INCIDENTS

If you have been exposed:

> Remove contaminated clothing if coming

from outside and seal it in a plastic bag

> Shower and wash with soap, if possible

To shelter-in-place and seal the room:

> Find a room with as few windows and

doors as possible

> Go to the highest level possible

> Turn off the air conditioner, heater, and

fans

> Close the fireplace damper

> Fill sinks and tubs with water

> Turn on the radio for instructions

> Keep a telephone handy

> To seal the room, tape plastic over

windows and doors; seal with duct tape.

Tape over vents and electrical outlets

(and any other openings)*

* Within a few hours, the plastic and tape may

need to be removed to allow fresh air to enter

the room to prevent suffocation. Follow the

instructions of emergency workers and/or

public health officials.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 99

CHEMICAL AGENT BREAKDOWN*

BLISTER AGENTS

Mustard agents:

Distilled mustard (HD), 

Mustard gas (H) (sulfur mustard),

Mustard/lewisite (HL), Mustard/T,

Nitrogen mustard (HN-1, HN-2,

HN-3), Sesqui mustard, 

Sulfur mustard (H) (mustard gas)

Lewisites/chloroarsine agents:

Lewisite (L, L-1, L-2, L-3),

Mustard/lewisite (HL), 

Phosgene oxime (CX)

BLOOD AGENTS

Arsine (SA)

Cyanide agents:

Cyanogen chloride (CK), Hydrogen

cyanide (AC), Potassium cyanide

(KCN), Sodium cyanide (NaCN)

CHOKING AGENTS

Ammonia (NH-3)

Chlorine (CL)

Hydrogen chloride (HCI)

Phosgene agents:

Diphosgene (DP), Phosphine,

Phosphorus (elemental, white, 

or yellow)

NERVE AGENTS

G agents:

Sarin (GB), Soman (GD), 

Tabun (GA)

V agents:

VX

* This list is not all inclusive. For information on additional chemicals, see http://www.bt.cdc.gov.
BLISTER AGENTS

OVERVIEW

100 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Symptoms include:

- Skin burns, in which blisters surface within a few days;

blisters become large and may be yellowish-brown in color

- Eyes burning and swelling, which can cause blindness

(lasting up to 10 days)

- If gas is inhaled, may result in coughing, bronchitis, 

long-term respiratory disease, and cancer in the airways

and lungs later in life

Mustard Gas Diagnosis and Treatment

> No effective medical test exists.

> Urine tests can be inconclusive.

> No specific antidote or treatment exists.

> Supportive medical care is given to the victim to minimize

the effects of exposure.

Lessening the Impact of Mustard Gas Exposure

> Move away from the site of exposure immediately and go to

higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> Blisters should be treated as burns.

> If mustard agents have been swallowed, do not induce

vomiting. Give milk to drink.

> Seek medical attention immediately.

LEWISITE

Basic Facts

> Lewisite is also known as L.

> This agent is a chemical warfare agent that causes immediate

blistering of the skin and damage to the respiratory system.

> Lewisite is an oily liquid that can be colorless or can appear

amber to black.

> This agent smells like geraniums and could be confused with

the smell of ammonia.

> Lewisite contains arsenic.

MUSTARD GAS

Basic Facts

> Mustard agent, in some forms, can be a colorless, oily,

odorless liquid.

> Mustard agent can be vaporized to form a gas, if heated.

> In some quantities, this agent may have a slight garlic odor

and a yellowish-to-brownish tint.

Mustard Gas as a Weapon

> The agent may be persistent in the soil for weeks but 

generally only remains on materials after release for days 

to hours. This is highly dependent on the air temperature 

and purity of the compound.

> It can still be harmful if it settles in the ground.

> It was introduced as a weapon in World War I.

Mustard Gas Illness

> The agent enters the body through inhalation or contact with

skin or eyes.

> The agent can cause skin damage on contact, especially on

hot, humid days or in tropical climates.

> Signs and symptoms may not occur immediately. Depending

on the severity of the exposure, symptoms may not occur for

2–24 hours.

This family of chemical agents is also called vesicant

agents:

> Mustards (e.g., sulfur mustard)

> Lewisites/chloroarsine agents

> Phosgene oxime

Mustards and lewisites cause blistering on the skin after

exposure. Mustard gas is the best-known example. A

lesser-known but possible threat is lewisite.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 101

Within hours:

- Blisters

- Diarrhea, nausea, and vomiting

- Low blood pressure or “lewisite

shock”

Within days:

- Blisters form lesions

Within weeks:

- Discoloration of the skin

> Lewisite may cause the following longterm health effects after prolonged

exposure or in the case of exposure to

high doses:

- Skin burning

- Chronic respiratory disease

- Permanent blindness

Lewisite Diagnosis and

Treatment

> The smell of lewisite may signal a

release.

> Lewisite is not found naturally in the

environment; when released there,

however, it can last for days.

Lewisite as a Weapon

> Lewisite was developed for use in

World War I by the United States but

was produced too late to be used.

> Lewisite has no other uses except as a

chemical warfare agent.

> In a vapor state, lewisite can be

released into the air.

> The liquid form of lewisite could possibly

be used to poison water or food.

> People are exposed to lewisite by

breathing in or ingesting it, or if it comes

into contact with their skin or eyes.

Lewisite Illness

> Lewisite causes immediate damage 

to the skin, eyes, and respiratory

(breathing) tract.

> In addition to its irritative effects, 

the effects of lewisite exposure are 

similar to those of arsenic poisoning,

including stomach ailments and low

blood pressure.

> Lewisite causes the following symptoms

(all health information was gathered

from animal studies, since there are no

known cases of human exposure):

Seconds to minutes:

- Skin pain and irritation

- Immediate eye irritation, pain,

swelling, and tearing

- Runny nose, sneezing, hoarseness,

bloody nose, sinus pain, shortness

of breath, and cough

15–30 minutes:

- Skin redness

> Diagnosis is confirmed from people’s

symptoms.

> British-Anti-Lewisite is the preferred

antidote and is most effective if given

immediately after exposure.

Lessening the Impact of Lewisite

Exposure

> Move away from the site of exposure

immediately and go to higher ground

for fresh air.

> Remove outer layer of clothing, place

in a plastic bag, and seal as soon as

possible.

> Immediately wash body thoroughly with

soap and water.

> Flush irritated eyes with plain water

for 10–15 minutes.

> If lewisite has been swallowed, do not

induce vomiting or drink fluids.

> Seek medical attention immediately.

Blister agent inhaled or absorbed through skin 

or eyes.

FIGURE 4–1: BLISTER AGENTS

1.

Symptoms include blisters or burns on skin or

lungs, eye irratation, coughing, and respiratory 

irritation.

2.
BLOOD AGENTS

OVERVIEW

102 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Blood agents include:

> Arsine

> Cyanide

These agents deprive the blood and organs of oxygen.

ARSINE

Basic Facts

> Arsine is a colorless toxic gas.

> Arsine has a mild garlic odor that can be detected only 

at levels greater than those necessary to cause poisoning.

> Accidental formation of arsine in the workplace is the most

common route of exposure.

Arsine as a Weapon

> Arsine was explored for chemical warfare in World War II by

the British but was never used.

> Arsine is relatively easy to create for a deliberate release 

into the air because it is most commonly used in the 

semiconductor and metals refining industries and is 

readily available.

Arsine Illness

> The severity of arsine poisoning depends on the amount and

duration of exposure.

> Arsine enters the bloodstream and damages red blood cells.

> Exposure to low or moderate doses of arsine causes 

symptoms within 2–24 hours, including:

- Weakness

- Fatigue

- Headache

- Drowsiness

- Confusion

- Shortness of breath

- Rapid breathing

- Nausea, vomiting, and/or abdominal pain

- Red or dark urine

- Yellow skin and eyes (jaundice)

- Muscle cramps

> Exposure to high doses of arsine can cause:

- Loss of consciousness

- Convulsions

- Paralysis

- Respiratory failure possibly leading to death

> Long-term side effects of exposure include:

- Kidney damage

- Numbness and pain in the extremities

- Memory loss or confusion

Arsine Diagnosis and Treatment

> A release is confirmed when people start exhibiting symptoms.

> Only during a large release will arsine’s garlic odor be prevalent.

> There is no antidote for arsine poisoning.

Lessening the Impact of Arsine Exposure

> Move away from the site of exposure and get fresh air

immediately.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> Seek medical attention immediately.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 103

Blood agent inhaled or ingested.

FIGURE 4–2: BLOOD AGENTS

1.

Chemical deprives cells and tissues of oxygen

causing rapid breathing, nausea, convulsions, 

and loss of consciousness.

2.

CYANIDE

Basic Facts

> Cyanide can come in many different

forms, however, the following four

types are more likely to be seen:

- Hydrogen cyanide

- Cyanogen chloride

- Potassium cyanide

- Sodium cyanide

> Legitimate uses of cyanide compounds

include manufacturing applications,

such as metal refining and

photography.

> In gas form, the agent is colorless and

may have a slight almond odor.

Cyanide as a Weapon

> The agent can be released into the air,

soil, drinking water, or food supply.

> Cyanide is fast acting.

> Breathing in and ingesting cyanide are

the most harmful routes of exposure.

> Cyanide is most dangerous in enclosed

spaces.

> Cyanide evaporates quickly in open

areas.

> Cyanide is relatively easy to obtain

and release.

Cyanide Illness

> Cyanide deprives the body’s cells from

using oxygen.

> The agent is most harmful to the heart

and brain, which rely heavily on oxygen.

> Symptoms include:

- Rapid breathing, restlessness,

dizziness, weakness, and headache

- Nausea, vomiting, and convulsions

- Loss of consciousness, injury to the

lungs, and respiratory failure

- Permanent heart and brain damage

- Rapid progression to coma and

death

Cyanide Diagnosis and Treatment

> Environmental testing can confirm a

release.

> Blood tests can confirm individual

exposure.

> Immediate medical attention is 

recommended.

> Preferred antidotes are a nitrite or a

thiosulfate compound.

Lessening the Impact of Cyanide

Exposure

> Move away from the site of exposure

and get fresh air immediately.

> Remove outer layer of clothing, place

in a plastic bag, and seal as soon as

possible.

> Immediately wash body thoroughly

with soap and water.

> Flush irritated eyes with plain water

for 10–15 minutes.

> Seek medical attention immediately.
CHOKING AGENTS

OVERVIEW

104 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

CHLORINE

Basic Facts

> Chlorine is used in industry and is found in bleach and other

common household products.

> Chlorine can take a gas or yellow-green liquid form.

> Chlorine emits a strong odor, which is like the odor of bleach,

and can become explosive and flammable when mixed with

other chemicals.

Chlorine as a Weapon

> Chlorine is most likely to be released as a gas.

> It can be released into the air and spreads rapidly.

> Chlorine settles close to the ground.

> In liquid form, it can be released into the water or food supply.

> Chlorine was used in World War II as a chemical weapon.

> Terrorists may attempt to access large quantities stored at

water treatment facilities, swimming pool complexes, and

industrial sites.

Chlorine Illness

Symptoms of exposure include:

> Coughing and tightness in the chest

> Burning eyes, nose, and throat

> Blurred vision, nausea, and vomiting

> Blistered skin

> Shortness of breath and fluid in the lungs

> Long-term complications, including pneumonia and chronic

bronchitis

Chlorine Diagnosis and Treatment

> Air sampling is conducted to confirm a release.

> No antidote exists.

> Supplemental oxygen should be given as needed.

> Immediate medical treatment is essential.

Lessening the Impact of Chlorine Exposure

> Move away from the site of exposure immediately and move

to higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> If you have ingested chlorine, do not induce vomiting or 

drink fluids.

> Seek medical attention immediately.

PHOSGENE

Basic Facts

> Phosgene is also known as CG.

> Phosgene is an industrial chemical used to make plastics 

and pesticides.

> Phosgene is a poisonous gas at room temperature.

> When cooled, phosgene is converted into liquid form.

Choking agents include:

> Ammonia

> Chlorine

> Hydrogen chloride

> Phosgene

> Phosphine

> Phosphorus (certain forms)

These agents attack the respiratory system, making it

difficult to breathe.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 105

> In a liquid release or spill, phosgene

changes to gas and stays close to the

ground.

> Phosgene may appear colorless, or as

a white or pale yellow cloud.

> In low concentrations, phosgene smells

like newly mown hay.

> In high doses, phosgene has a strong

unpleasant odor. 

> Phosgene can cause flammable

substances to burn but is not

flammable itself.

> Phosgene is not found naturally in the

environment.

> Phosgene may be relatively easy to

obtain since it is used in industry.

Phosgene as a Weapon

> Phosgene was used extensively during

World War I, by both German and

Allied armies, causing many deaths.

> Phosgene could be released into the air.

> Phosgene liquid could be released into

water to expose those who drink it or

touch it.

> Phosgene could be used in liquid form

to poison food.

Phosgene Illness

> In gas or liquid form, phosgene can

damage the skin, eyes, nose, throat,

and lungs.

> Proximity to a release and the length of

exposure determine how serious the

phosgene illness is.

> Symptoms may occur immediately

after exposure if doses are extremely

high. These include:

- Coughing

- Burning sensation in the throat 

and eyes

- Watery eyes

- Blurred vision

- Difficulty breathing or shortness of

breath

- Nausea and vomiting

- With skin contact, possible

development of lesions similar to

those from frostbite or burns

- Within 2–6 hours after exposure to

high doses of phosgene, possible

development of fluid in the lungs

(pulmonary edema)

> Exposure to low or moderate concentrations of phosgene may have few

early clinical findings. Development of

worsening signs and symptoms may

occur 12–24 hours after the initial

exposure. Delayed symptoms may

surface up to 48 hours after exposure.

These include:

- Difficulty breathing

- Coughing up white- to pink-tinged

fluid and developing fluid in the

lungs (pulmonary edema)

Choking agent inhaled.

FIGURE 4–3: CHOKING AGENTS

1.

Chemical attacks respiratory system.

2.

Symptoms include coughing, burning eyes or

throat, nausea, fluid in lungs, and difficulty

breathing.

3.
106 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

- Low blood pressure

- Heart failure

- Severe respiratory distress

Phosgene Diagnosis and Treatment

> There is no known antidote.

> Quickly moving away from the source of exposure is most

important.

> Supplemental oxygen should be given as needed. 

> People should be monitored for up to 48 hours for delayed

symptoms.

> Most people exposed recover, but high doses can result 

in chronic bronchitis and emphysema.

Lessening the Impact of Phosgene Exposure

> Move away from the site of exposure immediately and move

to higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> If you have ingested phosgene, do not induce vomiting or

drink fluids.

> Seek medical attention immediately.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 107

A REAL-LIFE EXAMPLE OF HOW STATE, LOCAL, AND FEDERAL AGENCIES COLLABORATED ON AN ACCIDENTAL CHEMICAL RELEASE IN

THE UNITED STATES: GRANITEVILLE, SOUTH CAROLINA 

Although this case study only provides a snapshot of a highly complex

event, it does provide some insight for what the response to a chemical

release may look like and how health officials at the local, state, and

federal levels work together and with many other agencies to respond to

such an event.

At approximately 2:40 a.m. on January 6, 2005, two freight trains collided

in Graniteville, South Carolina, releasing an estimated 11,500 gallons of

chlorine gas, which caused nine deaths and sent at least 529 persons

seeking medical treatment for possible chlorine exposure. Because of

the potential for death and injury, local emergency management officials

initially issued a shelter-in-place order for a 1-mile radius around the

site. At noon, South Carolina declared a state of emergency and local

officials issued a mandatory evacuation for over 5,000 residents within

this 1-mile radius. Area schools and businesses were closed.

Hazardous materials teams worked together to contain the chlorine

exposure and remove it from the site—including personnel from the

local fire departments, the U.S. Environmental Protection Agency (EPA),

the U.S. Department of Energy’s Savannah River Site Fire Department,

and state response teams. Meanwhile, federal responders from the CDC,

EPA, and the U.S. Coast Guard arrived to assist local and state officials

in sampling air in factories, homes, and schools within the 1-mile radius.

Additional free inspections were offered to residents and business

owners with continued concerns. 

Local law enforcement personnel enforced a curfew and the mandatory

evacuation. Local, state, and federal agencies assisted in perimeter

security, investigations, and coordination. The Federal Bureau of

Investigation, National Transportation Safety Board, and the Federal

Railroad Administration conducted investigations into the train

derailment.

Starting January 13, residents were allowed to return to their homes

gradually as air quality was deemed safe, depending on where their

homes were located in relation to the release. Residents were also

provided with HHS guidance about what to do when returning home (e.g.,

what to do with existing food and medicine, what to do about pets that

were left in the evacuation area).

A rapid epidemiological assessment indicated that out of 511 persons

examined in emergency rooms after the exposure, 69 were hospitalized

in seven area hospitals. An ongoing assessment began to examine the

public health impact associated with exposure to chlorine gas. Those

exposed were interviewed about their symptoms, the location and

duration of their exposures, and demographic information needed to

monitor long-term health effects. 

Sources:

Centers for Disease Control and Prevention. (2005). Public health consequences from

hazardous substances acutely released during rail transit—South Carolina, 2005; selected

states, 1999–2004. Morbidity and Mortality Weekly Report, 54(3), 64–67.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a2.htm.

U.S. Environmental Protection Agency. (2005). Norfolk Southern Graniteville derailment.

http://www.epa.gov/Region4/graniteville/index.htm.
NERVE AGENTS

108 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

OVERVIEW

SARIN

Basic Facts

> Sarin is a manufactured compound that is colorless, 

odorless, and tasteless.

> Sarin can take a gas or liquid form and is highly volatile 

and lethal.

> Sarin is absorbed through the skin or respiratory tract and

causes severe respiratory damage.

> Even very small amounts can kill people.

> Vaporized sarin stays near the ground.

> Sarin remains deadly in warm, dry temperatures but can

degrade in humidity.

Sarin as a Weapon

> Sarin can be released into the air and expose people through

ingestion or contact with the skin or eyes.

> Sarin can be released into water and expose people who

touch or drink the contaminated water.

> Sarin can be used to contaminate food.

> Sarin is most dangerous in enclosed spaces.

> Victims need only be exposed to a small amount to become ill.

> Sarin was used by Aum Shinrikyo, a Japanese cult, in a

1995 Tokyo subway attack, which demonstrated to the

world that it could be used as a terrorist weapon.

Sarin Illness

Symptoms include:

> Difficulty breathing, tightness in chest, and respiratory arrest

> Nausea, drowsiness, vomiting, and diarrhea

> Confusion and seizures

> Drooling, runny nose, eye irritation, and tearing

> Severe muscle weakness

Sarin Diagnosis and Treatment

> With large doses, death can occur within seconds to minutes

after exposure.

> Rapid recognition after a suspected attack is the key to

successful treatment.

> Atropine and pralidoxime are the preferred antidotes but

must be used quickly to be effective.

> Oxygen should be administered to those having difficulty

breathing.

Lessening the Impact of Sarin Exposure

> Move away from the site of exposure immediately and move

to higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> If you have ingested sarin, do not induce vomiting or 

drink fluids.

> Seek medical attention immediately.

SOMAN

Basic Facts

> Soman is also known as GD.

> Soman is a clear, colorless, tasteless liquid that can smell

fruity or like oil of camphor.

> Soman can be heated into a vapor form.

> Soman is not found naturally in the environment.

Nerve agents do damage by affecting the nervous 

system of victims. These agents are of the greatest 

concern because of the low amounts needed to produce

significant symptoms and even death. These agents

include:

> Sarin

> Soman

> Tabun

> VX
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 109

Nerve agent inhaled.

FIGURE 4–4: NERVE AGENTS

1.

Chemical affects the nervous system creating

seizures, eye irritation, and muscle weakness.

2.

- Cough

- Chest tightness

- Rapid breathing

- Diarrhea

- Increased urination

- Confusion

- Drowsiness

- Weakness

- Headache

- Nausea, vomiting, and/or abdominal

pain

- Slow or fast heart rate

- Abnormally low or high blood

pressure

> Exposure to a large dose of soman, by

any route, may result in these

additional health effects:

- Loss of consciousness

- Convulsions

- Paralysis

- Respiratory failure, possibly leading

to death

> Vapors can be trapped on a person’s

clothing and can expose others.

Soman Diagnosis and Treatment

> The odor of soman may be a signal of

a release.

> Treatment of soman poisoning with

antidotes (atropine and pralidoxime) is

recommended as soon as possible

(ideally within minutes).

> Long-term supportive health care may

be necessary.

> Mild or moderately poisoned people

who are treated both rapidly and 

adequately usually recover completely.

> Severely exposed people or those 

victims who are ineffectively treated

may not survive.

Soman as a Weapon

> Soman is a human-made chemical

warfare agent.

> Germany developed soman as an

insecticide in 1944.

> Soman is suspected of being used

during the Iran-Iraq war in the 1980s.

> Soman can be released into the air in

vapor form.

> Soman could be used in liquid form to

poison water or food.

Soman Illness

> People can get sick after inhaling

soman or by absorbing it through skin

or eye contact.

> People can get sick by drinking 

poisoned water or swimming in 

contaminated water.

> Illness can follow eating food 

contaminated with soman.

> Symptoms will appear within a few

seconds after exposure to the vapor

form of soman.

> In liquid form, soman produces

symptoms within a few minutes or up

to 18 hours after exposure.

> Even a tiny drop of the nerve agent on

the skin can cause sweating and

muscle twitching at the site of contact.

> Low or moderate doses of soman

cause the following symptoms:

- Runny nose

- Watery eyes

- Small, pinpoint pupils

- Eye pain

- Blurred vision

- Drooling and excessive sweating
110 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Lessening the Impact of Soman Exposure

> Move away from the site of exposure immediately and move

to higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> If you have ingested soman, do not induce vomiting or 

drink fluids.

> Seek medical attention immediately.

TABUN

Basic Facts

> Tabun is also known as GA.

> Tabun is a clear, colorless, tasteless liquid with a faint 

fruity odor.

> Tabun can become a vapor, if heated.

> Tabun is not found naturally in the environment.

> Tabun is toxic and affects the body rapidly.

Tabun as a Weapon

> Tabun is human-made for chemical warfare.

> Tabun was originally developed by Germany in 1936 as a

pesticide.

> Tabun was possibly used in the 1980s during the 

Iran-Iraq war.

> Tabun could be released through the air.

> Tabun could be used to poison water.

> Tabun could be used to contaminate food.

Tabun Illness

> People can become ill after breathing in tabun, ingesting it,

or through contact with skin or eyes.

> People can get sick by eating food contaminated with tabun,

by drinking contaminated water, or by coming into contact

with contaminated water.

> After exposure to tabun in vapor form, symptoms should

appear within a few seconds.

> Exposure to tabun in liquid form produces symptoms within

a few minutes or up to 18 hours later.

> Tabun can remain active on a person’s clothing, leading to

exposure of others.

> A tiny drop of this nerve agent on the skin can cause

sweating and muscle twitching at the site of contact.

> People exposed to a low or moderate dose of tabun may

experience some or all of the following symptoms within

seconds to hours after exposure:

- Runny nose

- Watery eyes

- Small, pinpoint pupils

- Eye pain

- Blurred vision

- Drooling and excessive sweating

- Cough

- Chest tightness

- Rapid breathing

- Diarrhea

- Increased urination

- Confusion

- Drowsiness

- Weakness

- Headache

- Nausea, vomiting, and/or abdominal pain

- Slow or fast heart rate

- Abnormally low or high blood pressure

> Exposure to a large dose of tabun may result in:

- Loss of consciousness

- Convulsions

- Paralysis

- Respiratory failure, possibly leading to death
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 111

Tabun Diagnosis and Treatment

> The fruity odor of tabun may provide warning of a release.

> Atropine and pralidoxime are antidotes which can be given

for poisoning. They should be administered ideally as soon 

as possible.

> Other supportive care in a hospital setting should be given as

needed (such as oxygen, assistance with breathing, etc.).

> A complete recovery is likely for those with mild or moderate

poisoning who are treated both rapidly and adequately.

> Those who inhale or are contaminated with large amounts of

tabun or those who are ineffectively treated can die.

> Repeated exposure to tabun can result in long-term damage

to the body.

Lessening the Impact of Tabun Exposure

> Move away from the site of exposure immediately and move

to higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> If you have ingested tabun, do not induce vomiting or 

drink fluids.

> Seek medical attention immediately.

VX

Basic Facts

> VX can be heated to create a vapor form, but only in small

amounts.

> The agent is stable in the environment.

> In average weather, VX can last on objects for days.

> In extremely cold weather, VX can sustain its potency for

months.

> VX can be a long-term hazard on surfaces.

> VX is considered more toxic than other nerve agents.

VX as a Weapon

> VX is a human-made chemical warfare agent.

> The agent was originally developed in the United Kingdom in

the early 1950s.

> VX may have been used in the Iran-Iraq war in the 1980s.

> VX is primarily used in liquid form to contaminate water 

or food.

VX Illness

> People are exposed to VX by ingesting it, breathing in a VX

mist, or by coming into contact with it through skin or eyes.

> The vapor form of VX can produce symptoms within seconds

after exposure.

> In liquid form, VX produces symptoms within a few minutes

or up to 18 hours after exposure.

> Unless washed off immediately, VX liquid on the skin can 

be lethal.

> Even a tiny drop of nerve agent on the skin can cause

sweating and muscle twitching at the site of contact.

> VX remains potent on a person’s clothing, meaning that 

others can be exposed.

> Within seconds or hours of moderate exposure to VX, 

symptoms include:

- Runny nose

- Watery eyes

- Small, pinpoint pupils

- Eye pain

- Blurred vision

- Drooling and excessive sweating

- Cough

- Chest tightness

- Rapid breathing

- Diarrhea

- Increased urination

- Confusion

- Drowsiness
112 04. CHEMICAL AGENTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

- Weakness

- Headache

- Nausea, vomiting, and/or abdominal pain

- Slow or fast heart rate

- Abnormally low or high blood pressure

> Exposure to a large dose of VX may cause:

- Loss of consciousness

- Convulsions

- Paralysis

- Respiratory failure possibly leading to death

VX Diagnosis and Treatment

> A release may not be easy to detect because VX has no odor.

> A release is confirmed by the symptoms of those exposed.

> Atropine is the preferred antidote and must be given quickly

after exposure.

> People can recover completely from mild or moderate 

poisoning that is both rapidly and effectively treated.

> Those exposed to large doses of VX or those people

ineffectively treated may not survive.

> Prolonged exposure (e.g., in a war setting) can result 

in long-term damage to the body.

Lessening the Impact of VX Exposure

> Move away from the site of exposure immediately and move

to higher ground for fresh air.

> Remove outer layer of clothing, place in a plastic bag, and

seal as soon as possible.

> Immediately wash body thoroughly with soap and water.

> Flush irritated eyes with plain water for 10–15 minutes.

> If you have ingested VX, do not induce vomiting or drink

fluids.

> Seek medical attention immediately.

> Rescue personnel should wear the highest level of protection

in a release area until testing can be completed and the

safety of lower levels of protection is confirmed.

REFERENCES

2000 Emergency response guidebook: A guidebook for first 

responders during the initial phase of a dangerous goods/

hazardous materials incident. (2000). Washington, DC: The

Office of Hazardous Materials Safety, U.S. Department of

Transportation.

NIOSH pocket guide to chemical hazards (NPG). (2003). 

Atlanta, GA: Centers for Disease Control and Prevention, 

The National Institute for Occupational Safety and Health. 

Agency for Toxic Substances and Disease Registry. (2003).

ToxFAQsTM for sulfur mustard. http://www.atsdr.cdc.gov/

tfacts49.html.

Battlebook Project Team, USACHPPM, & OSG. (2000). 

The medical NBC battle book USACHPPM tech guide 244.

Aberdeen Proving Ground, MD: U.S. Army Research Institute of

Medical Defense. 

Bevelacqua, A., & Stilp, R. (1998). Hazardous materials field

guide. Albany, NY: Delmar Publications. 

Bevelacqua, A., & Stilp, R. (2004). Terrorism handbook for 

operational responders. Clifton Park, NY: Delmar Thomson

Learning. 

Centers for Disease Control and Prevention. (2003). Fact

sheet—Chemical emergencies: Chemical agents: Facts about

sheltering in place. http://www.bt.cdc.gov/planning/

Shelteringfacts.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about arsine.

http://www.bt.cdc.gov/agent/arsine/pdf/arsinefactsheet.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about chlorine.

http://www.bt.cdc.gov/agent/chlorine/basics/pdf/chlorinefacts.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about lewisite.

http://www.bt.cdc.gov/agent/lewisite/basics/pdf/lewisitefacts.pdf.

Centers for Disease Control and Prevention. (2003). Fact

sheet—Chemical emergencies: Facts about personal cleaning and

disposal of contaminated clothing. http://www.bt.cdc.gov/

planning/personalcleaningfacts.pdf.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 113

REFERENCES (cont.)

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about phosgene.

http://www.bt.cdc.gov/agent/phosgene/basics/pdf/

phosgene-facts.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about soman.

http://www.bt.cdc.gov/agent/soman/basics/pdf/soman-facts.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about sulfur mustard.

http://www.bt.cdc.gov/agent/sulfurmustard/basics/pdf/

sulfur-mustard-facts.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about tabun.

http://www.bt.cdc.gov/agent/tabun/basics/pdf/tabun-facts.pdf.

Centers for Disease Control and Prevention. (2003). 

Fact sheet—Chemical emergencies: Facts about VX.

http://www.bt.cdc.gov/agent/vx/basics/pdf/vx-facts.pdf.

Centers for Disease Control and Prevention. (2004). 

Fact sheet—Chemical emergencies: Facts about cyanide.

http://www.bt.cdc.gov/agent/cyanide/basics/pdf/cyanide-facts.pdf.

Centers for Disease Control and Prevention. (2004). 

Fact sheet—Chemical emergencies: Facts about sarin.

http://www.bt.cdc.gov/agent/sarin/basics/pdf/sarin-facts.pdf.

Centers for Disease Control and Prevention. (2005). Public health

consequences from hazardous substances acutely released during

rail transit—South Carolina, 2005; selected states, 1999–2004.

Morbidity and Mortality Weekly Report, 54(3), 64–67.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a2.htm.

Davis, L.E., LaTourrette, T., Mosher, D., Davis, L., & Howell, D.

(2003). Individual preparedness and response to chemical, 

radiological, nuclear, and biological terrorist attacks. 

Santa Monica, CA: Rand Corporation. 

Federal Emergency Management Agency. (2000). Emergency

response to terrorism: Job aid. Washington, DC: FEMA, U.S. 

Fire Administration, National Fire Academy: U.S. Department 

of Justice, Office of Justice Programs. 

Forsberg, K., & Mansdorf, S.Z. (2003). Quick selection guide to

chemical protective clothing. (Fourth ed.). New York: John Wiley

& Sons. 

Harville, D., & Williams, C. (2003). The WMD handbook: 

A guide to Weapons of Mass Destruction. New York: 

First Responder Inc. 

Keller, J.J. (1998). Hazardous materials compliance manual.

Neenah, WI: J.J. Keller & Associates. 

Sidell, F.R., Patrick, W.C., Dashiell, T.R., & Alibek, K. (2002).

Jane’s chem-bio handbook. (2nd ed.). Alexandria, VA: Jane’s

Information Group.

U.S. Environmental Protection Agency. (2005). Norfolk Southern

Graniteville derailment. http://www.epa.gov/Region4/graniteville/

index.htm.

05RADIATION EMERGENCIES
GOAL OF THIS SECTION

RADIATION EMERGENCIES

116 05. RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

BASIC FACTS

> Radiation is energy moving in the form of particles or waves.

Some examples of electromagnetic radiation are heat, light,

radio waves, and microwaves. The specific type of radiation

discussed in this guide is ionizing radiation.

> Ionizing radiation is a very high-energy form of electromagnetic

radiation and cannot be detected without specialized

equipment.

> Radioactivity is the process of spontaneous transformation of

the nucleus of an atom, generally with the emission of alpha

or beta particles often accompanied by gamma rays. This

process is referred to as decay or disintegration of an atom.

- An alpha particle is the nucleus of a helium atom, made up

of two neutrons and two protons. Alpha particles generally

carry more energy than gamma or beta particles and

deposit that energy very quickly while passing through

human body tissue. Alpha particles can be stopped by a

thin layer of light material, such as a sheet of paper, and

cannot penetrate the outer, dead layer of skin. Therefore,

they do not damage living tissue when outside the body.

When alpha-emitting atoms are inhaled or swallowed,

however, they are especially damaging because they transfer

relatively large amounts of ionizing energy to living cells.

- Beta particles are electrons ejected from the nucleus of a

decaying atom. Although they can be stopped by a thin

sheet of aluminum, beta particles can penetrate the dead

skin layer, potentially causing burns. They can pose a

serious direct or external radiation threat and can be lethal

depending on the amount received. They also pose a

serious internal radiation threat if beta-emitting atoms are

ingested or inhaled.

- Gamma rays are a high-energy electromagnetic radiation.

Gamma rays are very penetrating and generally require

material such as lead or thick concrete to reduce the

exposure. Gamma rays are a serious direct or external

radiation threat. They also pose a threat when they are

inhaled or ingested. Gamma rays are very similar to X-rays.

- Neutrons are small atomic particles found within an atom’s

nucleus. Neutrons are a highly penetrating radiation when

released by nuclear fission (the splitting of an atom) and

are a serious direct or external radiation threat after a

nuclear detonation (e.g., nuclear weapon or an improvised

nuclear device). These types of radiation incidents are

discussed later in this section.

> To provide information on nuclear events (e.g., nuclear

bomb, improvised nuclear devise) 

> To provide information on radiological events (e.g.,

radiological dispersal device, such as a dirty bomb;

sabotage of a nuclear power plant)

WHAT THIS SECTION INCLUDES

> Explanation of the differences between nuclear and 

radiological events and how they might affect people

> Sources for additional information

> How to lessen the impact of radiation exposure

WHAT THIS SECTION DOES NOT INCLUDE AND WHY

> Extensive detail on radiological emergencies is not

provided in this section due to the complexity of the topic.

> Radiological accidents are not covered in detail in this

section. However, much of the material in this section

would be applicable to radiological accidents (e.g., nuclear

reactor issues, a spill of radiological materials, accidents

with nuclear weapons).
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 117

Any or all of the types of radiation described above may be

present after a radiological event. Public health officials would

determine the specific protective actions that the public should

take as soon as the nature of the event is determined by

radiological experts.

> Radioactive material is material that contains unstable

(radioactive) atoms that give off radiation as they decay.

> Radioactive decay is the spontaneous disintegration of the

nucleus of an atom.

> Radioactive half-life is the time required for a quantity of a

radioactive material to decay by half.

> Radioactive contamination is the deposition of radioactive

material (e.g., dirt, dust, debris, liquid) on the surfaces of

structures, areas, objects, or people. It can be airborne,

external, or internal.

> Radiation exposure is not the same as contamination.

Exposure occurs when radiation penetrates the body and

deposits its energy. For example, when a person has a chest

X-ray, he or she is exposed to radiation, but he or she is 

not contaminated.

NUCLEAR/RADIOLOGICAL AGENTS—

TIMELINE OF SELECTED IMPORTANT EVENTS

1940: Scientists based in Britain first report that the production

of a nuclear bomb is possible.

1941: British nuclear weapons research begins.

1943: Americans join the research effort with the “Manhattan

Project.”

1945: The United States uses two atomic bombs against

Japan in World War II.

1957: First full-scale nuclear power plant goes into service in

Shippingport, PA.

1968: Treaty on the Non-Proliferation of Nuclear Weapons is

developed.

1979: Three Mile Island nuclear power plant near Harrisburg,

PA, releases small amounts of radioactive gases into the

atmosphere after the power plant’s core accidentally overheats

and partially melts. There were no deaths or injuries to plant

workers or members of the nearby community from this accident.

1986: An accidental chain reaction in the Soviet Union’s

Chernobyl nuclear power plant, near Kiev, leads to an explosion

that releases radiation into the air. The accident kills more

than 30 people immediately and prompts the evacuation of

135,000 people as a result of the high radiation levels in the

surrounding 20-mile radius.

1987: Four people die of acute radiation sickness and others

are sickened in Goiania, Brazil, after two individuals discover

radioactive cesium in a canister scavenged from an abandoned

hospital. Children inadvertently spread the radiation

throughout the community after rubbing the canister’s

contents on their bodies so they could glow in the dark.

1999: An accident occurs at a nuclear fuel conversion plant in

Tokaimura, Japan. The accident was caused by human error

circumventing standard procedures. Three workers suffered

from acute radiation syndrome (one subsequently died). Other

workers and some members of the public were exposed to

radiation. Families within the 350-meter perimeter of the site

were evacuated and the population within the 10-kilometer

radius (300,000 people) were sheltered-in-place for 18 hours.

NUCLEAR/RADIOLOGICAL AGENTS AS WEAPONS

The first step in understanding radiation emergencies is to draw

the distinction between a nuclear event (like the bomb dropped

on Hiroshima, Japan) and a radiological event, such as a nuclear

power plant incident or a radiological dispersal device (e.g., dirty

bomb). In short, a nuclear event involves nuclear fission (splitting

of atoms) and a highly destructive explosion that instantly

devastates people and buildings because of extreme heat and

impact of the blast. A nuclear event typically leaves large

amounts of radioactivity behind. On the other hand, a radiological

event does not involve nuclear fission but may be accompanied

by an explosion and release of radioactivity. A radiological event

typically involves the release of less radioactivity than a nuclear

event. With both nuclear and radiological events, wind direction

and weather patterns can spread radioactivity beyond the 

immediate incident site.

Four specific radiation incidents will be discussed:

> Nuclear power plant attack

> Radiological dispersal device (e.g., dirty bomb)

> Improvised nuclear device (e.g., suitcase bomb)

> Nuclear weapon
118 05. RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

NUCLEAR POWER PLANT ATTACK

> This is a radiological threat that does not involve a nuclear

blast.

> Terrorists could attack a nuclear power plant by using

explosives, hacking into the computer system, or crashing a

plane into the reactor or other structures on site.

> Security measures are in place so that such attempts are

likely to be detected early. Also, nuclear power plants have

well-established emergency response procedures in place.

> Nuclear power plants are built to sustain extensive damage

without releasing radioactive material.

> Theoretically, radioactive materials could escape in some

cases and contaminate the surrounding area and the 

environment.

> Costly and time-consuming cleanup efforts could be required to

remove released radioactive materials from the environment.

> Though the death toll and radiation exposure could be limited,

the psychological impact could be severe. In the case of the

limited meltdown accident at Pennsylvania’s Three Mile

Island in 1979, a governor’s commission report showed that

one of the main health effects of the accident was 

on the mental health status of people in the region.

RADIOLOGICAL DISPERSAL DEVICE (RDD)

> This is a radiological threat that does not involve a nuclear

blast.

> Terrorists could obtain radioactive materials to use in 

such a device. Radioactive materials can come from a

nuclear power plant, medical or research facility, or foodprocessing plant.

> Radioactive materials could be dispersed by using explosives

(e.g., dirty bomb) or other means, such as aerosols or sprays.

> A dirty bomb involves conventional explosives laced with

radioactive material, so that the blast would contaminate an

area with radioactive particles.

> In the case of a dirty bomb, the resulting blast could kill

people in the immediate area and spread contamination

around an area the size of several city blocks.

> Though the death toll and radiation exposure would be limited,

the psychological impact could be severe. In this vein, some

have dubbed the dirty bomb a “weapon of mass disruption.”

> Radiological material can also be covertly placed in areas

where it could easily expose people to radiation. This hidden

source is often referred to as a “silent” source or may be

called a radiation-emitting device. This method of radiation

release does not involve an explosion or dispersal of

radioactive materials by any other means.

IMPROVISED NUCLEAR DEVICE (IND)

> This is a small nuclear weapon (see section below) capable

of producing a nuclear blast.

> The physical size of these weapons can be small enough to

fit in a suitcase (i.e., suitcase bomb).

> The design and destructive nature of an improvised nuclear

device is comparable to the bomb dropped on Hiroshima,

Japan, at the end of World War II.

NUCLEAR WEAPON

> A nuclear weapon produces a nuclear detonation involving

the joining (fusion) or splitting (fission) of atoms to produce

an intense pulse or wave of heat, light, air pressure, and

radiation.

> Highly processed plutonium or uranium undergoes fission in

a chain reaction blast.

> The blast is designed to cause catastrophic damage to 

people, buildings, and the environment.

> Highly guarded materials and technical expertise are

required to produce these weapons.

> The extent of damage depends on the yield (power) of the

bomb. The destructive nature of these weapons can be in the

order of 100 times the bomb dropped on Hiroshima.

> When a nuclear weapon explodes, a large fireball is created.

Everything inside of this fireball vaporizes, including soil and

water, and is carried upwards. This creates the mushroom

cloud that is associated with a nuclear blast, detonation, or

explosion.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 119

> Radioactive material from the nuclear device mixes with the

vaporized material in the mushroom cloud. As this vaporized

radioactive material cools, it becomes condensed and forms

particles, such as dust. The condensed radioactive material

then falls back to the earth; this is what is known as fallout.

> Because fallout is in the form of particles, it can be carried

long distances on wind currents and end up miles from the

site of the explosion.

> Fallout is radioactive and can cause contamination of

anything on which it lands, including food and water

supplies.

WHAT WE DO NOT KNOW ABOUT NUCLEAR/RADIOLOGICAL 

AGENTS AS WEAPONS

> Because there is a wide range of possible scenarios, it is

difficult to predict beforehand how elevated radiation

exposures will be, how extensive the radioactive

contamination will be, or how much effort would be involved

in cleanup and recovery.

> In the case of an attack on a nuclear power plant, it is

unlikely that any radioactive materials would be released to

the area outside the facility, but the possibility cannot be

categorically ruled out.

> In the case of a dirty bomb, the overall impact will depend

on many factors, such as specific radioactive material used

in the bomb and wind and weather conditions at the time of

the blast.

> The impact of other types of RDDs and silent sources also

depends on a variety of factors, including size of the source

and how early the device or source is detected.

> The overall impact of a nuclear blast depends on its size,

whether there is fallout, how populated the target area is,

and how much of the potential local response infrastructure

is destroyed.

ASSESSING THE RISK

> The highly purified plutonium and uranium needed to make

a nuclear weapon or suitcase bomb are difficult to acquire.

Considerable engineering skill and expertise would be

required to construct a nuclear device using plutonium;

devices using uranium are technically easier to construct.

> Other radiological materials, such as cesium-137 or cobalt60, that would be suitable for use in a RDD are moderately

available since they can be found in research, medical, and

food irradiation facilities.

> Certain radioactive materials can persist for years or even

decades in the environment. The half-life of cesium-137, for

example, is about 30 years. Other radioisotopes have much

shorter half-lives (e.g., iodine-131 has a half-life of about 

8 days).

> Though the construction of a nuclear weapon or suitcase

bomb involves advanced scientific knowledge, terrorists

would only have to be moderately skilled to construct a dirty

bomb, which simply involves wrapping conventional

explosives around radioactive materials.

> A nuclear blast would be highly lethal, potentially killing a

very large number of victims, whereas the effects of an RDD

attack would almost certainly be much less severe.
120 05. RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TABLE 1: EFFECTS OF DIFFERENT RADIATION EMERGENCIES

Type of Event

Examples of Radiation

Dispersal

Nuclear Blast

Amount of Radiation Exposure

Consequences

Radiological

Possible escape of 

radioactive material 

from attack on plant

• Conventional explosives

laced with radioactive 

material (e.g., dirty bomb)

• Aerosols or sprays

No

Radiological

No

• Less than a nuclear event

• Although unlikely, radioactive

materials could escape/

contaminate the area and

environment

• Death toll could be limited

• Plants are built to sustain

extensive damage without

releasing radioactive material

• Psychological impact could

be severe

• Limited 

• Dirty bomb blast could

spread contamination around

area the size of several city

blocks

• Limited death toll 

• In the case of a dirty bomb,

initial explosion could kill 

or injure people in the 

immediate area

• Psychological impact could

be severe

NUCLEAR POWER PLANT ATTACK

RADIOLOGICAL DISPERSAL

DEVICE (RDD)
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 121

Hiding radioactive material in

a populated area

Radiological

No • Smaller nuclear explosion of

varying size

• Can be as large as the bomb

dropped on Hiroshima

• Limited 

• Depends on the size of 

the source and speed of

detection

• Depends on the size of

source, how early it is

detected, and other factors

• Psychological impact could

be severe

RADIATION-EMITTING DEVICE

(RED)

Nuclear Nuclear

Smaller nuclear weapon 

(e.g., suitcase bomb)

• Varying 

• May or may not include 

fallout

• Depends on the size of the

blast, whether there is

fallout, and population of

area

• Psychological impact could

be severe

• Highly destructive nuclear

explosion 

• Can be in the order of 100

times the bomb dropped on

Hiroshima

Nuclear weapon developed

for strategic military 

purposes

• Large 

• Radioactive particles from

the fallout could be carried

long distances

• Catastrophic damage to 

people, buildings, and the

environment

• Psychological impact could

be severe

IMPROVISED NUCLEAR DEVICE

(IND) NUCLEAR WEAPON
122 05. RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

INSTRUCTIONS TO SHELTER-IN-PLACE

AND SEAL THE ROOM DUE TO 

RADIATION EMERGENCIES

If you have been exposed:

> If coming from outside, remove outer

layer of clothing and seal it in a plastic

bag

> Shower and gently wash with soap, 

if possible

To shelter-in-place and seal the room:

> Find a room with as few windows and

doors as possible

> Go to the lowest level possible

> Turn off the air conditioner, heater, 

and fans

> Close the fireplace damper

> Fill sinks and tubs with water

> Turn on the radio for instructions

> Keep a telephone handy

> If emergency officials instruct you to seal

the room, tape plastic over windows and

doors; seal with duct tape. Tape over

vents and electrical outlets (and any

other openings).*

* Within a few hours, the plastic and tape may

need to be removed to allow fresh air to enter

the room to prevent suffocation. Follow the

instructions of emergency workers and/or

public health officials.

LESSENING THE IMPACT 

OF EXPOSURE 

(to Radiological Agents, in General)

> Follow the instructions of emergency

workers, if possible.

> The most important concepts to 

minimize exposure are time, distance,

and shielding.

- Time: Decrease the amount of time

spent near the radiation source.

- Distance: Increase your distance

from the radiation source.

- Shielding: Increase the shielding

between you and the radiation source.

Shielding is anything that creates a

barrier between people and the

radiation source.

> Stay indoors and “shelter-in-place” 

to reduce exposure. Being inside a

building (particularly basement), inside

a vehicle, or behind a wall would

provide some protection.

> Close doors and windows and shut off

ventilation systems using outside air.

> If outdoors, cover mouth and nose with

a scarf, handkerchief, or other type of

cloth to avoid inhaling radioactive dust.

> If near the site of an attack and dust or

debris is on one’s body or clothing,

decontaminate (remove outer layer of

clothing and bag it, shower without

harsh scrubbing, and wash hair)

before leaving to avoid spreading 

contamination.

> Treatment of life-threatening injuries

should not be delayed in order to

perform decontamination. Seek medical

attention if injured by the explosion.

> Do not eat potentially contaminated

foods or drink potentially contaminated

water.

> Federal agencies have developed realtime models to predict how a nuclear

or radiological attack would affect a

given area. This information can be

used to quicken response efforts and

limit the number of people affected by

an attack.

THE IMPACT OF RADIATION

EMERGENCIES

A nuclear or radiological event could

have a wide range of impacts, including

immediate or long-term health effects,

psychological impacts, environmental

contamination, and economic

consequences. The magnitudes of these

impacts are highly dependent on 

specific circumstances of the incident.

RADIATION INJURIES

> Radiation injuries could result from

the aftermath of a nuclear blast and

are less likely following a radiological

incident.

> Health effects may not be apparent for

months or even years after exposure to

radiation.

> The type and extent of injury may

depend on:

- The amount (dose) of radiation to

which a person is exposed

- The type of radiation (alpha, beta,

gamma) to which a person is

exposed

- Whether a person is exposed to

radiation externally (e.g., skin) 

versus internally (e.g., inhaled)
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 123

> If the radiation dose is small, no

immediate health effects will be

observed. In the long-term, there may

be an increased risk of developing

cancer.

> In general, the higher the radiation

dose the greater the severity of

immediate health effects and the

greater the possibility of long-term

health effects.

> Children exposed to radiation may be

more at risk than adults. Radiation

exposure to the unborn child is of

special concern because the human

embryo or fetus is extremely sensitive

to radiation.

TREATMENT

> After a nuclear or radiological incident,

many victims would likely need to be

treated for injuries associated with the

explosion, such as burns, wounds,

fractures, and bleeding.

> Those who have been contaminated

with radioactive materials should

decontaminate themselves by removing

the outer layer of clothing, placing 

the clothing in a bag and sealing it,

and taking a shower without harsh

scrubbing, and wash hair.

> For victims suffering from radiation

sickness, treatment would depend 

on the severity of the symptoms.

Physicians will treat symptoms, provide

supportive care, and try to prevent

infections.

> There are different classes of drugs

that can help treat people who have

been contaminated with or exposed 

to radiation.

> If someone is contaminated with

radioactive materials externally (e.g.,

on his or her clothing), exposure may

be reduced by decontamination (e.g.,

removing outer layer of clothing and

showering).

> Internal contamination occurs if 

someone ingests or inhales radioactive

materials and the materials are

incorporated by the body. Medications

may help reduce the amount of

radioactive materials in the body.

> A person may be exposed to radiation

without being contaminated with

radioactive materials. For example,

after a nuclear detonation, penetrating

radiation may expose a person to

radiation (similar to receiving an X-ray)

without necessarily contaminating the

person with radioactive materials.

More information on the distinction

between exposure and contamination

(internal and external) can be found at

http://www.bt.cdc.gov/radiation/

contamination.asp.

> If the radiation dose is large enough,

victims can develop what is called

acute radiation syndrome or radiation

sickness. Symptoms, not all of which

develop at the same time, include

nausea, vomiting, diarrhea, fever, loss

of appetite, skin damage (e.g.,

redness, itching, swelling, blisters),

seizures, and coma. These symptoms

are non-specific and may be

indistinguishable from those of other

injuries or illness. More information on

acute radiation syndrome can be found

at http://www.bt.cdc.gov/radiation/

ars.asp.

SHELTER-IN-PLACE* SUPPLY LIST

(Maintain enough for 3 days; check

supplies every 6 months)

> Food

> Bottled water (1 gallon per day per 

person, plus water for pets)

> Change of clothing (including

undergarments)

> Shoes

> First aid kit

> Paper goods and plastic utensils

> Plastic garbage bags

> Bedding

> Battery-operated radio

> Batteries

> Flashlight

> Medicines

> Toiletries

> Telephone (hard-wired phones are best)

> Emergency-contact phone list

> Extra eyeglasses or contact lenses

> Baby formula

> Pet food

> Plastic sheeting

> Duct tape

* More extensive emergency supply checklists

can be found in appendices F and G (see pp.

241–244).
124 05. RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

- Blocking agents prevent absorption of certain radioactive

material in the body. Example: Potassium iodide

- Decorporation agents speed up elimination of certain

radioactive materials from the body. Examples: Prussian

blue; diethylenetriaminepentaacetate

- Other drugs are used to help recovery from radiation 

sickness. Example: Neupogen®

> Potassium iodide, when taken before or soon after exposure

to radioactive iodine, can protect the thyroid gland from

absorbing radioactive iodine and developing thyroid cancer,

but this does not help against other forms of radioactivity

that may come with an attack. In addition, not all attacks will

involve the release of radioactive iodine.

> Prussian blue can be used to remove cesium and thallium

from the body.

> Diethylenetriaminepentaacetate is a calcium or zinc salt and

is typically used for medical imaging of certain organs but

can also remove a number of radioactive materials from

people’s bodies.

> Neupogen® can be used to help the recovery of bone marrow.

> The worst cases of radiation sickness may require blood

transfusions and bone marrow transplants.

> There is no vaccine or drug that can make people immune to

the effects of radiation.

ADDITIONAL SOURCES OF INFORMATION 

ON RADIATION EMERGENCIES

> Centers for Disease Control and Prevention Hotline for the

Public, 1-888-246-2675 (http://www.bt.cdc.gov/radiation/)

> Conference of Radiation Control Program Directors, 

1-502-227-4543 (http://www.crcpd.org)

> Environmental Protection Agency (http://www.epa.gov/

radiation/rert)

> Nuclear Regulatory Commission, 1-301-415-8200

(http://www.nrc.gov)

> Federal Emergency Management Agency, 1-202-646-4600

(http://www.fema.gov)

> Radiation Emergency Assistance Center/Training Site, 

1-865-576-3131 (http://www.orau.gov/reacts)

> U.S. National Response Team (http://www.nrt.org)

> U.S. Department of Energy, 1-800-dial-DOE

(http://www.energy.gov)
REFERENCES

2000 Emergency response guidebook: A guidebook for first

responders during the initial phase of a dangerous goods/

hazardous materials incident. (2000). Washington, DC: The Office

of Hazardous Materials Safety, U.S. Department of Transportation.

Battlebook Project Team, USACHPPM, & OSG. (2000). 

The medical NBC battle book USACHPPM tech guide 244.

Aberdeen Proving Ground, MD: United States Army Research

Institute of Medical Defense.

Bevelacqua, A., & Stilp, R. (1998). Hazardous materials field

guide. Albany, NY: Delmar Publications.

Bevelacqua, A., & Stilp, R. (2004). Terrorism handbook for 

operational responders. Clifton Park, NY: Delmar Thomson Learning.

Centers for Disease Control and Prevention. (2002). 

CDC's roles in the event of a radiological terrorist event.

http://www.bt.cdc.gov/radiation/pdf/cdcrole.pdf.

Centers for Disease Control and Prevention. (2003). Fact sheet—

Radiation emergencies: Dirty bombs. http://www.bt.cdc.gov/

radiation/pdf/dirtybombs.pdf.

Centers for Disease Control and Prevention. (2003). Fact sheet—

Radiation emergencies: Potassium iodide (KI). http://www.bt.cdc.gov/

radiation/pdf/ki.pdf.

Centers for Disease Control and Prevention. (2003). Fact sheet—

Radiation emergencies: Sheltering in place during a radiation

emergency. http://www.bt.cdc.gov/radiation/pdf/shelter.pdf.

Centers for Disease Control and Prevention. (2004). Frequently

asked questions (FAQs)—Radiation emergencies: Frequently

asked questions about a nuclear blast. http://www.bt.cdc.gov/

radiation/pdf/nuclearblastfaq.pdf.

Davis, L.E., LaTourrette, T., Mosher, D., Davis, L., & Howell, D.

(2003). Individual preparedness and response to chemical, 

radiological, nuclear, and biological terrorist attacks. 

Santa Monica, CA: Rand Corporation.

Federal Emergency Management Agency. (2000). Emergency

response to terrorism: Job aid. Washington, DC: FEMA, U.S. 

Fire Administration, National Fire Academy: U.S. Department 

of Justice, Office of Justice Programs.

Harville, D., & Williams, C. (2003). The WMD handbook: 

A guide to Weapons of Mass Destruction. New York: 

First Responder Inc.

Keller, J.J. (1998). Hazardous materials compliance manual.

Neenah, WI: J.J. Keller & Associates.

Monterey Institute of International Studies, & Center for NonProliferation Studies. (2002). Suitcase nukes: A reassessment.

http://cns.miis.edu/pubs/week/020923.htm.

U.S. Environmental Protection Agency. (2002). Understanding

radiation: Exposure pathways. http://www.epa.gov/radiation/

understand/pathways.htm.

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 125

06TERRORISM AND THE FOOD SUPPLY

06TERRORISM AND THE FOOD SUPPLY
GOAL OF THIS SECTION

TERRORISM AND THE FOOD SUPPLY

128 06. TERRORISM AND THE FOOD SUPPLY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

WHAT THIS SECTION DOES NOT INCLUDE AND WHY

> Detailed descriptions of specific biological agents are not

provided here. (Information on these agents can be found

in the “Biological Agents” section [see p. 39].)

> Discussion of agroterrorism, or the use of biological

agents against the agricultural industry, is not provided

here because agencies other than the U.S. Department of

Health and Human Services (HHS) have primary

responsibility. Primary responsibility for these issues rests

with the U.S. Department of Agriculture (USDA)

(http://www.usda.gov) and the U.S. Environmental

Protection Agency (EPA) (http://www.epa.gov).

To provide information about the challenges involved in

protecting the nation’s food supply from deliberate 

contamination.

WHAT THIS SECTION INCLUDES

> Description of threats involving intentional contamination

of food products

> Discussion of risks from foodborne illnesses

> Review of new systems for information sharing and

reporting, and for inspections that will improve the 

safety of imported and domestic foods

However, some causes of foodborne illness, such as

Salmonella and E. coli O157:H7, are also Category B

bioterrorism agents. They are designated by HHS’ Centers for

Disease Control and Prevention (CDC) as Category B agents

because they are relatively easy to spread and can make

people sick or can even result in death. (Definitions of CDC

Categories A, B, and C and details on foodborne organisms

that terrorists could use in attacks can be found in the

“Biological Agents” section [see p. 39].)

Intentional contamination of the food supply by terrorists is a

new threat with unique challenges. Thus, it requires increased

food inspection, disease surveillance, laboratory capacity, and

awareness among health professionals and the general public.

WHAT ARE THE RISKS?

American consumers spend more than $617 billion a year on

food, including $511 billion on food grown on American farms

(Strongin 2002).

Overall, the $900 billion (Nestle 2002) U.S. food industry

accounts for 20 percent of the gross national product and

employs 14 million people directly and another 4 million people

in related industries. The farm-to-table process, thus, involves

millions of people who handle a variety of foods every day.

IMPACT OF FOODBORNE ILLNESSES

Most experts believe that terrorist acts involving the food

supply are unlikely because they lack the dramatic impact of

a bomb or chemical attack, but they are not impossible or

implausible scenarios. Being able to detect the difference

between an intentional and an unintentional outbreak of

foodborne illness is made difficult because foodborne illness

outbreaks occur every year in the United States. Alert

consumers, health professionals, pharmacists, food retailers,

and many others in the food industry play a vital role in the

defense against both intentional and unintentional outbreaks

of food-related illnesses.

U.S. consumers enjoy one of the safest food supplies in the

world, yet a terrorist attack on the food supply is possible.

Contaminating food does not require as much technical skill and

organization as does weaponizing anthrax. Opportunities for

access to the food supply stretch from farms and feedlots to

restaurants and cafeterias. For example, terrorists could

introduce an agent during the harvesting, packing, shipping,

delivery, or preparation stage. Clearly, these acts are possible.

Intentional criminal acts, such as the Rajneeshee Cult’s

Salmonella contamination of salad bars in Oregon in the

1980s, demonstrate that fact. Public health officials, the food

industry, and health care providers already have a lot of

experience with treating and preventing unintentional outbreaks.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 129

Foodborne illnesses are more common than most people

realize. They include infections caused by bacteria such as

Salmonella, Shigella, E. coli, and Listeria; and by parasites

such as Cryptosporidium and Cyclospora. According to CDC,

there are approximately 76 million illnesses; 325,000

hospitalizations; and 5,000 deaths every year due to naturally

occurring foodborne illnesses in the United States (Mead et al.

1999). The exact numbers are unknown because many people

just wait for their symptoms to go away and do not go to see

a doctor. Even if someone seeks professional medical advice,

the health professional may not attribute the case to a

foodborne illness and will not report it to the local health

department. The estimated annual costs for medical treatment

and lost productivity due to naturally occurring foodborne

illnesses range from $7 to $37 billion (Democratic Staff of the

Commerce Committee 2004).

Deliberate contamination of the food supply could have a

devastating public health and economic impact, with the

possibility of global consequences. For example, fearful public

reaction to bovine spongiform encephalopathy, known also as

BSE or “mad cow disease,” and the refusal of Europe and

Japan to import United States beef demonstrated how quickly

a domestic food-related health issue can become a global

economic issue.

WHAT ARE THE SYMPTOMS?

Foodborne illnesses cause symptoms such as nausea,

vomiting, diarrhea, or fever. Symptoms can occur between 1

hour and 3 weeks after eating contaminated food, depending

on the agent ingested (bacterial, viral, or parasitic), so tracing

the source of a foodborne outbreak can be very complicated

and time consuming (USDA Food Safety and Inspection

Service 2003).

Certain people can suffer more severe and serious reactions to

naturally occurring illnesses. Very young children; pregnant

women; older adults; and people with compromised immune

systems due to chemotherapy, HIV/AIDS, or other conditions

are particularly vulnerable. These groups would be at greatest

risk in a terrorist attack and would need special attention from

health professionals and public health officials.

To help health professionals be on the alert for foodborne 

illnesses, several associations and federal agencies

collaborated in 2004 to produce a free educational primer on

food safety called “Diagnosis and Management of Foodborne

Illnesses: A Primer for Physicians and Other Health Care

Professionals” (http://www.ama-assn.org/ama/pub/category/print/

3629.html). The collaborators were the American Medical

Association and American Nurses Association, along with

CDC, HHS’ Food and Drug Administration (FDA), and the

USDA’s Food Safety and Inspection Service (FSIS).

The primer has consumer-friendly charts and tables, and tips

on how to prevent food-related diseases. It also helps health

professionals recognize that any patient with foodborne illness

could be the first case of a more widespread outbreak.

THE ROLES OF FDA AND USDA IN FOOD SAFETY 

AND SECURITY

Two federal agencies account for the majority of food safety

spending and regulatory responsibilities: FDA, within HHS,

and FSIS, within USDA. The U.S. Secretaries of HHS and

USDA have publicly agreed to coordinate their responses to

the various threats, risks, and vulnerabilities that the agrarian

sector and the food supply are facing (Dyckman 2003).

INTENTIONAL CONTAMINATION OF THE FOOD SUPPLY BY

TERRORISTS IS A NEW THREAT WITH UNIQUE CHALLENGES.

Thus, it requires increased food inspection, disease surveillance, laboratory

capacity, and awareness among health professionals and the general public.
130 06. TERRORISM AND THE FOOD SUPPLY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

FDA

FDA is responsible for overseeing all domestic and imported

food sold in interstate commerce, including shell eggs, 

bottled water, and wine beverages with less than 7 percent

alcohol. FDA inspections take a broad approach to food

inspections to ensure that the overall food production process

within a given establishment is functioning appropriately. 

To do this, FDA conducts a scientific evaluation and risk

analysis to analyze potential hazards associated with the foods

under its jurisdiction. Next, the agency identifies critical

control points in a food’s production at which the potential

hazard could be controlled or eliminated; this includes

processing, shipping, consumption, etc. Most importantly,

FDA establishes preventative measures and procedures to

monitor the correct use of these measures; for example,

reprocessing or disposing of food if the minimum cooking

temperature is not met. In addition, FDA also oversees animal

drugs, feeds, and veterinary devices. FDA has about 770

inspectors for 57,000 food establishments and 132 ports.

Once proper preventative measures and monitoring procedures

are in place, FDA does a comprehensive evaluation of a

specific food establishment about every 5 years.

FSIS

In contrast, FSIS is responsible for a more ongoing inspection

of the foods under its jurisdiction. FSIS, a public health 

regulatory agency of USDA, protects consumers by ensuring

that meat, poultry, and egg products (e.g., dried egg yolks,

scrambled egg mix, liquid eggs), those foods not inspected by

FDA, are safe, wholesome, and accurately labeled. Due to the

fact that the production of these foods requires the slaughter

of animals, much of USDA inspections focus on the ensuring

of sanitary conditions for all slaughter and processing

activities. This type of scrutiny requires frequent, even daily,

onsite inspections. FSIS has more than 7,600 inspectors and

veterinarians in meat, poultry, and egg product plants every

day and at ports-of-entry to prevent, detect, and act in

response to food safety emergencies. 

FDA and USDA have both issued a number of industry 

security guidance documents, which can be found on their

Web sites. Examples include:

> USDA, “FSIS Security Guidelines for Food Processors”

(http://www.fsis.usda.gov/oa/topics/biosecurity2.htm)

> FDA, “Food Producers, Processors, and Transporters: Food

Security Preventive Measures Guidance” (http://vm.cfsan.

fda.gov/~dms/secguid6.html)

> FDA, “Retail Food Stores and Food Service Establishments:

Food Security Preventive Measures Guidance” (http://vm.cfsan.

fda.gov/~dms/secguid5.html)

CDC, EPA, and U.S. Customs and Border Protection (Customs)

also have some limited responsibilities for food security. CDC

reports and tracks foodborne disease, EPA evaluates

environmental safety (e.g., levels of pesticides and herbicides),

and Customs monitors food imports.

NEW REGULATIONS UNDER THE BIOTERRORISM ACT

The Public Health Security and Bioterrorism Preparedness and

Response Act (Bioterrorism Act) of 2002 provides

authorization for a series of federal actions that will help 

protect the American public against bioterrorism. In response

to the food safety requirement of the act, FDA has issued the

following four regulations:

> Food Facility Registration

> Prior Notice of Imported Food Shipments

> Administrative Detention

> Establishment and Maintenance of Records

More information on the provisions of the act that apply 

to FDA can be found at http://www.fda.gov/oc/bioterrorism/

bioact.html.

Food Facility Registration

Under the Bioterrorism Act, companies that manufacture,

process, pack, or hold food for consumption in the United

States must register with FDA. In October 2003, FDA

launched an electronic system that provides each registrant

with a unique number. More than 200,000 foreign and

domestic establishments are registered, and there are several

hundred more new registrants each week. The ID numbers will

help FDA quickly identify and notify food processors 

or other facilities involved in deliberate or accidental food

contamination.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 131

By registering companies that do business with the U.S. food

market, federal officials will have the first-ever roster of trade

partners, along with basic information that will make it easier

to “trace back” foodborne illnesses.

Prior Notice of Imported Food Shipments

Companies must now provide advance notice to FDA about

food shipments entering the United States. The law covers all

human and animal food, drinks, and dietary supplements

imported or offered for import to this country. The amount of

advance notice needed depends on the mode of transportation

being used but at a minimum ranges between 2 and 8 hours.

FDA expects to receive roughly 25,000 notifications per day

about incoming shipments. Under the new law, FDA will

commission thousands of Customs officers to conduct

investigations and examinations of foods imported through

ports and other locations. FDA and Customs are working

together to share information and computer systems and to

keep food imports safe without creating unnecessary delays.

Though Customs cannot perform physical inspections of every

shipment, notification will allow federal inspectors to target

their resources more effectively.

Administrative Detention

FDA is now authorized to administratively detain suspect food.

This means that FDA can remove food from the food supply if

it has credible evidence or information that it presents a threat

of serious adverse health consequences or death to humans or

animals. The final regulation clarifies the agency’s administrative

detention procedures and the process for appealing the

detention order.

Establishment and Maintenance of Records

Another new regulation under the Bioterrorism Act creates 

a requirement regarding the establishment and maintenance,

for no longer than 2 years, of records by persons (excluding

farms and restaurants) who manufacture, process, pack,

transport, distribute, receive, hold, or import food. The records

that must be kept by this regulation are those that are needed

to allow the Secretary to identify the immediate previous

sources and immediate subsequent recipients of food, including

its packaging, in order to address credible threats of serious

adverse health consequences or death to humans or animals.

FOODNET

Detecting a terrorist attack on the food supply requires some

kind of real-time alarm to indicate that more people are

experiencing symptoms than would normally be the case with

natural causes. Flu and normal outbreaks of foodborne

diseases affect many people every year. Statistics on this

number would serve as a baseline of the “typical” number 

of occurrences of certain illnesses. Without accurate baseline

levels of these common illnesses, it would be difficult to

detect, diagnose, and treat illnesses due to a terrorist attack.

Most existing reporting systems rely on “passive surveillance,”

meaning generally that:

> A sick person visits a doctor

> The doctor takes a sample and sends it to the laboratory 

for evaluation

> The clinical laboratory tests a sample, finds bacteria 

or parasites, and reports the finding to the state health

department

> The state health department makes a report to CDC

No overall national disease-tracking system exists yet.

However, in the mid-1990s, CDC began to develop the

Foodborne Diseases Active Surveillance Network (FoodNet)

(http://www.cdc.gov/foodnet), to help public health experts

track and detect existing patterns of foodborne diseases.

FoodNet has expanded from five states in 1995 to include 10

states and more than 450 clinical laboratories, with

collaboration among CDC, USDA, and FDA.

As of 2004, information is being collected on every laboratorydiagnosed case of bacterial pathogens, including Salmonella,

Shigella, Campylobacter, E. coli O157:H7, Listeria monocytogenes,

Yersinia enterocolitica, and Vibrio; and parasitic organisms,

including Cryptosporidium and Cyclospora infections among

residents in the areas within the 10 states where FoodNet

collects information.

PULSENET

Another promising use of technology in food safety is 

“DNA fingerprinting.” This molecular system uses networked

computers to identify distinctive patterns and genetic makeup

of E. coli and other bacteria and match strains of bacteria from
132 06. TERRORISM AND THE FOOD SUPPLY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

different locations. PulseNet enables CDC to determine when

people in different locations are becoming sick from a single

source of contamination based on the bacteria’s specific DNA.

If scientists can determine the source of contamination, it may

be possible to track down other people who are ill or may

become ill.

SPECIAL CONCERNS: TAMPERING AND RECALL

Safety inspections and surveillance systems are part of a

comprehensive program to improve food safety. But consumers

must also play an active role by noticing anything unusual

about their food. Consumer education and vigilance may be

the best protection against food-tampering. The FDA Center for

Food Safety and Applied Nutrition distributes consumer guides

and tips to prevent illness by increasing awareness 

of the risk of food tampering (http://www.cfsan.fda.gov/

~dms/fstamper.html). The Center for Food Safety and Applied

Nutrition recommends the following to detect tampering at the

grocery store:

> Carefully examine all food product packaging. Be aware of

the normal appearance of food containers. That way you’ll be

more likely to notice if an outer seal or wrapper is missing.

Compare a suspect container with others on the shelf.

> Check any anti-tampering devices on packaging. Make sure

the plastic seal around the outside of a container is intact or

that the safety button on the lid of a jar is down.

> Don’t purchase products if the packaging is open, torn, 

or damaged. This includes products on the shelf or in the

refrigerator or freezer sections of the grocery store.

> Don’t buy products that are damaged or that look unusual.

For example, never purchase canned goods that are leaking

or that bulge at the ends. Likewise for products that appear to

have been thawed and then refrozen.

> Check the “sell-by” dates printed on some products and only

buy items within that time frame.

Once consumers get home, they should check purchases 

for the following:

> When opening a container, carefully inspect the product.

Don’t use products that are discolored, moldy, have an 

off odor, or that spurt liquid or foam when the container 

is opened.

> Never eat food from products that are damaged or that look

unusual. For example, cans that are leaking or that bulge at

the ends.

If consumers suspect product tampering at the grocery 

store, report it to the store manager. Once consumers get a

commercial food product home, a suspected tampering

incident should be reported to the local police department. If

the food contains meat or poultry, consumers should also call

USDA’s Meat and Poultry Hotline at 1-800-535-4555. If the

food contains seafood, produce, or eggs, consumers should

call FDA’s 24-hour emergency number (1-301-443-1240) or

its nonemergency number (1-888-SAFEFOOD).

A food recall is a voluntary action by a manufacturer or 

distributor to protect the public from products that may cause

health problems or possible death. Neither USDA nor FDA has

mandatory recall authority. One exception for FDA is that

infant formula recalls are mandatory. USDA will issue a recall

announcement for recalls of foods under its jurisdiction. 

For FDA regulated foods, FDA will issue a recall

announcement if a company does not do so within 24 hours.

These announcements are meant to alert consumers about

dangerous foods that they may have in their homes.

PULSENET ENABLES CDC TO DETERMINE

when people in different locations are becoming sick from a single source of contamination based on the bacteria’s specific DNA.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 133

REFERENCES

American Medical Association, American Nurses Association,

Centers for Disease Control and Prevention, Center for Food

Safety and Applied Nutrition of the U.S. Food and Drug

Administration, & Food Safety and Inspection Service of the U.S.

Department of Agriculture. (2004). Diagnosis and management

of foodborne illnesses: A primer for physicians and other health

care professionals. Chicago, IL: American Medical Association.

Democratic Staff of the Commerce Committee. (2004). H.R.

3075, “Imported food safety act of 2001:” Fact sheet.

Dyckman, L.J. (2003). Bioterrorism: A threat to agriculture and

the food supply. http://www.gao.gov/new.items/d04259t.pdf.

Harvard Medical School Office of Public Affairs. (2002).

Consortium awarded CDC grant to coordinate national health 

system “radar” to catch bioterror events. http://www.hms.harvard.edu/

news/releases/1002platt.html.

Mead, P.S., Slutsker, L., Dietz, V., McCaig, L.F., Bresee, J.S.,

Shapiro, C., et al. (1999). Food-related illness and death in 

the United States. Emerging Infectious Diseases, 5(5).

http://www.cdc.gov/ncidod/eid/vol5no5/mead.htm.

Nestle, M. (2002). Food politics: How the food industry influences

nutrition and health. Berkeley, CA: University of California Press.

Platt, R. AcademyHealth National Health Policy Conference

2004, January 28, 2004, Washington, DC: Presentation during

breakout session on bioterrorism preparedness: Linking the 

medical care and public health systems.

RAND Center for Domestic and International Health Security.

(2004). Syndromic surveillance: An effective tool for detecting

bioterrorism? http://www.rand.org/publications/RB/RB9042/

RB9042.pdf.

Strongin, R.J. (2002). How vulnerable is the nation’s food 

supply? Linking food safety and food security. http://www.nhpf.org/

pdfs_ib/IB773_FoodSafety_5-17-02.pdf.

U.S. Department of Agriculture Food Safety and Inspection

Service. (2003). Food safety and security: What consumers need

to know. http://www.fsis.usda.gov/OA/topics/foodsec_cons.pdf.

U.S. Food and Drug Administration. (2003a). FDA and CBP

announce their transitional compliance policy on food imports

under the Bioterrorism Act. http://www.fda.gov/bbs/topics/news/

2003/new00995.html.

U.S. Food and Drug Administration. (2003b). FDA and CBP 

bolster safeguards on imported food. Unprecedented agreement

between the agencies advances FDA’s implementation of the

Bioterrorism Act. http://www.fda.gov/bbs/topics/NEWS/2003/

NEW00988.html.

U.S. Food and Drug Administration. (2003c). FDA introduces

new technology to improve food security: Electronic food facility

registration goes “live,” allowing more than 400,000 facilities to

register in minutes; FDA reports on progress in developing rapid

tests of food contamination. http://www.fda.gov/bbs/topics/NEWS/

2003/NEW00960.html.

U.S. Food and Drug Administration. (2003d). HHS issues new

rules to enhance security of the U.S. food supply. http://www.hhs.gov/

news/press/2003pres/20031009.html.

U.S. Food and Drug Administration. (2004). FDA’s budget 

proposal for FY 2005 requests increase for food safety.

http://www.fda.gov/bbs/topics/NEWS/2004/NEW01015.html.

U.S. Food and Drug Administration, Center for Food Safety and

Applied Nutrition, & Industry Affairs Staff Brochure. (2002). FDA

recall policies. http://vm.cfsan.fda.gov/~lrd/recall2.html.

Zadjura, E.M., Schuster, L.J., Oleson, KW., Swearingen, S.E., 

& Tomco, R.R. (1992). Food safety and quality: Uniform, riskbased inspection system needed to ensure safe food supply.

http://161.203.16.4/d33t10/147179.pdf.

07ENVIRONMENTAL SAFETY AND TESTING
GOAL OF THIS SECTION

ENVIRONMENTAL SAFETY AND TESTING

136 07. ENVIRONMENTAL SAFETY AND TESTING Terrorism and Other Public Health Emergencies: A Reference Guide for Media

To provide information on terrorist threats to the air and

water supply in the United States.

WHAT THIS SECTION INCLUDES

> A description of threats to air and water

> The importance of environmental surveillance and

monitoring systems

WHAT THIS SECTION DOES NOT INCLUDE AND WHY

> Detailed descriptions of waterborne and airborne toxins

because any one of thousands of substances could be

used to contaminate air or water. However, a number of

substances of high concern are included in the sections

on terrorism agents.

WATER SUPPLY

Water has always been a strategic target during times of war,

and the fear of a terrorist threat to the water supply is intense

and widespread. Most experts agree that the actual risk that

an attack on the water supply would cause casualties is low

because the millions of gallons of water would dilute the toxins,

or the chlorination, ozone, filters, or other means of water

purification at the treatment plant would render the toxins

inactive (Johns Hopkins Center for Public Health Preparedness

2004). However, water supply and distribution systems are

vulnerable components of the nation’s critical infrastructure. In

addition to the water supply, the infrastructure for drinking and

wastewater includes treatment plants, pumping stations,

pipelines, and storage facilities. Nationally, there are more

than 168,000 public drinking water facilities, with tens of

thousands of miles of aqueducts and pipelines in remote rural

areas and other unguarded locations.

Terrorist threats to the water supply include:

> Deliberate contamination with biological, chemical, or

radiological agents

> Bombs or explosives at pumping stations or other critical

facilities

> Sabotage and disruptions of the distribution of drinking water

or firefighting supplies

Many environmental health experts are concerned about

unguarded chlorine gas supplies at water treatment facilities,

which terrorists could release into the air or water or put into

the food supply. Most treatment plants use chlorine to kill

bacteria and viruses in drinking water, but in stronger

concentrations, chlorine causes choking and tissue damage and

can be fatal (Centers for Disease Control and Prevention 2003).

To reduce terrorism risks from chlorine, some treatment plants

have converted to safer purification technologies, such as

sodium hypochlorite.

No known terrorist act has ever involved the water supply.

However, public health officials had a water supply crisis in

the spring of 1993, when water contaminated by a parasite

called Cryptosporidium made more than 400,000 people sick

with diarrhea in Milwaukee, WI. Contaminated water from

Lake Michigan entered a city water treatment plant. This

contaminated water was then inadequately treated. The parasite

is present in animal waste and may have come from a nearby

sewage plant or slaughterhouse (MacKenzie et al. 1994).

In response to this crisis, public health officials in Milwaukee

set up one of the nation’s first disease-monitoring systems to

help them track future outbreaks, and the city water treatment

plant improved its filtration system. Emergency preparedness

courses often cite the Milwaukee experience to illustrate the

rapid and widespread consequences of water contamination.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 137

PROTECTING THE WATER SUPPLY

The Environmental Protection Agency (EPA) is the agency with

primary responsibility for water infrastructure security, 

working in coordination with the U.S. Department of

Homeland Security (DHS). EPA is responsible for protecting

the nation’s water supply by enforcing the Clean Water Act

(http://www.epa.gov/region5/water/cwa.htm) and the Safe

Drinking Water Act (http://www.epa.gov/safewater/sdwa/

sdwa.html), and the Public Health Security and Bioterrorism

Preparedness and Response Act of 2002. In January 2003,

EPA established a new homeland security research center to

address detection and characterization of contaminants, response

and mitigation, and prevention and protection of water systems.

EPA’s Water Security Division, also established in 2003,

assists the water sector by providing guidance, tools, training,

and technical assistance to address water security concerns.

More information can be found at http://www.epa.gov/

watersecurity.

Water treatment and distribution systems are public utilities,

and industry associations have played a major role in their

preparedness and protection efforts. The Public Health,

Security, and Bioterrorism Preparedness and Response Act

requires all public water systems serving more than 3,000

people to prepare vulnerability assessments and submit them

to EPA for review and certify the completion of emergency

response plans (http://cfpub.epa.gov/safewater/watersecurity/

bioterrorism.cfm). While developing their plans, public drinking

water systems need to partner with their community waste

water utilities and local government officials, including law

enforcement and public health. Continuing to update

vulnerability assessments and practice emergency response plans

is essential for an effective response in the event of an emergency.

The American Water Works Association; Sandia National

Laboratory; and many other industries, state drinking water

agencies, and research organizations are working with EPA to

help water systems reduce any possible risks to their water

supply (Greenblatt et al. 2003; EPA 2004).

HHS’ ROLE IN WATER SECURITY

While the role of the U.S. Department of Health and Human

Services (HHS) in water security is to provide technical

assistance and support during emergency response and

recovery, the Federal Emergency Management Agency and the

U.S. Army Corps of Engineers may have lead roles. Within

HHS’ Centers for Disease Control and Prevention (CDC), the

Environmental Public Health Readiness Branch of the National

Center for Environmental Health works with federal, state, and

local agencies after natural and technological disasters. CDC’s

environmental disaster epidemiologists help communities to

assess the impact of hurricanes, floods, and other extreme

weather conditions on health (http://www.cdc.gov/nceh/hsb/

disaster/default.htm).

CDC team’s activities may include conducting laboratory tests

on water samples to identify toxic contaminants, setting up

surveillance programs to monitor the number of people with

waterborne diseases or other serious health risks, setting up

programs to control the spread of disease, and providing other

support and technical assistance.

AIR

Terrorists could release harmful chemical and biological agents

into the air, which might not be recognized for several days. An

airborne communicable disease can spread through a

ventilation system or pass person-to-person through coughing

or sneezing before anyone realizes what has happened.

Noncommunicable bioagents, like anthrax, also spread readily

through the air, and technology has not kept pace with the

need to detect them or remove them from the air by advanced

surveillance and filtering techniques. Recognizing these

technical gaps, the federal government is exploring several

new biosurveillance programs, including new sensor networks

and new health-tracking data analysis programs (http://www.dhs.

gov/dhspublic/display?theme=43&content=3092&print=true).

Many federal agencies are now working to coordinate their

scientific, technical, and regulatory responsibilities. These

agencies must share the responsibility for monitoring and

protecting air quality. EPA is responsible for outdoor air quality,

but the National Aeronautics and Space Administration and

the National Oceanic and Atmospheric Administration operate

weather satellites that would provide critical information during

a large-scale chemical attack. For example, satellite photos,

along with meteorological data about wind direction, speed,
138 07. ENVIRONMENTAL SAFETY AND TESTING Terrorism and Other Public Health Emergencies: A Reference Guide for Media

and temperature, could help officials

determine the best responses to protect

the public health by advising evacuation

or shelter-in-place.

CDC’s National Institute for

Occupational Safety and Health

(NIOSH) has the primary responsibility

for research and recommendations on

air quality in the workplace, thus

protecting the health of the workforce.

In 2002, NIOSH issued detailed

guidance for defending building

environments against airborne

chemical, biological, or radiological

attacks. Its recommendations address

physical security, ventilation and

filtration, maintenance, and other

preventive strategies based on

vulnerability assessments.

EPA’s Environmental Technology

Verification Program (http://www.epa.

gov/etv) is working with DHS to develop

new ways to monitor, measure, detect,

and filter out, rinse out, or otherwise

remove chemical and biological warfare

agents from indoor air and water

systems. The program is funding

research to develop the next generation

of environmental monitoring technologies

and warning programs.

BIOWATCH

Project BioWatch is an air-monitoring

system that will provide an early

warning for biothreats in urban areas.

The initiative is led by DHS, in

partnership with EPA, and CDC’s

Laboratory Response Network. This

biosurveillance system includes roundthe-clock air-monitoring stations, which

have been operating in more than 30

cities across the nation since 2003.

720

111

28

33

105

64

230

Sensors are located in cities throughout the 

country.

FIGURE 7–1: HOW BIOWATCH WORKS

1.

EPA collects samples and sends them to CDC.

2.

CDC analyzes samples.

3.

IF AGENT DETECTED:

Rapid-response protocol implemented: DHS, HHS,

EPA, and the Federal Bureau of Investigation (FBI).

4.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 139

REFERENCES

Centers for Disease Control and Prevention. (2003). Fact sheet—

Chemical emergencies: Facts about chlorine. http://www.bt.cdc.gov/

agent/chlorine/basics/pdf/chlorine-facts.pdf.

Centers for Disease Control and Prevention, National Center for

Environmental Health. (2004). Disaster epidemiology and assessment:

Mission, goals and objectives. http://www.cdc.gov/nceh/hsb/

disaster/mission.htm.

Greenblatt, M., Donohue, J., & Wagner, K. (2003). Homeland security

for drinking water supplies. http://www.environmental-center.com/

articles/article1264/article1264.htm.

Johns Hopkins Center for Public Health Preparedness. (2004).

Water security. http://www.jhsph.edu/CPHP/Topic_Centers/

water_security.html.

MacKenzie, W.R., Hoxie, N.J., Proctor, M.E., Gradus, M.S., Blair,

K.A., Peterson, D.E., et al. (1994). A massive outbreak in Milwaukee

of cryptosporidium infection transmitted through the public water supply.

New England Journal of Medicine, 331, 161–167.

Marburger, J. BioSecurity 2003, October 20, 2003, Washington, DC:

Keynote address on national preparedness. http://www.ostp.gov/

html/10-20-03%20jhm%20BioSecurity%202003.pdf.

The Associated Press. (2003). Bioterror plan ‘won’t save everyone.’

http://msnbc.msn.com/id/3475823/.

U.S. Department of Health and Human Services, Centers for Disease

Control and Prevention, National Institute for Occupational Safety

and Health. (2002). Guidance for protecting building environments

from airborne chemical, biological, or radiological attacks.

http://www.cdc.gov/niosh/bldvent/pdfs/2002-139.pdf.

U.S. Environmental Protection Agency. (2002). Vulnerability

assessment factsheet. http://www.epa.gov/safewater/watersecurity/

pubs/va_fact_sheet_12-19.pdf.

U.S. Environmental Protection Agency. (2004). Environmental

technology verification program. http://www.epa.gov/etv/.

U.S. Environmental Protection Agency. (2004). Water security.

http://www.epa.gov/safewater/watersecurity/.

U.S. Environmental Protection Agency Environmental Technology

Verification Program for Homeland Security. (2003). ETV takes on

important role in Homeland Security technology verifications.

http://www.epa.gov/etv/pdfs/fs/03_fs_hs.pdf.

How BioWatch Works

Technicians collect air samples from BioWatch sensors at least

once a day. The samples then go to labs to undergo testing for

the presence of specific bioagents, including anthrax,

smallpox, and plague. In general, EPA collects the samples

and designated labs that are a part of the Laboratory Response

Network, including the Rapid Response and Advance

Technology lab at CDC, analyze them.

Rapid Response Protocols

If lab workers at the Laboratory Response Network facilities or

CDC lab workers detect a bioagent, a rapid response protocol

goes into effect. This protocol involves DHS, CDC, EPA, and

the Federal Bureau of Investigation. Though federal officials

have not released the protocol to the public, they have

indicated that CDC would notify the other agencies and the 

designated members of the rapid response team would quickly

make decisions and communicate a coordinated response and

mitigation strategy (with recommended actions) to local health

departments (Marburger 2003).

Critics say that the air-monitoring technology is not sensitive

enough to detect small releases of biological or chemical toxins.

Critics also point out that BioWatch does not monitor indoor

releases and that there can be delays of several hours between

the collection and the analysis of air samples (The Associated

Press 2003).

08THE ROLE OF THE FEDERAL GOVERNMENT
GOAL OF THIS SECTION

THE ROLE OF THE FEDERAL GOVERNMENT

142 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media

To explain the roles and responsibilities held by the U.S.

Department of Health and Human Services (HHS), the U.S.

Department of Homeland Security (DHS), and other

agencies of the federal government to manage a range of

public health crises, from naturally occurring disasters to

terrorist attacks, namely: 

> The role HHS would play in response to terrorist threats

to public health

> How HHS, DHS, and other federal agencies would work

together in a crisis

> The responsibilities of various HHS offices and agencies

in a crisis

> The legal basis for public health authority in a crisis

WHAT THIS SECTION INCLUDES AND WHY

This section clarifies how various parts of the federal 

government work together and with state, local, and tribal

officials to manage a health crisis. Responses to crises are

complex. In recent years, there have been changes 

in the types of public health challenges facing our nation

and the world. In addition, there have been changes in

crisis response systems, as well as response organizations,

and their responsibilities. Because these roles will continue

to evolve, updated information will be made available at

http://www.hhs.gov/emergency. Information published in

this guide is current as of spring 2005.

WHAT THIS SECTION DOES NOT INCLUDE

A detailed explanation of the National Response Plan

(NRP) or the National Incident Management System

(NIMS) is not included. The purpose of the section is 

to explain the public health response. See the NRP

(http://www.dhs.gov/nrp) and NIMS (http://www.dhs.gov/

interweb/assetlibrary/NIMS-90-web.pdf) Web sites for

descriptions.

WHAT TO EXPECT FROM HHS

HHS is the U.S. government’s principal agency for protecting

the health of all Americans. The overall goal of HHS’

preparedness and response program is to ensure sustained

public health and medical preparedness within our

communities and our nation in defense against terrorism,

infectious disease outbreaks, medical emergencies, and other

public health threats.

In a public health emergency, HHS’ responsibilities include:

> Monitoring, assessing, and following up on people’s health

> Ensuring the safety of workers responding to an incident

> Ensuring that the food supply is safe

> Providing medical, public health, and mental/behavioral

health advice

> Establishing and maintaining a registry of people exposed to

or contaminated by a given agent

To fulfill this role, HHS works closely with state, local, and tribal

public health departments; DHS; other federal agencies; and

medical partners in the private and nonprofit sectors. Under

the Public Health Service Act (see appendix D [p.234]), 

HHS has the authority to:

> Declare a public health emergency

> Make and enforce regulations (including isolation and 

quarantine) to prevent the introduction, transmission, 

or spread of communicable diseases into the United States

or from one state or possession into another

> Conduct and support research and investigation into the

cause, treatment, or prevention of a disease or disorder
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 143

> Direct the deployment of officers of the Public Health

Service, a division of HHS, in support of public health and

medical operations

> Provide public health and medical services and advice

> Provide for the licensure of biological products

On behalf of the Secretary, the Assistant Secretary for Public

Health Emergency Preparedness coordinates the Department’s

efforts to prevent, prepare for, respond to, and recover from

public health and medical consequences of disasters or

emergencies.

THE NATIONAL RESPONSE PLAN

The structures, capabilities, and resources of federal agencies

are unified in the NRP, an all-hazards plan that establishes 

a single comprehensive framework for the management of

domestic incidents. The NRP can be found in its entirety on

the Web (http://www.dhs.gov/nrp).

PUBLIC HEALTH OR MEDICAL EMERGENCIES

Federal public health and other medical assistance in federally

declared public health or medical emergencies is provided

under Emergency Support Function (ESF) #8 of the NRP. ESF

#8 is 1 of 15 ESFs, which are described later in this section.

HHS is the primary agency for ESF #8 and coordinates federal

health and medical assistance in support of state, local, and

tribal jurisdictions. HHS performs this responsibility with 

DHS, which has overall responsibility for domestic incident

management.

The following table describes the coordinated federal 

assistance to supplement state, local, and tribal resources 

in response to public health and medical care needs in a

national crisis (called “Incident of National Significance” in the

NRP). It also includes veterinary assistance. Please note that

HHS has the authority to implement the activities described

below, but specific activities described under each function will be

implemented as appropriate for a specific incident.

In addition to these functions, HHS is responsible for continuing

actions to acquire and assess information on the incident.

Staff continues to identify the nature and extent of public

health and medical problems and establishes appropriate

monitoring and public surveillance. Continuing responsibilities

include:

> Activation of health/medical response teams

> Coordination of requests for medical transportation

> Coordination for obtaining, assembling, and delivering 

medical equipment and supplies to the incident area

> Communications to coordinate federal public health 

and medical assistance

> Information requests, which are referred to ESF #15

> After-Action Reports

It is important to recognize that state, local, or tribal governments have

the initial responsibility for responding to an emergency and

protecting the people, property, and environment within their

jurisdiction. The federal government generally supports the state,

local, and tribal response when one or more of the following occurs:

> A state requests assistance from the federal government and the

President

> The President declares a state of emergency

> An incident takes place in areas that are owned or controlled by the

federal government

Federal response is coordinated through DHS.
144 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TABLE 1. ESF #8—PUBLIC HEALTH AND MEDICAL SERVICES: ROLES AND RESPONSIBILITIES

FUNCTION DESCRIPTION

Health/Medical Equipment and

Supplies

Deploys assets from the Strategic National Stockpile. Requests DHS, DOD, or VA to provide medical equipment and supplies, including

medical, diagnostic, and radiation-emitting devices; pharmaceuticals; and biologic products, in support of immediate medical

response operations and for restocking health care facilities in an area affected by a major disaster or emergency.

Patient Evacuation Requests DOD to evacuate seriously ill or injured patients to locations where hospital care or outpatient services are available; 

DOD will be responsible for regulating and tracking patients transported on DOD assets to appropriate treatment facilities 

(e.g., National Disaster Medical System non-federal hospitals).

Patient Care Tasks HHS, the Medical Reserve Corps, VA, DOD, and DHS to provide available personnel to support inpatient hospital care and

outpatient services to victims who become seriously ill or injured regardless of location (may include mass care shelters).

Safety and Security of Human

Drugs, Biologics, Medical Devices, 

Veterinary Drugs, etc.

Ensures the safety, efficacy, and advises industry on security measures of regulated human and veterinary drugs, biologics 

(including blood and vaccines), medical devices (including radiation-emitting and screening devices), and other HHS-regulated products.

Blood and Blood Products Monitors blood availability and maintains contact with the American Association of Blood Banks Interorganizational Task Force on

Domestic Disasters and Acts of Terrorism to determine the need for blood, blood products, and the supplies used in their manufacture,

testing, and storage; the ability of existing supply chain resources to meet these needs; and any emergency measures needed to 

augment or replenish existing supplies. 

Worker Health/Safety Requests the U.S. Department of Labor/Occupational Safety and Health Administration to implement the processes in the Worker

Safety and Health Support Annex to provide technical assistance for worker safety and health.

Requests support from the U.S. Department of Labor and other cooperating agencies to assist in monitoring the health and well-being

of emergency workers, performing field investigations and studies addressing worker health and safety issues, and providing technical

assistance and consultation on worker health and safety measures and precautions.

Food Safety and Security In cooperation with ESF #11, ensures the safety and security of federally regulated foods. (Note: HHS, through the Food and Drug

Administration, has statutory authority for all domestic and imported food except meat, poultry, and egg products, which are under 

the authority of the U.S. Department of Agriculture Food Safety and Inspection Service.)

Agriculture Safety and Security In cooperation with ESF #11, ensures the safety and security of food-producing animals, animal feed, and therapeutics. 

(Note: HHS, through the Food and Drug Administration, has statutory authority for animal feed and for the approval of animal drugs

intended for both therapeutic and nontherapeutic use in food animals as well as companion animals.)

Assessment of Public Health/

Medical Needs

In collaboration with DHS, deploys ESF #8 personnel. Assesses public health and medical needs. Assesses the public health care 

system/facility infrastructure.

Health Surveillance In coordination with state health agencies, enhances existing surveillance systems to monitor the health of the general population and

special high-risk populations. Carries out field studies and investigations. Monitors injury and disease patterns and potential disease

outbreaks. Provides technical assistance and consultations on disease and injury prevention and precautions. 

Medical Care Personnel Deploys HHS staff (e.g., U.S. Public Health Service Commissioned Corps). Requests support from the U.S. Department of Defense (DOD)

in casualty clearing/staging and other missions, as needed. Seeks individual clinical health and medical care specialists from the

Department of Veterans Affairs (VA) to assist state, local, and tribal personnel. 
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 145

All-Hazard Public Health 

and Medical Consultation,

Technical Assistance, and Support

Assists in assessing public health and medical effects resulting from all hazards (e.g., assessing exposures on the general population

and on high-risk population groups; conducting field investigations, including collection and analysis of relevant samples; providing

advice on protective actions related to direct human and animal exposures, and on indirect exposure through contaminated food,

drugs, water supply, and other media; and providing technical assistance and consultation on medical treatment, screening, and

decontamination of injured or contaminated individuals). At the request of a state (who, along with local governments, retain the primary

responsibility for victim screening or decontamination) or other federal agency, deploys teams with limited capabilities for victim

decontamination (e.g., National Disaster Medical System or U.S. Department of Energy assistance for nuclear/radiological incidents);

these teams typically arrive on scene within 24–48 hours.

Behavioral Health Care Assists in assessing mental health and substance abuse needs. Provides disaster mental health training materials for disaster 

workers. Provides liaison with assessment, training, and program development activities undertaken by federal, state, local, and tribal

mental health and substance abuse officials. 

TABLE 1. ESF #8—PUBLIC HEALTH AND MEDICAL SERVICES: ROLES AND RESPONSIBILITIES (cont.)

FUNCTION DESCRIPTION

Public Health and Medical

Information

Provides public health, disease, and injury prevention information that can be transmitted to members of the general public who are

located in or near affected areas.

Protection of Animal Health In coordination with ESF #11, protects the health of livestock and companion animals by ensuring the safety of the manufacture and

distribution of foods and drugs given to animals used in human food production.

Vector Control Assists in assessing the threat of vector-borne diseases. Conducts field investigations, including the collection and laboratory analysis of

relevant samples. Provides vector control equipment and supplies. Provides technical assistance and consultation on protective actions

regarding vector-borne diseases. Provides technical assistance and consultation on medical treatment of victims of vector-borne diseases. 

Victim Identification/

Mortuary Services

Requests DHS and DOD to assist in providing victim identification and mortuary services; establishing temporary morgue facilities; 

performing victim identification by fingerprinting, forensic dental, and/or forensic pathology/anthropology methods; and processing,

preparing, and disposing of remains.

Potable Water/Wastewater and

Solid Waste Disposal 

In coordination with ESF #3 and ESF #10, assists in assessing potable water, wastewater, solid waste disposal issues, and other

environmental health issues. Conducts field investigations, including collection and laboratory analysis of relevant samples. 

Provides water purification and wastewater/solid waste disposal equipment and supplies. Provides technical assistance and 

consultation on potable water and wastewater/solid waste disposal issues.

ALL EMERGENCY SUPPORT FUNCTIONS IN THE NATIONAL

RESPONSE PLAN

The Public Health and Medical Services function is one of 15

ESFs under the NRP. The following list includes all ESFs and

the agencies responsible for accomplishing each one:

> The ESF Coordinator, listed first, is the agency with primary

ongoing responsibilities throughout the prevention,

preparedness, response, recovery, and mitigation phases of

incident management.

> Primary Agencies orchestrate federal support within a

functional area, provide staff, manage mission assignments,

and coordinate with support agencies.

> Support Agencies (not listed in table 2 but described in the

full NRP [http://www.dhs.gov/nrp]), at the request of the

Coordinating and Primary Agency, conduct operations,

furnish personnel and resources, assist with assessments,

and provide ongoing planning and other essential functions.

Many federal agencies play critical roles in each ESF.
146 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media FUNCTION ESF COORDINATOR WITH PRIMARY AGENCY(IES) RESPONSIBLE FOR ACCOMPLISHING THE MISSION OF THE ESF Note: For some ESFs, one agency serves as both the ESF Coordinator and Primary Agency. SCOPE ESF #1 Transportation U.S. Department of Transportation • Processing and coordinating requests for federal and civil transportation support • Reporting damage to transportation infrastructure as a result of the incident • Coordinating alternate transportation services • Coordinating restoration and recovery of transportation infrastructure • Performing activities conducted under the direct authority of U.S. Department of Transportation elements, such as air, maritime, surface, rail, and pipelines • Coordinating and supporting prevention/preparedness/mitigation among transportation infrastructure stakeholders at the state and local levels ESF #3 Public Works and Engineering U.S. Department of Defense/ U.S. Army Corps of Engineers -with- U.S. Department of Homeland Security/ Emergency Preparedness and Response/ Federal Emergency Management Agency • Conducting pre- and post-incident assessments of public works and infrastructure • Executing emergency contract support for life-saving and life-sustaining services • Providing technical assistance to include engineering expertise, construction management, and contracting and real estate services • Providing emergency repair of damaged infrastructure and critical facilities • Implementing and managing the Federal Emergency Management Agency Public Assistance Program and other recovery programs ESF #5 Emergency Management U.S. Department of Homeland Security/ Emergency Preparedness and Response/ Federal Emergency Management Agency • Responsible for all functions critical to support and facilitate multiagency planning and coordination • Deployment and staffing of the U.S. Department of Homeland Security emergency response teams • Incident action planning • Coordination of operations, logistics and material, and direction and control • Information management • Facilitation of requests for federal assistance • Resource acquisition and management • Worker safety and health • Facilities management • Financial management • Other support as required ESF #2 Communications U.S. Department of Homeland Security/ National Communications System • Coordinating federal actions to provide temporary telecommunication and information technology services • Restoring telecommunication and information technology infrastructure ESF #4 Firefighting U.S. Department of Agriculture/ U.S. Forest Service • Managing and coordinating firefighting activities, including the detection and suppression of fires on federal lands • Providing personnel, equipment, and supplies in support of state, local, and tribal agencies involved in rural and urban firefighting operations TABLE 2. NATIONAL RESPONSE PLAN EMERGENCY SUPPORT FUNCTIONS
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 147 ESF #6 Mass Care, Housing, and Human Services U.S. Department of Homeland Security/ Emergency Preparedness and Response/ Federal Emergency Management System -with- American Red Cross • Mass care, including nonmedical mass care services to include sheltering of victims, organizing feeding operations, providing emergency first aid at designated sites, collecting and providing information on victims to family members, and coordinating bulk distribution of emergency relief items • Housing, including assistance for short- and long-term housing needs of victims • Human services, including victim-related recovery efforts, such as counseling, identifying support for persons with special needs, expediting processing of new federal benefits claims, assisting in collecting crime victim compensations for acts of terrorism, and expediting mail services in affected areas ESF #7 Resource Support General Services Administration • Resource support to federal, state, local, and tribal governments, including emergency relief supplies, facility space, office equipment, office supplies, telecommunications, contracting services, transportation services, security services, and personnel required to support immediate response activities • Support for requirements not specifically identified in other ESFs, including excess and surplus property ESF #10 Oil and Hazardous Materials Response Environmental Protection Agency -with- U.S. Department of Homeland Security/ U.S. Coast Guard • Hazardous materials (oil, chemical, biological, and radiological) response and recovery, including efforts to detect, identify, contain, clean up, or dispose of released oil and other hazardous materials • Environmental safety, and short- and long-term cleanup ESF #9 Urban Search and Rescue U.S. Department of Homeland Security/ Emergency Preparedness and Response/ Federal Emergency Management Agency • Coordination and logistical support to urban search and rescue task forces during emergency operations • Needs assessments • Technical advice and assistance to state, local, and tribal government emergency managers ESF #8 Public Health and Medical Services U.S. Department of Health and Human Services • Provide supplemental assistance to state, local, and tribal governments in meeting the public health needs of victims • Assess public health/medical needs, including behavioral health • Public health surveillance • Medical care personnel • Medical equipment and supplies ESF #11 Agriculture and Natural Resources U.S. Department of Agriculture -with- U.S. Department of the Interior • Nutrition assistance by the Food and Nutrition Service, including obtaining food supplies, arranging for food delivery, and authorizing disaster food stamps • Implementing integrated federal, state, local, and tribal response to an outbreak of a highly contagious or economically devastating animal/zootonic disease, an outbreak of a highly infective exotic plant disease, or an economically devastating plant pest infestation. • Assurance of the safety and security of the commercial food supply, including inspection and verification of food safety aspects of slaughter and processing plants, products in distribution and retail sites, and import facilities or ports of entry; laboratory analysis of food samples; control of products suspected to be adulterated; plant closures; foodborne disease surveillance; and field investigations • Protection of natural and cultural resources and historic property resources ESF #12 Energy U.S. Department of Energy • Collecting, evaluating, and sharing information on energy system damage and estimations on the impact of energy system outages within affected areas • Provides information concerning the energy restoration process
148 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media FUNCTION ESF COORDINATOR WITH PRIMARY AGENCY(IES) RESPONSIBLE FOR ACCOMPLISHING THE MISSION OF THE ESF Note: For some ESFs, one agency serves as both the ESF Coordinator and Primary Agency. SCOPE TABLE 2. NATIONAL RESPONSE PLAN EMERGENCY SUPPORT FUNCTIONS (cont.) ESF #13 Public Safety and Security ESF #13 has three Coordinating Agencies: U.S. Department of Homeland Security U.S. Department of Homeland Security/ Emergency Preparedness and Response/ Federal Emergency Management Agency -and- U.S. Department of Justice • Support for non-investigative/non-criminal law enforcement, public safety, and security capabilities and resources • Support incident management requirements, including force and critical infrastructure protection, security planning and technical assistance, technology support, and public safety in both pre- and post-incident situations ESF #14 Long-term Community Recovery and Mitigation U.S. Department of Homeland Security/ Emergency Preparedness and Response/ Federal Emergency Management Agency -with- U.S. Department of Commerce U.S. Department of Health and Human Services U.S. Department of Housing and Urban Development U.S. Department of the Treasury -and- Small Business Administration • Generally activated when state and local resources are overwhelmed or inadequate • Working with state, local, and tribal governments; non-government organizations; and private-sector organizations to enable long- term community recovery and reduce or eliminate risk from future incidents, where feasible • Assesses incident impacts • Varies depending on magnitude and type of incident and potential for long-term severe consequences ESF #15 External Affairs U.S. Department of Homeland Security • External affairs support to federal, state, and tribal governments • Public affairs, including coordinating messages among federal, state, local, and tribal governments; establishing a federal Joint Information Center; gathering information; and disseminating information to media and other sources • Community relations, including initial action plan with incident-specific guidance; coordinating with states to assist with dissemination of information; identifying unmet needs; and facilitating collaboration • Congressional affairs, including contact with congressional offices representing affected areas and conducting congressional briefings • International affairs, including coordinating with the U.S. Department of State on all matters of international involvement • State and local coordination, including implementing a system of information sharing and informing officials • Tribal affairs, including providing a Tribal Relations Office to coordinate with tribal governments on all aspects of incident management
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 149

HOW HHS WORKS WITH OTHER FEDERAL AGENCIES:

WHO IS RESPONSIBLE FOR WHAT IN DIFFERENT

SITUATIONS

IN ALL EMERGENCY SITUATIONS

In all disasters, HHS’s Secretary’s Operations Center becomes

operational immediately upon notification and begins the

collection, analysis, and dissemination of requests for medical

and public health assistance.

HHS operates under the NRP in all situations involving an

“Incident of National Significance.” This is defined in the NRP

as “an actual or potential high-impact event that requires a

coordinated and effective response by an appropriate

combination of federal, state, local, tribal, and nongovernmental and/or private sector entities in order to save

lives and minimize damage and provide the basis for long-term

community recovery and mitigation activities.”

Incidents of national significance are declared by the Secretary

of Homeland Security under these criteria:

1. A federal department or agency acting under its own authority

has requested the assistance of the Secretary of DHS

2. The resources of state and local authorities are overwhelmed

and federal assistance has been requested by the

appropriate state and local authorities

3. More than one federal department or agency has become

substantially involved in responding to an incident

4. The Secretary of Homeland Security has been directed to

assume responsibility for managing a domestic incident by

the President

IN A NATURAL DISASTER

DHS coordinates the federal response to a natural disaster,

which may include floods, earthquakes, hurricanes, tornadoes,

droughts, and epidemics. As in all crises, the Secretary’s

Operations Center will coordinate medical and public health

support to local and state governments. HHS will also gather

and analyze data to help identify, monitor, and manage medical

and health consequences for the public. HHS’s activities will

be closely coordinated with several other agencies and

organizations, including the Federal Emergency Management

Agency under DHS, the National Guard and Reserve, and the

American Red Cross.

IN A NATURAL OUTBREAK

As the primary public health agency in the nation, HHS will,

through its Centers for Disease Control and Prevention (CDC),

work closely with local and state public health officials to

identify, track, and monitor outbreaks of diseases. Disease

surveillance and detection systems, including the National

Electronic Disease Surveillance System, provide the framework

for communication of public health information throughout the

nation and help public health officials detect and fight

outbreaks. CDC has also provided funding and other support

to develop additional epidemiological and laboratory capacity

for states and territories to address infectious disease. In

coordination with DHS, HHS will provide direct public health

support—both staff and medical supplies—to a state, if

requested by its leadership (see National Response Plan:

Biological Incident Annex [http://www.dhs.gov/interweb/

assetlibrary/NRP_FullText.pdf]).

Many federal agencies would play a role in the management of

an outbreak considered to be an Incident of National

Significance, such as pandemic influenza or serious emerging

infectious disease. HHS will coordinate all federal response for

such an incident.

IN A BIOTERROR ATTACK

HHS has primary responsibility for federal public health and

medical response in a bioterrorist incident because response

and recovery efforts will rely on public health and medical

emergency response. The Assistant Secretary for Public Health

Emergency Preparedness will coordinate responses with DHS

and other federal and state agencies from the Secretary’s

Operations Center. HHS will coordinate the federal public

health and medical response to a bioterror attack (see National

Response Plan: Biological Incident Annex [http://www.dhs.gov/

interweb/assetlibrary/NRP_FullText.pdf]).
150 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media

IN A CHEMICAL INCIDENT

If a chemical attack or other chemical incident occurs, HHS

will work as part of the emergency management team in the

emergency operations center of the agency with primary

responsibility, the Environmental Protection Agency or the

DHS/U.S. Coast Guard (see National Response Plan: Oil and

Hazardous Materials Annex and ESF #10 [http://www.dhs.gov/

interweb/assetlibrary/NRP_FullText.pdf]), in the event that the

emergency activates ESF #8. CDC, through its Agency for

Toxic Substances and Disease Registry (http://www.atsdr.

cdc.gov) and National Institute for Occupational Safety and

Health (http://www.cdc.gov/niosh/topics/emres), will assume

roles in evaluating chemical spills and environmental

contamination and providing safety and health

recommendations to responders (e.g., the wearing of personal

protective equipment). HHS will determine whether illnesses,

diseases, or complaints may be attributed to exposure to a

hazardous substance. It will establish disease exposure

registries, conduct appropriate testing, and provide information

on the health effects of toxic substances.

WHEN RADIOLOGICAL MATERIALS HAVE BEEN RELEASED

DHS is responsible for the overall coordination of incident

management activities for all radiological or nuclear Incidents

of National Significance. If radiological materials have been

released, HHS will work in cooperation with the emergency

operations center of DHS and/or the agency it appoints as the

coordinating agency. For example:

> Radiological terrorism incidents would be initially

coordinated by the U.S. Department of Energy (DOE), unless

the material or facilities were either owned or operated by the

U.S. Department of Defense (DOD) or licensed by the

Nuclear Regulatory Commission. In those cases, the

respective agency would serve as the coordinating agency.

Radiological terrorism incidents include:

- Radiological Dispersal Device, e.g., radioactive material plus

conventional explosives

- Improvised Nuclear Device, e.g., “suitcase bomb,” crude

nuclear bomb

- Radiation-Emitting Device, e.g., hidden (not exploded)

radiological materials used to expose people to radiation

(sometimes referred to as a “silent” source)

> Management of an incident at a nuclear facility would be

coordinated by the agency that licenses, owns, or operates

the facility; this would be the Nuclear Regulatory Commission,

DOD, or DOE. For nuclear facilities not licensed, owned, or

operated by a federal agency, the Environmental Protection

Agency would coordinate incident management.

> In the event of a nuclear weapon accident/incident, DOD or

DOE would serve as the coordinating agency, based on

custody at the time of the event.

HHS will assess, monitor, and follow people’s health; ensure

the safety of workers and responders involved in the incident;

ensure that the food supply is safe; and provide medical and

public health advice. If there is a mass casualty situation, 

the American Red Cross will take a lead role in management

as well.

THE ROLES OF HHS AGENCIES AND OFFICES

HHS OFFICE OF THE SECRETARY EMERGENCY RESPONSE

ROLES

Within the Office of the Secretary, the following are the

organizations in emergency response:

Immediate Office of the Secretary of HHS 

Responsible for the overall response to public health and

medical emergencies. The Secretary or his/her designee

determines the nature and scope of HHS’ response to a 

public health or medical emergency.

Office of Public Health Emergency Preparedness

(http://www.hhs.gov/ophep)

Working on behalf of the Secretary, directs and coordinates the

Department’s efforts to prevent, prepare for, respond to, and

recover from the public health and medical consequences of

disaster or emergency. The Office of Public Health Emergency

Preparedness (OPHEP) acts as the liaison office of HHS to

DHS. As directed by the Secretary, OPHEP establishes and

deploys the Secretary’s Emergency Response Team (SERT) to

be the Secretary’s agent on scene at emergency sites.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 151

> Secretary’s Operations Center 

(http://www.hhs.gov/news/facts/command.html)

Provides a central location of public health information

and intelligence for the Secretary of HHS. The Secretary’s

Operations Center coordinates the response activities of HHS

with local, state, federal, and international public health

authorities.

> Secretary’s Emergency Response Team

Directs and coordinates the activities of all HHS personnel

deployed to the emergency site to assist local, state, and other

federal and government agencies. The Secretary’s Emergency

Response Team (SERT), which is rapidly deployed, has

cross-HHS representation and acts for HHS onsite for all

types of public health emergencies, from emerging diseases

and terrorism to natural disasters.

Office of the Assistant Secretary for Health

(http://www.hhs.gov/ash)

Directs the Office of the Surgeon General, who operates the U.S.

Public Health Service Commissioned Corps, and oversees

Regional Health Administrators.

> Office of Public Health and Science

(http://www.osophs.dhhs.gov/ophs)

- Regional Health Administrators

(http://www.osophs.dhhs.gov/ophs/rha.htm)

Oversee public health relationships at the local, regional,

and state levels as well as relationships with other federal

agency offices in their regions. Regional Health Administrators

may, under some circumstances, serve on a SERT.

Office of the Assistant Secretary for Public Affairs

(http://www.hhs.gov/aspa)

Directs HHS’ emergency public information and communications

efforts.

Office of Intergovernmental Affairs

(http://www.hhs.gov/iga)

> Regional Directors

(http://www.hhs.gov/iga/regions.html)

Act as the Secretary’s primary representatives, unless a SERT

has been deployed. Regional Directors serve as members of a

SERT and can be appointed SERT team leader.

> Regional Emergency Coordinators

Assists state, local, and tribal public health, medical,

emergency management, and law enforcement officials in the

development of comprehensive and integrated preparedness

and response plans. Regional Emergency Coordinators work

with the health and medical planners in their regions to

determine response capabilities, when and what type of

federal support might be needed, and how federal assistance

would be integrated into the region’s incident management

system. They also serve on SERTs.

THE ROLES OF HHS OPERATING DIVISIONS

Within HHS, the following operating divisions play key roles in

the Department’s response:

Centers for Disease Control and Prevention

(http://www.bt.cdc.gov)

> Prevents and intervenes on disease and injury.

> Detects and investigates disease outbreaks and other health

problems.

> Develops strategies for dealing with the public health aspects

of an emergency.

> Plays a role in evaluating chemical spills and environmental

contamination and provides safety and health recommendations

to responders (e.g., the wearing of personal protective

equipment).

Food and Drug Administration

(http://www.fda.gov/oc/opacom/hottopics/bioterrorism.html)

> Assures the safety, efficacy, and security of human and 

veterinary drugs, biological products, medical devices, our

nation’s food supply, cosmetics, and products that emit

radiation.
152 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media

> Advances the public health by helping to speed innovations

that make medicines and foods more effective, safer, and

more affordable.

> Helps the public obtain the accurate, science-based

information they need to use medicines and food to improve

their health.

Health Resources and Services Administration

(http://www.hrsa.gov/bioterrorism.htm)

> Works to ensure the availability of quality health care to lowincome, uninsured, isolated, and special-needs populations

that meets their unique health needs.

> Increases access to basic health care for those who are

medically underserved.

> Manages the National Bioterrorism Hospital Preparedness

Program as well as the Bioterrorism Training and Curriculum

Development Program.

> Maintains an Emergency Response Center capability, which

is activated in emergency situations.

Indian Health Service

(http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/

IHSintro.asp)

> Provides a comprehensive health service delivery system,

including personal and public health care for American

Indians and Alaska Natives.

> Addresses issues pertaining to mental health, environmental

health, engineering, dentistry, pharmaceuticals, nursing,

laboratory, and community health and oversees varied

surveillance activities for disease outbreaks and other health

problems among American Indians and Alaska Natives.

> Provides special water purification and waste disposal

assistance during national and international disasters and

emergencies.

Substance Abuse and Mental Health Services

Administration

(http://www.samhsa.gov/)

> Addresses the psychosocial factors (mental health,

substance abuse, and related concerns) in preparedness,

response, and recovery for natural and manmade disasters.

(For more information, see the “Range of Public Reactions”

section [p. 169].)

> May staff interagency emergency operations centers; deploy

personnel; and provide grants, services, and technical

assistance to local and state jurisdictions.

National Institutes of Health

(http://www.nih.gov/about/NIHoverview.html)

> Serves as the steward of medical and behavioral research for

the nation.

> Conducts science in pursuit of fundamental knowledge about

the nature and behavior of living systems and the application

of that knowledge to extend healthy life and reduce the

burdens of illness and disability.

> Within HHS’ National Institutes of Health, the National

Institute of Allergy and Infectious Diseases conducts and

supports most of the research aimed at developing new and

improved medical tools against potential bioterror agents.

Agency for Healthcare Research and Quality

(http://www.ahrq.gov/browse/bioterbr.htm)

> Supports research preparing models and practices that

enhance the preparedness efforts of local, state, and national

jurisdictions.

> Develops and assesses alternative approaches that ensure

health surge capacity for mass casualty events.

> Develops and assesses alternative uses of information

technology and electronic communication networks, protocols,

and technologies to enhance interoperability among health

care systems, the public health system, and other

organizational participants in the emergency response

network.

> Assesses training and information needs of health care providers

for enhanced emergency response.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 153

Administration on Aging

(http://www.aoa.gov/about/over/over_mission.asp)

> Assists a nationwide network of organizations focused on the

needs of older Americans in emergency preparedness and

response to disaster events related to weather, terrorism, and

other catastrophies that adversely affect the lives of and service

delivery system for older persons.

> Works with state and area agencies on aging, tribal

organizations, and aging service providers in partnering with

emergency preparedness systems to assure that the special

needs of the elderly are included in emergency planning and

response management.

Administration for Children and Families

(http://www.acf.hhs.gov/programs/orr/partners/hthcoord.htm)

> Manages resettlement for domestic refugees and entrant

resettlement through the Office of Refugee Resettlement.

> Provides services including resettlement, medical assistance,

and social service programs.

COORDINATION OF THE FEDERAL RESPONSE

The federal response to Incidents of National Significance will

be coordinated under the National Incident Management

System (NIMS) and the NRP. These two documents utilize the

principles of the Incident Command System (ICS). This system

provides a means to coordinate the efforts of individual

agencies as they work toward the common goal of stabilizing

an incident and protecting life, property, and the environment.

ICS was developed by the fire and rescue community in the

1970s in response to a series of major wildland fires in

southern California. It is the model tool for command, control,

and coordination of a complex response situation and has been

used by first responders for many years.

ICS principles include the use of:

> Common terminology

> Modular organization, enabling expansion and contraction

> Integrated communications with common plan, procedures,

etc.

> Unified command structure, with a common set of objectives

and strategies and consolidated action planning among

different agencies

> A manageable span of control of personnel and material

resources

> Comprehensive resource management, to maximize 

resource use

NIMS provides the framework for interoperability and

compatibility that will, in turn, enable a diverse set of public

and private organizations to conduct well-integrated and

effective incident management. More detailed information on

NIMS can be found at http://www.fema.gov/nims/.

COMMUNICATING WITH THE INCIDENT COMMAND

STRUCTURE

The Joint Information System provides a structure for

coordination of public communication. Each federal agency

will operate its own press operation and will coordinate with

the Joint Information Center (JIC) onsite. The JIC does not

supplant the federal agencies but provides coordination among

the various agencies. The JIC also includes local and state

entities, as applicable.

The primary JIC will be authorized to release general medical

and public health response information. Other JICs may also

release general medical and public health response

information to the public at the discretion of the lead public

affairs officer.

PUBLIC HEALTH SOURCES OF AUTHORITY

At the federal level, there are several main sources of legal

authority related to public health emergencies. Two of the

most important of these sources are described in more detail

in this section. The federal government also often has legal

jurisdiction in situations involving multiple states and other

countries. However, it is important to note that many

important laws related to public health emergencies are also

enacted at state and local levels. For example, all levels of

government have the legal authority to issue isolation and

quarantine orders, but the authority shifts based on geographic

details of the outbreak. Because the state laws vary greatly in
154 08. THE ROLE OF THE FEDERAL GOVERNMENT Terrorism and Other Public Health Emergencies: A Reference Guide for Media

general and need updating to reflect current threats and

community needs, many states are currently working on

revising their public health laws. Some of the important issues

being addressed by states include privacy and protection,

clarity of jurisdiction, and liability.

Public Health Service Act*

(http://www.fda.gov/opacom/laws/phsvcact/phsvcact.htm)

The Public Health Service Act authorizes the Secretary of

HHS, acting at both the department level and through

agencies of the Public Health Service (e.g., CDC, the Food and

Drug Administration, the National Institutes of Health, the

Health Resources and Services Administration, the Substance

Abuse and Mental Health Services Administration, and the

Indian Health Service) to protect the public well-being and

provide public health and medical services during

emergencies. Under the Public Health Service Act, 42 U.S.C.

§ 241 et seq., the Secretary is authorized to take the following

actions, among others:

> Declare a public health emergency and take appropriate

discretionary actions to respond to the emergency

> Act to prevent the introduction, transmission, and spread of

communicable diseases

> Deploy the Public Health Service Commissioned Corps

> Develop and stockpile countermeasures, such as antibiotics,

chemical antidotes, antitoxins, and medical material, to agents

that could be used in a bioterror event

Public Health Security and Bioterrorism

Preparedness and Response Act of 2002

(http://thomas.loc.gov/cgi-bin/query/z?c107:H.R.3448.ENR:)

This Act authorizes HHS’ Secretary to further develop and

implement a coordinated strategy for carrying out healthrelated activities to prepare for and respond effectively to

bioterrorism and other public health emergencies. Among its

provisions it requires:

* Summarized sections include amendments made by the Public Health Security and

Bioterrorism Preparedness and Response Act of 2002 and the Homeland Security Act

of 2002.

> Assistance to state and local governments

> Extensive training and coordination to prepare for responses

to an emergency

> The development and maintenance of the Strategic National

Stockpile

> Awards to improve state, local, and hospital preparedness

> Enhanced control of certain biological agents and toxins

> Enforced protection of the food and drug supply

In addition to these authorizations in the Public Health Service

Act and the Public Health Security and Bioterrorism Preparedness

and Response Act of 2002:

> A section of the Social Security Act provides authorization for

waiver of Medicare, Medicaid, or State Children’s Health

Insurance Program requirements in an emergency.

> Sections of the Federal Food, Drug, and Cosmetic Act provide

authorization to inspect and investigate food that may be

adulterated, to refuse imports suspected of being adulterated,

and to detain or seize any adulturated food introduced into

interstate commerce.

Descriptions of selected sections of the Public Health Service

Act; the Public Health Security and Bioterrorism Preparedness

and Response Act of 2002; the Social Security Act; and the

Federal Food, Drug, and Cosmetic Act can be found in

appendix D (p. 234).
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 155

REFERENCES

107th Congress of the United States of America. (2002). Title V

Emergency preparedness and response (from the Homeland Security

Act of 2002). http://www.whitehouse.gov/deptofhomeland/analysis/

title5.html and http://www.dhs.gov/interweb/assetlibrary/

hr_5005_enr.pdf.

Centers for Disease Control and Prevention. (2002). CDC's roles 

in the event of a radiological terrorist event. http://www.bt.cdc.gov/

radiation/pdf/cdcrole.pdf.

Federal Emergency Management Agency, & Emergency Management

Institute. (1998). Basic incident command system (ICS) independent

study course. http://training.fema.gov/EMIWeb/IS/is195.asp.

Hall, B. (2003). Emergency response at the Department of

Health and Human Services. PowerPoint presentation. 

Mee, E. (2002). The Public Health Security and Bioterrorism

Preparedness and Response Act of 2002 (P.L. 107-188): 

Overview of grants for states and local governments.

http://www.ncsl.org/statefed/health/PL107-188overview.htm and

http://www.ncsl.org/statefed/health/PL107-188overview.pdf.

National Emergency Management Association. (2004). National

response plan: Initial plan: Draft. http://www.nemaweb.org/

docs/national_response_plan.pdf.

U.S. Department of Health and Human Services. (2004). Concept

of operations plan (CONOPS) for public health and medical

emergencies. http://www.hhs.gov/nvpo/pandemicplan/hhs_conops.pdf.

U.S. Department of Homeland Security. (2004). National 

incident management system. http://www.dhs.gov/interweb/

assetlibrary/NIMS-90-web.pdf.

U.S. Department of Homeland Security. (2005). National

response plan. http://www.dhs.gov/nrp.

U.S. Food and Drug Administration. (2004). Table of contents,

Public Health Service Act, References are to Title 42 United States

Code: Title 42—The public health and welfare, Chapter 6A—

Public health service. http://www.fda.gov/opacom/laws/phsvcact/

phsvcact.htm.

U.S. Nuclear Regulatory Commission Office of Nuclear Security

and Incident Response. (2004). “Enhancing Security for Radioactive

Materials.” Presented at Northern Ohio Symposium on Homeland

Security and Radiation Emergency Preparedness. PowerPoint 

presentation.

09SELF-CARE FOR MEDIA
GOAL OF THIS SECTION

SELF-CARE FOR MEDIA

158 09. SELF-CARE FOR MEDIA Terrorism and Other Public Health Emergencies: A Reference Guide for Media

THE IMPORTANCE AND CHALLENGE OF SAFETY

Reporting on a public health emergency can make your career,

but only if you take precautions to make sure that you do not

become a victim of the emergency that you are covering.

Regardless, the event will prove to be a stressful experience for

even the most seasoned professionals. You have probably

interviewed crime victims and others who have experienced

trauma, but relatively few journalists have worked in an

environment devastated by a terrorist attack or profound public

health emergency. Adding to the stress and potential danger is

the fact that the nature of the threat may be unclear, 

particularly in the early hours of an emergency.

Many issues complicate reporting during such events, including:

> Physical and mental trauma or “burnout”

> Potential exposure to pathogens, poisons, and other 

health threats

> The challenge of covering a story when you and/or your loved

ones are part of the “affected public”

> Individual distress responses that may manifest as irritability,

depression, anxiety, or other posttraumatic stress symptoms

(see “Distress Responses” box)

The large scale of a public health emergency almost certainly

means there is a limitless amount of work to do, and you may

feel the need to push yourself beyond your usual limits. It can

be difficult to leave the scene and go home or to take a break.

But it is important for you to monitor your needs and wellbeing so you will be able to stay focused.

What you do in your role as a reporter may have as much

impact on public safety as those providing medical assistance.

Therefore, it is very important to ensure your physical safety

and well-being.

To provide practical suggestions and tips to promote 

your safety and well-being while covering a public 

health emergency.

WHAT THIS SECTION INCLUDES

> Tips to help you manage the major risks

> Recommendations gathered from a variety of organizations

for approaches that may help you be better prepared

physically and emotionally

WHAT THIS SECTION DOES NOT INCLUDE

Guidelines are not included for confronting specific public

health emergencies.

DISTRESS RESPONSES

Distress responses are virtually universal when confronting trauma

and usually resolve over time. In some cases, they may persist and

interfere with personal relationships; impair functions; cause suffering;

or develop into psychiatric disorders, such as post-traumatic stress

disorder (PTSD), major depression, substance abuse, phobias, or

other anxiety disorders. Distress can also manifest as irritability,

social withdrawal, new onset or exacerbation of physical illness, and

changes in behavior or personality. Editors, producers, and colleagues

should keep an eye out for these persisting signs so that an affected

journalist (or other members of the news team) can be offered help.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 159

SELF-CARE DURING THE

EMERGENCY

PHYSICAL CARE

Personal Safety Policies

When breaking news of a suspected

terror attack occurs, you will want to

protect your personal safety as much as

possible while covering the story.

Because policies and procedures for

sending media staff into hazardous 

situations vary from newsroom to

newsroom and bureau to bureau, you

may want to become familiar with 

policies in your workplace.

Standards of Safety

Policies and standards for protecting

media personnel, both in the newsroom

and in the field, are evolving rapidly in

the wake of September 11 and the 2001

anthrax attacks. Both the International

Federation of Journalists and the

International News Safety Institute have

published safety codes for journalists

facing danger in covering assignments.

These codes, developed by more than

100 media organizations and journalistic

associations, suggest standards for

journalist safety. Among other provisions,

both codes urge news organizations to

consider safety first, before competitive

advantage, for journalists in dangerous

environments. Although originally designed

for journalists covering wars and civil

emergencies overseas, much of this

guidance may also be useful at home

during a terrorist attack or other public

health emergency.

The box on page 160 presents 11 steps

for personal safety, which have been

gathered through a review of safety tips

from a variety of organizations, such as

the International News Safety Institute,

the Committee to Protect Journalists

(CPJ), and the American Press Institute.

Working In Teams

You may want to consider working with

a partner or a group, if possible, when

out in the field. Some situations may

require putting aside competitive

pressures and instead collaborating with

other media personnel to increase

security. In addition, your teammates

should be aware of your movements

and able to alert others if a situation

arises. CPJ recommends making sure

that at least one person, preferably a

supervising editor, knows where you

are, with whom you are meeting, and

when you will return (CPJ 2003).

Personal Protective Equipment

Media professionals who work in areas

where biological or chemical agents of

terrorism may have been in use face

particular dangers. Some newsrooms

have purchased “escape hoods” for the

employees in their offices, while others

have outfitted most of their news

vehicles with full biochemical protection

suits. Still, other news organizations

have, after careful consideration,

decided against issuing biochemical

suits, concluding that they may give a

false sense of security.

Training and practice are crucial for

using protective gear. For example,

according to the U.S. Army Medical

Research Institute of Infectious

Diseases’ Medical Management of

Biological Casualties Handbook, a

complete biochemical protection suit

TIP

CARRYING IDENTIFICATION 

AND OTHER INFORMATION

CPJ recommends ensuring that all personal

identification is secure but accessible,

along with required press credentials and

any personal medical alert emblems. In

some situations, copies of vaccination

records should be carried as well.

(CPJ 2003)

TIP

PROTECTING IMPORTANT

DOCUMENTS

Keep these records in a waterproof,

portable container:

> Will, insurance policies, contracts, deeds,

stocks and bonds

> Passports, social security cards,

immunization records

> Bank account numbers

> Credit card account numbers and

companies

Note: You may also want to keep copies of

these documents in a safe location outside

of your home or workplace.

Most news organizations agree ... that

issuing protective gear is not for the

purpose of outfitting reporters and crews

to go into a hazardous situation, but rather

to protect them and allow them to get out

of danger.

– “Girding For Terror” 

American Journalism Review, April 2003
160 09. SELF-CARE FOR MEDIA Terrorism and Other Public Health Emergencies: A Reference Guide for Media

I JUST TRY TO TELL PEOPLE TO STAY SAFE. “

I may not always know the short-term or long-term effects of the story—or even the competitive aspects

of the story. But I do know how it will affect this newsroom if they are not here tomorrow. “

Angie Kucharski, vice president of news and station manager, KCNC-TV, Denver, CO

From an interview about her staff and its coverage of Colorado’s historic wildfires in 2002.

1. Be physically and mentally prepared for the situation you will be facing on assignment. It may be advisable to enroll in a biohazards hostileenvironment course that includes basic first aid training before your assignment in a biohazardous situation.

2. If you are going into a physically risky situation, make sure to take a well-known, frequently used travel route.

3. If you have to make a road trip into a dangerous area, you might consider taking two vehicles, so that you will have a backup in case something

goes wrong with one of them.

4. It is almost always wise to buddy-up with another correspondent for mutual protection when traveling into a hazardous location.

5. Let someone you can count on know when you are leaving and when you expect to return, and have him or her get word to the office if you do

not get back in time.

6. If the situation at a hazardous site suddenly turns explosive, make sure you have figured out an escape route and how to flee as soon as possible.

It is a good idea to park a car with nothing blocking its escape.

7. If you have a biohazard suit, it is important for you to know that it takes a minimum of 10 minutes to unpack the suit from its vacuum-sealed

container. If you think that you may be in danger of sudden exposure, it may make sense to repack your suit into a sealed plastic bag.

8. Keep emergency phone numbers at hand, programmed into mobile phones, with a key (24/7) contact number on speed dial, if possible. 

Know the location of hospitals and their capabilities.

9. It is always a good idea when covering a hazardous assignment to review your current vaccination and immunization history. A general

practitioner can either advise you on necessary vaccinations or refer you to someone who can provide advice and inoculations. Carry bloodtype identification and information on any medical conditions on your person in the field.

10. In any situation that requires covering stories involving viral or bacterial agents, it is even more important than in normal circumstances to

wash your hands carefully. Be sure to use good quality soap and plenty of warm water. (The U.S. Department of Health and Human Services’

(HHS) Centers for Disease Control and Prevention (CDC) recommends that you wash for 15–20 seconds.) When soap and water are not

available, you can use alcohol-based disposable hand wipes or gel sanitizers.

11. Consider whether there are other ways to get a story. In some cases, it might be possible to cover a story from a safer location.

Sources: American Press Institute 2001; CDC 2004; Centurion Risk Assessment Services Ltd. 2004; CPJ 2003; Franklin 2002; International News Safety Institute 2004b; Paterno 1998

TABLE 1: SAFETY AND THE STORY—11 STEPS FOR PERSONAL SAFETY
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 161

STAYING IN TOUCH MEANS STAYING ALIVE. typically consists of a protective mask,

full-body overgarment, protective gloves,

and overboots. Both the respirators and

the oversuits come in a wide range of

sizes and must fit properly to be

effective. However, this equipment may

not fit properly if the wearer has long

hair, glasses, or facial hair (Paterno

1998).

Depending on the circumstances of a

given situation, a respirator may be

used even if a full body suit is not.

Respirators and masks come in different

types and each type is designed for use

against specific kinds of airborne

contaminants. Thus, it is critical to choose

the right type of respirator for a given

purpose. Further, to be effective, a

respirator must be used in a total

program of proper selection, training,

maintenance, and fit testing (to ensure

that contaminated air does not leak

around the edges of the mask). If you

are unsure whether your company has a

safety program that would include the

use of a respirator, ask your employer.

Among the different types of respirators

that you may have heard of are “escape

hoods” that are designed to provide

short-term protection and are intended

only to provide a short amount of

additional time (generally 15–30

WHEN CONSIDERING WHETHER TO ENTER “

an area affected by a terrorism event or other public health emergency, journalists should also be concerned

about the welfare of their equipment. In many cases it is difficult or impossible to decontaminate electronic

equipment. As a result, cameras, audio equipment, and sound trucks could be declared contaminated.

In such a situation, the only alternative would be to leave them behind, with unknown chances of recovery. “

Vincent T. Covello, Ph.D. director of the Center for Risk Communication

TIP

MONITORING SUBSTANCE USE

It is not uncommon for people who

typically use alcohol or drugs to increase

their use during stressful situations. It is

also common for people who are in

recovery to start using substances again.

People should be cautious of changes in

their alcohol and drug use, because use of

these substances may impair their ability

to work, as well as their judgment, in

potentially hazardous environments. These

changes in substance use may be an

indication of a need for more support. They

are usually temporary; however, if the

increased use continues, the individual

may want to consider seeking professional

help.

minutes) to escape from a dangerous

situation and move to a safer location.

Other types of respirators provide more

robust and more prolonged protection

against the dangers of inhaling

hazardous particles, gases, fumes,

dusts, and vapors. You may be familiar

with respirators sold in hardware and

home improvement stores; the simplest

form of these are masks that fit over the

nose and mouth and are held in place

with an elastic band. Whatever the

design, a respirator will be effective only

if it has been tested and certified for use

against a given type of contaminant and

is used as part of a total program of

respiratory protection. CDC’s National

Institute for Occupational Safety and

Health provides information to help you

understand the purpose and use of

respirators (http://www.cdc.gov/niosh/

npptl/topics/respirators/factsheets/

respfact.html). At the time of an event,

public health officials may also provide

guidance about the use of masks and

respirators, depending on the situation.

Staying In Touch

Staying in touch means staying alive.

Several people, both in the field and back at

the office, should have a list of emergency

contacts as well as detailed instructions

on how to get in touch with them.

Typical communication arrangements

for personal security include receiving

clearance from a supervising editor

before travel, letting associates and

editors know arrival and departure

times, and checking in with a

designated contact on a regular,

predefined basis.
162 09. SELF-CARE FOR MEDIA Terrorism and Other Public Health Emergencies: A Reference Guide for Media

It is also critical that you stay in touch with friends and loved

ones during such events. According to Sunny Mindel, former

press secretary for Rudolph Giuliani, many first responders felt

more focused on their work during the response to September

11 after having checked in with loved ones and letting them

know that they were OK.

EMOTIONAL CARE

Taking emotional care of oneself is particularly important in a

public health emergency, because you may also be a survivor

of the emergency. You may wish to look up the Dart Center for

Journalism and Trauma (http://www.dartcenter.org), whose

mission includes creating and sustaining partnerships among

media professionals, therapists, and others concerned with

trauma and encouraging peer support among working

journalists. A helpful resource on this site is “Tragedies &

Journalists: A Guide for More Effective Coverage,” by Joe Hight

and Frank Smyth. Even if you did not experience the same

kind or degree of trauma as those whom you are interviewing,

you may still be coping with the event. Few people who

respond to a mass casualty event remain untouched by it. You

may experience anxiety, sadness, grief, or anger—but postpone

your need for rest and recovery while covering the emergency.

This can work up to a point, particularly with practice, but

such strategies have their limits, and experts recommend that

you develop other psychological coping strategies, such as

those described in the following sections (“Setting Boundaries”

and “Self-Monitoring”), both for self-care and possibly in

support of colleagues. It is most helpful to get together and

talk after you have had a hot shower, a few warm meals, and

a chance to catch up on sleep.

Setting Boundaries

An important tool in protecting your emotional health during a

crisis is one you probably use already in other aspects of your

life—setting personal boundaries. By determining these before

the crisis occurs, you will be better able to take care of

yourself. Personal boundaries require a realistic assessment of

your limits and what you need to be effective in covering the

event. Keep in mind that it may be harder to maintain personal

boundaries in a crisis because you also may have endured the

event that you are covering, and this can make it harder to

remain emotionally detached. Two examples of personal

boundaries that you might set include:

> Setting work hours (e.g., limiting shifts to 12 hours or less

after the initial emergency phase of the event).

> Limiting exposure to the event during “off” hours. Although it

is natural to want to keep on top of the developments in the

story while at home, constant exposure to a traumatic event

takes its toll. A study on psychological responses to the

events of September 11 indicated that the number of hours

of television coverage an individual watched per day in the

days following the attacks correlated with his or her

development of PTSD or symptoms of clinically significant

psychological distress (Schlenger et al. 2002). It is unclear

whether this association is actually causal or only

correlational (i.e., Does television coverage lead to increased

psychological distress, or do those who have more

psychological distress seek out more television exposure than

those who do not?).

A BUNCH OF OLD FELLAS, MYSELF INCLUDED, ALL SAID, “

‘All right, Whew!’ Took a deep breath and said, ‘Where are we going from here?’ I’ve seen some stuff after

21 years, 22 years. [Reporting on September 11] put me through a whole range of emotions that I never

felt before in this business. “

Charles Stroble, chief photographer, WBAL-TV, Baltimore, MD

From “Running Towards Danger: Stories Behind the Breaking News of 9/11”
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 163

Regardless of the story you are following, it is clear that taking

some kind of break from work is important for refueling

yourself emotionally and physically. For example, perhaps it’s

possible to rotate jobs so that you are not constantly on the

front line of the disaster.

Self-Monitoring

Even the most seasoned professional needs to be attentive 

to his or her own stress responses. Continual self-monitoring is

an important component in managing stress. Though this may

seem obvious, when you are involved in covering a public

health emergency, self-monitoring may seem like a luxury.

Functioning well will depend on many factors, such as

stamina, expectations, prior traumatic experiences, and even

eating habits. The way you function in your regular role may 

be very different from the way you function in a crisis.

Therefore, continual self-monitoring is critical to make sure

that stress is at a manageable level. You may find it helpful to

partner with a colleague (“buddy care”), so that you can help

monitor each other’s stress levels to determine when relief is

needed.

The Self-Monitoring Checklist developed by HHS’ Substance

Abuse and Mental Health Services Administration (see appendix

H [p. 245]) is a useful tool for measuring stress levels during

and following a public health emergency. Experiencing a few of

the listed symptoms generally does not constitute a problem,

but experiencing several symptoms from each category may

indicate a need for stress reduction. By taking care of yourself,

you will be better able to do your job and, for that matter, to

return to “normal” personal functioning after the event.

THERE IS A FEAR IN NEWSROOMS “

of being labeled as weak or unable to do a story. Culturally, journalists need to realize that they are entitled to grieve. “

David Handschuh, photographer, New York Daily News

From an interview reflecting on the severe physical injuries and emotional stress he experienced as

a result of covering the attack on the World Trade Center in New York City on September 11, 2001.

Excessive Desensitization

A potentially harmful coping mechanism to both the media

and the community is the effect of desensitization to others’

emotional pain and psychological distress. While it is

sometimes possible to compartmentalize your emotions

temporarily to get through a difficult period and do what it

takes to get a story written, it is harmful to stop feeling

altogether or to put away the emotions for too long. You need

time and encouragement to process your emotions—to deal

with your feelings of sadness, anger, horror, or confusion and 

not repress them (Bull & Newman 2003).

How can you tell you’re becoming desensitized? One sign is

projecting negative feelings experienced on the job onto others

at home in angry or abusive ways. Sooner or later,

compartmentalization, an effective short-term coping

mechanism, breaks down. “Walling off one’s feelings” may

even hinder a reporter’s ability to cover the story, because his

capacity for empathy has been diminished. Reporters who

retreat into an emotional shell may find it painful to build

rapport with and listen to others who have experienced

alarming or tragic circumstances.

Talking With Others

Making mental health services readily available for those who

need them has proved helpful after many community

tragedies. This may be a particularly good strategy for media

employers to use in providing support for their journalist

employees. However, the benefits of the common practice 

of group debriefings (voluntary or mandatory and whether

facilitated by a certified professional or not) has been debated.

(Institute of Medicine of the National Academies 2003;

National Institute of Mental Health 2002).
164 09. SELF-CARE FOR MEDIA Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Organizations may find it helpful to offer mental health services

to their employees (e.g., through an Employee Assistance

Program) and to create an environment that supports seeking

these kinds of services when needed. A mental health

consultant or counselor can also serve as a resource for

disaster mental health questions and can provide names of

professionals with expertise in particular areas.

The Institute of Medicine’s Committee on Responding to the

Psychological Consequences of Terrorism further noted that:

Some workplace environments have a culture that is not

conducive to seeking help for psychological issues. Seeking

help or publicly sharing fears may be seen as a weakness.

Alternative strategies may be necessary in such cases. An

easily accessible anonymous service outside the workplace

may be preferable to ensure confidentiality, and initiatives,

such as group debriefings, may be less useful (Institute of

Medicine of the National Academies 2003).

It is important for employers to de-stigmatize the act of seeking

mental health support so that everyone can feel comfortable

accessing these services. Peer support is also beneficial. Often

there are individuals in media organizations whom troubled

employees can seek out for empathy and friendly counsel. The

persons providing this counsel, however, need to be careful not

to become overwhelmed by others’ emotional pain (Bull &

Newman 2003).

SELF-CARE BEFORE THE EMERGENCY

Making preparations before you get an assignment to cover

terrorism or another public health emergency can make a big

difference in your physical and emotional health when the time

comes. Fortunately, recommendations have been developed by

professional societies, news organizations, and journalists for

actions that can protect you from injury or illness in those

stressful times. The following are some considerations as you

start to plan for an emergency event and determine whether

you’re ready:

> Management structure and support. Is your media organization

prepared to respond to a public health emergency? Has there

been special training/education in disaster reporting?

> Social support. Do you have a strong support network of

peers, friends, and/or family to count on?

> Competing demands. Do you have family responsibilities to

deal with? Are there ways to plan ahead of time to meet

those responsibilities?

> Physical health. Do any health considerations limit your ability

to work in certain conditions or environments? Do you have

a lot of stamina? Do you take care of yourself when under

stress, or do you tend to get sick or experience stress levels

that interfere with getting your job done? Do you take any

medications?

> Prior traumas. Have you experienced prior traumas of any

sort (e.g., disasters, accidents, abuse, sexual assault) or the

recent death of a loved one? Will certain situations have

personal significance due to prior experiences? (Note: Prior

traumas or losses may make coping with a dramatic health

emergency more difficult for some people but easier for others.

You will need to decide for yourself whether to get involved,

based on whether you have resolved the emotional issues

surrounding the earlier trauma or grief.)

> Prior mental health issues. Do you have any past mental

health issues that may affect your adjustment or functioning

in a disaster setting?

YOU RESPOND AND YOU KEEP DOING YOUR JOB. “

And I think because you become so focused, that’s where [it becomes] easy for a lot of people who do what 

we do to sort of compartmentalize and focus, and not realize ... the effect of how a tragedy might hit them. “

Angie Kucharski, vice president of news and station manager, KCMC-TV, Denver, CO

From an interview about her and her colleagues’ experiences covering 

the Columbine High School shootings and their aftermath in 1999.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 165

MAKING PERSONAL PREPARATIONS

Only you can decide how close you get to the actual disaster

scene and whether you will interview survivors. These decisions

depend on you knowing yourself, including your reactions and

limitations. Whether you do this kind of work or you simply

know that such an assignment may come your way, you can

help yourself adjust to working in a disaster setting by taking

the following steps in advance:

> Make arrangements for personal responsibilities.

Confidence and security in the field begin with the sense of

well-being that comes from knowing that plans are in place

for those you love. If you have children, elderly parents,

financial responsibilities, or other personal demands that

may compete for your attention during a disaster, you might

want to try to make arrangements ahead of time. Information

on how to prepare a Family Disaster Plan can be found in

appendix E (see p. 239).

> Create a self-care plan. You may want to consider how you

will take care of stress and your health while doing disaster

work.

> Participate in drills and other disaster training. Although

training can never completely simulate a disaster, it can help

prepare you for some of the issues that may arise in a

disaster setting. Some larger news organizations have

enrolled their front-line reporters, editors, and photojournalists

in “hostile-environment training” programs or safety courses

tailored for journalists. The central focus of such courses is

to improve knowledge and security awareness skills so that

journalists can avoid life-threatening situations in the field. A

variety of American and international companies offer

security, first aid, and emergency response training as well as

biological, chemical, and nuclear weapons training. Consider

approaching local emergency management and public health

agencies involved in planning and response for these events

to explore whether you can participate in their training

exercises. The benefit to the media is that such participation

helps media understand local response procedures and build

relationships with local public health officials and first

responders. Media participation is helpful to officials as it

can help test risk communication strategies. You may be

more successful in gaining participation if you agree not to

cover the exercises as a story but as a true participant.

> Work with employers to make workplace preparations.

You can work with your managers and colleagues to develop

emergency response plans and discuss the details of how

work will change during an emergency (e.g., whether 

managers will reassign regular work, change shifts).

> Ensure that your employer has a plan for providing

psychological support. This support, which may be needed

during and after such an event, may be offered through

Employee Assistance Program staff or contracted specialists.

Assistance should be confidential to assure journalists that

access to help will not harm their careers.

> Assemble a disaster supplies kit for home and workplace.

If you need to evacuate your home or office or need to 

shelter in place, having some essential supplies on hand 

will make you feel more comfortable. You should consider

preparing a disaster supplies kit in an easy-to-carry container,

such as a duffelbag or small plastic trash can. (More

information on disaster supplies can be found in appendix F

[see p. 241].) The American Red Cross recommends that

copies of essential documents—powers of attorney, birth and

I CONTINUE WITH THERAPY AND WORK “

through some of the issues of September 11.There are many, many newspapers and television stations that offer

employee assistance programs. That’s a good thing; however, it’s reactive, rather than proactive. You as 

the person who responds to an event have to seek them out. And while many of them do a very, very excellent

job ... many of these employee assistance programs aren’t trained to deal with traumatized journalists. “

David Handschuh, photographer, New York Daily News

From an interview reflecting on the severe physical injuries and emotional stress he experienced as

a result of covering the attack on the World Trade Center in New York City on September 11, 2001.
166 09. SELF-CARE FOR MEDIA Terrorism and Other Public Health Emergencies: A Reference Guide for Media

marriage certificates, insurance policies, life insurance

beneficiary designations, and a copy of your will—should

also be kept in a safe location outside the home. A safe

deposit box or the home of a friend or family member in a

different town is a good choice. (More information on

preparing a workplace disaster supplies kit can be found in

appendix G [see p. 243].) Additional supply checklists can

also be found at http://www.ready.gov.

SELF-CARE AFTER THE EMERGENCY

As the coverage of the event starts winding down, it 

is important to continue monitoring your behavioral,

psychological/emotional, physical, cognitive, and social

functioning, especially if you are experiencing challenges

returning to your normal routine. Tips for reducing stress 

and renewing energy, developed by HHS’ Substance Abuse 

and Mental Health Services Administration, can be found in

appendix I (see p. 246).

There may be times when stress reduction strategies are not

helpful enough. Research has shown that some changes

associated with exposure to trauma may involve a change in

brain chemistry and function. Antidepressants can be useful in

reducing both PTSD and depression (Bull & Newman 2003).

Cognitive-behavioral treatment models have also been shown

to be effective for these disorders. The Disaster Mental Health

Institute at the University of South Dakota provides the

following guidelines (Jacobs 2003), which may help you

decide if your reactions may require professional assistance:

> When disturbing behaviors or emotions last more than 

4–6 weeks

> When behaviors or emotions make it difficult to function

normally (including functioning at work or in the family)

> Any time an individual feels unstable or concerned about his

or her behavior or emotions
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 167

REFERENCES

American Press Institute. (2001). Crisis journalism: A handbook

for media response. http://www.americanpressinstitute.org/

articles/publications/crisisjournalism/.

Bull, C., & Newman, E. (2003). Self-study unit 2: Covering 

terrorism. http://www.dartcenter.org/resources/selfstudy/

2_terrorism/index.html.

Centers for Disease Control and Prevention. (2004). Fact sheet—

Influenza (flu): Stopping germs at home, work and school.

http://www.cdc.gov/germstopper/materials/home_work_school.pdf.

Centurion Risk Assessment Services Ltd. (2004). http://www.

centurionsafety.net/.

Committee to Protect Journalists. (2003). On assignment: 

A guide to reporting in dangerous situations. http://www.cpj.org/

Briefings/2003/safety/journo_safe_guide.pdf.

Franklin, S. (2002). Memo: Staying alive and other tips.

Columbia Journalism Review, May/June. http://archives.cjr.org/

year/02/3/franklin.asp.

Institute of Medicine of the National Academies. (2003).

Preparing for the psychological consequences of terrorism: 

A public health strategy. Washington, DC: The National

Academies Press. http://www.nap.edu/books/0309089530/html/.

International Federation of Journalists. (2004). http://www.ifj.org/

default.asp?index=829&language=EN.

International News Safety Institute. (2004a). http://www.newssafety.

com/safety/index.htm.

International News Safety Institute. (2004b). Safety first.

http://www.newssafety.com/safety/tips.htm.

Jacobs, G.A. (2003). Coping with the aftermath of a disaster.

Vermillion, SD: University of South Dakota, Disaster Mental

Health Institute. 

National Institute of Mental Health. (2002). Mental health and

mass violence: Evidence-based early psychological intervention

for victims/survivors of mass violence: A workshop to reach 

consensus on best practices. Washington, DC: U.S. Government

Printing Office. http://www.nimh.nih.gov/publicat/massviolence.pdf.

Newseum, Trost, C., & Shepard, A.C. (2002). Running toward

danger: Stories behind the breaking news of 9/11. Lanham, MD:

Rowman & Littlefield Publishers, Inc. 

Paterno, S. (1998). School for survival. American Journalism

Review, November. http://www.ajr.org/Article.asp?id=3362.

Schlenger, W.E., Caddell, J.M., Ebert, L., Jordan, B.K., Rourke,

K.M., Wilson, D., et al. (2002). Psychological reactions to 

terrorist attacks: Findings from the National Study of Americans’

Reactions to September 11. Journal of the American Medical

Association, 288, 581–588.

Smolkin, R. (2003). Girding for terror. American Journalism

Review. http://www.ajr.org/Article.asp?id=2885.

U.S. Army Medical Research Institute of Infectious Disease.

(2001). Medical management of biological casualties handbook.

(4th ed.). Fort Detrick, MD: U.S. Army Medical Research Institute

of Infectious Diseases.

ADDITIONAL READINGS

Bolton, E. (2004). PTSD in journalists: A National Center for

PTSD fact sheet. http://www.ncptsd.org/facts/specific/

fs_journalists.html.

Danieli, Y. (Ed.). (2001). Sharing the front line and the back

hills: International protectors and providers: Peacekeepers,

humanitarian aid workers and the media in the midst of crisis.

Amityville, NY: Baywood Publishing Company, Inc.

10RANGE OF PUBLIC REACTIONS
GOAL OF THIS SECTION

RANGE OF PUBLIC REACTIONS

170 10. RANGE OF PUBLIC REACTIONS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

To provide insight into the public’s range of posttraumatic

reactions to terrorism and other public health emergencies

so that the media better understand their audiences.

WHAT THIS SECTION INCLUDES

> Information about the ripple effect of terrorism, factors

that may influence individual reactions to a traumatic

event, the range of reactions, and the phases of recovery

> Information adapted from the field of disaster mental

health, which has focused mostly on reactions to 

natural events

WHAT IS NOT INCLUDED AND WHY

Reactions to specific categories of events or by specific

audiences are not included because it is difficult to predict

how audiences will react to specific events. There is little

data or research on this issue.

IMPACT OF TERRORISM

PANIC RARELY OCCURS

What happens when the unthinkable strikes? Will we see 

the typical Hollywood depiction of a disaster scene—people

screaming, stampeding, rioting? Will the general public be

irrational, uncoordinated, and uncooperative? Probably not. 

A study of responses to disasters shows a pattern of mostly

helpful and adaptive behaviors by the public (Glass & SchochSpana 2002). The most recent experiences with the public’s

reactions to September 11 provided more such evidence. For

example, people evacuating the World Trade Center towers

went out of their way to help disabled people get down the

stairs. People have a wide range of reactions, as described in

this section, but panic is not a common one.

Fear should not be misunderstood or mislabeled as panic. 

In fact, fear is a normal and often appropriate response to very

frightening circumstances. A more complete discussion about

fear can be found in the essay by Dr. Peter Sandman at the end

of the “Risk Communications During a Terrorist Attack or Other

Public Health Emergency” section (see p. 183).

Panic is not only rare but also preventable when timely and

accurate information, which includes personal protective measures,

is released to the public (Glass & Schoch-Spana 2002). 

The media play a critical role in helping public officials 

disseminate needed information. By doing so, the media not

only help mitigate potential panic reactions but also help

harness the capacities of the public to constructively participate

in disaster response.

RECOGNIZING THE RIPPLE EFFECT

Terrorism is primarily a psychological assault that erodes our

sense of safety and sense of security, two of the most basic

human needs. The physical impact of a terrorist or other public

health emergency involving mass trauma and casualties is

concrete and visible. The psychological impact, however, is

much more subtle in nature, sending waves of shock and

distress throughout the community, the state, and the nation.

As such, the psychological suffering from an act of terrorism 

is usually more extensive than the physical injuries 

(Institute of Medicine of the National Academies 2003).

Some experts use what is called the population exposure

model (DeWolfe, In press) to depict the emotional impact that

mass violence has on various victims, families, responders, and

community groups. In essence, the psychological impact of the

event ripples out from those immediately affected, such as

victims and their family members, through the community

beginning with rescue workers who are exposed to tremendous

suffering and other service providers who deal directly with
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 171

REDUCING PANIC WITH INFORMATION

By Vincent Covello, Ph.D.

The disaster research literature indicates that panic rarely occurs. 

The degree to which these general findings apply to a bioterrorist attack,

however, is debatable. Panic may be more of a risk following a

bioterrorist attack using contagious, dreaded, or lethal organisms, such

as pneumonic plague or smallpox.

Panic describes an intense contagious fear causing individuals to think

only of themselves. The risk factors for panic include:

> The belief that there is a small chance of escape

> Perceiving oneself at high risk of being injured or killed

> Available but limited resources for assistance

> Perceptions of a “first come, first served” disaster management system

> A perceived lack of effective disaster leadership and management

> Loss of credibility by authorities

The chance of panic occurring is even further reduced when 

people receive:

> Clear, brief, and consistent information

> Frequent information from trusted and credible leaders who are 

highly visible

> Meaningful tasks that increase group interaction, increase 

connectedness, and provide a sense of control

The assumption that people will immediately panic or behave irrationally

following a disaster can have negative consequences. Authorities may

provide inaccurate information or unfounded reassurance motivated 

by a wish to calm the public. The desire to avoid panic may also lead

authorities to miss opportunities to engage the public in managing 

the disaster.

Vincent Covello, Ph.D., is the founder and director of the Center for Risk

Communication in New York City. He is a nationally and internationally recognized

trainer, researcher, consultant, and expert in risk and crisis communication.

Seriously injured victims; bereaved family members, loved ones, close

friends

Victims with high exposure to trauma; victims evacuated from the

disaster

Bereaved extended family members and friends; rescue and recovery

workers with prolonged exposure; medical examiner’s office staff;

service providers directly involved with death notification and bereaved

families

People who lost homes, jobs, pets, valued possessions; mental health

providers; clergy, chaplains, spiritual leaders; emergency health care

providers; school personnel involved with survivors; families of victims;

media personnel

Government officials; groups that identify with the target victim group;

businesses with financial impacts

Community at large

FIGURE 10–1: EMOTIONAL IMPACT OF A MASS VIOLENCE OR TERRORISM EVENT (Population Exposure Model)1

1 DeWolfe, D.J. (Ed.). (In press). Mental health response to mass violence and terrorism: A training manual. Rockville, MD: Center for

Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

Note: This diagram is based on the “Population Exposure Model.”
172 10. RANGE OF PUBLIC REACTIONS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

family members, such as medical examiner staff and recovery

workers. The next ripple touches those who support members

of the community, such as clergy, spiritual leaders, mental

health providers, and journalists, who are all repeatedly

immersed in the details of the situation. The next ripple touches

the officials who are managing the situation, including

government officials, and businesses that are financially

impacted, and the ripple effect then continues through the

national community. Figure 10–1 illustrates this concept.

FACTORS THAT INFLUENCE INTENSITY OF REACTIONS

In an emergency, stress reactions often surface after people

have grappled with their immediate physical situations. 

The intensity of the reaction is determined by the magnitude

of the disaster, the level of trauma experienced, and individual

coping and stress management abilities. The intensity of the

reaction may also be influenced by certain characteristics of

the emergency, such as:

> Threat to life

> Severe physical harm or injury

> Receipt of intentional injury or harm

> Exposure to images of the grotesque

> Violent or sudden loss of a loved one

> Witnessing or learning of violence toward a loved one

> Exposure or fear of exposure to a noxious agent

> Intentional death or harm caused by others

> A large number of deaths, especially the deaths of children

In addition, people experience emergencies through their own

individual lenses. The meaning that a person assigns to the

emergency, his or her personality, and his or her world view and

spiritual beliefs contribute to how each person will perceive,

cope with, and recover from the event (DeWolfe 2000).

RANGE OF REACTIONS

Terrorism and traumatic events activate the body’s survival

response, i.e., fight, flight, or freeze. People who are exposed

to terrorism and traumatic events may experience a variety 

of reactions. These responses may be very different from

reactions they have had to other stressful events in their lives

in the past, and that difference itself can be unsettling and

even frightening. Nevertheless, the majority of people’s 

reactions are ordinary reactions to extraordinary events.

For most people, the return from crisis to the resumption 

of everyday activities and the resolution of stress reactions 

is an automatic process requiring little or no intervention other

than “tincture of time.” But for others, the return to a regular

routine is much more challenging. It is very difficult to predict

which individuals will have a difficult time recovering from a

particular event. Any person, regardless of existing coping

skills or psychological strength, may be particularly moved by

a specific event. This is a sign of being human, not of being

weak.

On the following page are some reactions common to people

who experience traumatic stress. Although these cognitive,

emotional, behavioral, and physical reactions can be upsetting,

they are normal reactions to extreme stresses (Jacobs 2003).

RESPONSES TO TRAUMA

September 11 Example

For every person who is physically harmed, many more are likely to

experience psychological and emotional effects. As a matter of fact,

most people will experience some psychological distress following a

terrorist attack. Immediately following September 11, a survey of

more than 3,500 New York City Metropolitan area residents found that

75 percent reported having problems attributed to the attacks, while

only 35 percent reported being or knowing a victim. The study also

found that: 

> 49 percent participated in religious or community memorial services.

> 48 percent experienced anger.

> 37 percent experienced worry.

> 21 percent of smokers increased smoking. 

> 12 percent of respondents with problems received help. 

Family members (36 percent) and friends or neighbors (31 percent)

were the main source for help. 

> 3 percent increased drinking. 

(Centers for Disease Control and Prevention 2002)
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 173

COGNITIVE REACTIONS

> Having recurring dreams and nightmares

about the event and its aftermath

> Reconstructing in one’s mind the

occurrences surrounding the event

itself, in an effort to make it play out

differently

> Having difficulty concentrating or

remembering things

> Questioning one’s own spiritual or

religious beliefs

> Having repeated thoughts or memories

of loved ones who died or the damage

that resulted from the event that are

hard to stop

EMOTIONAL REACTIONS

> Feeling numb, withdrawn, or

disconnected

> Feeling frightened or anxious when

sounds or smells remind one of the

event

> Feeling a lack of involvement or

enjoyment in everyday activities

> Feeling depressed, blue, or down much

of the time

> Feeling bursts of anger or intense 

irritability

> Feeling a sense of emptiness or 

hopelessness about the future

BEHAVIORAL REACTIONS

> Being overprotective of one’s own safety

and one’s family’s safety

> Isolating oneself from others

> Becoming very alert at times and

startling easily

> Having problems getting to sleep or

staying asleep

> Avoiding activities that remind one of

the event or its damage; avoiding places

or people that bring back memories

> Having increased conflict with family

members

> Keeping excessively busy to avoid

thinking about the event

> Being tearful or crying for no apparent

reason

PHYSICAL REACTIONS

> Stomach upset and nausea

> Diarrhea and intestinal cramps

> Elevated heart rate

> Elevated blood pressure

> Elevated blood sugar

A person experiencing any of these

reactions may need to seek assistance

from a mental health or medical

professional if the reaction interferes

with daily functioning. In addition, the

following reactions may indicate the

need for medical intervention or a

mental health evaluation:

> Disorientation—dazed; memory loss;

inability to cite the date, time, or state

in which one lives, recall events of the

past 24 hours, or understand what is

happening

> Inability to care for oneself (not eating,

bathing, or changing clothes); inability

to manage the activities of daily living

> Suicidal or homicidal thoughts or plans

> Problematic use of alcohol or drugs

> Domestic violence, child abuse, or

elder abuse

FLASHBACKS

Sometimes people exposed to trauma may

experience a “flashback,” which may be

triggered by a sight, sound, or smell that

reminds them of the event. Flashbacks are

much more than just intrusive and unwanted

memories. In a flashback, for a few seconds

the person feels as if he or she is back in

that traumatic moment again. Flashbacks

can be so real that people can see all the

colors, hear all the sounds, and even smell

all the smells—just as if the moment were

happening again. People who experience

flashbacks and are unfamiliar with them

sometimes fear that they are having a

psychotic breakdown. Flashbacks can be

fairly common, however, and generally

become less frequent with time until they

disappear altogether. If flashbacks persist

after an event or increase in frequency, the

flashback sufferer may find professional

mental health support beneficial.

PHYSICAL EFFECTS OF STRESS

Numerous studies have found that trauma

has negative effects on physical health. This

appears especially true for those suffering

from posttraumatic stress disorder. People

who are exposed to traumatic events may be

at increased risk not only for posttraumatic

stress disorder but also for major

depression, panic disorder, generalized

anxiety disorder, and substance abuse.

They may also have physical illnesses,

including hypertension, asthma, and chronic

pain syndromes (Yehuda 2002). One study

found that adults who reported traumatic

experiences as children had higher rates of

serious medical conditions, including cancer,

heart disease, and chronic lung disease

(Felitti et al. 1998).
174 10. RANGE OF PUBLIC REACTIONS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

THE AIM OF TERROR IS TO BREAK A SOCIETY’S RESOLVE, “

to separate a society from its traditional values, to cause it to break internally. The result of ongoing terror is

that people in Northern Ireland have experienced rising rates of alcoholism, domestic violence, suicide,

smoking, drug abuse, and a general hollowing out of society. The violence has stopped, but we still don’t know

how deeply the poison has run. “

Conor Brady, former editor of The Irish Times

From Reporting on Terrorism: The News Media and Public Health

CHILDREN AND ADOLESCENTS

Children process information, and experience and express

emotions, differently than adults. A child’s reaction to disasters,

violence, and the sudden death of loved ones is dependent 

on that child’s psychological development, life and family 

situation, and critical caretaking relationships (DeWolfe, In

press). Terrifying events can cause overwhelming and

unfamiliar physical and emotional reactions that can 

traumatize children.

Children have a difficult time deciding what is fact and what

is fantasy, which leads to fear and confusion. When trying to

make sense of what has happened, children often blame

themselves for causing or worsening an incident, which can

lead to feelings of guilt and shame.

Very young children depend on a stable environment and 

reliable people to take care of them. As children become older,

they may try to understand why the event happened and what

will happen next. Family, significant adults, pets, playmates,

school, and the neighborhood are important features in a

child’s world. When a public health emergency takes place in

a community, many of these significant features may be disrupted

or destroyed. Table 1, on the following page, provides more

information on the behavioral, physical, and emotional

symptoms children at different ages may experience.

Some youngsters are more vulnerable to trauma than others,

for reasons scientists do not fully understand. It has been

shown that the impact of a traumatic event is likely to be

greatest in the child or adolescent who previously has been the

victim of child abuse or some other form of trauma or who

already has a mental health problem (National Institute of

Mental Health 2001).

OLDER ADULTS

Older adults may in some ways be uniquely resilient to the

grief and trauma of acts of terrorism. The wisdom and

experience accrued over a lifetime can provide tools to help

cope with loss, changes, and painful emotions. As older adults

become more physically frail or develop significant health

problems, however, their reactions to terrorism can be greatly

affected by their physical needs. When an older person is

already feeling vulnerable due to changes in health, mobility,

and cognitive abilities, the feelings of powerlessness and

vulnerability that result from a terrorist event can be

overwhelming. Sudden evacuations from nursing or residential

facilities can be disorienting and confusing. Sensory

impairment may cause older adults to be unresponsive to

offers of help. Below are other ways that older adults might be

affected:

> Overwhelming grief after losing children or grandchildren

> Fear after losing children who were their primary caretakers

> Distress over having to step in to care for a child whose

parents have died (can be intensified as older adults worry

about changing their lifestyle and making sure there is

enough money to care for an extra person in the household)

> Memories of combat that could be stirred up in war veterans
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 175

TABLE 1. CHILDREN’S AND ADOLESCENTS’ REACTIONS TO TRAUMA

Source: DeWolfe, D.J. (Ed.). (In press). Mental health response to mass violence and terrorism: A training manual. Rockville, MD: Center for Mental Health Services, 

Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. 

AGE BEHAVIORAL SYMPTOMS PHYSICAL SYMPTOMS EMOTIONAL SYMPTOMS

1–5 • Clinging to parents or familiar

adults

• Helplessness and passive behavior

• Resumption of bed-wetting or

thumbsucking

• Fear of the dark

• Avoidance of sleeping alone

• Increased crying

• Loss of appetite

• Stomach aches

• Nausea

• Sleep problems, nightmares

• Speech difficulties

• Anxiety

• Generalized fear

• Irritability

• Angry outbursts

• Sadness

• Withdrawal

6–11 • Decline in school performance

• School avoidance

• Aggressive behavior at home 

or school

• Hyperactive or silly behavior

• Whining, clinging, or acting like a

younger child

• Increased competition with younger

siblings for parents’ attention

• Traumatic play and reenactments

• Change in appetite

• Headaches

• Stomach aches

• Sleep problems, nightmares

• Somatic complaints

• Fear of feelings

• Withdrawal from friends and 

familiar activities

• Fear triggered by reminders of 

the event

• Angry outbursts

• Preoccupation with crime, criminals,

safety, and death

• Self-blame

• Guilt

12–18 • Decline in school performance

• Rebellion at home or school

• Decline in previous responsible

behavior

• Agitation or decrease in energy

level; apathy

• Delinquent behavior

• Risk-taking behavior

• Social withdrawal

• Abrupt shifts in relationships

• Change in appetite

• Headaches

• Stomach aches

• Skin eruptions

• Complaints of vague aches 

and pains

• Sleep problems, nightmares

• Loss of interest in peer social 

activities, hobbies, recreation

• Sadness or depression

• Anxiety and fearfulness about safety

• Resistance to authority

• Feelings of inadequacy and 

helplessness

• Guilt, self-blame, shame, 

and self-consciousness

• Desire for revenge
176 10. RANGE OF PUBLIC REACTIONS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

In addition, certain vulnerabilities that are more common

among older adults may heighten reactions and/or interfere

with recovery. These include:

> Mobility limitations

> Susceptibility to hypothermia and hyperthermia

> Physical and sensory (sight, hearing) limitations

Table 2 provides some of the symptoms that older adults may

experience in reaction to a traumatic event.

RESILIENCY-BUILDING (AND STRESS-RELIEVING)

RECOMMENDATIONS

Following are some of the recommendations that media 

may hear from mental health and public health professionals

during these times. Helping community members cope with

the impact of terrorism and return to regular routines is an

important part of the public health message and is likely to

become a part of the story in the days and weeks after an act

of terrorism.

THINGS TO REMEMBER WHEN TRYING TO UNDERSTAND

DISASTROUS EVENTS

(Substance Abuse and Mental Health Services Administration

2003)

> Few people who see a disaster are untouched by it.

> It is normal to feel anxious about your and your family’s safety.

> Profound sadness, grief, and anger are ordinary reactions to

an extraordinary event.

> Acknowledging our feelings helps us recover.

> Focusing on our strengths and abilities will help us heal.

> Accepting help from community programs and neighbors 

is healthy.

> We each have different needs and different ways of coping.

> It is common to want to strike back at people who have

caused great pain, but it is important not to extend these

feelings toward people who merely look like those who

perpetrated an act of terrorism. Nothing good is

accomplished by hateful language or actions.

TABLE 2. OLDER ADULTS’ REACTIONS TO TRAUMA

BEHAVIORAL SYMPTOMS PHYSICAL SYMPTOMS EMOTIONAL SYMPTOMS

• Withdrawal and isolation

• Reluctance to leave home

• Relocation adjustment problems

• Worsening of chronic illnesses

• Sleep disorders

• Memory problems

• Somatic symptoms

• Feeling overwhelmed and shutting down

• Depression

• Despair about losses

• Apathy

• Confusion, disorientation

• Suspicion

• Agitation, anger

• Fears of institutionalization

• Anxiety with unfamiliar surroundings

• Embarrassment about receiving “handouts”

Source: DeWolfe, D.J. (Ed.). (In press). Mental health response to mass violence and terrorism: A training manual. Rockville, MD: Center for Mental Health Services, 

Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 177

SIGNS THAT ADULTS NEED ASSISTANCE

If the reactions listed below last longer than a period of 4–6

weeks or impair a person’s ability to function normally in dayto-day life, he or she may want to consider speaking to a

mental health professional:

> Difficulty communicating thoughts

> Difficulty sleeping

> Difficulty maintaining balance in lifestyle, activities, or

schedule

> Frustration triggered easily

> Increased use of drugs or alcohol

> Limited attention span

> Poor work performance

> Headaches or stomach problems

> Tunnel vision or muffled hearing

> Disorientation or confusion

> Difficulty concentrating

> Reluctance to leave home

> Depression, sadness

> Feelings of hopelessness

> Mood swings

> Crying easily

> Overwhelming guilt and self-doubt

> Fear of crowds, strangers, or being alone

WAYS TO EASE THE STRESS

> Talk with someone about your feelings—anger, sorrow, and

other emotions—but only if the conversation feels comfortable

to you.

> Do not hold yourself responsible for the disastrous event or

be frustrated because you feel that you cannot help directly

in the rescue work.

> Take steps to promote your own physical and emotional

healing by staying active or by adjusting your daily habits. A

healthy outlook (i.e., healthy eating, rest, exercise, 

relaxation, and meditation) will benefit you and your family.

> Maintain a normal household and daily routine and 

limit responsibilities that are demanding of yourself and 

your family.

> Spend time with family and friends.

> Participate in memorials, rituals, and symbolic gestures 

and events as a way to express feelings.

> Use existing support groups of family, friends, and church.

> Establish a family emergency plan. Taking an active role 

in this way (“doing something”) can be very comforting.

If these stress-relieving strategies are not helping, or loved 

ones are using drugs or alcohol to cope, outside or professional

assistance may be needed.

HELPING CHILDREN COPE

(American Red Cross 2001)

Routines. Children of all ages can benefit from the family

keeping its usual routines—meals, activities, and bedtimes—

as close to normal as possible. This allows a child to feel more

secure and in control. As much as possible, children should

stay with people with whom they feel most familiar.

Special needs. Accept the special needs of children by

allowing them to be more dependent on you for a period of

time. Give more hugs if they need them; let them keep the

light on at night, have their favorite teddy bear or blanket 

(even if previously put away), or not sleep alone; accept 

any clinging behavior.

Media coverage. Following a disaster, everyone is eager to

hear the latest news about what happened. Disaster research

has shown, however, that unexpected messages or images on

television can be frightening to children, causing an appearance

of stress-related problems. In addition, anyone who watches 

a lot of the disaster coverage can become what is called 

a “secondary victim” and suffer emotional and physical 

problems. Therefore, experts feel that it is best not to 

allow children to watch news coverage of the disaster.
178 10. RANGE OF PUBLIC REACTIONS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Feelings and reactions. Children express their feelings and

reactions in different ways. Your acceptance of this will make

a difference in how your child recovers from the trauma. 

This means accepting that some children will react by

becoming withdrawn and unable to talk about the event, while

others will at times feel intensely sad and angry and will at

other times act as if the disaster never happened. Children are

often confused about what has happened and about their

feelings. However, do not be surprised if some children appear

unaffected by what they have seen and heard. Not everyone

has immediate reactions; some have delayed reactions that

show up days, weeks, or even months later and some may

never have a reaction.

Talking About What Happened

> Listen to and accept children’s feelings.

> Give honest, simple, and brief answers to their questions.

> Make sure that children understand your answers and the

meaning you intend.

> Use words or phrases that will not confuse a child or make

the world more frightening.

> Create opportunities for children to talk with each other

about what happened and how they are feeling.

> Give your child an honest explanation if you are feeling so

upset that you do not want to talk about what happened. You

may want to take “time out” and ask a trusted family friend

to help talk to the child.

> If children keep asking the same question over and over it is

because they are trying to understand—trying to make sense

out of the disruption and confusion in their world. Younger

children will not understand that death is permanent, so their

repeated inquiries are because they expect everything to

return to normal.

> If the child feels guilty, ask him or her to explain what 

happened. Listen carefully to whether he or she attaches 

a sense of responsibility to some details or circumstances.

Explain the facts of the situation and emphasize that no one,

least of all the child, could have prevented the tragedy.

> Let the school help. The child’s teacher can be sensitive to

changes in the child’s behavior and may be able to talk to the

child in a helpful way.

> Even if you feel the world is an unsafe place, you can 

reassure your child by saying, “The event is over. Now we

will do everything possible to stay safe, and together we can

return things to normal.”

> Notice when children have questions and want to talk.

> Be especially loving and supportive and willing to talk; 

children need you at this time.

Certain circumstances may make a child more vulnerable 

to having difficulty coping with the disaster. If a child has

experienced a recent loss, such as a divorce or a death of

someone who was close, or has moved to a new neighborhood,

he or she may feel particularly overwhelmed. A traumatic

event can reactivate the emotions associated with previous

traumas, which can be overpowering. Seeing a counselor does

not mean that a child is “mentally ill” or that the parents have

failed to support him or her. Following a trauma, many adults

and children have found that it is helpful to talk with a 

counselor who has specialized training in posttraumatic 

reactions and can help them understand and deal with 

how they are feeling.

More information on helping children and adolescents cope with

violence and disaster can be found in appendix J (see p. 247).

COPING WITH DISASTER: TIPS FOR OLDER ADULTS 

(National Mental Health Association 2001)

> Talk about the experience and how you are feeling. Expressing

your thoughts with others gives you the opportunity to relieve

stress, reduce anxiety, and realize that other people share

your feelings.

> Communicate with loved ones often. Communicating with

family and friends following a disaster helps increase feelings

of safety and security.

> Take care of yourself physically. If exercise is a regular part of

your routine, continue to exercise. It is also important to eat

well, drink plenty of water, and rest.

> Be around others. Isolation and loneliness can increase the

degree to which you experience symptoms. If you do not

have a local network of family or friends to visit with often,

find a place where you can be with people. Volunteer at a
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 179

local nonprofit organization, offer to speak at local schools

about historical events you have experienced, contact local

churches or senior centers to see if they are holding any

activities of interest to you, or call your doctor or local mental

health center to see if there is an older adults support group

in your area that you could attend. If you are unable to drive,

do not hesitate to ask for a ride, look into reduced special taxi

fares for senior citizens, or take public transportation, if you

are able.

> Do things you enjoy. If you have put things aside that you

normally enjoy, get involved in those activities now. Go for

that walk, plant flowers, or play cards with your friends.

> Write about significant experiences in your life and how they

have affected you. Journaling gives you the opportunity to

express your feelings in your own words and at your own

pace. It is also an opportunity for you to share pieces of your

life with future generations.

TABLE 3: THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES’ MAJOR ACTIVITIES 

RELATING TO THE PSYCHOLOGICAL EFFECTS OF TERRORISM

The two major agencies within the U.S. Department of Health and

Human Services that are working on preparing for the psychological

effects of disasters and terrorism are the Substance Abuse and Mental

Health Services Administration (SAMHSA), which assists states with

funding and training on service delivery, and the National Institute of

Health’s National Institute of Mental Health (NIMH), which focuses on

research. The Centers for Disease Control and Prevention (CDC) is

becoming increasingly involved as it examines ways to incorporate

mental health into its public health activities. All three agencies work

closely together on many initiatives and frequently cosponsor

activities. The Health Resources Services Administration (HRSA) also

plays a role through terrorism grants administered by CDC and HRSA

to the states, which include benchmarks for integration of mental

health into public health and hospital preparedness activities.

SAMHSA (http://www.samhsa.gov)

Since 1974, SAMHSA has had a collaborative agreement with the

Federal Emergency Management Agency to administer crisis counseling

and training assistant programs after presidentially-declared disasters.

In 2001, SAMHSA initiated the Child Traumatic Stress Initiative to 

identify effective treatments and services; collect clinical data on child

trauma; develop resources for professionals, consumers, and the public;

and develop trauma-focused professional training. SAMHSA has

devoted significant resources to helping the states improve their 

disaster preparedness capacity. In 2003, SAMHSA sponsored a 

conference, Creating a Roadmap for Disaster Preparedness:

Strengthening State Capacity for Disaster Mental Health and

Substance Abuse, which was attended by more than 50 states and

territories. It was followed up by a series of regional meetings to further

develop plans. SAMHSA also awarded 2-year planning grants to 35

states to enhance their substance abuse and mental health service

provision in the event of a disaster, such as terrorism.

NIMH (http://www.nimh.nih.gov)

Through its research programs, NIMH conducts and supports mental

and behavioral health research relevant to preparation for and

response to the psychosocial effects of terrorism and mass emergencies.

This research spans and integrates basic science, clinical practice,

and health care system issues. Additional research focuses on 

preventing the damaging effects of traumatic stress through the study

of basic mechanisms; detection and diagnosis; treatment and prevention;

and education, training, and information resources.

This research contributes to better response planning; training for 

the health and human services workers; more communication before,

during, and after incidents to reduce anxiety or distress and promote

compliance with safety procedures; the design and deployment of

outreach and intervention programs to reduce symptoms and improve

functioning; and the treatment of psychiatric disorders that arise after

exposure to mass trauma.
180 10. RANGE OF PUBLIC REACTIONS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

It is important to return to your usual routine at your own pace;

however, if your symptoms do not seem to be subsiding or if

they appear to be getting worse, you may want to speak with

a mental health professional. If you have already been

diagnosed with a mental health disorder or if you find you are

distressed about traumatic events from your past, you may

want to meet with a mental health professional as a

precautionary measure. To find a mental health professional in

your community, contact your primary care physician, a local

mental health center, or your area mental health association.
REFERENCES

American Red Cross. (2001). Helping young children cope with

trauma. http://www.redcross.org/services/disaster/foreignmat/

1303en.pdf.

Centers for Disease Control and Prevention. (2002). Psychological

and emotional effects of the September 11 attacks on the World

Trade Center Connecticut, New Jersey, and New York, 2001.

Morbidity & Mortality Weekly Report, 51, 784–786.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a2.htm.

DeWolfe, D.J. (2000). Training manual for mental health and

human service workers in major disasters. (2nd ed.). Rockville,

MD: U.S. Department of Health and Human Services, Substance

Abuse and Mental Health Services Administration, Center for

Mental Health Services. 

DeWolfe, D.J. (Ed.). (In press). Mental health response to mass

violence and terrorism: A training manual. Rockville, MD: Center

for Mental Health Services, Substance Abuse and Mental Health

Services Administration, U.S. Department of Health and Human

Services.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz,

A.M., Edwards, V., et al. (1998). Relationship of childhood abuse

and household dysfunction to many of the leading causes of

death in adults. The Adverse Childhood Experiences (ACE) Study.

American Journal of Preventive Medicine, 14, 245–258.

Fred Friendly Seminars, Inc. (2004). Reporting on terrorism: The

news media and public health. Conference report. http://www.

fredfriendly.org/conf_report.pdf.

Glass, T.A., & Schoch-Spana, M. (2002). Bioterrorism and the

people: How to vaccinate a city against panic. Clinical Infectious

Diseases, 34, 217–223.

Institute of Medicine of the National Academies. (2003).

Preparing for the psychological consequences of terrorism: 

A public health strategy. Washington, DC: The National

Academies Press. http://www.nap.edu/books/0309089530/html/.

Jacobs, G.A. (2003). Coping with the aftermath of a disaster.

Vermillion, SD: University of South Dakota, Disaster Mental

Health Institute. 

National Institute of Mental Health. (2001). Helping children 

and adolescents cope with violence and disasters. http://www.nimh.

nih.gov/publicat/violence.cfm.

National Mental Health Association. (2001). Coping with disaster:

Tips for older adults. http://www.nmha.org/reassurance/

olderadulttips.cfm.

Substance Abuse and Mental Health Services Administration.

(2003). After a disaster: Self-care tips for dealing with stress.

http://www.mentalhealth.org/publications/allpubs/KEN-01-0097/

default.asp.

Yehuda, R. (2002). Current concepts: Post-traumatic stress 

disorder. New England Journal of Medicine, 346, 108–114.

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 181

11During a Terrorist Attack or Other Public Health Emergency RISK COMMUNICATIONS
RISK COMMUNICATIONS DURING A TERRORIST ATTACK

or Other Public Health Emergency

184 11. RISK COMMUNICATIONS DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

he release of health-related information during a 

terrorist attack or other public health emergency is 

a critical part of the national response to the event,

and government officials at the U.S. Department of Health 

and Human Services (HHS) and state and local health

departments are aware that the quality, timeliness, and

credibility of our messages and messengers may make the

difference between people staying safe or becoming vulnerable

to health risks presented by the emergency.

Federal officials have learned, sometimes the hard way, that

institutional pressures and deeply rooted processes can get 

in the way of effective communication during an emergency.

They are also learning that the public receives information and

makes decisions about how it will respond differently during

emergencies than during nonemergency times. This section

reflects a combination of what public health officials have

learned from experience as well as lessons learned from

previous terrorist attacks, natural disasters, and other public

health emergencies; communication research; and the insights

of risk communication experts.

Terrorist attacks and public health emergencies present

different situational characteristics and different emotional and

psychological dynamics in the general public that affect how

we deliver information. Some of the most significant emotions

expressed include fear and anxiety (This is horrifying. 

Where can we turn? What awful things are ahead?! What 

do I do now?); anger (How could they?!); misery, depression,

and empathy (poor victims); hurtfulness (Why do they hate us

so?); and guilt (How come I survived and they didn’t? How

dare I still care about day-to-day trivia?). Some of these

characteristics and their implications for how HHS and other

public health officials plan to communicate are discussed below.

Lives are at stake. As with many public health issues or 

natural disasters, information has the power to save lives—

possibly many, many lives. People require information to find

out what is actually happening and also what they must do to

safeguard their own and their family’s personal safety. 

But strong emotional responses to the event—fear, misery,

concern, guilt, anger—make understanding and acting upon

that information more difficult.

There is great uncertainty. Almost every instance of terrorism

would present a profoundly new and previously unknown set

of circumstances—to government officials working to manage

the situation and to the public at large. Many pathogens 

considered to be potential weapons are almost never seen 

in the United States. Even though a lot is known about these

agents and how they might present themselves, in reality not

everything is known, as one would like it to be, in the event of

a terrorist attack. (Such was the case when anthrax was

distributed through the mail. Before that time, medical experts

were not sure whether people could contract anthrax through

the mail.) Individuals and communities will be trying to cope

with the situation and take necessary actions to protect their

health and safety, while what is known and believed is unfolding

with the constantly evolving story.

Individual and community levels of distress peak. Fear and

uncertainty lead to unusually high levels of distress. Because

of the psychological impact of acts of terrorism—and of many

public health emergencies—it is not enough for HHS officials

to give the facts of the situation and tell the public what to do,

and expect that people will actually take these protective

actions. High distress levels can keep individuals and

communities from engaging in protective behaviors. However,

how public health officials communicate can actually help

channel this distress into productive and protective behaviors

instead of destructive ones. Distress, if not excessive, leads to

information-seeking and precautionary behavior. But great

distress or fear can also make it hard for people to process

information. HHS will be working hard to word messages

simply and repeat them often. People can better bear their 

fear and make appropriate decisions about safeguarding 

their health and safety when their fears are acknowledged, as

opposed to when they are told not to be fearful. HHS’ goal will

be to clear and be respectful of the distress people 

are feeling.

The psychology of response to a terrorist attack is different

from that of response to other types of emergencies.

Current knowledge and widely accepted theories of disaster

psychology suggest that there are many aspects of a terrorist

attack, biological or other, that have an impact on how the

public thinks, feels, and responds to information. This will have

implications for how HHS communicates with the public.

T
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 185

Some of these psychological aspects include:

> The intentional nature of the assault (as opposed to hurricanes

and floods, for example)

> Unfamiliar agents or pathogens (as opposed to typical strains

of influenza, which cause many deaths each year but are not

so greatly feared as anthrax, which has caused relatively 

few deaths)

> The random nature of the attacks and the fact that they 

are largely outside our (Americans’, the officials’, the media’s,

etc.) control

> The potential for permanent and catastrophic harm and loss

> The involuntary nature of exposure (as opposed to smoking,

for example, which causes smokers to suffer health and social

consequences because of their voluntary exposure to tobacco

and smoke)

Given these aspects of terrorism, it is known that people react

and respond to information differently in times of attack from

the way they do in ordinary times.

In What Ways Do People React Differently to

Terrorism?

Based on experience from past emergencies, many public health

experts believe that an individual’s decisionmaking process

changes during a catastrophic emergency related to terrorism.

The natural reactions people have in other emergencies may

become even more exaggerated. Examples include:

> People simplify. Individuals’ ability to comprehend numerous

levels of detail decreases early in their response to an

emergency. This means that people will generally miss

nuances that help define the situation early. Public health

guidance, including the protective actions individuals need to

take, should be stated clearly, simply, and repeatedly.

> People become much more vigilant in a crisis. They check

out their neighbors for signs of terrorism, surf the Internet for

background information, and become glued to the media for

news and context. This hypervigilance can have negative

emotional consequences (added trauma from additional

exposure to a traumatic event, for example), but is also

useful as it helps people collect and assess the information

they are getting. Is it consistent? What do people they

respect think about it?

> People maintain their current beliefs. People are adept 

at maintaining faith in their current beliefs during a crisis.

They tend to avoid contradictory or conflicting information.

This means that if a new situation challenges conventionally

held beliefs or views, it may be difficult to convince people

that there is a new truth. Resistance to change in 

beliefs increases.

> People rely on past experiences. Whether or not past 

experiences are relevant, people use them to help define new

ones. People remember what they see. They tend 

to believe what they have experienced in their own lives.

However, faced with a terrorism emergency, they will have to

rely on experts. But even reputable experts may disagree

about the level of threat, the risks, and the appropriate 

recommendations. In nonemergency times, there is a natural

give and take among experts that is expected and helps

shape scientific debate. However, in times of crisis, this 

lack of agreement may leave the public with increased

uncertainty and fear. According to some risk communication

experts, the first message to reach listeners may often 

be the most accepted message, even if more accurate 

information surfaces later.

What Are the Objectives of the Public in a 

Public Health Emergency?

Most citizens share five main objectives during public health

emergencies, including those caused by acts of terrorism:

> Protect themselves and loved ones

> Get the facts they want and need to protect themselves

> Be able to make choices and take action

> Be involved in the response

> Stabilize and normalize their lives

HIGH DISTRESS LEVELS

can help keep individuals and communities from engaging in protective behaviors.
186 11. RISK COMMUNICATIONS DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

How People Feel Can Affect Their Ability 

To Meet Those Objectives.

There are many ways people’s feelings can affect their responses.

Some examples include:

> Fear. Fear is one of the single most powerful emotions present

during a terrorism emergency. It has the capacity to propel

community members to action. Whether that action is helpful or

harmful to the community depends on whether the individual

can hear, understand, and act on sound guidance from public

health authorities. Public health officials have the capacity to

help individuals channel their fear and distress into protective

actions, rather than irrational behaviors. Interestingly, in the

aftermath of past emergencies, it has been observed that people

seldom panic. People act. Effective communication can help

people take the most appropriate actions to support the public

health response.

> Denial. No doubt, some members of the community will be in

denial. They may choose not to hear or heed warnings or

recommended actions. They may become confused by the

recommendations or simply not believe that the threat is real or

that it is an actual personal threat. In such cases, people will not

act on even the best advice. Denial, in fact, is one of the reasons

why panic is rarer than we realize. People go into denial as a

coping mechanism when the fear is too great. But there are

several important antidotes to denial. The two key ones are:

first, the legitimization of fear—people who feel entitled to be

afraid don’t have to go into denial; and second, action—people

with something to do have more capacity to tolerate their fear

and, therefore, are less vulnerable to denial.

> Hopelessness, helplessness. Some people can accept that the

threat is real, but it looms so large that they believe the situation

is hopeless and so they feel helpless to protect themselves. The

resulting withdrawal and paralysis can impair their ability to take

appropriate protective action in a public health emergency.

People who feel powerless to affect the outcome are more likely

to retreat to denial and the resulting hopelessness and

helplessness that lead to inaction. Therefore, self-efficacy is

important. Hopelessness, helplessness, and denial are all

reduced by messages of self-efficacy and empowerment (not

“everything will be fine,” but “it’s a bad situation, but there are

things you can do to make it better, such as...”).

> Stigmatization. Some members of the community may 

suffer even greater effects from the attack if the rest of the

community stigmatizes them. Fear or isolation of a group

may occur if the community perceives it as contaminated 

or “risky.” For example, in some cities, residents avoided

“Chinatown” and Chinese restaurants out of fear of exposure

to SARS. This type of stigmatization can hamper community

recovery and affect evacuation, relocation, or, when

necessary, quarantine efforts. In addition, groups people

perceive as related to those who are “to blame,” such as

Arab-American communities following September 11, can

become targets of local violence, even though they are 

as much victims of the terrorist attack as their neighbors.

> Vicarious rehearsal. Interestingly, experience has shown that

people farther away (by distance or relationship) may react

as strongly as those who are more directly impacted. Today’s

communication environment allows people to participate

vicariously in a crisis in which they are not in immediate

danger. This psychologically normal response to new risky

situations results in people mentally rehearsing the crisis as

if they were experiencing it and asking themselves, “What

would I do?” In their minds, they imagine that the risk is here

(instead of there), now (instead of soon), and definite

(instead of maybe). They may believe that they, too, are at

immediate risk and demand unnecessary services; as a

result, they may go to the emergency room or take

medications they do not need. Their stress reactions will be

THE ONLY THING OUR BOSSES TOLD US THAT WE MUST DO “

in every story that we did is to remind the public that how this thing spreads and the risk of

getting it is low ... with more knowledge people were more comfortable...

Piya Chattopadhyay, correspondent, Canadian Broadcasting Radio, Toronto

Reported on the SARS outbreak in Toronto 2003

“
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 187

high, even though they are not in

immediate danger, often resulting in

some of the health consequences of

stress. Further, because many of the

agents are invisible and difficult to

detect, we may not always be able to

tell a community with certainty that it

has not been exposed. This imaginative

leap from there/soon/maybe to here/

now/definitely can be beneficial if it is

acknowledged and the opportunity is

taken to prepare, emotionally and

logistically, for a real crisis.

What Does This Mean for How

HHS Will Communicate With the

Media and the Public?

In times of emergency, HHS will be

working hard to deliver the information

that people want and need: 

What happened? Am I safe? Is my family

safe? Who’s in charge? What is being

done to protect me, my family, and my

community? What can I do to protect

myself? Why did this happen? When

will it be over?

However, some things that people need

to know are not easy for them to hear:

that people are dying, that the risks are

not really understood, that it is not known

when the emergency will be over, and

that decisions may have to be made

with imperfect information. 

Most importantly, people need to know

what to do to protect themselves and

their families. Sometimes this is easy to

hear and easy to act on. But there are

times when public health guidelines are

not consistent with personal beliefs or

instincts. These are times when delivering

guidance takes more than printing

words on a page or reporting to the

viewing and listening audiences what

they need to do. It takes more because

the public will need to be led toward

protective actions.

For example, if a community is exposed to

the smallpox virus, public health guidance

will likely include recommending that

people not leave the region. A common

response might be: “Not leave the

region? But why not? I want to take my

children to my mother’s house in the next

state, where they will be safe.” However,

if a vaccination program starts, the

vaccine will be available in the affected

region and possibly not near Grandma’s

house. In addition, anyone potentially

exposed to the virus would not want to

carry it to another state, perhaps

spreading the disease.

This example shows how public health

guidance can conflict with personal

inclinations. This conflict can make it

difficult for the public to act on such

guidance.

HHS is committed to providing accurate

and timely information to affected

audiences, including state, local, and tribal

governments; the media; the private sector;

and the local populace. Communication

with special needs audiences, including

hearing and sight impaired populations or

people with other disabilities; non-English

speaking populations; and low-literacy

audiences is a high priority in a public

health emergency. In the case of terrorism

or a severe public health emergency where

several other federal agencies are involved,

HHS will coordinate its response with other

federal agencies as well as through the

federal Joint Information Center.

Based on the experiences with

September 11 and the subsequent

anthrax and ricin incidents, public

health professionals are developing new

ways to deliver information to the news

media and the public. Following are the

types of critically important information

that public health officials hope to be

able to deliver to reporters during public

health emergencies.

THE GOAL OF BIOTERRORISM IS TO CREATE TERROR; “

to inflict psychological injury. Terrorist acts involving biological agents and other Weapons of Mass

Destruction are particularly terrifying. Uncertainties about exposure, treatment options, and long-term

effects will produce widespread fear, anxiety, and distress. It is critical that reporters who write about

bioterrorism understand the psychological and mental impacts of bioterrorism. “

Vincent Covello, Ph.D., director of the Center for Risk Communication
188 11. RISK COMMUNICATIONS DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TABLE 1: INFORMATION THAT PUBLIC HEALTH OFFICIALS MAY PROVIDE IN A PUBLIC HEALTH EMERGENCY

WHAT WHY EXAMPLE

Expression of empathy and

acknowledgment of fear and

uncertainty

Public health officials have historically been trained not to speak with or about emotions;

rather, about fact. Therefore, expressing empathy, fear, or uncertainty can be particularly 

difficult for officials to do. Experts believe that citizens need to know that their feelings are

understood and acknowledged by authorities. This helps establish a connection and makes 

it a little easier for audiences to hear the difficult information that usually follows.

“Whatever it [the loss of lives] is, it will

be more than we can bear...”

R. Giuliani, 

September 11, 2001

Steps taken to get more facts Although there is much they may not know, public health officials can tell you the immediate

steps taken to get more facts and to begin to manage the public health emergency.

Immediate steps might include isolating patients, conducting an epidemiological investigation,

alerting the public to signs and symptoms, activating the Health Alert Network, etc.

The public can more easily accept high levels of uncertainty when they are aware of the

actions taken to find answers.

“We do not know yet how many people

have been exposed to the contaminated

food, but we are talking to everyone who

ate at the restaurant on May 6. If you ate

at Joe’s Restaurant on May 6, please call

1-800-xxx-xxxx.”

Call to action—giving people

things to do

In a crisis where immediate action needs to be taken (e.g., sheltering-in-place due to a 

radiological incident), this may be a key part of the message.

In some cases, even symbolic actions can help channel people’s energy and desire to 

do something.

Protective actions: Boil water before

drinking or drink bottled water.

Helpful actions: Donate time or money to

a charity providing assistance, check on

elderly neighbors.

Symbolic actions: Attend a vigil or fly 

the flag.

What is not known Just as expressions of empathy do not always come naturally, discussing the unknown 

elements of the situation also goes against years of professional training and experience.

Many public health officials are used to having confirmation of all of the facts before 

releasing information.

Just as important as what is known is what is not known. There will be many things 

public health officials do not know, especially when they suspect an illness but have not 

yet confirmed it. It is also likely that, in the initial stages of the investigation, they will not

know the route of exposure or what/who caused the situation.

The nature of terrorism is pushing public health officials to change the way they release

information to the public. They realize that waiting until they have an answer to every 

possible question could jeopardize public safety.

As their understanding of the situation evolves, they will provide you with updates on what 

is known and what is not known.

“We know that we have two confirmed

cases of pneumonic plague, but we do

not know right now how these patients

were exposed to plague bacteria.”

Clarification of facts Public health officials will try to provide as much factual information as they can about the

situation.

“At 2 p.m. today, a 34-year-old woman

entered the Johnston Hospital Emergency

Room with an unknown illness...”

Referrals Public health officials will tell you when the next update will occur and where you and the

public can go for more information, help, or support, such as hotlines or Web sites with more

detailed information.

“We expect to have the test results 

confirmed within the next 12 hours and

will let you know what we are dealing

with at that time...”
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 189

“IN THIS ENVIRONMENT, EVENTS AND INFORMATION PLAY OUT IN REAL-TIME; LIVE; 24/7; NONSTOP.

As a result, we get news by increment. Each little development becomes the latest

‘breaking news’ piece set into the mosaic of the larger story. This can be helpful or it

can be a terrible distraction. One of the challenges for news organizations is to make

sure incremental news is proportional and provides context.

The advent of incremental news brings with it the danger of ‘information lag.’That is the time between when

the media asks a question and a responsible official can answer it. That time lag can be minutes or it can

be hours. In some cases—such as with certain types of bioterrorism—it may even be days. This truly is the

most precarious time in the story process, when uninformed speculation and rumor can fill the information

void. This can be a very dangerous thing. We saw this play out during the anthrax attacks of 2001.

It is why news organizations and public officials alike need to learn and appreciate what I call the ‘language

of live.’ The ‘language of live’ recognizes the realities of the 24/7 world. It is a transparent language that

is deliberate and clear. It explicitly states what is and what is not known, confirmed or corroborated.

It directly attributes sources of information. It labels speculation as such. It quickly doubles back on bad

information to correct the record. The ‘language of live’ is a language that many journalists employed 

fluently in the days after 9/11...

There are some things the ‘language of live’ should not be—especially when we’re talking about the

coverage of terrorism. It should not be breathless. It should not be hyped. It does not need to be

accompanied by sensational graphics or ominous music. The facts will be ominous enough.

Frank Sesno, university professor of public policy and communication at George Mason University

and former Washington, D.C. bureau chief for CNN

Testimony before the House Select Committee on Homeland Security, September 2004

Similarly, news organizations were broadly praised after 9/11 for their measured and

purposeful work. There was a responsible attitude, humanity but also professionalism.

Questions were asked and answered in a measured way. The information and the tone

were straightforward and sober. Most sought to keep speculation to a minimum.

“
PUBLIC REACTIONS TO CRISIS SITUATIONS

and Communication Implications by Peter M. Sandman, Ph.D.

190 11. RISK COMMUNICATIONS DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

In the stairwells of the World Trade Center on September 11,

2001, survivors tell us, many people felt panicky, but their

behavior was calm, orderly, helpful to others, sometimes

even heroic. The panic attacks came later, when the crisis

and the need for urgent action were over.

The impression that people are panicking and the prediction

that they are likely to panic are not just mistakes. They are

dangerous mistakes. The impulse to “avert” panic too often

leads authorities—and sometimes even journalists—to

sound over-reassuring, withholding or shrugging off

information they consider too alarming for the public to

tolerate. Paradoxically, this may actually increase the

probability of panic, as people come to feel that those in

charge are “handling” and misleading them instead of

leveling with them.

The strongest antidote to denial is, paradoxically, 

the legitimization of fear.

Whereas panic is rare, another extreme reaction—denial—

is fairly common. Denial, in fact, is partly why panic is rare;

people at risk of panicking often trip a mental circuit-breaker

and go into denial instead. The dangerous thing about denial

is that people in denial do not take precautions in a crisis (or

the run-up to a crisis), and this can lead to more harm to

themselves and others. Apathetic people, of course, also fail

to take precautions. In communication terms, the problem

with denial is that it looks a lot like apathy. The difference is

that apathy responds well to scary warnings—but that is the

wrong prescription for denial, since it only forces people

deeper into it. Nor will over reassurance work for denial; 

it colludes with the denial and thus strengthens it. The

strongest antidote to denial is, paradoxically, the

legitimization of fear. If it is okay to be afraid, then I do not

have to deny my fear and can find ways to tolerate it instead.

The public can usually tolerate its own fear fairly

well, especially if there are things people can do

to protect themselves.

Crisis managers often find even modest levels of public fear

intolerable—which may be why some interpret the public’s

fear as panic. The public, on the other hand, can usually 

tolerate its own fear fairly well, especially if there are things

people can do to protect themselves; as psychiatrists and

soldiers have long recognized, action binds anxiety.

We are hardwired to respond fearfully to new dangers; that

response is more conducive to survival than fearlessness is. In

fact, it is arguable that we tend to recover rather too easily

from fear. We quickly get used to the New Normal; we relax

our vigilance and our sense of shared urgency. Finally, note

that when people become suddenly afraid of X, they typically

become less afraid of Y and Z and less vulnerable to freefloating anxiety. For the most part, each individual is as 

anxiety-prone and fear-prone as he or she is wired to be. 

We allocate our fear. During a crisis, we are temporarily 

more afraid; we draw on a reservoir of untapped fearfulness. 

But very quickly we revert to our normal level of fearfulness—

but with more of our normal fear attached to the new risk and

less of it available for other risks.

Fear is not a problem in a crisis. It is part of the

solution.

What level of fear is optimal for a public response so that

people will protect themselves and those around them? Panic,

denial, and apathy are all undesirable extremes. So is terror—

that is the terrorists’ goal. But if terror is too strong a response,

mere interest or mild concern is often too weak. In a crisis, we

want people to put their ordinary concerns aside, to be vigilant,

to take precautions, to tolerate inconveniences. Fear is not a

problem in a crisis. It is part of the solution.

But of course fear is not the only emotional response to crisis.

Just as important is the empathy/misery/depression complex

of emotions. One of the principal reactions to September 11

was and still is a sense of shared misery. Most people expect

to survive whatever the terrorists throw at us. But we expect

to have to watch a succession of terrorist attacks on CNN.

Whether or not life got scarier after September 11, it certainly

got more miserable. To a lesser but significant extent, all

calamities provoke misery.

It is important to distinguish empathic overreactions—

misery, even depression—from fear and its relatives. To tell a

ESSAY
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 191

miserable person to calm down misses the point; he or she 

is calm already. For those who communicate with a public 

in misery, here are a few effective ways to do so:

> Acknowledge and help us acknowledge that misery is part of

what we are feeling

> Affirm that in a situation like this misery is an appropriate

feeling

> Let us know that you feel it too

> Expect us (and yourself) to bear it, and in time to get past it

> Suggest empathic actions, ways we can help others

Hopefully, these guidelines will be followed by public officials

and can be of use to media as well, as the media also play a

critical leadership role in times of crisis.

Anger, hurt, and guilt are also common and 

appropriate reactions to a crisis.

Anger is also an appropriate reaction to crisis, and especially

to terrorism. It is useful: it fuels resolve, vigilance, precautiontaking. Of course it can also fuel scapegoating and

harassment—not all angry behaviors are useful, but some

degree of anger itself is. When anger escalates into rage or flips

into denial, it is no longer functional.

Hurt feelings often go unnoticed or unacknowledged as a

response to crisis, but many crises do threaten our self-esteem:

“Why did this happen to me?” Once again, terrorism crises are

an extremely vivid example. After September 11, virtually

everyone was asking the bewildered question, “Why do they

hate us so?” This is an important question to ask and to try to

answer. But not everyone was looking for answers; many just

wanted to express their hurt feelings. Hurt, too, can flip into

denial; it is hard to hold onto the idea that people actually hate

you so much that they want to kill you.

Guilt also plays an important role—caretaker guilt (I feel

powerless to protect my family, my community, my constituents);

survivor guilt (which results largely from projected relief—

I’m okay and they’re not); and above all guilt at continuing to be

preoccupied with our own mundane concerns. A Minnesota

County Commissioner who is also a florist told me about all his

wedding customers in the days and weeks after September

11. Shipments of flowers (among other things) were

disrupted, and his customers were worried about the flowers

for their weddings. But they also felt guilty about worrying

about such things. So he learned that he not only needed to

reassure them that they would have their flowers, he needed

to reassure them that we all need beauty right now ... that

their floral worries were not wrong or selfish.

Fear, misery, anger, hurt, guilt—all normal responses to

crisis (for public officials and media as well as the public).

But we bear them and we get beyond them—perhaps not

immediately, perhaps not easily, but we do it. Resilience is

also a normal response to crisis.

Peter M. Sandman, Ph.D., is a risk communication consultant

based in Princeton, NJ. Much of this essay is drawn from

work done jointly with his wife and colleague, Jody Lanard,

M.D. For more information, see the articles listed at

http://www.psandman.com/terror.htm#links.

FIGURE 11–1: RESPONSE TO CRISES

• Vigilant

• Taking precautions

• Ready to bear inconvenience
ESSAY

A JOURNALIST’S REFLECTIONS

on Fear and Risk by David Ropeik

192 11. RISK COMMUNICATIONS DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY Terrorism and Other Public Health Emergencies: A Reference Guide for Media

It is generally not the news media’s responsibility to consider

the effect their coverage will have on the public. But in

extraordinary cases, such as a terrorist attack, in which fear

is part of what the attackers are trying to inflict, news editors

and TV news directors, print and broadcast writers and

producers, and reporters and photographers need to

consider that their coverage may in fact serve as part of the

attackers arsenal. And while coverage of terrorism may 

not spawn direct copycats the way coverage of suicide or

bomb scares might, it certainly will spawn public fear, and

that fear can threaten public health far more profoundly than

the suicide and bomb scare stories about which the press is

already rightfully careful.

There is a body of research that can help news organizations

understand and consider the effect their coverage of a

terrorist attack might have on public attitudes, and

therefore, on public health. Psychological studies of risk

perception show that such an event will hit several intuitive

“fear factors” that we all use, subconsciously, to decide what

to be afraid of and how afraid to be.

Research has shown that our perceptions of risk are more

intuitive and emotional than fact-based, and that risks that

feature certain characteristics evoke a degree of fear that

rarely matches the actual degree of hazard. People are 

more afraid of risks that are:

> New (as opposed to risks we’ve lived with for a while)

> Uncertain (compared with risks we fully understand)

> Imposed (compared to risks we choose to take)

> Catastrophic (“event” risks, like plane crashes, as opposed

to risks that occur to individuals over time, like heart

disease)

> Available to our consciousness (the greater the awareness,

the greater the concern; studies show that the news media

play a critical role here)

> Personified (a risk that has a real victim with a name and 

a face in comparison to a theoretical risk)

> A personal threat (a risk you think can happen to you, 

like anthrax in the U.S. mail, compared to a risk that is 

real but you think will only happen to someone else)

A terrorist attack involves many of these perceived risks, and

therefore, is the perfect formula for elevated fear. This fear can

lead to dangerous choices, denial, or extreme stress 

and resulting damage to health and safety.

Clearly, the public will look to the news media for information

in the event of a terrorist attack. Appropriately, coverage will

be extensive, and certainly dramatic. The “Who, What, Where,

When, and Why” of the story will be inescapably alarming.

But, as with other disaster and emergency stories that can

directly affect public health, the quantity, quality, and tone of

the coverage of a terrorist attack will have a dramatic impact

on public behavior and health. It is my hope, as both a

journalist and a risk communicator, that responsible news

organizations will want to consider these issues as part of preevent reflection on covering such an attack should one occur:

> Keep the risk in perspective. Consider how many people are

actually exposed (radiation from a dirty bomb is a localized

risk) and the severity of the consequences (some weapons

are less harmful than others).

> Remember that, as mentioned above, the more frightening

your coverage, the more fear it will breed and the more the

coverage might help terrorists achieve their goals.

> While giving the public all the information available, try to

incorporate relevant public health instructions. When

appropriate, provide information that will help readers,

viewers, or listeners take actions to protect themselves, their

loved ones, and others for whom they may be responsible.

> Accept that in the unique circumstances of any such attack,

officials can’t possibly have all the answers to many critical

questions, especially early on. (Beware those that do!) That’s

not incompetence, just reality.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 193

> Beware of the instant experts. They’re a dime a dozen at

times like this and the knowledge many of them profess 

is often quite shallow. “Information” from self-described

experts stepping beyond the bounds of their knowledge 

can potentially confuse the public.

Don’t ignore the stress, loss, and other danger you and your

peers face. As some of the reporting from embedded

journalists under fire in Iraq demonstrated, the feelings you

face covering the story can challenge your objectivity.

David Ropeik is the director of risk communications at the

Harvard Center for Risk Analysis. Co-author of “RISK: 

A Practical Guide to What’s Really Safe and What’s Really

Dangerous in the World Around You,” he was a television

journalist for 22 years and has written for the Boston Globe,

MSNBC.com, and other news organizations.

REFERENCES

Covello, V.T., Peters, R.G., Wojtecki, J.G., & Hyde, R.C.

(2001). Risk communication, the West Nile virus epidemic,

and bioterrorism: Responding to the communication challenges

posed by the intentional or unintentional release of a pathogen

in an urban setting. Journal of Urban Health: Bulletin of the

New York Academy of Medicine, 78, 382–391.

Fischhoff, B., Gonzalez, R., Small, D., & Lerner, J. (2003).

Evaluating the success of terror risk communications.

Biosecurity and Bioterrorism: Biodefense Strategy, Practice,

and Science, 1, 255–258. http://www.liebertonline.com/doi/

pdf/10.1089/153871303771861450.

Hall, M., Norwood, A., Ursano, R., & Fullerton, C. (2003). 

The psychological impacts of bioterrorism. Biosecurity and

Bioterrorism: Biodefense Strategy, Practice, and Science, 1,

139–144. http://www.liebertonline.com/doi/pdf/10.1089/

153871303766275817.

Mullin, S. (2003). New York City’s communications trials by

fire, from West Nile to SARS. Biosecurity and Bioterrorism:

Biodefense Strategy, Practice, and Science, 1, 267–272.

http://www.liebertonline.com/doi/pdf/10.1089/

153871303771861478.

Sandman, P. (2004). Seminar handouts—Crisis communication:

Guidelines for action. Planning what to say when terrorists, 

epidemics, or other emergencies strike. http://www.psandman.com/

handouts/AIHA-DVD.htm.

Sesno, F. (2004, September). Covering terrorism: New challenges

in a new era. Testimony before the House Select Committee on

Homeland Security.

12of Biological, Chemical, and Radiation Emergencies HISTORY
HISTORY

of Biological, Chemical, and Radiation Emergencies

196 12. HISTORY OF BIOLOGICAL, CHEMICAL, AND RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media GOAL OF THIS SECTION

To put the current and potential use of biological, chemical,

and radiological weapons into historical context. 

WHAT THIS SECTION INCLUDES

> A brief summary of the history of biological, chemical,

and radiation emergencies

> Examples of chemical and radiological accidents and

their effects

WHAT THIS SECTION DOES NOT INCLUDE AND WHY

Extensive detail on any one event is not provided due to the

large number of events, weapons, and issues described

here.

The first public health emergencies were epidemics. 

With technological advances came the potential to harness

biological, chemical, and radiological agents for military and

terrorist ends. This section highlights the evolution of the 

relevant biological, chemical, and radiological technologies

and their use as agents of war or terrorism. This section also

gives examples of chemical and radiological accidents.

BIOLOGICAL WEAPONS

TIMELINE

14th–15th centuries: Armies use rotting and contaminated

bodies to transmit infection to the enemy.

18th century: British troops use smallpox as a weapon against

American Indians.

1914–1918 (World War I): Germans infect livestock with

glanders and anthrax to disrupt the food supply of Allies.

1925: Geneva Protocol prohibits the use of biological and

chemical weapons.

1928: USSR launches its bioweapons program.

1932–1945: Japan conducts bioweapons research and tests

on human subjects.

1939–1945 (World War II):

> Japan attacks 11 Chinese cities with anthrax, cholera, and

the plague.

> Allies experiment with anthrax.

1950s: The United States and the Soviet Union research new

ways of dispersing bioagents.

1969–1970: President Nixon orders the dismantling of the

U.S. bioweapons program.

1972: Biological Weapons Convention bans biological weapons.

1970s and 1980s: The Soviet Union continues to research

and produce bioweapons.

1980s and 1990s: Iraq, Iran, North Korea, and other nations

develop bioweapons.

1984: The Rajneeshee Cult contaminates salad bars in

Oregon with Salmonella.

2001: An unknown terrorist(s) attacks with anthrax via 

the U.S. Postal Service.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 197

THE PREMODERN ERA

In the 14th and 15th centuries, armies used rotting and infected

human and animal bodies to transmit infections to both civilian

and army populations. This tactic met with mixed success.

Medieval lore has it that, in the 14th century, Kaffa (which is

now Feodossia, Ukraine) was under siege by Tartars. During

that siege, bubonic plague broke out among the invaders. 

The invaders then used catapults to hurl plague-infected 

bodies into the city. The spread of the disease caused the city’s

fall, but it is impossible to know whether the outbreak actually

resulted from this primitive practice of biowarfare.

During the 18th century, the British used smallpox as a

bioweapon. In 1763, British troops took blankets and

handkerchiefs from smallpox patients and gave them to

Delaware Indians at a peace-making parley. Also, after an

outbreak of smallpox at Fort Pitt during the French and Indian

War, British officers took blankets from a smallpox hospital

and gave them to American Indians.

BIOWEAPONS IN THE ERA OF MICROBIOLOGY

The nature of biowarfare changed in the mid-19th century.

Before that time, the use of biowarfare depended on an 

existing epidemic. Along with germ theory and the ability to

use vaccines to control and prevent epidemics, scientists also

learned to isolate disease-causing germs in a form that was

easy to use and produce. With these advances, more

sophisticated tools for biowarfare became available.

Early efforts to use bioweapons during World War I met with

little success. German agents infected livestock with glanders

and anthrax (glanders is an infectious disease that typically

affects horses, donkeys, and mules). These animals were then

shipped through neutral countries to the Allies. The goal was

to disrupt the food supply and transportation in countries that

used animals for transport. A few thousand animals died as a

result of this program. Its impact was small compared to the

millions killed during World War I.

After World War I, in an effort to limit the use of biological and

chemical weapons, the 1925 Geneva Protocol (http://www.state.

gov/www/global/arms/treaties/geneva1.html) prohibited the use

of chemical and biological agents but did not bar research and

development on those agents. The treaty, however, was not fully

enforced for many years. The United States signed the

protocol, but Congress failed to ratify it for 50 years. Japan

also failed to ratify the treaty until 1970.

Prior to and during World War II, the Japanese were adept at

developing and using bioweapons. Between 1932 and 1945,

a staff of more than 3,000 scientists conducted bioweapons

research in Manchuria, near the town of Pingfan. Japanese

scientists used human subjects to test a number of bioagents,

killing hundreds, if not thousands, in the process.

During World War II, Japan conducted 12 large-scale field

trials of biological weapons. Japan attacked at least 11

Chinese cities with anthrax, cholera, and the plague. The

Japanese contaminated food and water supplies. They also

released contaminants and plague-infected fleas from aircrafts.

Each attack of plague-infected fleas may have involved the

release of as many as 15 million fleas.

The Japanese troops were themselves unprepared for their

own use of bioweapons. One bioattack on Changleh in 1941

resulted in illnesses in 10,000 Japanese soldiers and 1,700

deaths, mostly from cholera.

These Japanese field trials came to a halt in 1942, after

Franklin D. Roosevelt publicly denounced them. However,

basic research continued until the end of the war.

The Soviet Union launched its bioweapons program in 

1928 and expanded it significantly during World War II. 

The Soviets built their first anthrax factory in 1946 and their

first smallpox factory in 1947. During World War II, they

captured a number of Japanese experts who had worked on

their country’s bioweapons program. These experts helped

Soviet researchers advance the Soviet bioweapons program.

France, Canada, Great Britain, and the United States also had

significant bioweapons programs during World War II. These

countries wanted to be prepared to retaliate against any German

bioattack. Allied experiments with anthrax contaminated

Guinard Island, near the Scottish Coast. The island was

decontaminated with formaldehyde and seawater in 1986.
198 12. HISTORY OF BIOLOGICAL, CHEMICAL, AND RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

The United States had stockpiled thousands of anthrax bombs

during World War II, but many considered these weapons to

be impractical. The production facility in Terre Haute, Indiana,

lacked necessary engineering safety features. Tests of the

plant’s fermentation and storage processes revealed

contamination of the plant and nearby area. This discovery led

to limitations on the production of bioweapons. 

The bioweapons research programs in the United States and

the Soviet Union flourished during the Cold War. Researchers

studied many bioagents. They also developed more

sophisticated delivery systems—for example, dispersing

agents as fine-mist aerosols, packing them in bombs, and

launching them in missiles. From 1950 to 1953, the United

States, having learned a lesson from the Terre Haute plant,

built a new facility with better biosafety measures in Pine Bluff,

Arkansas. At Fort Detrick, Maryland, scientists studied the

effectiveness of different bioagents and various delivery systems.

They also studied vaccines and other defensive measures.

DISMANTLING BIOWEAPONS PROGRAMS

By the late 1960s, the tide had turned against bioweapons. In

1969 and 1970, President Nixon ordered the dismantling of

the U.S. bioweapons program. But efforts to improve defensive

measures continued. The U.S. Army Medical Research

Institute of Infectious Diseases (USAMRIID) continued to

develop medical defenses against bioattacks. USAMRIID has

since focused on defensive measures, such as detection

capabilities, personal protective equipment, vaccines, diagnostics,

and therapies.

In 1972, the Biological Weapons Convention (http://www.state.

gov/t/ac/trt/4718.htm#treaty) called for the destruction of

existing stocks of bioweapons and an end to bioweapons

research. Seventy-two countries ultimately signed the

convention (http://www.state.gov/t/ac/trt/4718.htm#signatory),

and it went into effect in 1975.

However, not all bioweapons development stopped with the

ratification of the Biological Weapons Convention. The Soviet

Union continued to operate at least six research facilities and

five production facilities in the 1970s and 1980s. The Soviet

Union employed up to 55,000 scientists and technicians in these

facilities and actually expanded its program during this period.

The sudden outbreak of anthrax in Sverdlovsk in 1979 revealed

the existence of a nearby Soviet bioweapons research facility.

It was only in 1991, when the Soviet Union broke up, 

that the rest of the world learned how massive the Soviet

bioweapons program was. The Soviets had been manipulating

genes to make anthrax and smallpox bioweapons more lethal.

Now disbanded, the Soviet program has left the bioweapons

poorly guarded and stored. The location of remaining

stockpiles of weapons is uncertain.

BIOWEAPONS TODAY

It is unclear at this time which countries have active

bioweapons programs. In addition, the threat of bioattacks

from non-state-sponsored terrorists remains. In 1984, the

Rajneeshee Cult tried to influence voter turnout by

contaminating salad bars in Oregon with Salmonella. A total

of 750 people became ill, though none fatally.

CHEMICAL WEAPONS AND EMERGENCIES

TIMELINE

600–200 B.C.: Athenian, Spartan, and Carthaginian forces

use poisons and smoke to quell enemies.

1618–1648: Smoke projectiles come into use in the Thirty

Years War.

1914–1918 (World War I):

> 1915: Germany uses chlorine against French troops.

> 1917: Both sides use mustard gas for the first time.

1925: Geneva Protocol prohibits the use of biological and

chemical weapons.

1935–1936: Italy uses chemical weapons in Ethiopia.

1939–1945 (World War II):

> Japan uses chemical weapons in China.

> The German army uses chlorine, mustard gas, and 

phosgene gas.

1980s: Iraqi army uses chemical weapons against Iraqi Kurds.

1981–1988: Mustard gas and nerve gas are used extensively

during the Iran-Iraq war, mainly by Iraq.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 199

1992: Chemical Weapons Convention bans chemical weapons.

1995: The Aum Shinrikyo Cult stages a sarin attack on the

Tokyo subway system.

2003–2004:

> Ricin appears in the Dirksen Senate Office Building on

Capitol Hill.

> London police discover a ricin plot.

> Ricin appears in a mailed parcel in South Carolina.

As with bioweapons, military use of chemicals has a long

history. But unlike bioweapons, chemical weapons have a

limited range and their impact resembles that of conventional

weapons.

THE PREMODERN ERA

Dating back to ancient times, armies reportedly used a number

of chemical agents in wartime. In 600 B.C., Solon of Athens

was said to have put roots of hellebore (a poisonous plant) in

the drinking water of Kirrha. During the Peloponnesian War, in

429 and 424 B.C., the Spartan forces used noxious smoke

and flames against Athenian cities. And around 200 B.C., the

Cathaginians attempted to sedate the enemy by leaving

mandrake root in wine.

There were also isolated instances of reported use of chemical

agents during the 17th–19th centuries—for example, smoke

projectiles during the Thirty Years War.

THE MODERN ERA OF CHEMICAL WEAPONS

Developments in the chemical industry in the 18th and 

19th centuries made possible the extensive use of chemical

weapons that began in World War I. Chlorine, which is an

asphyxiant, was first used in 1915. During the battle of Ypres

in Belgium in 1915, Germany exploded canisters filled with

chlorine gas, killing 5,000 French troops and injuring 15,000.

The French troops were unprepared for these chemical weapons

attacks. After that, troops began using respirators. However,

other chemical agents were in use at that time, including

chloropicrin, which could penetrate the respirators. The use of

mustard gas on both sides began in 1917. It resulted in

91,000 deaths and 1.2 million injuries during World War I. By

the end of that war, mustard gas had caused 80 percent of the

casualties resulting from chemical attacks. The use of

chemical weapons during World War I caused 3 percent of the

total war casualties.

The 1925 Geneva Protocol covered chemical as well as

biological weapons. But despite the Geneva Protocol, the use

of chemical weapons continued. Italy used them in 1935 and

1936 in Ethiopia. Japan used them in China during World War

II. New and more effective chemical agents were developed:

The Germans developed tabun, the first nerve gas, in 1936.

Sarin, soman, and VX followed. When World War II began,

phosgene and mustard gas were considered superior to

alternative chemical weapons, such as chlorine and tear gas.

During the war, Germany began manufacturing tabun. Sarin

later emerged as the preferred nerve gas for military purposes

because it could be produced in large quantities.

Experts believe that more than 20 countries in the Middle

East, Asia, Europe, and North American now have chemical

weapons capabilities. During the 1981–1988 Iran-Iraq War,

mustard gas and nerve agents were used extensively, mainly

by Iraq. Iraq’s chemical weapons killed more than 25,000

Iranians during this conflict. Most experts believe that the Iraqi

army also used chemical weapons against the Iraqi Kurds in

1988. The discovery of mustard gas and sarin in Kurdish

territory soil samples confirms these claims. The Aum Shrikyo

Cult also used sarin in its attack on the Tokyo subway system

in March 1995. That attack left 12 dead and 5,500 injured.

Large amounts of ricin have been discovered in caves in

Afghanistan. And it was ricin, injected by means of a specially

rigged umbrella, that caused the death in 1978 of Bulgarian

writer and journalist Georgi Markov.

After lengthy negotiations, the Chemical Weapons Convention

(http://www.state.gov/www/global/arms/treaties/cwctext.html)

passed in 1992. This chemical-disarmament agreement

makes it illegal to acquire, develop, produce, or stockpile

chemical weapons.

Nevertheless, the threat of chemical warfare persists. At the

time of the development of this guide, the most recent incident

was the 2004 discovery of ricin on Capitol Hill.
200 12. HISTORY OF BIOLOGICAL, CHEMICAL, AND RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

CHEMICAL ACCIDENTS

In 1979, Union Carbide began to manufacture methyl

isocyanate in its plant in Bhopal, India. Methyl isocyanate is a

poisonous gas used to make pesticides. Since it is heavier than

air, it does not rise when it escapes into the atmosphere.

On December 23, 1984, water seeped into one of the methyl

isocyanate storage tanks at the Bhopal factory. The water then

reacted with the methyl isocyanate, resulting in the release of

40 tons of methyl isocyanate into the atmosphere. The methyl

isocyanate spread over a city of nearly 900,000 people, and

thousands died as they slept. Hundreds of thousands were

injured or maimed.

Numerous safety problems were present in the plant:

> Gauges were faulty

> The facility lacked temperature control

> Devices for neutralizing escaping methyl isocyanate were

turned off for maintenance

> Warning systems were inadequate

> The tank was above its recommended capacity

Because of the Bhopal incident and later chemical accidents

in U.S. factories, the U.S. Congress enacted a law that directed

the Environmental Protection Agency (EPA) to develop a

program to prevent and prepare for chemical accidents. In

response to this directive, EPA created the Risk Management

Program in June 1999. The goal of this program is to prevent

releases of chemicals that could cause immediate, serious

harm to human health and the environment and to

communicate accident and prevention information to the

public. Chemical facilities regulated under this program must

develop and implement a risk management program and

submit a summary of this program, called a “Risk

Management Plan,” to EPA a minimum of every 5 years. Due

to concern that one part of the Risk Management Plans, the

Offsite Consequences Analysis section, could be misused by

terrorists, Congress passed the Chemical Safety Information,

Site Security, and Fuels Regulatory Relief Bill in August 1999.

This law created certain restrictions on public access to the

Offsite Consequences Analysis section of the reports. 

NUCLEAR WEAPON DEVELOPMENT AND TESTING

TIMELINE

1940: Scientists based in Britain first report that the production

of a nuclear bomb is possible.

1941: British nuclear weapons research begins.

1943: Americans join the research effort with the “Manhattan

Project.”

1945: The United States drops atomic bombs on Hiroshima

and Nagasaki, Japan.

1949: The Soviet Union conducts its first nuclear explosion test.

1968: Treaty on the Non-Proliferation of Nuclear Weapons is

developed.

Nuclear weapon development and testing has been conducted

by many countries since the 1940s. Because leaders of the

allied nations during World War II were concerned that

Germany was producing nuclear weapons, the Manhattan

Project was born. The project brought together many of the

world’s leading scientists. The project was unable to produce

a fission-based weapon before the surrender of Germany in

1945 but was able to produce two weapons later that year

that were used in the U.S. atomic bombings in Japan 

(see next section).

In 1949, the Soviet Union conducted its first nuclear explosion

test, which marked the beginning of the Cold War. The United

Kingdom, France, and the People’s Republic of China also

demonstrated nuclear capabilities during the Cold War. It is

thought that since 1949 there have been around 2,000

nuclear test explosions throughout the world.

In 1950, President Truman announced a program to develop

a hydrogen or fusion bomb in response to the Soviet Union’s

nuclear testing. The first bomb tested by the United States on

a remote island in 1952 was 450 times the power of the

bomb that fell on Nagasaki. Other countries, including the

Soviet Union, France, the United Kingdom, and the People’s

Republic of China, also developed similar devices in the years

to follow.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 201

Since the late 1950s, a number of treaties have been

developed and signed by various countries in an attempt to

control nuclear testing and proliferation. In 1968, the Treaty

on the Non-Proliferation of Nuclear Weapons was developed to

prevent the spread of nuclear weapons and weapons

technology, to promote cooperation in the peaceful uses of

nuclear energy, and to further the goal of achieving nuclear

disarmament (United Nations Department for Disarmament

Affairs 2002). In 1995, this treaty was extended indefinitely,

and to date, 187 parties have joined the treaty, including the

five countries mentioned previously that were active in nuclear

development and testing. However, the nuclear threat is not

over. Experts know that some countries, such as India and

Pakistan, have active weapons programs, and it is suspected

that a number of other countries also have active weapons

programs or are pursuing the development of nuclear

weapons.

RADIATION EMERGENCIES

THE ATOMIC BOMB

The first radiological public health emergency followed the use

of the atomic bomb during World War II. The United States

dropped the first bomb on Hiroshima, Japan, on August 6,

1945, resulting in about 60,000–70,000 deaths. When that

failed to persuade Japan to surrender, the United States

dropped a second bomb, on Nagasaki, on August 9. That

bomb resulted in about 40,000 deaths. Five hours after 

the second bomb dropped, the Japanese surrendered

unconditionally. Most of the damage from these bombs

resulted from the flash, shockwave, and subsequent fire.

THREE MILE ISLAND

The threat of accidental radiological contamination became

real to Americans with the Three Mile Island accident on

March 28, 1979, near Middletown, Pennsylvania. Equipment

malfunction and human error combined to cause one of the

reactor cores to melt down and release radioactive gases into

the atmosphere. In the following few days, additional

radioactive releases took place. There was a precautionary

evacuation advisory for pregnant women and young children

within a 5-mile radius of the plant. Most of the radiation 

was contained; therefore, offsite releases were minimal and no

apparent injuries resulted. The major health effect for 

portions of the nearby population was mental stress.

The plant experienced significant damage. The cleanup

process raised health concerns because of the radioactive

material trapped in the containment and auxiliary buildings.

This accident was a close call. The scope of what could 

have happened served as a wakeup call for regulators who

subsequently tightened and heightened the plant’s safety

oversight.

Several factors contributed to the accident: inadequate training

of Three Mile Island operators, unclear operator instructions,

and design flaws in the control room instructions and layout.

The following are some measures that regulators and the

nuclear industry took to improve U.S. nuclear plant safety after

the accident:

> Upgraded plant and equipment design

> More rigorous plant operator training

> Better emergency preparedness

> Regular scrutiny of plant performance

> More frequent plant inspections

> Establishment of the industry’s self-regulatory group, the

Nuclear Energy Institute, which serves as a unified voice 

for the nuclear energy industry and advises the Nuclear

Regulatory Commission on relevant regulatory issues

> Improved coordination among various federal and state

agencies that are responsible for responding to such an

emergency

CHERNOBYL

The most severe radiological accident to date occurred at the

Chernobyl Nuclear Power Plant in the former Soviet Union on

April 25–26, 1986. A reactor exploded, releasing massive

amounts of radiation into the environment. The local

population of about 135,000 within an 18-mile radius of the

plant was evacuated. The accident caused 31 deaths, but the

extent of delayed health effects is uncertain. The Chernobyl

reactor would not have met Western safety standards.

Fourteen such reactors are still operational in the former 

Soviet Union.
202 12. HISTORY OF BIOLOGICAL, CHEMICAL, AND RADIATION EMERGENCIES Terrorism and Other Public Health Emergencies: A Reference Guide for Media

The chances of a Chernobyl-type accident occurring in the

United States are small, because U.S. plants do not have the

same design features and they all have concrete and steel

containment structures to keep radiation inside. But the

Nuclear Regulatory Commission staff looked at this incident 

for ideas about how to improve plant operations, staff training,

and emergency preparedness in the United States, and many

new reactor safety measures have been developed and

implemented as a result.

REFERENCES

ABC News. (2001). Germ terror: Fighting a biological war.

Book excerpt from Broad, W., Engelberg, S., & Miller, J.

(2001). Germs: Biological weapons and America’s secret war.

New York, NY: Simon and Schuster. 

American University School of International Service. (1997).

TED case studies: Bhopal disaster. http://www.american.edu/

TED/bhopal.htm.

Belke, J.C. (2000). Chemical accident risks in U.S. industry—

A preliminary analysis of accident risk data from U.S. hazardous

chemical facilities. http://www.epa.gov/ceppo/pubs/

stockholmpaper.pdf.

Centers for Disease Control and Prevention. (2004). Fact sheet—

Chemical emergencies: Facts about ricin. http://www.bt.cdc.gov/

agent/ricin/pdf/ricinfacts.pdf.

Chandler, D., & Landrigan, I. (2004). Bioterrorism: A journalist’s

guide to covering bioterrorism. (2nd ed.). http://www.rtnda.org/

resources/bioguide.pdf.

Christopher, G.W., Cieslak, T.J., Pavlin, J.A., & Eitzen Jr., E.M.

(1997). Biological warfare. A historical perspective. Journal of

the American Medical Association, 278, 412–417.

Council for a Livable World. (2004). The history of nuclear

testing: A chronology. http://www.clw.org/archive/control/

ctbchron.html.

Eitzen Jr., E.M., & Takafuji, E.T. (1997). Historical overview of

biological warfare. In F.R. Sidell, E.T. Takafuji, & D.R. Franz

(Eds.), Medical Aspects of Chemical and Biological Warfare.

Washington, DC: Borden Institute, Walter Reed Army Medical

Center.

Harigel, G.G. Conference on Biosecurity and Bioterrorism,

September 18–19, 2000, Istituto Diplomatico Mario Toscano,

Villa Madama, Rome, Italy: The concept of weapons of mass

destruction: Chemical and biological weapons, use in warfare,

impact on society and environment. http://lxmi.mi.infn.it/

~landnet/Biosec/harigel.pdf.

Henderson, D.A. (1998). Bioterrorism as a public health threat.

Emerging Infectious Diseases, 4, 488–492. http://www.cdc.gov/

ncidod/EID/vol4no3/hendrsn.htm.

Lord, A.M. (2002). A brief history of biowarfare. http://lhncbc.nlm.

nih.gov/apdb/phsHistory/resources/pdf/biowar_pics.pdf.
REFERENCES (cont.)

Malloy, C.D. (2000). A history of biological and chemical warfare

and terrorism. Journal of Public Health Management and

Practice, 6, 30–37.

Moquin, R.R., & Moquin, M.E. (2002). Weapons of mass destruction:

Biological. Neurosurgical Focus, 12, 1–4. http://www.aans.org/

education/journal/neurosurgical/mar02/12-3-2.pdf.

Nova Online. (2002). History of biowarfare. http://www.pbs.org/

wgbh/nova/bioterror/hist_nf.html.

Nuclear Energy Institute. (2004). NEI profile. http://www.nei.org/

index.asp?catnum=2&catid=136.

President’s Commission on the Accident at Three Mile Island.

(1979). Report of the President’s commission on the accident 

at Three Mile Island: The need for change, the legacy of TMI.

http://stellar-one.com/nuclear/report_to_the_president.htm.

Public Broadcasting Service Online. (1998). Plague war: 

A timeline. http://www.pbs.org/wgbh/pages/frontline/shows/

plague/etc/cron.html.

Smart, J.K. (1997). History of chemical and biological warfare:

An American perspective. In F.R. Sidell, E.T. Takafuji, & D.R.

Franz (Eds.), Medical Aspects of Chemical and Biological

Warfare. Washington, DC: Borden Institute, Walter Reed Army

Medical Center.

U.S. Nuclear Regulatory Commission. (2000). Fact sheet on the

accident at the Chernobyl nuclear power plant. http://www.nrc.gov/

reading-rm/doc-collections/fact-sheets/fschernobyl.html.

U.S. Nuclear Regulatory Commission. (2004). Fact sheet—The

accident at Three Mile Island. http://www.nrc.gov/reading-rm/

doc-collections/fact-sheets/3mile-isle.pdf.

U.S. Senate Select Committee to Study Governmental Operation

with Respect to Intelligence Activities. (1975). Interim report:

Alleged assassination plots involving foreign leaders. http://historymatters.com/archive/church/reports/ir/html/ChurchIR_0008a.htm.

United Nations Department for Disarmament Affairs. (1992). 

The Chemical Weapons Convention (CWC). http://www.un.org/

Depts/dda/WMD/cwc/.

United Nations Department for Disarmament Affairs. (2002).

Treaty on the non-proliferation of nuclear weapons: Brief background.

http://www.un.org/Depts/dda/WMD/treaty/.

Wikipedia. (2004). History of nuclear weapons. http://en.wikipedia.

org/wiki/History_of_nuclear_weapons.

World Health Organization. (2004). Public health response 

to biological and chemical weapons: WHO guidance. http://www.who.

int/csr/delibepidemics/biochemguide/en/index.html/html.

Yale Law School. (2004). The Avalon Project at Yale Law School:

The atomic bombings of Hiroshima and Nagasaki: Chapter 10

Total casualties. http://www.yale.edu/lawweb/avalon/abomb/

mp10.htm.

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 203

13MEDIA CONTACTS
206 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

HHS Headquarters

HHS Press Office

Phone: (202) 690-6343

Fax: (202) 690-6247

Web site: http://www.hhs.gov/news

OTHER HHS AGENCIES

Administration for Children and Families (ACF)

Phone: (202) 401-9215

Fax: (202) 205-9688

Web site: http://www.acf.hhs.gov/news/index.html

Administration on Aging (AoA)

Phone: (202) 401-4541

Fax: (202) 357-3556

Web site: http://www.aoa.gov/press/press.asp

Agency for Healthcare Research and Quality (AHRQ)

Phone: (301) 427-1855

Fax: (301) 427-1873

Web site: http://www.ahrq.gov/news/vnewsix.htm

Agency for Toxic Substances and Disease Registry (ATSDR)

Phone: (404) 498-0070

Fax: (404) 498-0039

Web site: http://www.atsdr.cdc.gov/#NEWS

Centers for Disease Control and Prevention (CDC)

Phone: (404) 639-3286

Fax: (404) 639-7394

Web site: http://www.cdc.gov/od/oc/media/

Centers for Medicare & Medicaid Services (CMS)

Phone: (202) 690-6145

Fax: (202) 690-7159

Web site: http://www.cms.hhs.gov/media/

Food and Drug Administration (FDA)

Phone: (301) 827-6250

Fax: (301) 827-1681

Web site: http://www.fda.gov/opacom/hpwhats.html

Health Resources and Services Administration (HRSA)

Phone: (301) 443-3376

Fax: (301) 443-1989

Web site: http://newsroom.hrsa.gov/

Indian Health Service (IHS)

Phone: (301) 443-3593

Fax: (301) 443-0507

Web site: http://www.ihs.gov/PublicInfo/PressPub_index.asp

National Institutes of Health (NIH)

Phone: (301) 496-5787

Fax: (301) 496-0017

Web site: http://www.nih.gov/news/

Substance Abuse and Mental Health Services

Administration (SAMHSA)

Phone: (301) 443-8956

Fax: (301) 443-9050

Web site: http://www.samhsa.gov/news/news.html

OTHER FEDERAL AGENCIES

Department of Energy (DOE)

Phone: (202) 586-5806

Fax: (202) 586-5823

Web site: http://www.doe.gov/engine/content.do

Department of Homeland Security (DHS)

Phone: (202) 282-8010

Fax: (202) 282-8408

Web site: http://www.dhs.gov/dhspublic

Environmental Protection Agency (EPA)

Phone: (202) 564-4355

Fax: (202) 501-1761

Web site: http://www.epa.gov/newsroom

Federal Bureau of Investigation (FBI)

Phone: (202) 324-3691

Fax: (202) 324-6842

Web site: http://www.fbi.gov/pressroom.htm

MEDIA CONTACTS
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 207

I HAD A BETTER BASE THAN SOME OTHERS MIGHT HAVE, “

but then of course you don’t really know the intricacies of how hospitals work. I didn’t

have a number to call CDC. I didn’t know the media contact.Those things would have

been helpful to have in getting organized. “

Piya Chattopadhyay, correspondent, Canadian Broadcasting Radio, Toronto

Reported on the SARS outbreak in Toronto 2003

STATE-LEVEL MEDIA CONTACTS

This list was obtained from the National Public Health

Information Coalition and updated with their assistance in

the winter of 2004/2005.

ALABAMA

Dr. Jim McVay, D.P.A.

Director

Bureau of Health Promotion and Information

Alabama Department of Public Health

201 Monroe Street, Suite 968

Montgomery, AL 36104

Phone: (334) 206-5600

Fax: (334) 206-5609

E-mail: jmcvay@adph.state.al.us

ALASKA

Ms. Kerre Fisher

Public Health Preparedness Information Officer

Division of Public Health

Alaska Department of Health and Social Services

3601 C Street, Suite 760

Anchorage, AK 99503

Phone: (907) 269-2042

Fax: (907) 269-2048

E-mail: kerre_fisher@health.state.ak.us

Web site: http://health.hss.state.ak.us/dph/DPHPP/default.cfm

AMERICAN SAMOA

Mr. Joseph Tufa

Director

American Samoa Department of Health

American Samoa Government

Pago Pago, AS 96799

Phone: (684) 633-4606

Fax: (684) 633-5379

ARIZONA

Mr. Michael Murphy

Communications Director

Arizona Department of Health Services

150 North 18th Avenue

Phoenix, AZ 85007

Phone: (602) 542-1001

Fax: (602) 542-0883

E-mail: murphym@azdhs.gov

Ms. Mary Ehlert, M.S., A.B.C.

Public Information Officer

Office of the Assistant Director

Division of Public Health Services

Arizona Department of Health Services

Phone: (602) 364-1201

E-mail: ehlertm@azdhs.gov
208 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

ARKANSAS

Ms. Ann Wright

Director of Communications

Arkansas Department of Health

4815 West Markham Street, Slot 22

Little Rock, AR 72205

Phone: (501) 661-2474

Fax: (501) 661-2043

E-mail: awright@healthyarkansas.com

Mr. Bob Alvey

Risk Communication Specialist

Arkansas Department of Health

4815 West Markham Street, Slot 22

Little Rock, AR 72205

Phone: (501) 661-2743

Fax: (501) 661-2043

E-mail: ralvey@healthyarkansas.com

CALIFORNIA

Mr. Ken August

Deputy Director

Office of Public Affairs

California Department of Health Services

1501 Capitol Avenue, Suite 6130

MS 0025

Sacramento, CA 95814

Phone: (916) 440-7660

Fax: (916) 440-7656

E-mail: kaugust@dhs.ca.gov

COLORADO

Ms. Cindy Parmenter

Director of Communications

Colorado Department of Public Health and Environment

4300 Cherry Creek Drive, South

Denver, CO 80246

Phone: (303) 692-2013

Fax: (303) 782-0095

E-mail: cindy.parmenter@state.co.us

Ms. Barbara Beiser

BT Health Risk Communication Manager

Colorado Department of Public Health and Environment

4300 Cherry Creek Drive, South

Denver, CO 80246

Phone: (303) 692-2710

E-mail: barbara.beiser@state.co.us

CONNECTICUT

Mr. William Gerrish

Director

Office of Planning, Communications, and Workforce

Development

Connecticut Department of Public Health

410 Capitol Avenue, MS 13 CMN

Hartford, CT 06134

Phone: (860) 509-7270

Fax: (860) 509-7286

E-mail: william.gerrish@po.state.ct.us

Mr. Michael Purcaro

Connecticut Department of Public Health

410 Capitol Avenue, MS 13 CMN 

Hartford, CT 06134

Phone: (860) 509-7270

Fax: (860) 509-7286 

Mr. Xaviel Soto

Connecticut Department of Public Health

410 Capitol Avenue, MS 13 CMN 

Hartford, CT 06134

Phone: (860) 509-7270

Fax: (860) 509-7286

DELAWARE

Ms. Allison Taylor Levine

Communications Director

Office of the Secretary

Delaware Health and Social Services

1901 North Dupont Highway

New Castle, DE 19720

Phone: (302) 255-9037

Fax: (302) 255-4429

E-mail: allison.levine@state.de.us
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 209

Ms. Heidi Truschel-Light

Public Information Officer

Delaware Division of Public Health

P.O. Box 637

Dover, DE 19903

Phone: (302) 744-4907 at desk; (302) 744-4700 main

Pager: (302) 247-1560

Fax: (302) 739-6659

E-mail: htruschel-l@state.de.us

Web site: http://www.dhss.delaware.gov/dhss/dph/index.html

DISTRICT OF COLUMBIA 

Mr. Briant Keith Coleman, M.A.

Public Information Officer

DC Department of Health

64 New York Avenue, N.E.

Washington, DC 20001

Phone: (202) 671-0701

Fax: (202) 671-0843

E-mail: briant.coleman@dc.gov

Ms. Leila Abrar, M.P.H.

Public Information Officer

DC Department of Health

825 North Capitol Street, N.E., Fourth Floor

Washington, DC 20002

Phone: (202) 442-9186

Fax: (202) 442-4819

E-mail: leila.abrar@dc.gov

FEDERATED STATES OF MICRONESIA

Mr. Marcus Samo

Department of Health, Education, and Social Affairs

Federated States of Micronesia

P.O. Box PS 70

Palikir, Pohnpei, FM 96941

Phone: (691) 320-2619

Fax: (691) 320-5263

E-mail: mhsamo@mail.fm

FLORIDA

Mr. Irv B. “Doc” Kokol

Director of Communication

Florida Department of Health

4052 Bald Cypress Way, BIN A04

Tallahassee, FL 32399-1705

Phone: (850) 245-4111

Fax: (850) 410-3049

E-mail: doc_kokol@doh.state.fl.us

Ms. Lindsay Hodges

Press Secretary

Florida Department of Health

4052 Bald Cypress Way, BIN A04

Tallahassee, FL 32399-1705

Phone: (850) 245-4111

Fax: (850) 410-3049

E-mail: lindsay_hodges@doh.state.fl.us

GEORGIA

Mr. Tod Rose

Risk Communicator/Public Information Officer

Division Communication Officer

Georgia Division of Public Health

15th Floor, Suite 415

2 Peachtree Street, N.W.

Atlanta, GA 30303

Phone: (404) 463-2299

Mobile: (404) 597-9893

E-mail: tsrose@dhr.state.ga.us

Web site: http://www.health.state.ga.us

GUAM

Mr. Eugene Santos

Health Education Administrator

Guam Department of Public Health and Social Services

P.O. Box 2816

Hagatna, GU 96932-2816

Phone: (671) 475-0670

Fax: (671) 477-7626

E-mail: esnsantos@yahoo.com
210 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

HAWAII

Ms. Janice Okubo

Communications Director

Hawaii Department of Health

1250 Punchbowl Street, Third Floor

Honolulu, HI 96813

Phone: (808) 586-4442

Fax: (808) 586-4444

E-mail: jsokubo@health.state.hi.us

IDAHO

Mr. William Walker

Senior Public Information Officer

Idaho Department of Health and Welfare

P.O. Box 83720

Boise, ID 83720

Phone: (208) 334-5506

Fax: (208) 332-7226

E-mail: walkerw@idhw.state.id.us

Ms. Maureen Welcker, M.P.H.

Focus Area F Coordinator

Idaho Department of Health and Welfare

First Floor, West

450 West State Street

Boise, ID 83720-0036

Phone: (208) 334-5876

Fax: (208) 334-6580

E-mail: welckerm@idhw.state.id.us 

ILLINOIS

Mr. Tom Schafer

Director’s Office

Illinois Department of Public Health

535 West Jefferson Street

Springfield, IL 62761

Phone: (217) 782-5750

Fax: (217) 782-3987

E-mail: tschafer@idph.state.il.us

Ms. Tammy Leonard

Communication Manager

Office of Communication and Information

Illinois Department of Central Management Services

611 Stratton Office Building

Springfield, IL 62706

Phone: (217) 558-1540

Fax: (217) 558-0547

E-mail: tammy_leonard@cms.state.il.us

INDIANA

Mr. Andrew Zirkle

Risk Communication Director

Indiana State Department of Health

2 North Meridian Street, 6–G

Indianapolis, IN 46204

Phone: (317) 233-7306

Fax: (317) 233-7873

E-mail: azirkle@isdh.state.in.us

Ms. Jennifer Dunlap

Marketing Director

Indiana State Department of Health

2 North Meridian Street, 6–G

Indianapolis, IN 46204

Phone: (317) 233-7090

Fax: (317) 233-7873

E-mail: jdunlap@isdh.state.in.us

Web site: http://www.statehealth.in.gov

IOWA

Mr. Kevin J. Teale, B.S., M.A.

Communications Director

Iowa Department of Public Health

Lucas State Office Building

Des Moines, IA 50319

Phone: (515) 281-6692

Fax: (515) 281-4958

E-mail: kteale@idph.state.ia.us

Web site: http://www.idph.state.ia.us
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 211

Ms. Lucinda Parker

Public Affairs Manager

Iowa Homeland Security and Emergency Management

Wallace State Office Building

Des Moines, IA 50319-0075

Phone: (515) 281-4939

Fax: (515) 281-7539

E-mail: lucinda.parker@hlsem.state.ia.us

KANSAS

Ms. Sharon Watson

Public Information Director

Kansas Department of Health and Environment

1000 Southwest Jackson Street, Suite 550

Topeka, KS 66612

Phone: (785) 296-5795

Fax: (785) 368-6368

E-mail: swatson@kdhe.state.ks.us

KENTUCKY

Mr. Gil Lawson

Branch Manager

Office of Communications

Kentucky Cabinet for Health Services

275 East Main, 5C–A

Frankfort, KY 40621

Phone: (502) 564-6786

Fax: (502) 564-0274

E-mail: gil.lawson@mail.state.ky.us

Ms. Gwenda Bond

Office of Communications

Kentucky Cabinet for Health Services

275 East Main, 5C–A

Frankfort, KY 40621

Phone: (859) 254-9420

E-mail: gwenda.bond@mail.state.ky.us

LOUISIANA

Ms. Melissa C. Walker

Public Information Officer

Louisiana Department of Health/BT Preparedness

6867 Bluebonnet Boulevard, Suite B

Baton Rouge, LA 70810

Phone: (225) 763-3558

Fax: (225) 763-5727

E-mail: mwalker2@dhh.la.gov

MAINE

Mr. Michael Norton

Director

Public and Media Relations

Maine Department of Human Services

State House Station 11

Augusta, ME 04333-0011

Phone: (207) 287-3707

Fax: (207) 287-3005

E-mail: michael.norton@maine.gov

MARSHALL ISLANDS

Ms. Justina R. Langidrik

Assistant Secretary

Marshall Islands Ministry of Health and Environment

P.O. Box 16

Majuro, MH 96960

Phone: (692) 625-3355

Fax: (692) 625-3432

E-mail: jusmohe@ntmar.com

MARYLAND

Ms. Karen Black

Director

Office of Public Relations

Maryland Department of Health and Mental Hygiene

201 West Preston Street

Baltimore, MD 21201

Phone: (410) 767-6490

Fax: (410) 333-7525

E-mail: kblack@dhmh.state.md.us
212 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Mr. John Healy

Bioterrorism Public Information Officer

Maryland Department of Health and Mental Hygiene

201 West Preston Street

Baltimore, MD 21201

Phone: (410) 767-0590

Fax: (410) 333-7525

E-mail: jhealy@dhmh.state.md.us 

MASSACHUSETTS

Ms. Nicole St. Peter

Director of Public Affairs

Massachusetts Department of Public Health

250 Washington Street

Boston, MA 02108

Phone: (617) 624-5200

Fax: (617) 624-5206

E-mail: nicole.st.peter@dph.state.ma.us

MICHIGAN

Mr. T.J. Bucholz

Director of Communications

Michigan Department of Community Health

Lewis Cass Building, Sixth Floor

320 South Walnut Street

Lansing, MI 48913

Phone: (517) 241-2112

Fax: (517) 241-3700

E-mail: bucholztj@michigan.gov

Web site: http://www.michigan.gov/mdch 

MINNESOTA

Mr. John Stieger

Director

Communications Office

Minnesota Department of Health

85 East Seventh Place, Suite 400

St. Paul, MN 55101

Phone: (651) 215-1301

Mobile: (651) 485-8265

Fax: (651) 215-1317

E-mail: john.stieger@health.state.mn.us

Mr. Buddy Ferguson

Risk Communications Specialist

Minnesota Department of Health

85 East Seventh Place, Suite 400

St. Paul, MN 55101

Phone: (651) 215-1306

Mobile: (651) 295-1071

Fax: (651) 215-1317

E-mail: buddy.ferguson@health.state.mn.us 

MISSISSIPPI

Ms. Liz Sharlot

Communications Director

Mississippi State Department of Health

570 East Woodrow Wilson Drive, O-100

P.O. Box 1700

Jackson, MS 39215

Phone: (601) 576-7667

Mobile: (601) 942-5504

Pager: (800) 489-2535 (2807)

Fax: (601) 576-7517

E-mail: lsharlot@msdh.state.ms.us

Ms. Camille Foretich

Special Projects Officer

Mississippi State Department of Health

570 East Woodrow Wilson Drive, O-100

P.O. Box 1700

Jackson, MS 39215

Phone: (601) 576-7670

Mobile: (601) 955-5579

Pager: (800) 489-2535 (2888)

Fax: (601) 576-7517

E-mail: cforetich@msdh.state.ms.us
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 213

Kelly French

Special Projects Officer

Mississippi State Department of Health

570 East Woodrow Wilson Drive, O-100

P.O. Box 1700

Jackson, MS 39215

Phone: (601) 576-7176

Mobile: (601) 955-5578

Pager: (800) 489-2535 (2921)

Fax: (601) 576-7517

E-mail: kshannon@msdh.state.ms.us

Ms. Elizabeth Hogue

Public Relations Rep III

Mississippi State Department of Health

570 East Woodrow Wilson Drive, O-100

P.O. Box 1700

Jackson, MS 39215

Phone: (601) 576-7677

Mobile: (601) 955-5502

Pager: (800) 489-2535 (2835)

Fax: (601) 576-7517

E-mail: elizabeth.hogue@msdh.state.ms.us

MISSOURI

Ms. Nanci Gonder

Chief

Office of Public Information

Missouri Department of Health

P.O. Box 570

Jefferson City, MO 65102

Phone: (573) 751-6062

Fax: (573) 751-6041

E-mail: gonden@dhss.mo.gov

MONTANA

Ms. Gayle C. Shirley

Public Information Officer

Montana Department of Public Health and Human Services

P.O. Box 4210

Helena, MT 59604

Phone: (406) 444-2596

Fax: (406) 444-1970

E-mail: gshirley@mt.gov

Ms. Mary Ann Dunwell

Risk Communications Coordinator

Montana Department of Public Health and Human Services

P.O. Box 4210

Helena, MT 59604

Phone: (406) 444-0732

Fax: (406) 444-3044

E-mail: mdunwell@mt.gov

NEBRASKA

Ms. Kathie Osterman

Administrator

Communications and Legislative Services

Nebraska Health and Human Services System

301 Centennial Mall, South

P.O. Box 95026

Lincoln, NE 68509

Phone: (402) 471-9313

Fax: (402) 471-3996

E-mail: kathie.osterman@hhss.state.ne.us

Ms. Dianna Seiffert

Public Information Officer

Nebraska Health and Human Services System

301 Centennial Mall, South

P.O. Box 95026

Lincoln, NE 68509

Phone: (402) 471-1695

Fax: (402) 471-3996

E-mail: dianna.seiffert@hhss.ne.gov

NEVADA

Ms. Martha Framsted

Public Information Officer

Nevada State Health Division

505 East King Street, Room 201

Carson City, NV 89710

Phone: (775) 684-4014

Fax: (775) 684-4211

E-mail: mframsted@nshd.state.nv.us
214 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Ms. Annie Uccelli

PHP–Public Information Officer

Nevada State Health Division

505 East King Street, Room 204

Carson City, NV 89403

Phone: (775) 684-4013

Fax: (775) 684-5951

E-mail: auccelli@nvhd.state.nv.us

Web site: http://www.health2k.state.nv.us 

NEW HAMPSHIRE

Ms. Nicola Whitley

Public Information Officer

New Hampshire Department of Health and Human Services

129 Pleasant Street

State Office Park, South

Concord, NH 03301

Phone: (603) 271-6526

Fax: (603) 271-4332

E-mail: nwhitley@dhhs.state.nh.us

NEW JERSEY

Ms. Gretchen Michael

Director of Communications

New Jersey Department of Health and Senior Services

P.O. Box 360

Trenton, NJ 08625

Phone: (609) 984-7160

Fax: (609) 984-5474

E-mail: gretchen.michael@doh.state.nj.us

Mr. Tom Slater

Risk Communications Manager

New Jersey Department of Health and Senior Services

P.O. Box 360

Trenton, NJ 08625

Phone: (609) 984-7160

Fax: (609) 984-5474

E-mail: thomas.slater@doh.state.nj.us

NEW MEXICO

Ms. Beth Velasquez

Marketing and Communications Director

New Mexico Department of Health

1190 St. Francis Drive, Suite N–4100

Santa Fe, NM 87504

Phone: (505) 827-2619

Fax: (505) 827-2530

E-mail: beth.velasquez@doh.state.nm.us

NEW YORK

Mr. Robert Kenny

Acting Director of Public Affairs

New York State Department of Health

Corning Tower, Room 1455

Albany, NY 12237

Phone: (518) 747-7354

Fax: (518) 473-7071

E-mail: nyhealth@health.state.ny.us

NORTH CAROLINA

Ms. Debbie Crane

Director of Public Affairs

North Carolina Department of Health and Human Services

2001 Mail Service Center

Raleigh, NC 27699-2001

Phone: (919) 733-9190

Fax: (919) 733-7447

E-mail: debbie.crane@ncmail.net

Ms. Carol Schriber

Public Information Officer

North Carolina Department of Health and Human Services

2001 Mail Service Center

Raleigh, NC 27699-2001

Phone: (919) 733-9190

Fax: (919) 733-7447

E-mail: carol.schriber@ncmail.net
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 215

Mr. Bill Furney

Public Information Officer for Public Health Preparedness and

Response

North Carolina Department of Health and Human Services

1902 Mail Service Center

Raleigh, NC 27699-1902

Phone: (919) 715-4174

Fax: (919) 715-2246

E-mail: bill.furney@ncmail.net

NORTH DAKOTA

Ms. Loreeta Leer Frank

Public Information Officer

North Dakota Department of Health

600 East Boulevard Avenue, Department 301

Bismarck, ND 58505-0200

Phone: (701) 328-1665

Fax: (701) 328-4727

E-mail: rfrank@state.nd.us

Ms. Stacy Eberl

Public Information Coordinator

North Dakota Department of Health

600 East Boulevard Avenue, Department 301

Bismarck, ND 58505-0200

Phone: (701) 328-4619

Fax: (701) 328-4727

E-mail: sleberl@state.nd.us

NORTH MARIANA ISLANDS

Mr. Thomas G. Greening

Department Head

Radiology Imaging Services

Northern Mariana Islands Department of Public Health 

and Environmental Services

P.O. Box 409CK

Saipan, MP 96950

Phone: (670) 322-6765

Fax: (670) 233-1464

E-mail: thomas.greening@saipan.com

OHIO

Mr. Jay Carey

Director of Public Affairs

Ohio Department of Health

P.O. Box 118

Columbus, OH 43216

Phone: (614) 644-8562

Fax: (614) 644-8208

E-mail: jcarey@gw.odh.state.oh.us

OKLAHOMA

Ms. Leslea E. Bennett-Webb, M.P.H.

Director

Office of Communications

Oklahoma State Department of Health

1000 Northeast 10th Street

Oklahoma City, OK 73117

Phone: (405) 271-5601

Fax: (405) 271-2865

E-mail: leslea@health.state.ok.us

Mr. Larry Weatherford

Terrorism Communications Officer

Oklahoma State Department of Health

1000 Northeast 10th Street

Oklahoma City, OK 73117

Phone: (405) 271-5601

Fax: (405) 271-2865

E-mail: larryw@health.state.ok.us

Ms. Pamela Williams

Public Information Officer

Oklahoma State Department of Health

1000 Northeast 10th Street

Oklahoma City, OK 73117

Phone: (405) 271-5601

Fax: (405) 271-2865

E-mail: pamelaw@health.state.ok.us

Web site: http://www.health.state.ok.us
216 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

OREGON 

Ms. Bonnie Widerburg

Communications Officer

Oregon Department of Human Services

800 Northeast Oregon Street

Portland, OR 97232

Phone: (503) 731-4180

Fax: (503) 731-4078

E-mail: bonnie.l.widerburg@state.or.us

Ms. Christie Holmgren

Public Health Information Planner

Oregon Department of Human Services

800 Northeast Oregon Street

Portland, OR 97232

Phone: (503) 731-4000 ext. 882

Fax: (503) 731-4078

E-mail: christie.j.holmgren@state.or.us

PENNSYLVANIA

Mr. Jay Pagni

Director of Communications

Pennsylvania Department of Health

P.O. Box 90

Harrisburg, PA 17108

Phone: (717) 787-1783

Fax: (717) 772-6959

E-mail: jpagni@state.pa.us

Mr. Richard McGarvey

Press Secretary

Pennsylvania Department of Health

P.O. Box 90

Harrisburg, PA 17108

Phone: (717) 787-1783

Mobile: (717) 576-3077

Fax: (717) 772-6959

E-mail: rmcgarvey@state.pa.us

Ms. Jessica Seiders

Press Secretary

Pennsylvania Department of Health

P.O. Box 90

Harrisburg, PA 17108

Phone: (717) 787-1783

Fax: (717) 772-6959

E-mail: jeseiders@state.pa.us

PUERTO RICO

Ms. María Cristina Santos

Risk Communications Coordinator

Biosecurity Preparedness Program

Puerto Rico Department of Health

Phone: (787) 773-0600 ext. 248

Fax: (787) 773-0622

E-mail: mcsantos@salud.gov.pr

REPUBLIC OF PALAU

Ms. Laura Ierago

Statistics Specialist

Bureau of Health Services

Republic of Palau

P.O. Box 100

Koror, PW 96940

Phone: (116) 809-9813

Fax: (116) 808-8121

RHODE ISLAND

Dr. Robert J. Marshall, Ph.D.

Assistant Director of Health

Rhode Island Department of Health

3 Capitol Hill, Room 401

Providence, RI 02908

Phone: (401) 222-1017

Fax: (401) 222-6548

E-mail: robert.marshall@health.ri.gov

Web site: http://www.health.ri.gov
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 217

SOUTH CAROLINA

Mr. Thom Berry

Director

Education and Information Services

South Carolina Department of Health and Environmental

Control

2600 Bull Street

Columbia, SC 29201

Phone: (803) 898-3885

Fax: (803) 898-3887

E-mail: berrytw@dhec.sc.gov

Mr. Jim Beasley

Public Information Director

South Carolina Department of Health and Environmental

Control

2600 Bull Street

Columbia, SC 29201

Phone: (803) 898-7769

Fax: (803) 898-7279

E-mail: beaslejc@dhec.sc.gov

SOUTH DAKOTA

Ms. Barbara E. Buhler

Director

Public Information and Media Relations

South Dakota Department of Health

600 East Capitol Avenue

Pierre, SD 57501

Phone: (605) 773-3361

Fax: (605) 773-5683

E-mail: barb.buhler@state.sd.us

Ms. Cindy Bahe

Crisis Communications Coordinator

South Dakota Department of Health and Senior Services

600 East Capitol Avenue

Pierre, SD 57501

Phone: (605) 773-3364

Fax: (605) 773-5904

E-mail: cindy.bahe@state.sd.us 

TENNESSEE

Ms. Diane Denton

Director of Communications and Media Relations

Tennessee Department of Health

Cordell Hull Building, Third Floor

425 Fifth Avenue, North

Nashville, TN 37247-0101

Phone: (615) 741-3111

Fax: (615) 741-2491

E-mail: diane.denton@state.tn.us

Mr. Perry Stevens

Risk Communication Coordinator

Tennessee Department of Health

Cordell Hull Building, Fourth Floor

425 Fifth Avenue, North

Nashville, TN 37247-0101

Phone: (615) 253-1398

Fax: (615) 741-3857

E-mail: perry.stevens@state.tn.us

TEXAS

Ms. Emily Palmer

Press Officer

Public Health Emergency Preparedness

Texas Department of Health

1100 West 49th Street

Austin, TX 78756

Phone: (512) 458-7111 ext. 2213

Fax: (512) 458-7379

E-mail: emily.palmer@tdh.state.tx.us

Mr. Doug McBride

Press Officer

Public Health Emergency Preparedness

Texas Department of State Health Services

1100 West 49th Street

Austin, TX 78756

Phone: (512) 458-7524

Fax: (512) 458-7622

E-mail: doug.mcbride@dshs.state.tx.us
218 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media

Ms. Mary Lenz

Public Information Officer

Terrorism

Texas Division of Emergency Management

1100 West 49th Street

Austin, TX 78756

Phone: (512) 424-2432

Fax: (512) 458-7622

E-mail: mary.lenz@txdps.state.tx.us

UTAH

Ms. Jana Kettering

Public Information Officer

Utah Department of Health

P.O. Box 141000

Salt Lake City, UT 84114

Phone: (801) 538-6339

Fax: (801) 538-9338

E-mail: jkettering@utah.gov

VERMONT

Ms. Nancy Erickson

Director of Communication

Vermont Department of Health

108 Cherry Street, Box 70

Burlington, VT 05402

Phone: (802) 863-7281

Fax: (802) 951-1275

E-mail: nericks@vdh.state.vt.us

Ms. Linda Dorey

Director of Communication

Vermont Department of Health

108 Cherry Street, Box 70

Burlington, VT 05402

Phone: (802) 863-7281

Fax: (802) 951-1275

E-mail: ldorey@vdh.state.vt.us

VIRGINIA

Ms. Lucy Caldwell

Northern Virginia Regional Public Information Officer

Virginia Department of Health

10777 Main Street, Suite 300

Fairfax, VA 22030

Phone: (703) 934-0623

Fax: (703) 934-0633

E-mail: lucy.caldwell@vdh.virginia.gov

Ms. Jimeequa Williams

Central Virginia Region Public Information Officer

Virginia Department of Health

P.O. Box 2448

Richmond, VA 23218

Phone: (804) 225-3881

Fax: (804) 225-3888

E-mail: jimeequa.williams@vdh.virginia.gov

Mr. Larry Hill

Hampton Roads Regional Public Information Officer

Virginia Department of Health

830 Southampton Avenue, Suite 200

Norfolk, VA 23510

Phone: (757) 683-9175

E-mail: larry.hill@vdh.virginia.gov

Mr. Mike Stater

Southwest Regional Public Information Officer

Virginia Department of Health

515 Eighth Street, S.W.

Roanoke, VA 24016

Phone: (540) 857-7600

E-mail: mike.stater@vdh.virginia.gov

Mr. Jeffery Caldwell

Public Relations Manager

Virginia Department of Health

109 Governor Street, 13th Floor

Richmond, VA 23219

Phone: (804) 864-7008

Fax: (804) 864-7022

E-mail: jeffery.caldwell@vdh.virginia.gov

Web site: http://www.vdh.virginia.gov
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 219

VIRGIN ISLANDS

Ms. Anne L. Thurland

Public Information Specialist

Virgin Islands Department of Health

Charles Harwood Complex

3500 Estate Richmond

Christiansted, VI 00820-4370

Phone: (340) 773-1311

Fax: (340) 773-8354

E-mail: dbprev@islands.vi

WASHINGTON

Mr. Tim Church

Communications Director

Washington State Department of Health

P.O. Box 47890

Olympia, WA 98504

Phone: (360) 236-4077

Fax: (360) 236-4024

E-mail: timothy.church@doh.wa.gov

WEST VIRGINIA

Mr. John D. Law

Director of Communications

West Virginia Department of Health and Human Resources

350 State Capitol Street, Room 702

Charlestown, WV 25301

Phone: (304) 558-8886

E-mail: johnlaw@wvdhhr.org

Ms. Kim Fetty

Public Information Officer

Division of Threat Preparedness

West Virginia Department of Health and Human Resources 

500 Capitol Street, Suite 200

Phone: (304) 558-1218

Fax: (304) 558-0464

E-mail: kimberlyfetty@wvdhhr.org

WISCONSIN

Ms. Lisa White-Pentony

Risk Communication Coordinator

Wisconsin Department of Public Health

1 West Wilson Street, Room 250

Madison, WI 53701

Phone: (608) 267-3319

Fax: (608) 267-2832

E-mail: whitela@dhfs.state.wi.us

WYOMING

Mr. Ross Doman

Public Information Officer

Wyoming Department of Health

117 Hathaway Building

Cheyenne, WY 82002

Phone: (307) 777-6420

Fax: (307) 777-7439

E-mail: rdoman@state.wy.us
220 13. MEDIA CONTACTS Terrorism and Other Public Health Emergencies: A Reference Guide for Media STATE AND LOCAL CONTACTS These fill-in-the-blank forms are designed for media professionals who would like to add contact information to this guide for their state and local public health departments and other contacts. LOCAL CONTACTS ORGANIZATION OTHER LOCAL CONTACTS (e.g., HOSPITALS) Public Health Department Emergency Medical Services Local Red Cross Local FBI Fire Department Police Department NAME/TITLE BUSINESS PHONE CELL PHONE E-MAIL HOME PHONE/ FAX/E-MAIL ADDRESS
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 221 ADDITIONAL CONTACTS (e.g., PERSONAL CONTACTS) ORGANIZATION NAME/TITLE BUSINESS PHONE CELL PHONE E-MAIL HOME PHONE/ FAX/E-MAIL ADDRESS STATE CONTACTS ORGANIZATION Public Health Department OTHER STATE CONTACTS (e.g., STATE EMERGENCY MANAGEMENT) NAME/TITLE BUSINESS PHONE CELL PHONE E-MAIL HOME PHONE/ FAX/E-MAIL ADDRESS

APPENDICES
APPENDIX A. Acronyms

The following acronyms may be helpful. Most of these terms

appear in this guide.

AHRQ Agency for Healthcare Research and Quality

(part of HHS)

AoA Administration on Aging (part of HHS)

APHL Association of Public Health Laboratories

API American Press Institute

ARC American Red Cross

ASTHO Association of State and Territorial Health

Officials

ATSDR Agency for Toxic Substances and Disease

Registry (part of CDC)

BSE Bovine Spongiform Encephalopathy (Mad Cow

Disease)

BSL Biosafety Level

CBP Customs and Border Protection (part of DHS)

CCRF Commissioned Corps Readiness Force (part of

PHS)

CDC Centers for Disease Control and Prevention 

(part of HHS)

CFSAN Center for Food Safety and Applied Nutrition

(part of FDA)

CG Phosgene

CIA Central Intelligence Agency

Cipro Ciprofloxacin Hydrochloride

CMS Center for Medicare & Medicaid Services (part of

HHS)

CPJ Committee to Protect Journalists

DFO Disaster Field Office

DHS U.S. Department of Homeland Security

DMAT Disaster Medical Assistance Team (part of

NDMS)

DMORT Disaster Mortuary Operational Response Team

(part of NDMS)

DNA Deoxyribonucleic Acid

DoD U.S. Department of Defense

DOE U.S. Department of Energy

DOL U.S. Department of Labor

DQ Division of Global Migration and Quarantine

(part of CDC)

EAP Employee Assistance Program

EEE Eastern Equine Encephalitis

EIS Epidemic Intelligence Services (part of CDC)

EMS Emergency Medical Services

EOC Emergency Operations Center

EPA U.S. Environmental Protection Agency

Epi-X Epidemic Information Exchange (part of CDC)

ESF Emergency Support Function

FDA Food and Drug Administration (part of HHS)

FEMA Federal Emergency Management Agency (part of

DHS)

FOIA Freedom of Information Act

FoodNet Foodborne Diseases Active Surveillance Network

(part of CDC)

FSIS Food Safety and Inspection Service (part of

USDA)

GA Tabun

GD Soman

HAN Health Alert Network (part of CDC)

HHS U.S. Department of Health and Human Services

HRSA Health Resources and Services Administration

(part of HHS)

ICS Incident Command System

IFJ International Federation of Journalists

IHS Indian Health Service (part of HHS)

IND Improvised Nuclear Devise

IV Intravenous

JIC Joint Information Center

KI Potassium Iodide

L Lewisite

LRN Laboratory Response Network (part of CDC)

MRC Medical Reserve Corps (part of HHS)

NACCHO National Association of County and City Health

Officials

NDMS National Disaster Medical System (part of DHS)

NECC National Emergency Coordination Center (part of

FEMA)

NEDSS National Electronic Disease Surveillance System

(part of CDC)

NIAID National Institute of Allergy and Infectious

Diseases (part of NIH)

NIH National Institutes of Health (part of HHS)

NIMH National Institute of Mental Health (part of NIH)

NIMS National Incident Management System 

224 APPENDICES: APPENDIX A Terrorism and Other Public Health Emergencies: A Reference Guide for Media
NIOSH National Institute for Occupational Safety and

Health (part of CDC)

NMRT National Medical Response Team (part of

NDMS)

NNRT National Nursing Response Team (part of

NDMS)

NPHIC National Public Health Information Coalition

NPHPP National Bioterrorism Hospital Preparedness

Program (part of HRSA)

NPRT National Pharmacy Response Team (part of

NDMS)

NRC U.S. Nuclear Regulatory Commission

NRP National Response Plan (part of DHS)

NRT National Response Team

NVPO National Vaccine Program Office (part of HHS)

OPHEP Office of Public Health Emergency Preparedness

(part of HHS)

OSHA Occupational Safety and Health Administration

(part of DOL)

PHS Public Health Service (part of HHS)

PHSA Public Health Service Act

PIO Public Information Officer

PTSD Posttraumatic Stress Disorder

RDD Radiation Dispersal Device

RED Radiation-Emitting Device

RNA Ribonucleic Acid

RRR Rapid Response Registry (part of ATSDR)

SAMHSA Substance Abuse and Mental Health Services

Administration (part of HHS)

SAP Select Agent Program (part of CDC)

SARS Severe Acute Respiratory Syndrome

SEB Staphyloccal Enterotoxin B

SERT Secretary’s Emergency Response Team (part of

HHS)

SNS Strategic National Stockpile (part of CDC)

TMP–SMX Trimethoprim/Sulfamethoxazole

USAMRIID U.S. Army Medical Research Institute for

Infectious Diseases (part of DOD)

USDA U.S. Department of Agriculture

VA U.S. Department of Veterans Affairs

vCJD Creutzfeldt-Jackob Disease

VEE Venezuelan Equine Encephalitis

VHF Viral Hemorrhagic Fever

VMAT Veterinary Medical Assistance Team (part of

NDMS)

WHO World Health Organization

WMD Weapons of Mass Destruction

WNV West Nile Virus

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 225
APPENDIX B. Web Sites

The Web sites in the following list may be helpful sources of

additional information. They are organized into three categories:

federal government organization Web sites, federal government

topical Web sites, and other Web sites. Please note that many

of these Web sites, as well as additional Web sites referencing

specific documents, also appear throughout the text.

FEDERAL GOVERNMENT ORGANIZATION WEB SITES

A

Administration for Children and Families (ACF)

http://www.acf.hhs.gov/

Administration on Aging (AoA)

http://www.aoa.gov/

Agency for Healthcare Research and Quality (AHRQ)

http://www.ahrq.gov/

Agency for Toxic Substances and Disease Registry (ATSDR)

http://www.atsdr.cdc.gov/

C

Center for Biologics Evaluation and Research (CBER)

http://www.fda.gov/cber/

Center for Devices and Radiological Health (CDRH)

http://www.fda.gov/cdrh/

Center for Drug Evaluation and Research (CDER)

http://www.fda.gov/cder/

Center for Food Safety and Applied Nutrition (CFSAN)

http://vm.cfsan.fda.gov/list.html

Center for Medicare & Medicaid Services (CMS)

http://www.cms.hhs.gov

Centers for Disease Control and Prevention (CDC)

http://www.cdc.gov/

Central Intelligence Agency (CIA)

http://www.cia.gov/

Commissioned Corps Readiness Force (CCRF)

http://www.usphs.gov/

Customs and Border Protection (CBP)

http://www.customs.ustreas.gov/

D

Defense Logistics Agency (DLA)

http://www.dla.mil/

Department of Agriculture (USDA)

http://www.usda.gov/

Department of Commerce (DOC)

http://www.commerce.gov/

Department of Defense (DoD)

http://www.defenselink.mil/

Department of Energy (DOE)

http://www.energy.gov/

Department of Health and Human Services (HHS)

http://www.hhs.gov/

Department of Homeland Security (DHS)

http://www.dhs.gov/

Department of Justice (DOJ)

http://www.usdoj.gov/

Department of Labor (DOL)

http://www.dol.gov/

Department of State (DOS)

http://www.state.gov/

Department of the Interior (DOI)

http://www.doi.gov/

Department of Transportation (DOT)

http://www.dot.gov/

Department of Veterans Affairs (VA)

http://www.va.gov/

Division of Global Migration and Quarantine (DQ)

http://www.cdc.gov/ncidod/dq/

E

Environmental Protection Agency (EPA)

http://www.epa.gov/

226 APPENDICES: APPENDIX B Terrorism and Other Public Health Emergencies: A Reference Guide for Media
F

Federal Bureau of Investigation (FBI)

http://www.fbi.gov/

Federal Communications Commission (FCC)

http://www.fcc.gov/

Federal Emergency Management Agency (FEMA)

http://www.fema.gov/

Food and Drug Administration (FDA)

http://www.fda.gov/

Food Safety and Inspection Service (FSIS)

http://www.fsis.usda.gov/

H

Health Resources and Services Administration (HRSA)

http://www.hrsa.gov/

I

Indian Health Service (IHS)

http://www.ihs.gov/

M

Medical Reserve Corps (MRC)

http://www.medicalreservecorps.gov/

N

National Advisory Committee on Children and Terrorism (NACCT)

http://www.bt.cdc.gov/children/index.asp

National Center for Environmental Health (NCEH)

http://www.cdc.gov/nceh/

National Center for Health Statistics (NCHS)

http://www.cdc.gov/nchs/

National Center for Toxicological Research (NCTR)

http://www.fda.gov/nctr/

National Communications System (NCS)

http://www.ncs.gov/

National Institute for Occupational Safety and Health (NIOSH)

http://www.cdc.gov/niosh/homepage.html

National Institute of Allergy and Infectious Diseases (NIAID)

http://www.niaid.nih.gov/

National Institute of Mental Health (NIMH)

http://www.nimh.nih.gov/

National Institutes of Health (NIH)

http://www.nih.gov/

National Library of Medicine (NLM)

http://www.nlm.nih.gov/

National Vaccine Program Office (NVPO)

http://www.hhs.gov/nvpo/

National Weather Service (NWS)

http://www.nws.noaa.gov/

Nuclear Regulatory Commission (NRC)

http://www.nrc.gov/

O

Occupational Safety and Health Administration (OSHA)

http://www.osha.gov/

Office for Domestic Preparedness (ODP)

http://www.ojp.usdoj.gov/odp/

Office of Public Health Emergency Preparedness (OPHEP)

http://www.hhs.gov/ophep/

Office of the Assistant Secretary for Public Affairs (OASPA)

http://www.hhs.gov/aspa/

P

Public Health Service (PHS)

http://www.usphs.gov/

R

Ready.Gov (from the U.S. Department of Homeland Security)

http://www.ready.gov/

S

Substance Abuse and Mental Health Services Administration

(SAMHSA)

http://www.samhsa.gov/

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 227
U

U.S. Army Medical Research Institute for Infectious Diseases

(USAMRIID)

http://www.usamriid.army.mil/

FEDERAL GOVERNMENT TOPICAL WEB SITES

A

Acute Radiation Syndrome (ARS)

http://www.bt.cdc.gov/radiation/ars.asp

Anthrax

http://www.bt.cdc.gov/agent/anthrax/

Arsine

http://www.bt.cdc.gov/agent/arsine/pdf/arsinefactsheet.pdf

B

Bio-Surveillance Initiatives

http://www.dhs.gov/dhspublic/display?theme=43&content=

3092&print=true

Biological Weapons Convention

http://www.state.gov/t/ac/trt/4718.htm#treaty

http://www.state.gov/t/ac/trt/4718.htm#signatory

BioSense

http://www.syndromic.org/pdf/work3-JL-BioSense.pdf

BioShield

http://www.hhs.gov/news/press/2004pres/20040721b.html

Botulism

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/botulism_g.htm

Brucellosis

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/brucellosis_g.htm

C

Chemical Agent List

http://www.bt.cdc.gov/agent/agentlistchem.asp

Chemical Weapons Convention

http://www.state.gov/www/global/arms/treaties/cwctext.html

Chlorine

http://www.bt.cdc.gov/agent/chlorine/basics/pdf/chlorine-facts.pdf

Cholera

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm

Clean Water Act

http://www.epa.gov/region5/water/cwa.htm

Cyanide

http://www.bt.cdc.gov/agent/cyanide/basics/pdf/cyanide-facts.pdf

D

Dirty Bombs

http://www.bt.cdc.gov/radiation/pdf/dirtybombs.pdf

Disaster Epidemiology and Assessment

http://www.cdc.gov/nceh/hsb/disaster/default.htm

E

Ebola

http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola.htm

E. coli

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm

Environmental Technology Verification Program (ETV)

http://www.epa.gov/etv/

Epidemic Information Exchange (Epi-X)

http://www.cdc.gov/epix/

Epidemic Intelligence Service (EIS)

http://www.cdc.gov/eis/

F

Federal Radiological Emergency Response Plan (FRERP)

http://www.fas.org/nuke/guide/usa/doctrine/national/frerp.htm

Foodborne Diseases Active Surveillance Network (FoodNet)

http://www.cdc.gov/foodnet/

Food Producers, Processors, and Transporters: Food Security

Preventive Measures Guidance

http://vm.cfsan.fda.gov/~dms/secguid6.html

Food Safety and Inspection Service (FSIS) Security Guidelines

for Food Processors

http://www.fsis.usda.gov/oa/topics/biosecurity2.htm

228 APPENDICES: APPENDIX B Terrorism and Other Public Health Emergencies: A Reference Guide for Media
Food Safety Requirements of the Bioterrorism Act

http://www.fda.gov/oc/bioterrorism/bioact.html

Food Tampering

http://vm.cfsan.fda.gov/~dms/fstamper.html

G

Geneva Protocol

http://www.state.gov/www/global/arms/treaties/geneva1.html

H

Health Alert Network (HAN)

http://www.phppo.cdc.gov/han/

L

Laboratory Response Network (LRN)

http://www.bt.cdc.gov/lrn/pdf/lrnfactsheet.pdf

Lewisite

http://www.bt.cdc.gov/agent/lewisite/basics/pdf/lewisite-facts.pdf

N

National Bioterrorism Hospital Preparedness Program

(NBHPP)

http://www.hrsa.gov/bioterrorism/

National Disaster Medical System (NDMS)

http://ndms.dhhs.gov/

National Electronic Disease Surveillance System (NEDSS)

http://www.cdc.gov/nedss/

National Incident Management System (NIMS)

http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web.pdf

National Response Plan (NRP)

http://www.dhs.gov/nrp

Nuclear Blast

http://www.bt.cdc.gov/radiation/pdf/nuclearblastfaq.pdf

P

Pandemic Influenza

http://www.hhs.gov/nvpo/pandemics/index.html

Phosgene

http://www.bt.cdc.gov/agent/phosgene/basics/pdf/phosgenefacts.pdf

Plague

http://www.bt.cdc.gov/agent/plague

Potassium Iodide (KI)

http://www.bt.cdc.gov/radiation/pdf/ki.pdf

Public Health Security and Bioterrorism Preparedness and

Response Act of 2002

http://thomas.loc.gov/cgi-bin/query/z?c107:H.R.3448.ENR:

Public Health Service Act (PHSA)

http://www.fda.gov/opacom/laws/phsvcact/phsvcact.htm

R

Radiation Emergencies

http://www.bt.cdc.gov/radiation

Radiation Emergency Assistance Center/Training Site

(REAC/TS)

http://www.orau.gov/reacts

Radioactive Contamination and Radioactive Exposure

http://www.bt.cdc.gov/radiation/contamination.asp

Radiological Emergency Response

http://www.epa.gov/radiation/rert

Respirator Fact Sheet

http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/

respfact.html

Retail Food Stores and Food Service Establishments: Food

Security Preventive Measures Guidance

http://vm.cfsan.fda.gov/~dms/secguid5.html

Ricin

http://www.bt.cdc.gov/agent/ricin/facts.asp

S

Safe Drinking Water Act (SDWA)

http://www.epa.gov/safewater/sdwa/sdwa.html

Salmonellosis

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/salmonellosis_g.htm

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 229
Sarin

http://www.bt.cdc.gov/agent/sarin/basics/pdf/sarin-facts.pdf

Select Agent Program (SAP)

http://www.cdc.gov/od/sap/

Severe Acute Respiratory Syndrome (SARS)

http://www.cdc.gov/ncidod/sars

Sheltering In Place—General

http://www.bt.cdc.gov/planning/Shelteringfacts.pdf

Sheltering In Place—Radiation

http://www.bt.cdc.gov/radiation/pdf/shelter.pdf

Shigellosis

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm

Smallpox

http://www.bt.cdc.gov/agent/smallpox/disease/faq.asp

Soman

http://www.bt.cdc.gov/agent/soman/basics/pdf/soman-facts.pdf

Strategic National Stockpile (SNS)

http://www.bt.cdc.gov/stockpile/index.asp

Sulfur Mustard

http://www.bt.cdc.gov/agent/sulfurmustard/basics/pdf/sulfurmustard-facts.pdf

T

Tabun

http://www.bt.cdc.gov/agent/tabun/basics/pdf/tabun-facts.pdf

Tularemia

http://www.bt.cdc.gov/agent/tularemia/facts.asp

V

Vulnerability Assessments

http://www.epa.gov/safewater/watersecurity/pubs/va_fact_

sheet_12-19.pdf

VX

http://www.bt.cdc.gov/agent/vx/basics/pdf/vx-facts.pdf

W

Water Security Division

http://www.epa.gov/watersecurity

Water Security Requirements of the Bioterrorism Act

http://cfpub.epa.gov/safewater/watersecurity/bioterrorism.cfm

West Nile Virus (WNV)

http://www.cdc.gov/ncidod/dvbid/westnile/index.htm

OTHER WEB SITES

A

American Medical Association (AMA)

http://www.ama-assn.org/

American Medical Association, Diagnosis and Management

of Foodborne Illnesses: A Primer for Physicians and Other

Health Care Professionals

http://www.ama-assn.org/ama/pub/category/print/3629.html

American Press Institute (API)

http://www.americanpressinstitute.org/

American Red Cross (ARC)

http://www.redcross.org/

Association of Public Health Laboratories (APHL)

http://www.aphl.org/

Association of State and Territorial Health Officials (ASTHO)

http://www.astho.org/

C

Committee to Protect Journalists (CPJ)

http://www.cpj.org/

Council of State and Territorial Epidemiologists (CSTE)

http://www.cste.org/

I

Institute of Medicine, National Academy of Sciences (IOM)

http://www.iom.edu/

International Federation of Journalists (IFJ)

http://www.ifj.org/

International News Safety Institute (INSI)

http://www.newssafety.com/

230 APPENDICES: APPENDIX B Terrorism and Other Public Health Emergencies: A Reference Guide for Media
M

Medical NBC Online Information Server (NBC-MED)

http://www.nbc-med.org

N

National Academy of Sciences (NAS)

http://www4.nationalacademies.org/nas/nashome.nsf

National Association of County and City Health Officials

(NACCHO)

http://www.naccho.org/

National Disaster Education Coalition, The (NDEC)

http://www.disastereducation.org/

National Public Health Information Coalition (NPHIC)

http://www.nphic.org/

National Voluntary Organization Active in Disaster (NVOAD)

http://www.nvoad.org/

Nuclear Energy Institute (NEI)

http://www.nei.org/

P

Pan American Health Organization (PAHO)

http://www.paho.org/

S

South Central Center for Public Health Preparedness—

Media Response to Bioterrorism and Other Threats to 

Public Health

http://mediaresponse.ua.edu

W

Water Terrorism

http://www.WaterHealthConnection.org/bt

World Health Organization (WHO), Communicable Disease

Surveillance and Response Program (CSR)

http://www.who.int/csr/en

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 231
APPENDIX C. Epidemiology Glossary

This glossary of epidemiology terms was created to provide the

media with accurate, straightforward definitions of epidemiology

terms as they relate to terrorism. The glossary is adapted from

several authoritative sources—including the U.S. Department

of Health and Human Services’ Centers for Disease Control

and Prevention. Experts from state and federal health agencies

have also provided assistance in simplifying these definitions

to meet the needs of journalists.

EPIDEMIOLOGY TERMS

Agent: A germ, chemical, or type of radiation that can cause

disease or damage to the human body.

Attack rate: Also known as case rate, is the proportion of the

population who developed a disease or injury out of a particular

group of people during a limited time period. The secondary

attack rate is the proportion of the population who were

around the initially affected people and who also ended up

getting sick.

Case: A person in the population identified as having a particular

disease, health disorder, or condition under investigation.

Case definition: A set of standard criteria, usually based on

symptoms, timing, and laboratory results, used for deciding

whether a person should be counted as having a particular

disease or health-related condition.

Contraindications: Any physical or medical reason why a

medicine or vaccine should not be given to an individual.

Epidemic: The occurrence of more cases of a disease than

expected in a given area or among a specific group of people

over a particular period of time.

Epidemic curve: A histogram (chart) that shows the course of

a disease outbreak or epidemic by plotting the number of

cases by time of onset.

Exposure: Contact with an agent by swallowing, breathing, or

touching the skin or eyes. Exposure may be short-term (acute

exposure), of intermediate duration, or long-term (chronic

exposure).

False negative: When, due to a negative test result, a person

who actually has the disease or condition in question is not

counted as a case.

False positive: When, due to a positive test result, a person

who does not have the disease or condition in question is

counted as a case.

Host: Any person or other living thing that can be infected by

an agent that causes disease.

Incidence: The number of new cases of a disease in a defined

population over a specific time period.

Incubation period: The time period from when a person gets

infected to when the first signs or symptoms of the disease

occur.

Index case: The first case that is known to investigators or

researchers. Determining the index case can be helpful in

tracing the origins of a disease outbreak.

Infection: Invasion and multiplication of living agents (bacteria,

fungi, viruses) that cause disease in body tissues. Infection

does not necessarily lead to illness.

Infectiousness: How easy it is for an infection to spread to

another living thing.

Immunization: The process of introducing weakened or killed

germs or toxins into the body to induce the immune system to

produce protective antibodies that will destroy the disease

causing agent if it enters the body at a later date. Immunization

is also known as vaccination.

Morbidity: Illness.

Mortality: Death. Usually the cause (a specific disease, a

condition, or an injury) is stated.

Pandemic: An epidemic occurring over a very wide area

(usually multicountry) and usually affecting a large proportion

of the population.

232 APPENDICES: APPENDIX C Terrorism and Other Public Health Emergencies: A Reference Guide for Media
Pathogen: An organism capable of causing disease.

Prevalence: The number of cases of a given disease or other

condition in a given population at a designated time.

Screening: The use of tests or examinations to identify

unrecognized disease. Positive screening tests may require

further examination and/or testing to confirm disease.

Sensitivity: The ability of a test to detect the proportion of

people with the disease who have a true positive test result.

The higher the sensitivity, the greater the detection rate and

the lower the false negative rate.

Specificity: The ability of a test to detect the proportion of

people without the disease who have a true negative test

result. The higher the specificity, the lower the false positive

rate and the lower the proportion of people who have the

disease who will be unnecessarily worried or exposed to

unneeded treatment.

Surveillance: Collecting information on cases of disease or

other conditions in a standard way to detect increases or

decreases in disease over time and differences between

various geographic areas. Public health officials use the

information to detect outbreaks and to plan programs to help

prevent and control disease.

Vaccination: See immunization.

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 233

ADDITIONAL RESOURCES

Agency for Toxic Substances Disease Registry. ATSDR Glossary

of Terms: http://www.atsdr.cdc.gov/glossary.html.

Centers for Disease Control and Prevention. “Crisis and

Emergency Risk Communication,” September 2002.

Centers for Disease Control and Prevention. Glossary of

Epidemiology Terms: http://www.cdc.gov/reproductivehealth/

EpiGlossary/glossary.htm.

University of Toronto, Centre for Evidence-Based Medicine,

University Health Network. http://www.cebm.utoronto.ca/glossary/.
APPENDIX D. Descriptions of Selected Sections of Acts 

Related to Public Health Emergencies

234 APPENDICES: APPENDIX D Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TABLE 1: SPECIFIC SECTIONS OF THE PUBLIC HEALTH SERVICE ACT

TITLE/SECTION KEY POINTS DESCRIPTION

42 U.S.C. § 247(d)

Declaration of a Public Health

Emergency

Provides authority to:

• Declare a public health emergency and take

action

• Make grants

• Provide expense awards

• Enter into contracts

• Conduct/support investigations about prevention

and treatment

The Secretary of the U.S. Department of Health and Human Services 

(HHS) may declare a public health emergency and take appropriate actions,

including making grants, providing awards for expenses, entering into

contracts, and conducting/supporting investigations into the cause,

prevention, or treatment of the disease or disorder that presents the

emergency.

42 U.S.C. § 264

Prevention of Communicable

Diseases

• Provides authority to quarantine or conditionally

release individuals to prevent transmission of

infectious diseases

Executive Order 13295 (4/4/03) permits the apprehension, detention, or

conditional release of individuals to prevent transmission of cholera,

diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral

hemorrhagic fevers, and severe acute respiratory syndrome (SARS). The

Secretary may quarantine individuals arriving into the United States, moving

from one state or possession into another, or when individuals are a

probable source of infection to other individuals moving between states. 

42 U.S.C. § 203–204, 214–216

Commissioned Corps and PHS

Personnel

(http://www.usphs.gov)

• Commissioned Corps (regular and reserved)

established for duty

• Public health personnel can be detailed

The Commissioned Regular Corps and a Commissioned Reserve Corps are

established for duty in time of emergency. Public health personnel can be

detailed to other federal departments or to state health and mental health

authorities.

42 U.S.C. § 247(d)-6(h)

Accelerated Research and

Development on Priority

Pathogens and Countermeasures

• Provides authority to prioritize counter terrorism

research

• Secretary may designate counterterrorism

medical products for priority review

The Secretary may give priority funding to research related to

countermeasures to pathogens of potential use in a bioterrorist attack or

other agents that may cause a public health emergency. The Secretary may

designate medical products for counterterrorism for priority review.

42 U.S.C. § 243

Quarantine Enforcement and

Temporary Assistance to States

• Local and state authorities may assist in

enforcing federal regulations of quarantine

• The Secretary may aid local and state authorities

in enforcing quarantines

The Secretary may accept assistance from local and state authorities in the

enforcement of federal regulations of quarantine and to aid the local and

state authorities in the enforcement of their quarantine or other prevention

or suppression of communicable diseases.

42 U.S.C. § 233

Defense of Certain Malpractice

and Negligence Suits, Smallpox

Compensation

• Provides remedies for malpractice and

negligence claims against the Public Health

Service (PHS) under the Federal Tort Claims Act

Provides that remedies under the Federal Tort Claims Act are the exclusive

remedy for malpractice and negligence claims against Commissioned Corps

officers and employees of PHS.

42 U.S.C. § 241

Research and Development

• Provides authority to conduct and support health

research

The Secretary is authorized to conduct and support research and studies

relating to the causes, diagnosis, treatment, control, and prevention of

physical and mental diseases.

This appendix includes sections of the Public Health Service Act; the Social Security Act; the Federal Food, Drug, and Cosmetic

Act; and the Public Health Security and Bioterrorism Preparedness and Response Act.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 235

TABLE 1: SPECIFIC SECTIONS OF THE PUBLIC HEALTH SERVICE ACT (cont.)

TITLE/SECTION KEY POINTS DESCRIPTION

42 U.S.C. § 265

Prohibition of Entry and Imports

• The Secretary may prohibit entry of individuals or

property into the United States in the interest of

public health

If there is a serious danger of a communicable disease in a foreign country

being introduced into the United States, in the interest of public health 

to avert such danger and in accordance with regulations approved by the

President, the Secretary can prohibit people or property from entering 

the country.

42 U.S.C. § 248

Establishment of Hospitals

• The Secretary may operate PHS hospitals The Secretary is able to operate PHS hospitals, including the management

of hospitals, treatment of patients, transfer of patients between hospitals,

disposal of articles produced by patients in the course of treatment, and

disposal of money and effects of deceased patients.

42 U.S.C. § 242(p)

National Disease Prevention

Data Profile

• The Secretary must compile and disseminate a

national disease prevention profile to provide a

database for emergencies

• Database includes morbidity rates and profiles

of population segments

The Secretary must compile and disseminate a national disease prevention

data profile to provide a database for use in an emergency situation. This

database includes such items as morbidity rates for diseases and health

profiles on segments of the population.

42 U.S.C. § 266

War-Time Quarantine

• Provides authority to apprehend and provide

examination of any individual suspected likely to

be a source of infection to military or war

workers

In time of war, to protect the military and war workers of the United States

against specified communicable diseases, the Secretary, in consultation

with the Surgeon General, is authorized to provide for the apprehension 

and examination of any individual believed to be infected with such disease

and likely to be a source of infection to members of the armed forces or 

war workers.

42 U.S.C. § 300 (hh)–12

Pharmaceutical Stockpile

• Provides for maintenance of a stockpile of

medical supplies and drugs for U.S. emergency

health security

The Secretary of the U.S. Department of Homeland Security, in coordination

with the Secretary of HHS and the Secretary of Veterans Affairs, may

maintain a stockpile of drugs, vaccines, and other biological products,

medical devices, and other supplies in such numbers, types, and amounts

as are determined by the Secretary of HHS to be appropriate and

practicable to provide for the emergency health security of the United

States, including children and other vulnerable populations.

42 U.S.C. § 267(a)

Quarantine Stations

• The Secretary controls, directs, and manages all

quarantine stations

• The Secretary designates quarantine borders

The Secretary shall control, direct, and manage all U.S. quarantine stations,

designate their boundaries, and designate the quarantine officers to be 

in charge.

42 U.S.C. § 249

Care and Treatment for Persons

Under Quarantine

• PHS cares for person under quarantine

• PHS pays expenses for treatment

PHS is responsible for the care and treatment of persons under quarantine

or the expense of their treatment and care in public or private medical

facilities if authorized by the officer in charge of the quarantine station.

42 U.S.C. § 262

Regulation of Biological

Products

• No person may introduce biological products into

interstate commerce without a license, label,

manufacturing identity, and expiration date

No person may introduce or deliver for introduction into interstate

commerce any biological product unless it is licensed and plainly marked

with the name, identity of manufacturer, and expiration date.

42 U.S.C. § 290(aa)

Crisis Counseling

• Provides for awards to public entities to address

emergency substance abuse or mental health

needs

The Secretary may make awards to public entities to address emergency

substance abuse or mental health needs.
236 APPENDICES: APPENDIX D Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TABLE 1: SPECIFIC SECTIONS OF THE PUBLIC HEALTH SERVICE ACT (cont.)

TITLE/SECTION KEY POINTS DESCRIPTION

42 U.S.C. § 247(d)-1

National Needs to Combat

Threats to Public Health

• Provides authority to improve/expand response

capacities of local, state, and national public

health agencies 

The Secretary is authorized to establish reasonable capacities to improve,

enhance, or expand the abilities of local, state, and national public health

agencies to detect and respond to public health threats.

42 U.S.C. § 247(d)-6(g)(1)

Emergency Response Personnel

Training

• Provides authority to develop educational and

training materials for public health and medical

professionals

• The Secretary may develop curricula for

proficiency testing of laboratory testing for

bioweapons

The Secretary is authorized to develop teaching materials and curricula 

to be given to public health officials, medical professionals, and other

personnel working in health care facilities for the following reasons: (1) for

identifying potential bioweapons and other agents that may create a public

health emergency, describing the care of victims of such an emergency, and

recognizing the special needs of children and other vulnerable populations;

(2) for community-wide planning by local and state governments, health

care facilities, and appropriate public and private sector entities to respond

to a bioterrorist attack or other public health emergency; and (3) for

proficiency testing of laboratory and other public health personnel for the

recognition and identification of potential bioweapons and other agents that

may create a public health emergency.

42 U.S.C. § 247(d)-2

Assessment of Public Health Needs

• Provides authority to award grants to perform

evaluations of the response capabilities of local

and state public health agencies

The Secretary is authorized to award grants to perform evaluations of the

capabilities of local and state public health agencies to respond to public

health threats.

42 U.S.C. § 247-7c

Supplies and Equipment

• The Secretary may provide supplies and

equipment for HHS, local, and state agencies in

response to emergencies

The Secretary may provide supplies, equipment, and services and detail

HHS officers and employees to deal with, among other things, action in

response to public health emergencies and support capacity building 

of local and state public health systems to detect and respond to public

health threats.

42 U.S.C. § 247(d)-7b

Credentialing of Health

Professionals

• Provides authority to maintain a system of

credentialing for health professionals

• The Secretary may encourage states to provide

authority to health professionals authorized in

another state to practice in the state

The Secretary is authorized to maintain a system for advance registration of

health professionals to verify credentials, licenses, accreditations, and

hospital privileges when such professionals volunteer to provide services

during public health emergencies. The Secretary may encourage, but not

require, each state to provide legal authority during a public health

emergency for health professionals authorized in another state to provide

such services in the state.

42 U.S.C. § 300(hh)

Public Health Response and

Recovery Preparations

• Provides authority to develop and implement a

state-coordinated strategy for planning and

responding to emergencies

• Provides authority to develop and implement an

emergency response plan and assist local and

state governments

The Secretary is authorized to develop and implement a coordinated

strategy for carrying out health-related preparations, response, and recovery

to public health emergencies and do so in coordination with states. The

Secretary is also authorized to develop and implement a preparedness and

response plan and provide effective assistance to local and state

governments to ensure that they have the appropriate capabilities to

coordinate emergency response.

42 U.S.C. § 300(ff)-81

Protection of Emergency

Response Workers

• Provides authority to create a list of lifethreatening infectious diseases to protect first

responders

The Secretary is authorized to complete a detailed list of potentially lifethreatening infectious diseases to which emergency response workers may

be exposed in responding to emergencies.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 237

TABLE 1: SPECIFIC SECTIONS OF THE PUBLIC HEALTH SERVICE ACT (cont.)

TITLE/SECTION KEY POINTS DESCRIPTION

42 U.S.C. § 300(aa)-10

National Vaccine Injury

Compensation Program

• Establishment of the National Vaccine Injury

Compensation Program

This section establishes the National Vaccine Injury Compensation Program,

administered by the Secretary, under which compensation may be paid for a

vaccine-related injury or death from covered childhood vaccines.

42 U.S.C. 247(d)-3a

Improvement of Hospital

Preparedness

• Provides authority to award grants to develop

and implement regional plans to improve

hospital and health system capacity to respond

to terrorism and other public health emergencies

The Secretary is authorized to award grants to states and other entities to

develop and implement regional plans to improve the capacity of hospitals

and other health system components to respond to incidents requiring mass

immunization, isolation, decontamination, diagnosis, and treatment in the

aftermath of terrorism or other public health emergencies.

TABLE 3: SPECIFIC SECTIONS OF THE FEDERAL FOOD, DRUG, AND COSMETIC ACT

TITLE/SECTION KEY POINTS DESCRIPTION

21 U.S.C. § 334

Detention of Food; Seizure of Food

• HHS and the Food and Drug Administration (FDA)

may detain food if there is credible evidence of

an adverse health consequence

• The United States may seize adulterated food

introduced into the interstate commerce or

obtained by the U.S. Customs and Border

Protection

FDA may, by Administrative Order, detain food (which includes live food

animals) for up to 30 days if it has credible evidence that it presents a

threat of serious adverse health consequences or death to humans or other

animals. The United States may seize any adulterated article of food that

has been introduced into interstate commerce or in the custody of the U.S.

Customs and Border Protection.

42 U.S.C. 247(d)-3a

Improvement of Hospital

Preparedness

• Provides authority to award grants to develop

and implement regional plans to improve

hospital and health system capacity to respond

to terrorism and other public health emergencies

Food is adulterated if it bears or contains any added poisonous or

deleterious substance that may render it injurious to health; is unfit for

food; or has been prepared, packed, or held under unsanitary conditions,

whereby it may have been rendered injurious to health.

TABLE 2: SPECIFIC SECTION OF THE SOCIAL SECURITY ACT

TITLE/SECTION KEY POINTS DESCRIPTION

42 U.S.C. § 1320(b)-5

Waiver of Medicare, Medicaid, 

or SCHIP Requirements

• The Secretary may ensure that health services

are available for Medicare, Medicaid, and SCHIP

enrollees

• Health care personnel who cannot comply with

program requirements yet provide services will

be reimbursed and exempt from sanctions

The Secretary may ensure, to the maximum extent feasible, that health care

services are available to meet the needs of individuals enrolled in the

Medicare, Medicaid, and SCHIP programs. Health care personnel who

provide services in good faith but are unable to comply with specific

program requirements are reimbursed and exempted from sanctions for

noncompliance, save for fraud or abuse.
238 APPENDICES: APPENDIX D Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TABLE 3: SPECIFIC SECTIONS OF THE FEDERAL FOOD, DRUG, AND COSMETIC ACT (cont.)

TITLE/SECTION KEY POINTS DESCRIPTION

21 U.S.C. § 350(c), 372, 374

Inspections and Investigations

• Provides authority to inspect food facilities and

vehicles used in all points of food production

FDA is authorized to inspect any location or vehicle where foods are

manufactured, processed, packed, or held for introduction into interstate

commerce or after such introduction, and this inspection extends to records

of such persons (excluding farms and restaurants) who manufacture,

process, pack, transport, distribute, hold, or import food when HHS/FDA has

a reasonable belief that the food is adulterated and presents a threat of

serious adverse health consequences or death to humans or animals.

21 U.S.C. § 381

Imports and Exports

• The United States may refuse all foods or

cosmetics that appear to be adulterated

Imports of food or cosmetics that appear to be adulterated are subject to

refusal of admission to the United States.

TABLE 4: SPECIFIC SECTIONS OF THE PUBLIC HEALTH SECURITY AND BIOTERRORISM PREPAREDNESS AND RESPONSE ACT

TITLE/SECTION KEY POINTS DESCRIPTION

Title I: National Preparedness for

Bioterrorism and Other Public

Health Emergencies

• Federal, state, and local coordination

• Strategic National Stockpile

• Improving state, local, and hospital

preparedness

Directs the Secretary to further develop and implement a coordinated

strategy for carrying out health-related activities to prepare for and respond

to bioterrorism or other public health emergencies. Provides support for the

National Disaster Medical System, an integrated system of public health

alert communication and surveillance; Strategic National Stockpile; and

development of priority countermeasures. The act also requires grants for

state- and community-wide plans for responding to bioterrorism or other

public health emergencies; to address deficiencies in those plans; to

provide materials, training, surveillance, and detection and communication

systems; and to support state, local, and hospital preparedness. Expands

authority of the Secretary, under certain conditions, to specify communicable

diseases subject to individual detention orders.

Title II-Subtitle A: Enhancing

Controls on Dangerous Biological

Agents and Toxins

• Provides for enhanced control of certain

biological agents and toxins

Directs the Secretary to establish a list of biological agents and toxins with

potential to pose a severe threat to public health and safety. Regulates

transfer of those agents. Requires standards and procedures for their use,

registration for their use, and safeguards and security requirements for their

possession, use, or transfer.

Title III: Protecting Safety and

Security of Food and Drug Supply

• Protects imported foods

• Requires linkages across federal agencies and

with states and tribal governments to protect the

food supply

• Establishes research to improve food safety

testing

• Requires regulation of foreign drug

manufacturers and importers

Directs the Secretary to increase port inspections of foods and extends

authority of FDA to temporarily detain food that may present a serious

threat to humans or animals. Improves FDA information management

systems relating to imported foods. Improves linkages with other federal

regulatory agencies dealing with food safety and state and Indian tribes.

Provides research to develop tests and methodologies to rapidly detect

adulteration of food. Mandates the annual registration of foreign

manufacturers engaged in food import into the United States.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 239

APPENDIX E. Family Disaster Planning—Five Steps to Safety

1. Find Out What Could Happen to You

> Contact your local American Red Cross chapter or emergency

management office before a disaster occurs—be prepared to

take notes.

> Ask what types of disasters are most likely to happen.

Request information on how to prepare for each.

> Learn about your community’s warning signals: what they

sound like and what you should do when you hear them.

> Ask about animal care after a disaster. Animals are not

allowed inside emergency shelters because of health

regulations.

> Find out how to help elderly or disabled persons, if necessary.

> Find out about the disaster plans at your workplace, your

children’s school or day care center, and other places where

your family spends time.

2. Create a Disaster Plan

> Meet with your family and discuss why you need to prepare

for disaster. Explain the dangers of fire, severe weather, and

earthquakes to children. Plan to share responsibilities and

work together as a team.

> Discuss the types of disasters that are most likely to happen.

Explain what to do in each case.

> Pick two places to meet:

- Right outside your home in case of a sudden emergency,

like a fire.

- Outside your neighborhood in case you cannot return home.

Everyone must know the address and phone number.

> Ask an out-of-state friend to be your “family contact.” After a

disaster, it is often easier to call long distance than locally.

Family members should call this person after an event and

tell them where they are. Everyone must know your contact’s

phone number.

> Discuss what to do in an evacuation. Plan how to take care

of your pets.

3. Complete the Following Tasks

> Post emergency telephone numbers by telephones (fire,

police, ambulance, school, etc.).

> Post the addresses and phone numbers for at least three

nearby hospitals (one near home, one near work, one near

your child’s school).

> Teach children how and when to call 9–1–1 or your local

Emergency Medical Services number for emergency help.

> Show each family member how and when to turn off the

utilities (water, gas, and electricity) at the main switches.

> Check to see if you have adequate insurance coverage.

> Get training from the fire department for each family member

on how to use the household fire extinguishers (ABC type)

and show everyone where you keep them.

> Install smoke detectors on each level of your home, especially

near bedrooms.

> Conduct a home hazard hunt.

> Stock emergency supplies and assemble a disaster supplies

kit (see appendix F).

> Take an American Red Cross first aid and cardiopulmonary

resuscitation (CPR) class.

> Determine the best escape routes from your home. Find two

ways out of each room.

> Find the safe places in your home for each type of disaster.

4. Make Sure That You Have All Essential Personal

Information for You and Each Member of Your Family

> Blood types

> Allergies

> Medications

> Past and current medical conditions (e.g., diabetes, high blood

pressure)

> Immunization history

> Names and numbers for family physicians
(It may be helpful to put this information in a document, along

with a photo ID. If there are mass immunizations or medicine

distributions in your community, you may need a photo ID for

each member of your family.)

5. Practice and Maintain Your Plan

> Quiz your children every 6 months or so.

> Conduct fire and emergency evacuations.

> Replace stored water and stored food every 6 months.

> Test and recharge your fire extinguisher(s) according to

manufacturer’s instructions.

> Test your smoke detectors monthly and change the batteries

at least once a year.

Based on the “Your Family Disaster Plan” developed by the

Federal Emergency Management Agency (http://www.fema.gov)

and American Red Cross (http://www.redcross.org).

240 APPENDICES: APPENDIX E Terrorism and Other Public Health Emergencies: A Reference Guide for Media

REFERENCE

Federal Emergency Management Agency, & American Red Cross.

(2004). Your family disaster plan. http://www.fema.gov/pdf/

library/yfdp.pdf.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 241

APPENDIX F. Disaster Supplies Kit

There are six basics that you should stock for your home: water,

food, first aid kit, clothing and bedding, tools and emergency

supplies, and special items. Keep the items that you would

most likely need during an evacuation in an easy-to-carry

container—suggested items are marked with an asterisk(*) in

the list below. Possible containers include a large, covered trash

container; a camping backpack; or duffelbag.

WATER

Store water in plastic containers, such as soft drink bottles.

Avoid using containers that will decompose or break, such as

milk cartons or glass bottles. A normally active person needs to

drink at least 2 quarts of water each day. Hot environments and

intense physical activity can double that amount. Children,

nursing mothers, and ill people will need more.

> Store 1 gallon of water per person per day. (2 quarts for

drinking, 2 quarts for each person in your household for food

preparation/sanitation).*

> Keep at least a 3-day supply of water per person.

FOOD*

Store at least a 3-day supply of nonperishable food. Select

foods that require no refrigeration, preparation, or cooking and

little or no water. If you must heat food, pack a can of sterno.

Select food items that are compact and lightweight. Include a

selection of the following foods in your disaster supplies kit:

> Ready-to-eat canned meats, fruits, and vegetables

> Canned juices

> Staples (salt, sugar, pepper, spices, etc.)

> High energy foods

> Vitamins

> Food for infants and elderly

> Comfort/stress foods

FIRST AID KIT*

Assemble a first aid kit for your home and one for each car.

> Twenty adhesive bandages, various sizes

> One 5” x 9” sterile dressing

> One conforming roller gauze bandage

> Two triangular bandages

> Two 3” x 3” sterile gauze pads

> Two 4” x 4” sterile gauze pads

> One roll 3” cohesive bandage

> Two germicidal hand wipes or waterless alcohol-based hand

sanitizer

> Six antiseptic wipes

> Two pairs of large medical grade nonlatex gloves

> Adhesive tape, 2” width

> Antibacterial ointment

> Cold pack

> Scissors (small, personal)

> Tweezers

> Cardiopulmonary resuscitation (CPR) breathing barrier, such

as a face shield

NONPRESCRIPTION DRUGS

> Aspirin or nonaspirin pain reliever

> Antidiarrhea medication

> Antacid (for stomach upset)

> Syrup of Ipecac (use to induce vomiting, if advised by the

Poison Control Center)

> Laxative

> Activated charcoal (use if advised by the Poison Control

Center)

CLOTHING AND BEDDING

Include at least one complete change of clothing and footwear

per person.*

> Sturdy shoes or work boots*

> Rain gear*

> Blankets or sleeping bags*

> Hat and gloves

> Thermal underwear

> Sunglasses
242 APPENDICES: APPENDIX F Terrorism and Other Public Health Emergencies: A Reference Guide for Media

TOOLS AND EMERGENCY SUPPLIES

> Mess kits, or paper cups and plates,

and plastic utensils*

> Emergency preparedness manual*

> Battery-operated radio and extra

batteries*

> Flashlight and extra batteries*

> Cash or traveler’s checks and change*

> Nonelectric can opener and utility knife*

> Fire extinguisher: small canister ABC

type

> Tube tent

> Pliers

> Tape

> Compass

> Matches in a waterproof container

> Aluminum foil

> Plastic storage containers

> Signal flare

> Paper and pencil

> Needles and thread

> Medicine dropper

> Shutoff wrench (to turn off household

gas and water)

> Whistle

> Plastic sheeting

> Map of the area (for locating shelters)

SANITATION

> Toilet paper and towelettes*

> Soap and liquid detergent*

> Feminine supplies*

> Personal hygiene items*

> Plastic garbage bags and ties

(for personal sanitation uses)

> Plastic bucket with tight lid

> Disinfectant

> Household chlorine bleach (may also be

used for purifying drinking water—see

http://www.redcross.org for instructions)

SPECIAL ITEMS

Remember family members with special

requirements, such as infants and elderly

or disabled persons.

FOR BABY*

> Formula

> Diapers

> Bottles

> Powdered milk

> Medications

FOR ADULTS*

> Heart and high blood pressure

medication

> Insulin

> Prescription drugs

> Denture needs

> Contact lenses and supplies

> Extra eye glasses

ENTERTAINMENT

> Games, playing cards, and books

IMPORTANT FAMILY DOCUMENTS

Keep these records in a waterproof,

portable container:

> Will, insurance policies, contracts deeds,

stocks and bonds

> Passports, social security cards,

immunization records

> Bank account numbers

> Credit card account numbers and

companies

> Inventory of valuable household goods

and important telephone numbers

> Family records (birth, marriage, and

death certificates)

Based on the “Your Family Disaster

Supplies Kit” developed by the Federal

Emergency Management Agency

(http://www.fema.gov) and the American

Red Cross (http://www.redcross.org).

Additional supply checklists can also be

found at http://www.ready.gov.

STORAGE

> Store your kit in a convenient place known

to all family members. Keep a smaller

version of the supplies kit in the trunk of

your car.

> Keep items in airtight plastic bags. Change

your stored water supply every 6 months

so it stays fresh. Also, replace your stored

food every 6 months. Rethink your kit

and family needs at least once a year.

Replace batteries, update clothes, etc.

> Ask your physician or pharmacist about

storing prescription medications.

REFERENCE

Federal Emergency Management

Agency, & American Red Cross. (2004).

Your family disaster supplies kit.

http://www.fema.gov/pdf/library/fdsk.pdf.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 243

APPENDIX G. Personal Workplace Disaster Supplies Kit

In the workplace, where you might be confined for several

hours or perhaps overnight, you may need the following

supplies.

FLASHLIGHT WITH EXTRA BATTERIES

Use the flashlight to find your way if the power is out. Do not

use candles or any other open flame for emergency lighting.

BATTERY-POWERED RADIO WITH EXTRA BATTERIES

News about the emergency may change rapidly as events

unfold. You will also be concerned about family and friends in

the area. Radio reports will give information about the areas

most seriously affected.

FOOD

Enough nonperishable food to sustain you for at least 1 day

(three meals) is a good idea. Select foods that require no

refrigeration, preparation, or cooking and little or no water.

Suggested items include:

> Ready-to-eat canned meals, meats, fruits, and vegetables

> Canned juices

> High-energy foods (granola bars, energy bars, etc.)

WATER

Keep at least 1 gallon of water available, more if you are on

medications that require water or increase thirst. Store water

in plastic containers, such as soft drink bottles, not ones that

will decompose or break, such as milk cartons or glass bottles.

MEDICATIONS

Include any nonprescription medications you usually take,

including pain relievers, stomach remedies, and so forth.

If you use prescription medications, keep at least a 3-day

supply at your workplace. Consult with your physician or

pharmacist about how to store these medications and talk to

your employer about any storage concerns.

FIRST AID SUPPLIES

If your employer does not provide first aid supplies, have the

following essentials:

> Twenty adhesive bandages, various sizes

> One 5” x 9” sterile dressing

> One conforming roller gauze bandage

> Two triangular bandages

> Two 3” x 3” sterile gauze pads

> Two 4” x 4” sterile gauze pads

> One roll 3” cohesive bandage

> Two germicidal hand wipes or waterless alcohol-based 

hand sanitizer

> Six antiseptic wipes

> Six pair large medical grade nonlatex gloves

> Adhesive tape, 2” width

> Antibacterial ointment

> Cold pack

> Scissors (small, personal)

> Tweezers

> CPR breathing barrier, such as a face shield

TOOLS AND SUPPLIES

> Emergency “space” blanket (mylar)

> Paper plates and cups, plastic utensils

> Nonelectric can opener

> Personal hygiene items, including a toothbrush, toothpaste,

comb, brush, soap, contact lens supplies, and feminine

supplies

> Plastic garbage bags and ties (for personal sanitation uses)

> One complete change of clothing and footwear, including 

a long-sleeved shirt, long pants, and closed-toed shoes 

or boots

> An extra pair of eyeglasses, if you wear them
GENERAL INFORMATION

> Adjust your kit according to your own personal needs.

> Do not include candles, weapons, toxic chemicals, or

controlled drugs unless prescribed by a physician.

TOOLS FOR WORK

You may wish to have some additional tools in case you are

working during an emergency. These may include:

> Police scanner

> Binoculars

> Walkie-talkies

> Whistle

> Lighter

> Waterproof pouches

Based on the “Your Family Disaster Supplies Kit” developed by

the Federal Emergency Management Agency (http://www.fema.gov)

and the American Red Cross (http://www.redcross.org).

244 APPENDICES: APPENDIX G Terrorism and Other Public Health Emergencies: A Reference Guide for Media

REFERENCE

Federal Emergency Management Agency, & American Red Cross.

(2004). Your family disaster supplies kit. http://www.fema.gov/

pdf/library/fdsk.pdf.

PREPARING FOR POWER OUTAGE

Consider buying a “power inverter” from an electronics store. You can

plug the inverter into the power outlet in your car and it will allow you

to run a laptop and portable printer with the car running (of course, 

in a well-ventilated area—not a garage). A car cell-phone charger is

also helpful.

TIP
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 245

APPENDIX H. Self-Monitoring Checklist

Developed by the U.S. Department of Health and Human

Services’ Substance Abuse and Mental Health Services

Administration, this checklist is a useful tool for measuring

stress levels during and following a public health emergency.

Check off anything that pertains to feelings, thoughts, or

behaviors in the last 24–48 hours. Experiencing a few of these

symptoms may not be a problem, but experiencing several

from each category may indicate the need to reduce stress.

BEHAVIORAL

❑ I am more or less active than normal.

❑ I am not as effective or efficient as usual.

❑ People do not seem to understand what I am trying to say.

❑ I feel irritable or angry all the time.

❑ I cannot seem to rest, relax, or calm down.

❑ I am eating a lot more/less than usual.

❑ I have trouble sleeping/am sleeping too much.

❑ I cry a lot or feel like crying all the time.

❑ I am drinking or smoking more than I usually do.

PHYSICAL

❑ My heart seems to beat fast all the time.

❑ I have an upset stomach, nausea, or diarrhea more often

than normal.

❑ I have been gaining/losing a lot of weight.

❑ I perspire more than normal or often have chills.

❑ I have been having headaches.

❑ I have sore or aching muscles.

❑ My eyes are more sensitive to light.

❑ I have lower back pain.

❑ I feel there is a “lump in my throat” all the time.

❑ I jump at loud noises or when people come up behind me.

❑ I sleep okay, but I am still tired.

❑ I cannot get rid of this cold/I feel I am coming down with

the flu.

❑ My allergies, asthma, arthritis, or other chronic health

condition(s) have been bothering me more than usual.

PSYCHOLOGICAL/EMOTIONAL

❑ I have been on a natural high/an adrenaline rush for days.

❑ I often feel anxious or fearful.

❑ I cannot keep my mind on my work.

❑ I feel sad, moody, or depressed.

❑ I have been having disturbing dreams.

❑ I feel guilty about what the survivors are going through.

❑ I feel overwhelmed, helpless, or hopeless.

❑ I feel isolated, lost, or alone.

❑ No one seems to understand or appreciate me.

COGNITIVE

❑ I am having trouble remembering things.

❑ I get confused easily.

❑ I cannot figure things out as quickly as I usually do.

❑ I keep making mistakes or cannot make decisions well.

❑ I have trouble concentrating.

❑ I cannot quit thinking about the disaster or incident.

SOCIAL

❑ I do not want to be around people.

❑ I do not want to listen to people.

❑ Trying to work with the group seems like a waste.

❑ I do not like to ask for help.

❑ People seem so slow or unresponsive.

REFERENCE

Carter, N.C. (2001, draft). Stress management handbook for

disaster response and crisis response personnel. Rockville,

MD: Center for Mental Health Services, Substance Abuse and

Mental Health Services Administration, U.S. Department of

Health and Human Services.
APPENDICES: APPENDIX I

APPENDIX I. Reducing Stress and Renewing Energy

> Take a walk or stretch.

> Stop and breathe deeply for a few moments.

> Talk to a trusted friend about your situation.

> Eat nutritious foods (e.g., lean protein, whole grains, fruits,

and vegetables) and avoid sugar, caffeine, and alcohol.

> Take a hot bath.

> Read a humorous or interesting book on a topic completely

unrelated to what you are dealing with.

> Sit in a dark room for a few minutes to help relieve

headaches.

> Get to sleep early, if possible.

> Be patient with yourself.

> Ask people who have been through a similar experience how

they handled their stress.

> Get a friend to partner with you for stress monitoring and

reduction.

> If you feel lonely or isolated, ask someone to go to dinner or

a movie.

> Meditate.

> Exercise.

> Spend some time with friends, family, and/or pets.

246 Terrorism and Other Public Health Emergencies: A Reference Guide for Media

REFERENCE

Carter, N.C. (2001, draft). Stress management handbook for

disaster response and crisis response personnel. Rockville,

MD: Center for Mental Health Services, Substance Abuse and

Mental Health Services Administration, U.S. Department of

Health and Human Services.
APPENDIX J. Helping Children and Adolescents 

Cope With Violence and Disasters

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 247

The U.S. Department of Health and Human Services’ (HHS)

National Institute of Mental Health (NIMH) and other federal

agencies are working to address the issue of assisting children

and adolescents who have been victims of or witnesses to

violent and/or catastrophic events. The purpose of this fact

sheet is to tell what is known about the impact of violence and

disasters on children and adolescents and suggest steps to

minimize long-term emotional harm.

In the aftermath of the September 11 terrorist attacks on New

York City and Washington, DC, both adults and children

struggled with the emotional impact of such large-scale

damage and losses of life. Other major acts of violence that

have been felt across the country include the 1995 bombing

of the Alfred P. Murrah Federal Building in Oklahoma City and

the 1999 shootings at Columbine High School in Littleton,

Colorado. While these disastrous events have caught the

nation’s attention, they are only a fraction of the many tragic

episodes that affect children’s lives. Each year, many children

and adolescents sustain injuries from violence, lose friends or

family members, or are adversely affected by witnessing a

violent or catastrophic event. Each situation is unique,

whether it centers upon a plane crash where many people are

killed, automobile accidents involving friends or family

members, or natural disasters, such as the Northridge,

California earthquake (1994) or Hurricane Floyd (1999),

where deaths occur and homes are lost—but these events

have similarities as well and cause similar reactions in

children. Even in the course of everyday life, exposure 

to violence in the home or on the streets can lead to 

emotional harm.

Research has shown that both adults and children who

experience catastrophic events show a wide range of reactions

(Smith & North 1993; Yehuda et al. 1998). Some suffer only

worries and bad memories that fade with emotional support

and the passage of time. Others are more deeply affected and

experience long-term problems. Research on posttraumatic

stress disorder (PTSD) shows that some soldiers; survivors of

criminal victimization, torture and other violence; and

survivors of natural and man-made catastrophes suffer longterm effects from their experiences. Children who have

witnessed violence in their families, schools, or communities are

also vulnerable to serious long-term problems. Their emotional

reactions, including fear, depression, withdrawal, or anger, can

occur immediately or sometime after the tragic event.

Youngsters who have experienced a catastrophic event often

need support from parents and teachers to avoid long-term

emotional harm. Most will recover in a short time, but the few

who develop PTSD or other persistent problems need

treatment.

TRAUMA—WHAT IS IT?

“Trauma” has both a medical and a psychiatric definition.

Medically, “trauma” refers to a serious or critical bodily injury,

wound, or shock. This definition is often associated with

trauma medicine practiced in emergency rooms and represents

a popular view of the term. Psychiatrically, “trauma” has

assumed a different meaning and refers to an experience that

is emotionally painful, distressful, or shocking, which often

results in lasting mental and physical effects.

Psychiatric trauma, or emotional harm, is essentially a normal

response to an extreme event. It involves the creation of

emotional memories about the distressful event that are stored

in structures deep within the brain. In general, it is believed

that the more direct the exposure to the traumatic event, the

higher the risk for emotional harm (March et al. 1997). Thus,

in a school shooting, for example, the student who is injured

probably will be most severely affected emotionally; and the

student who sees a classmate shot, even killed, is likely to be

more emotionally affected than the student who was in

another part of the school when the violence occurred. But

even second-hand exposure to violence can be traumatic. For

this reason, all children and adolescents exposed to violence

or a disaster, even if only through graphic media reports,

should be watched for signs of emotional distress.

HOW CHILDREN AND ADOLESCENTS REACT TO

TRAUMA

Reactions to trauma may appear immediately after the

traumatic event or days and even weeks later. Loss of trust in

adults and fear of the event occurring again are responses seen

in many children and adolescents who have been exposed to

traumatic events. Other reactions vary according to age

(Marans & Adelman 1997; Osofsky 1995; Pynoos et al.

1996; Vogel & Vernberg 1993):
For children 5 years of age and younger, typical reactions can

include a fear of being separated from the parent, crying,

whimpering, screaming, immobility and/or aimless motion,

trembling, frightened facial expressions, and excessive

clinging. Parents may also notice children returning to

behaviors exhibited at earlier ages (these are called regressive

behaviors), such as thumb-sucking, bedwetting, and fear of

darkness. Children in this age bracket tend to be strongly

affected by the parents’ reactions to the traumatic event.

Children 6–11 years old may show extreme withdrawal,

disruptive behavior, and/or inability to pay attention.

Regressive behaviors, nightmares, sleep problems, irrational

fears, irritability, refusal to attend school, outbursts of anger,

and fighting are also common in traumatized children of this

age. Also, the child may complain of stomachaches or other

bodily symptoms that have no medical basis. Schoolwork

often suffers. Depression, anxiety, feelings of guilt, and

emotional numbing or “flatness” are often present as well.

Adolescents 12–17 years old may exhibit responses similar to

those of adults, including flashbacks, nightmares, emotional

numbing, avoidance of any reminders of the traumatic event,

depression, substance abuse, problems with peers, and

antisocial behavior. Also common are withdrawal and

isolation, physical complaints, suicidal thoughts, school

avoidance, academic decline, sleep disturbances, and

confusion. The adolescent may feel extreme guilt over his or

her failure to prevent injury or loss of life and may harbor

revenge fantasies that interfere with recovery from the trauma.

Some youngsters are more vulnerable to trauma than others,

for reasons scientists do not fully understand. It has been shown

that the impact of a traumatic event is likely to be greatest in

the child or adolescent who previously has been the victim of

child abuse or some other form of trauma or who already had

a mental health problem (Boney-McCoy & Finkelhor 1995;

Duncan et al. 1996; Garbarino et al. 1991; Roth et al. 1997).

And the youngster who lacks family support is more at risk for

a poor recovery (Morrison 2000).

HELPING THE CHILD OR ADOLESCENT TRAUMA

SURVIVOR

Early intervention to help children and adolescents who have

suffered trauma from violence or a disaster is critical. Parents,

teachers, and mental health professionals can do a great deal

to help these youngsters recover.

After violence or a disaster occurs, the family is the first-line

resource for helping. Among the things that parents and other

caring adults can do are:

> Explain the episode of violence or disaster as well as you are

able.

> Encourage the children to express their feelings and listen

without passing judgment. Help younger children learn to

use words that express their feelings. However, do not force

discussion of the traumatic event.

> Let children and adolescents know that it is normal to feel

upset after something bad happens.

> Allow time for the youngsters to experience and talk about

their feelings. At home, however, a gradual return to routine

can be reassuring to the child.

> If your children are fearful, reassure them that you love them

and will take care of them. Stay together as a family as much

as possible.

> If behavior at bedtime is a problem, give the child extra time

and reassurance. Let him or her sleep with a light on or in

your room for a limited time if necessary.

> Reassure children and adolescents that the traumatic event

was not their fault.

> Do not criticize regressive behavior or shame the child with

words like “babyish.”

> Allow children to cry or be sad. Do not expect them to be

brave or tough.

> Encourage children and adolescents to feel in control. Let

them make some decisions about meals, what to wear, etc.

> Take care of yourself so you can take care of the children.

Most children and adolescents, if given support such as that

described above, will recover almost completely from the fear

and anxiety caused by a traumatic experience within a few

weeks. However, some children and adolescents will need

248 APPENDICES: APPENDIX J Terrorism and Other Public Health Emergencies: A Reference Guide for Media
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 249

more help perhaps over a longer period of time to heal. Grief

over the loss of a loved one, teacher, friend, or pet may take

months to resolve and may be reawakened by reminders such

as media reports or the anniversary of the death.

In the immediate aftermath of a traumatic event and the weeks

following, it is important to identify the youngsters who are in

need of more intensive support and therapy because of

profound grief or some other extreme emotion. Children and

adolescents who may require the help of a mental health

professional include those who show avoidance behavior, such

as resisting or refusing to go places that remind them of the

place where the traumatic event occurred, and emotional

numbing, a diminished emotional response or lack of feeling

toward the event. Youngsters who have more common

reactions, including re-experiencing the trauma, or reliving it

in the form of nightmares and disturbing recollections during

the day, and hyperarousal, including sleep disturbances and a

tendency to be easily startled, may respond well to supportive

reassurance from parents and teachers.

WHAT ARE SCIENTISTS LEARNING ABOUT TRAUMA IN

CHILDREN AND ADOLESCENTS?

NIMH, a part of the National Institutes of Health, supports

research on the brain and a wide range of mental disorders,

including PTSD and related conditions. The Department of

Veterans Affairs also conducts research in this area with adults

and their family members.

Recent research findings include:

> Some studies show that counseling children very soon after

a catastrophic event may reduce some of the symptoms of

PTSD. A study of trauma/grief-focused psychotherapy among

early adolescents exposed to an earthquake found that brief

psychotherapy was effective in alleviating PTSD symptoms

and preventing the worsening of co-occurring depression

(Goenjian et al. 1997).

> Parents’ responses to a violent event or disaster strongly

influence their children’s ability to recover. This is particularly

true for mothers of young children. If the mother is depressed

or highly anxious, she may need to get emotional support or

counseling to be able to help her child (Bromet et al. 2000;

Deblinger et al. 1999; McFarlane 1987).

> Either being exposed to violence within the home for an

extended period of time or exposure to a one-time event, like

an attack by a dog, can cause PTSD in a child.

> Research has demonstrated that PTSD after exposure to a

variety of traumatic events (family violence, child abuse,

disasters, and community violence) is often accompanied by

depression (Ackerman et al. 1998; Lipschitz et al. 1999;

March et al. 1997; McCloskey & Walker 2000; Pfefferbaum

et al. 1999). Depression must be treated along with PTSD,

and early treatment is best.

NIMH-supported scientists are continuing to conduct research

into the impact of violence and disaster on children and

adolescents. Through research, NIMH hopes to gain

knowledge to lessen the suffering that violence and disasters

impose on children and adolescents and their families.

The General Public can obtain publications about PTSD and

other anxiety disorders by calling NIMH’s toll-free information

service, 1-888-ANXIETY, or calling the Institute’s public

inquiries office at 301-443-4513. Information is also available

online from NIMH’s Web site (http://www.nimh.nih.gov/

healthinformation/anxietymenu.cfm). The accompanying resource

list indicates agencies or organizations that may have

additional information about helping children and adolescents

cope with violence and disasters.

Reporters interested in PTSD and other anxiety disorders may

contact the NIMH press office at 301-443-4536.

Based on the NIMH booklet “Helping Children and Adolescents

Cope With Violence and Disasters”—http://www.nimh.nih.gov/

publicat/violence.cfm.
250 APPENDICES: APPENDIX J Terrorism and Other Public Health Emergencies: A Reference Guide for Media

REFERENCES

Ackerman, P.T., Newton, J.E., McPherson, W.B., Jones, J.G., 

& Dykman, R.A. (1998). Prevalence of post traumatic stress

disorder and other psychiatric diagnoses in three groups of

abused children (sexual, physical, and both). Child Abuse and

Neglect, 22(8), 759–774.

Bell, C.C., & Jenkins, E.J. (1991). Traumatic stress and children.

Journal of Health Care for the Poor and Underserved, 2(1),

175–185.

Boney-McCoy, S., & Finkelhor, D. (1995). Prior victimization: 

A risk factor for child sexual abuse and for PTSD-related

symptomatology among sexually abused youth. Child Abuse and

Neglect, 19(12), 1401–1421.

Bremner, J.D., Randall, P., Scott, T.M., Bronen, R.A., Seibyl, J.P.,

Southwick, S.M., et al. (1995). MRI-based measurement of

hippocampal volume in patients with combat-related

posttraumatic stress disorder. American Journal of Psychiatry,

152, 973–981.

Breslau, N., Kessler, R.C., Chilcoat, H.D., Schultz, L.R., Davis,

G.C., & Andreski, P. (1998). Trauma and posttraumatic stress

disorder in the community: The 1996 Detroit Area Survey of

Trauma. Archives of General Psychiatry, 55(7), 626–632.

Bromet, E.J., Goldgaber, D., Carlson, G., Panina, N., Golovakha,

E., Gluzman, S.F., et al. (2000). Children’s well-being 11 years

after the Chornobyl catastrophe. Archives of General Psychiatry,

57(6), 563–571.

Cahill, L. (1997). The neurobiology of emotionally influenced

memory: Implications for understanding traumatic memory. 

In R. Yehuda & A.C. McFarlane (Eds.), Psychobiology of

posttraumatic stress disorder. Annals of the New York Academy of

Sciences (Vol. 821, pp. 238–246). New York, NY: The New York

Academy of Sciences.

De Bellis, M.D., Baum, A.S., Birmaher, B., Keshavan, M.S.,

Eccard, C.H., Boring, A.M., et al. (1999). A.E. Bennett Research

Award. Developmental traumatology. Part I: Biological stress

systems. Biological Psychiatry, 45(10), 1259–1270.

De Bellis, M.D., Keshavan, M.S., Clark, D.B., Casey, B.J., Giedd,

J.N., Boring, A.M., et al. (1999). A.E. Bennett Research Award.

Developmental traumatology. Part II: Brain development.

Biological Psychiatry, 45(10), 1271–1284.

Deblinger, E., Steer, R.A., & Lippmann, J. (1999). Maternal

factors associated with sexually abused children’s psychosocial

adjustment. Child Maltreatment, 4(1), 13–20.

Duncan, R.D., Saunders, B.E., Kilpatrick, D.G., Hanson, R.F., &

Resnick, H.S. (1996). Childhood physical assault as a risk factor

for PTSD, depression, and substance abuse: Findings from a

national survey. American Journal of Orthopsychiatry, 66(3),

437–448.

Earls, F.J. Child exposure to violence and PTSD across urban

settings. NIMH Grant No. 5R01MH56241-05. In progress. 

Garbarino, J., Kostelny, K., & Dubrow, N. (1991). What children

can tell us about living in danger. American Psychologist, 46(4),

376–383.

Goenjian, A.K., Karayan, I., Pynoos, R.S., Minassian, D., Najarian,

L.M., Steinberg, A.M., et al. (1997). Outcome of psychotherapy

among early adolescents after trauma. American Journal of

Psychiatry, 154(4), 536–542.

Gold, P.E., & McCarty, R.C. (1995). Stress regulation of memory

processes: Role of peripheral catecholamines and glucose. In M.J.

Friedman, D.S. Charney, & A.Y. Deutch (Eds.), Neurobiological

and clinical consequences of stress: From normal adaptation to

post-traumatic stress disorder (pp. 151–162). Philadelphia, PA:

Lippincott-Raven.

Golier, J., & Yehuda, R. (1998). Neuroendocrine activity and

memory-related impairments in posttraumatic stress disorder.

Developmental Psychopathology, 10(4), 857–869.

Lipschitz, D.S., Winegar, R.K., Hartnick, E., Foote, B., &

Southwick, S.M. (1999). Posttraumatic stress disorder in

hospitalized adolescents: Psychiatric comorbidity and clinical

correlates. Journal of the American Academy of Child and

Adolescent Psychiatry, 38(4), 385–392.

Marans, S., & Adelman, A. (1997). Experiencing violence in a

developmental context. In J.D. Osofsky (Ed.), Children in a

violent society (pp. 202–222). New York, NY: Guilford Press.

March, J.S., Amaya-Jackson, L., & Pynoos, R.S. (1997).

Pediatric posttraumatic stress disorder. In J.M. Weiner (Ed.),

Textbook of child and adolescent psychiatry (2nd ed., pp.

507–524). Washington, DC: American Psychiatric Press.
Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 251

REFERENCES (cont.)

March, J.S., Amaya-Jackson, L., Terry, R., & Costanzo, P. (1997).

Posttraumatic symptomatology in children and adolescents after

an industrial fire. Journal of the American Academy of Child and

Adolescent Psychiatry, 36(8), 1080–1088.

McCloskey, L.A., & Walker, M. (2000). Posttraumatic stress in

children exposed to family violence and single-event trauma.

Journal of the American Academy of Child and Adolescent

Psychiatry, 39(1), 108–115.

McFarlane, A.C. (1987). Family functioning and overprotection

following a natural disaster: The longitudinal effects of posttraumatic morbidity. Austraoam and New Zealand Journal of

Psychiatry, 21(2), 210–218.

Morrison, J.A. (2000). Protective factors associated with

children’s emotional responses to chronic community violence

exposure. Trauma, Violence, and Abuse: A Review Journal, 1(4),

299–320.

Murphy, L., Pynoos, R.S., & James, C.B. (1997). The

trauma/grief-focused group psychotherapy module of an

elementary school-based violence prevention/intervention program.

In J.D. Osofsky (Ed.), Children in a violent society (pp. 223–255).

New York, NY: Guilford Press.

National Institute of Mental Health. (2001). Helping children and

adolescents cope with violence and disasters. http://www.nimh.

nih.gov/publicat/violence.cfm.

Osofsky, J.D. (1995). The effects of exposure to violence on

young children. American Psychologist, 50(9), 782–788.

Pfefferbaum, B., Nawaz, S., & Kearns, L.J. (1999). Posttraumatic

stress disorder in children: Implications for assessment,

prevention, and referral in primary care. Journal of the Oklahoma

State Medical Association, 92(7), 309–315.

Pynoos, R.S., Steinberg, A.M., & Goenjian, A.K. (1996).

Traumatic stress in childhood and adolescence: Recent

developments and current controversies. In B.A. Van der Kolk,

A.C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The

effects of overwhelming experience on mind, body, and society

(pp. 331–358). New York, NY: Guilford Press.

Rauch, S.L., & Shin, L.M. (1997). Functional neuroimaging

studies in posttraumatic stress disorder. In R. Yehuda & A.C.

McFarlane (Eds.), Psychobiology of posttraumatic stress disorder.

Annals of the New York Academy of Sciences (Vol. 821, pp.

83–98). New York, NY: The New York Academy of Sciences.

Richards, M.H. Risky context and exposure to violence in urban

youth. NIMH Grant No. 5R01MH57938-02. In progress. 

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel,

F.S. (1997). Complex PTSD in victims exposed to sexual and

physical abuse: Results from the DSM-IV Field Trial for

Posttraumatic Stress Disorder. Journal of Traumatic Stress,

10(4), 539–555.

Smith, E.M., & North, C.S. (1993). Posttraumatic stress disorder

in natural disasters and technological accidents. In J.P. Wilson &

B. Raphael (Eds.), International handbook of traumatic stress

syndromes (pp. 405–419). New York, NY: Plenum Press.

Smith, E.M., North, C.S., & Spitznagel, E.L. (1993). Posttraumatic stress in survivors of three disasters. Journal of Social

Behavior and Personality, 8(5), 353–368.

Stein, M.B., Hanna, C., Koverola, C., Torchia, M., & McClarty, B.

(1997). Structural brain changes in PTSD. Does trauma alter

neuroanatomy? In R. Yehuda & A.C. McFarlane (Eds.),

Psychobiology of posttraumatic stress disorder. Annals of the

New York Academy of Sciences (Vol. 821, pp. 76–82). New

York, NY: The New York Academy of Sciences.

Vogel, J.M., & Vernberg, E.M. (1993). Psychological responses 

of children to natural and human-made disasters: I. Children’s

psychological responses to disasters. Journal of Clinical Child

Psychology, 22(4), 464–484.

Yehuda, R., McFarlane, A.C., & Shalev, A.Y. (1998). Predicting

the development of posttraumatic stress disorder from the acute

response to a traumatic event. Biological Psychiatry, 44(12),

1305–1313.

Yule, W., & Canterbury, R. (1994). The treatment of post traumatic

stress disorder in children and adolescents. International Review

of Psychiatry, 6(2), 151.

INDEX
A

absolute versus relative risks, 32

achievements in public health during the 20th

century, 7

acute radiation syndrome, 123

Administration for Children and Families (ACF),

153, 206

Administration on Aging, 153, 206

adolescents, reactions to traumatic events, 174,

175

Agency for Healthcare Research and Quality

(AHRQ), 152, 206

Agency for Toxic Substances and Disease

Registry (ATSDR), 8, 26, 150, 206

agroterrorism, 128

air quality, 137–138

alpha particles, 116

alphaviruses, 88

American Water Works Association, 137

ammonia, 99, 104

animals/animal-borne illnesses

bovine spongiform encephalopathy (BSE), 28

brucellosis, 74

E. coli O157:H7, 76–77, 128–129, 131 

Ebola, 27–28, 70–72

emerging infectious diseases, 27–31

glanders, 79, 197

psittacosis, 81

Q fever, 82–83

tularemia, 66–69

typhus fever, 87

veterinary assistance, 25

viral encephalitis, 88–89

viral hemorrhagic fevers (VHFs), 70–72

West Nile virus, 28

anthrax, 48–53

attacks in 2001, 48, 52–53, 196

cutaneous, 50

diagnosis, 50–51

environmental testing for, 43, 48. See also

nasal swabs

gastrointestinal, 50

inhalation, 49–51

testing for, 13, 43, 48

vaccine available for, 22, 51

World War I, 197

World War II, 197–198

antibiotics, 42

for anthrax, 49–51

for brucellosis, 74

antibiotics continued

for cholera, 91

for glanders, 79

for melioidosis, 80

for plague, 60

for psittacosis, 81

for Q fever, 82

for salmonellosis, 77

for shingellosis, 78

for smallpox, for secondary infections, 64

for tularemia, 66–67

for typhus fever, 87

antibodies, 21, 44

antidotes (chemical agents)

for cyanide, 103

for lewisite, 101

for sarin, 108

for soman, 109

for tabun, 111

for VX, 112

antigenic shift, 29

antigens, 44

for anthrax, 51

antitoxins, 56

for botulinum toxin, 56

arboviruses, 88. See also insect-borne illnesses

Argentine hemorrhagic fever, 70

arsine, 99, 102

Asian flu pandemic, 29

atomic bombs, 117. See also radiation/

radiological events

Aum Shinrikyo cult, 57, 72, 97, 108, 199

avian influenza/avian flu, 13, 29–30

B

Bacillus anthracis. See anthrax 

bacteria/bacterial infections, 42, 43

Bacillus anthracis, 48. See also anthrax

Brucella species (Brucellosis), 74

Burkholderia mallei (glanders), 79

Burkholderia (melioidosis), 80

Chlamydia psittaci (psittacosis), 81

Clostridium botulinum, 54. See also

botulinum toxin

Coxiella burnetti (Q fever), 82–83

Escherichia coli (E. coli O157:H7), 76–77,

128, 129, 131

foodborne, 76–78. See also food

Francisella tularensis (tularemia), 66

Rickettsia prowazekii (typhus fever), 87

bacteria/bacterial infections continued

Salmonella (salmonellosis), 77, 128, 129, 131

Shigella (shingellosis), 78, 129, 131

Staphylococcus aureus (staphylococcal

enterotoxin B (SEB)), 86

Vibrio cholerae (cholera), 90–91

Yersinia pestis, 58. See also plague

behavioral reactions to trauma, 173

beta particles, 116

Bhopal, India, 200

biological agents, 39–93, 149

background information, 39–45

Category A agents, 47–72. See also Category

A biological agents

Category B agents, 73–93. See also Category

B biological agents

chemical agents compared to, 97

history of, 196–198

Biological Weapons Convention, 196, 198

Bio-LRN, 14

biosafety level (BSL), 8

classification levels, 15

Ebola tested in level 4 laboratory, 70

labs at levels 3 and 4, 16

BioSense, 10

bioterrorism, indications of, 12–13. See also

biological agents

Bioterrorism Act, 130

BioWatch, 10, 14, 138–139

birds/bird-borne illnesses, 13, 29–30, 81. See

also animals/animal-borne illnesses and

avian influenza/avian flu

Black Death, 60

blister agents, 100–101

blocking agents (radiation exposure treatment), 124

blood agents (chemical), 102–103

blood cultures, 44, 60

blood transfusions, 76, 124

bone marrow tests, 74

bone marrow transplants, 124

botulinum toxin, 54–57

bovine spongiform encephalopathy (BSE), 28, 129

Brill-Zinsser disease, 87

Brucella species (brucellosis), 74

brucellosis, 74

bubonic plague, 58, 197

bunyavirus, 88

Burkholderia mallei (glanders), 79

Burkholderia (melioidosis), 80

INDEX

254 INDEX Terrorism and Other Public Health Emergencies: A Reference Guide for Media
C

Category A biological agents, 47–72

anthrax, 48–53

botulinum toxin, 54–57

plague, 58–61

smallpox, 62–65

tularemia, 66–69

viral hemorrhagic fevers (VHFs), 70–72

Category B biological agents, 73–93

brucellosis, 74

cholera, 90–91

E. coli O157:H7, 76–77, 128–129, 131

epsilon toxin, 75

glanders, 79

melioidosis, 80

psittacosis, 81

Q fever, 82–83

ricin toxin, 73, 84–85, 96

salmonellosis, 77, 128–129, 131

shigellosis, 78, 129, 131

staphylococcal enterotoxin B (SEB), 73, 86

typhus fever, 87

viral encephalitis, 28, 88–89

Category C biological agents, 40

Center for Food Safety and Applied Nutrition

(CFSAN), 132

Centers for Disease Control and Prevention

(CDC), 8, 206. See also Department of

Health and Human Services (HHS)

BioSense as part of, 10

bovine spongiform encephalopathy (BSE), 28

Chem-LRN, as part of network, 15

Division of Global Migration and Quarantine, 24

Health Alert Network (HAN), 8, 17–18

infectious disease investigations, 13

Laboratory Response Network (LRN), 14. See

also Laboratory Response Network (LRN)

National Notifiable Disease Surveillance

System, 69

National Electronic Disease Surveillance

System (NEDSS), 9, 149

Rapid Response Registry, 26

role in emergencies, 107, 151

Select Agent Program as part of, 16

Strategic National Stockpile (SNS) managed

by, 18. See also Strategic National

Stockpile (SNS)

Centers for Medicare & Medicaid Services (CMS),

206

cesium-137, 119

CG (phosgene), 104. See also phosgene

chemical agents, 95–113, 150

background information, 96–99

blister agents, 100–101

blood agents, 102–103

choking agents, 104–107

history of, 198–200

nerve agents, 108–112

Chemical Weapons Convention, 199

Chem-LRN, 15

Chernobyl nuclear power plant accident, 117,

201–202

children

coping with trauma, 177–178

reaction to trauma, 174–175

Child Traumatic Stress Initiative, 179

Chlamydia psittaci (psittacosis), 81

chlorination of water, 90. See also Water safety

chlorine, 99, 104, 107

accidental release in Graniteville, SC, 107

at water treatment plants, 136

World War I, 97, 198–199

choking agents, 104–107

cholera, 90–91

Cities Readiness Initiative, 21

Clean Water Act, 137

Clostridium botulinum, 54, 57. See also

botulinum toxin

Clostridium perfringens (epsilon toxin), 75

cognitive reactions to trauma, 173

Commissioned Corps of the U.S. Public Health

Service, 26

Communicable Disease Surveillance and

Response program, 11

communications. See also information

of risks, 32–34, 53, 183–193. See also risk

communications

sharing information within public health

community, 17

confirmatory diagnosis, 45

contacts for the media, 205–222. See also

media personnel

contact tracing, 12

containment of threats to public health, 18–24

contamination, radioactive, 117, 118, 123

coping strategies for traumatic events, 176–180

Covello, Vincent T., 32, 34, 161, 171, 187

covert threats to public health, 8

Coxiella burnetti (Q fever), 82–83

cryptosporidiosis, 90

Cryptosporidium, 129, 136

cultures (laboratory), 44, 89

cyanide, 97, 99, 103

cyanogen chloride, 99, 103

Cyclospora, 129

D

Dart Center for Journalism and Trauma, 162

decay, radioactive, 117–118

decontamination, chemical attacks, 98

decorporation agents, 124

Deer Fly Fever, 66

delivery of biological/chemical agents, 42–43, 97

Department of Agriculture (USDA), 28, 128,

131, 132, 144

Department of Energy (DOE), 107, 145, 147,

150, 206

Department of Health and Human Services

(HHS), 2, 7–8, 141–154. See also Centers

for Disease Control and Prevention (CDC)

and under names of individual agencies

achievements in public health during the 20th

century, 7

agency contacts for media, 205

hospital preparedness, 16–17

legal acts granting authority to, 153–154

offices and operating divisions, responsibilities

of, 150–154

responses to different types of events,

149–150

risk communications, 187. See also risk

communications

water safety, 137

Department of Homeland Security (DHS),

142–150, 206

emergency preparedness, 8, 142, 146–150

Environmental Technology Verification

Program, 138

National Disaster Medical System (NDMS),

24–26

water safety, 137

Department of Veterans Affairs (VA), 24–25, 144

detection of public health threats, 8–13, 137, 149

biological agents, 43–45

chemical attacks, 97

environmental safety and testing, 135–139.

See also environmental safety and testing

epidemiology, 11–13

foodborne illnesses, 54, 76–77, 128–129,

131–132

syndromic surveillance, 8–9

diagnosis/diagnostic testing, 13–15, 45. See

also tests/testing

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 255
dirty bombs, 118–119

Disaster Medical Assistance Teams, 25

Disaster Mortuary Operational Response Teams, 25

distress responses, 158, 184

Division of Global Migration and Quarantine, 24

E

E. coli O157:H7, 76–77, 128–129, 131

Eastern equine encephalitis (EEE), 88–89

Ebola, 27–28, 70–72

emergency preparedness, 7

National Response Plan (NRP), 142–143

Project BioShield, 23

personal protective equipment, 159, 161

self-care for media personnel, 164–166

shelter-in-place instructions, 98, 122

stockpiling medicines, caution against, 44

supply list, 98, 123

Emergency Support Function (ESF) #8 of the

National Response Plan (NRP), 143–145,

147

emerging infectious diseases, 27–28

encephalitis, 10, 28, 88–89

encephalomyelitis, 88

Environmental Protection Agency (EPA), 107,

128, 137, 139, 147, 151, 200, 206

environmental safety and testing, 135–139

airborne agents, 137–138 

anthrax, testing for, 13, 43, 48

biological agents, testing for, 43

chlorine, testing for, 104

cyanide, testing for, 103

mosquitoes, eliminating breeding conditions

for, 89

tularemia, testing for, 66

water, 136–137. See also water safety

Epidemic Intelligence Exchange (Epi-X), 8, 18–19

Epidemic Intelligence Service (EIS), 26

epidemiology, 11–13

epsilon toxin, 75

equipment for protection, 159, 161

Escherichia coli O157:H7, 76–77, 128–129,

131. See also E. coli O157:H7

exposure to radiation, 122, 123

F

fallout, nuclear, 119, 121

federal agencies

contacts for, 205

emergencies, functioning in, 7, 146–148, 153

federal agencies continued

National Response Plan (NRP), 142, 143.

See also National Response Plan (NRP)

Federal Bureau of Investigation (FBI), 13, 107,

206

flashbacks, 173

flaviviruses, 88

fleas, 87

flu viruses (influenza), 10, 13, 29–31

Food and Drug Administration (FDA), 129–131,

132, 206

emergency-use authorization from, 23

role in emergencies, 151–152

foodborne botulism, 54–56

food issues, 127–133

botulism, 54–56, 57

brucellosis in unpasteurized milk, 74

chemical agents in, 97

chlorine, 104

cholera, 90

cyanide, 102

E. coli O157:H7, 76–77

epsilon toxin, 75

federal government’s role in food safety,

129–131

impact of foodborne illnesses, 128–129

lewisite, 101

melioidosis, 80

phosgene, 105

PulseNet, 131–132

Q fever, 82–83

ricin, 84

salmonellosis, 77, 128–129

sarin, 108

shigellosis, 78

soman, 108–109

staphylococcal enterotoxin B (SEB), 86

tabun, 110

tampering and recall, 132

tularemia, 66

VX, 111

FoodNet, 131

Food Safety and Inspection Service (FSIS),

129–130

Francisella tularensis, 66. See also tularemia

G

gamma rays, 116

GA (tabun), 110. See also tabun

GD (soman), 108. See also soman

gene amplification assays, 45

genetic patterns in foodborne illnesses, 131–132

Geneva Protocol, 196–199

giardiasis, 90

glanders, 79, 196–197

Global Outbreak Alert and Response Network,

11

Global Public Health Information Network, 11

gram staining, 44

Gulf War, anthrax vaccinations for, 52

H

half-life, radioactive, 117, 119

hantaviruses, 40

Hantavirus Pulmonary Syndrome, 13

Health Alert Network (HAN), 8, 17–18

Health and Human Services. See Department of

Health and Human Services (HHS)

Health Resources and Services Administration

(HRSA), 16, 153, 179, 206

HHS (Department of Health and Human

Services). See Department of Health and

Human Services (HHS)

history of biological, chemical, and radiation

emergencies, 196–203. See also World

War I; World War II

biological, 196–198

chemical, 198–200

nuclear weapons development, 200–201

radiation, 201–202

Homeland Security. See Department of

Homeland Security (DHS)

Hong Kong flu, 29

hospital preparedness, 16–17, 26

hydrogen chloride, 99, 104

hydrogen cyanide, 97, 99, 103

I

immunization. See vaccination/vaccines

immunoassays, 44

improvised nuclear device (IND), 116–118,

121, 150

Incident Command System (ICS), 153

incubation period, 41, 62, 89

Indian Health Service (IHS), 152–153, 206

industrial chemicals, 96

infectious diseases, 7, 10, 13, 16, 23–24,

27–31, 40–42, 73–75, 142, 149,

197–198. See also bacteria/bacterial

infections; viruses/viral infections

256 INDEX Terrorism and Other Public Health Emergencies: A Reference Guide for Media
influenza viruses, 7–8, 10, 13, 29–31, 149,

185. See also avian influenza/avian flu;

pandemic influenza

information. See also communications; risk

communications

contacts for public health, 205–222

flow from local to federal, 9, 10

provided in an emergency, 187–189

reducing panic with, 171

sharing in public health community, 17

insect-borne illnesses 43, 97

plague, 58, 60, 87, 197

typhus fever, 87

viral encephalitis, 28, 88–89

West Nile virus, 10, 13, 18, 28, 88, 89

International Federation of Journalists (IFJ), 159

International News Safety Institute, 159–160

investigations of outbreaks, 10–12, 44, 142,

144, 149, 151–152. See also public

health

iodine-131, 119

iodine; radioactive, 44, 119, 124

ionizing radiation, 116

isolation (to protect public health), 23–24, 60,

64–65, 70–71, 142

J

Japanese encephalitis, 88–89

Joint Information Center (JIC), 148, 153, 187

K

KI (potassium iodide), 44, 124

L

Laboratory Response Network (LRN), 8, 13–14,

45, 138–139

laboratory testing, 13–16, 43–45, 70

legal authority, 153

isolation and quarantine, 24

Public Health Security and Bioterrorism

Preparedness and Response Act of 2002,

130, 137, 153–154

Public Health Service Act, 142, 153

Lewisite (L), 99–101

load; viral, bacterial or toxic, 45

louse-borne typhus, 87

M

“mad cow” disease, 28, 129

“Manhattan Project,” 117, 200

Marburg virus, 70–72

mass vaccination, 22, 64

media for growing cultures, 44

media personnel, 159–160, 163–164,

206–222

federal agency contacts, 206

Health and Human Services contacts, 205

self-care for, 157–167. See also self-care for

media personnel

state agency contacts, 207–219 

worksheet for contacts, 221–222

medical personnel, resources for emergencies,

24–26

Medical Reserve Corps, 26, 144

medical supplies, Strategic National Stockpile

(SNS), 18, 20–21. See also Strategic

National Stockpile (SNS)

melioidosis, 80

meningitis, 88

mental health, 145, 152–153, 163–166,

171–180. See also stress/stress reduction

mortuary assistance, 25, 145

mustard agents/mustard gas, 96–97, 99–100,

198–199

N

nasal swabs, 13, 44, 48, 51. See also anthrax;

environmental safety and testing

National Aeronautics and Space Administration

(NASA), 137

National Bioterrorism Hospital Preparedness

Program, 16–17, 153

National Disaster Medical System (NDMS),

24–26, 144–145

National Electronic Disease Surveillance System

(NEDSS), 9, 149

National Incident Management System (NIMS),

142, 153

National Institute for Occupational Safety and

Health (NIOSH), 138, 150, 161

National Institute of Allergy and Infectious

Diseases (NIAID), 16, 23, 152

National Institute of Mental Health (NIMH), 179

National Institutes of Health (NIH), 152, 206

National Notifiable Disease Surveillance System

(NNDSS), 69

National Nurse Response Teams (NNRT), 25

National Oceanic and Atmospheric

Administration, 137

National Pharmacy Response Teams (NPRT),

25–26

National Response Plan (NRP), 142–149

Emergency Support Function (ESF) #8,

143–145, 147

emergency support functions and

responsibilities, 145–149

incidents of national significance, definition of,

149–150

nerve agents, 97, 99, 108–112, 199

neutrons, 116

Non-Proliferation of Nuclear Weapons Treaty,

117, 200–201

nuclear events, 116–124. See also radiation/

radiological events

nuclear power plants, 116–120, 201

nursing assistance, 25

O 

Office of Public Health Emergency Preparedness

(OPHEP), 151

older adults, 174, 176, 178–179

P

pandemic influenza, 29–31

Pandemic Influenza Preparedness and Response

Plan, 30

parrot fever, 81

pathogens, 23, 41, 131

personal protective equipment, 159, 161

pharmaceutical assistance, 18, 21, 23, 26, 144

pharmaceuticals contaminated with chemical

agents, 97

phosgene, 97, 99, 104–106

phosphine, 99, 104

phosphorus, 99, 104

physical care for media personnel, 158–161.

See also self-care for media personnel

physical reactions to trauma, 173

plague, 58–61, 196–197

plutonium, 118–119

pneumonic plague, 41, 58–60

population exposure model, 170–171

post-traumatic stress disorder (PTSD), 158,

166, 173

potassium cyanide, 99, 103

potassium iodide (KI), 44, 124

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 257
preparation for emergencies. See emergency

preparedness

presumptive diagnosis, 13, 45

Project BioShield, 23–24

Project BioWatch, 10, 14, 138–139

psittacosis, 81

PTSD (post-traumatic stress disorder), 158,

166, 173

public health, 6–37

containment of threats to, 18–24

detection of threats to, 8–13, 149

government response to threats to, 7, 13–26,

30–31, 142–154. See also federal

agencies

Public Health Security and Bioterrorism

Preparedness Response Act, 130, 137,

154

Public Health Service Act (PHSA), 154

public information contacts, 205–219

public reactions to terrorist events, 169–181

communications affecting, 190–191

comparing responses to terrorist attacks and

other crises, 184–185

objectives of public during emergencies,

185–187

range of reactions, 172–176

ripple effect, 170–172

strategies for coping, 176–180

PulseNet, 131–132

Q

Q fever, 82–83

quarantine, 23–24, 81, 83, 142, 156

R 

Rabbit Fever, 66

radiation-emitting device (RED), 121, 150

radiation/radiological events, 115–125,

150–151

background information, 116–117

historical events, 117, 201–202

impact of emergencies, 122–124

injuries, 122–123

KI (potassium iodide) for, 44, 124

nuclear weapons development and testing,

117, 200–201

treatment, 123–124

types of attacks, 117–119, 120–121

radiological dispersal device (RDD), 118–120, 150

Rajneeshee Cult, 128, 196, 198

rapid response protocols, 138–139

Rapid Response Registry (RRR), 26

Rapid Toxic Screen, 15

RDD (radiological dispersal device), 118–120, 150

reactions to traumatic events, 171–176. See

also public reactions to terrorist events

recall of food products, 132

record-keeping, food products, 130–131

Red Cross, 27, 147, 149–150, 165

RED (radiation-emitting device), 121, 150

relative risks, 32

resiliency-building recommendations, 176–180

respirators, use of, 161, 199

response to public health threats, 13–18,

143–154

ricin toxin, 73, 84–85, 96, 199

Ricinus communis (ricin toxin), 84–85

Rickettsia prowazekii (typhus fever), 87

Rift Valley encephalitis, 88–89

ring vaccination, 22, 64–65

ripple effect of terrorism on public, 170–172

risk communications, 2, 32–34, 183–193

comparisons between public reaction to

terrorist attacks vs. other crises, 184–185

Department of Health and Human Services

(HHS), 187

objectives of public during emergencies,

185–187

public reaction, affecting, 190–191

types of information given during emergencies,

188. See also information

Ropeik, David, 192–193

S

Safe Drinking Water Act, 137

safety precautions for media personnel,

157–167. See also self-care for media

personnel

St. Louis encephalitis, 88

Salmonella (salmonellosis), 73, 77, 131,

196–198

salmonellosis, 77, 128–129

SAMHSA (Substance Abuse and Mental Health

Services Administration), 152, 163, 166,

179, 206

Sandman, Peter M., 190–191

sarin, 97, 99, 108, 199

SARS (severe acute respiratory syndrome), 2,

11, 13–14, 18, 24, 28

Secretary’s Emergency Response Team (SERT),

150–151

Select Agent Program (SAP), 16

selective media, 44

self-care for media personnel, 157–167

communication during emergencies, 161–162

emotional care, 162–166

preparation for emergencies, 164–166

safety during emergencies, 158–161

stress reduction, 158, 162–167

September 11, 2001

focusing attention on emergency

preparedness, 6

people in World Trade Center stairwells, 190

public reactions to, 170, 172, 186, 190–191

septicemic plague, 58–59

severe acute respiratory syndrome (SARS). See

SARS (severe acute respiratory syndrome)

shelter-in-place instructions, 98, 122–123

Shigella (shigellosis), 78, 131

shigellosis, 78, 129

smallpox, 6, 62–65, 72, 171, 187, 196–198

vaccination, 6–7, 22, 62–65

sodium cyanide, 99, 103

soman, 99, 108–110, 199

Spanish flu pandemic, 29

spores, anthrax, 48–52. See also anthrax 

sputum, 44, 59, 60

staphylococcal enterotoxin B (SEB), 86

Staphylococcus aureus (staphylococcal

enterotoxin B (SEB)), 86

state agencies

Health Alert Network (HAN), using, 17

media contacts for, 207–219

preparation for flu pandemics, 31

surveillance, 9, 31

Strategic Health Operations Center (SHOC), 11

Strategic National Stockpile (SNS), 17–18,

20–21, 144, 153

anthrax antibiotics, 51

smallpox vaccine, 64

stress/stress reduction

children, 174, 177–178

general public, 170, 172, 176–180

journalists, 3, 158, 163–167

physical effects of, 173

Substance Abuse and Mental Health Services

Administration (SAMHSA), 152, 163, 166,

179, 206

sulfur mustard, 99–100. See also mustard

agents/mustard gas

258 INDEX Terrorism and Other Public Health Emergencies: A Reference Guide for Media
supplies for sheltering-in-place, 98, 123,

165–166

syndromic surveillance, 8–11

T

tabun, 99, 110–111, 199

tampering of packages, 132

tests/testing, 13–15. See also detection of public

health threats

biological agents, 43–45, 137

bone marrow tests, 74

environmental, 13–14, 43–44, 48, 66, 103,

135–139. See also environmental safety

and testing

laboratory testing, 13–15, 43–45, 48, 70,

131, 137

MRI for viral encephalitis, 89

nasal swabs, 13, 44, 48, 51

X-rays, 51, 67, 85

Three Mile Island nuclear power plant accident,

117–118, 201

tick-borne encephalitis, 88–89

toxins, biological, 16, 23, 41, 43–45, 49, 51,

54–57, 75, 84–86

Clostridium botulinum bacteria producing,

54–57. See also botulinum toxin

ricin toxin, 73, 84–85, 96, 199

staphylococcal enterotoxin B (SEB), 73, 86

toxins, chemical, 23, 41, 84–85, 95–113. See

also chemical agents

treatment. See under individual diseases or

toxins

tuberculosis, 40

tularemia, 66–69

12-hour Push Packages, 18, 20–21

typhoidal tularemia, 66

typhus fever, 87

U

ulceroglandular tularemia, 66

U.S. Postal Service, 50, 52, 196

uranium, 118–119

USDA (Department of Agriculture), 128–132

V

vaccination/vaccines, 6–7, 21–23, 48, 51–52,

56, 60, 62–65, 67, 70–72, 74, 83, 86,

89, 91, 144, 159–160, 187, 198

anthrax, 48, 51–52

vaccination/vaccines continued

botulinum toxin, 56

brucellosis, 74

Ebola virus, 71

plague, 60

polio, 6–7

Project BioShield, 23

Q fever, 83

smallpox, 6–7, 22, 62–65, 187

staphylococcal enterotoxin B (SEB), 86

strategies for outbreaks, 21–22, 65

tularemia, 67

viral encephalitis, 89

viral hemorrhagic fevers (VHFs), 70–72

variant Creutzfeldt-Jackob disease (vCJD), 28

Variola major, 62. See also smallpox 

Venezualan equine encephalitis (VEE), 88–89

Veterinary Medical Assistance Teams (VMAT), 25

Vibrio cholerae (cholera), 90–91, 196

viral encephalitis, 28, 88–89

viral hemorrhagic fevers (VHFs), 16, 27, 70–72

viruses/viral infections, 42, 43

Ebola, 70–72

influenza viruses, 10, 13, 29–31

smallpox, 62–65, 171, 187 

viral encephalitis, 28, 88–89

viral hemorrhagic fevers (VHFs), 16, 27,

70–72

VX, 96, 99, 111–112, 199

W

water safety, 41, 54–55, 66, 68, 78, 80, 82,

84, 86, 90–91, 97, 103, 110–111,

136–137, 196–197, 199

botulinum toxin, 54–55

chemical agents contaminating supply, 97, 199

cholera, 90–91, 196–197

cyanide poisoning, 97, 103

melioidosis, 80

Q fever, 82–83

ricin, 84

shigellosis, 78

staphylococcal enterotoxin B (SEB), 73, 86

tabun, 110

tularemia, 66, 68

VX, 96, 99, 111–112, 199

Weather, 42–43, 97, 111, 117, 137, 153

chemical agents, 97

nuclear fallout, 117, 119

use of weather satellites, 137

Western equine encephalitis, 88–89

West Nile virus, 10, 18, 28, 88–89

worksheet for contacts, 221–222

World Health Organization (WHO), 11, 27–28, 65

World Trade Center, 163, 165, 170, 190. See

also September 11, 2001

World War I, 79, 97, 100–101, 105, 196,

198–199

chemical weapons in, 97, 198–199

glanders in, 79, 196–197

lewisite developed for, 101

mustard gas used in, 97, 100, 199

phosgene used in, 97, 105

World War II, 57, 60, 96–97, 102, 117,

196–201

development and use of bioweapons in,

196–198

arsine developed during but not used, 102

atomic bomb dropped in Japan, 117, 200, 201

chemical weapons in, 97, 102, 198–199

chlorine used during, 97, 104

Y

yellow fever, 24, 40, 70

Yersinia pestis, 58. See also plague 

zoonotic illnesses. See animals/animal-borne

illnesses

Information in this section is current as of September 2005. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 259


U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES http://www.hhs.gov/emergency