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Principles for Emergency Response to Bioterrorism

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Abstract

The recent occurrence of a series of anthrax-related hoaxes illustrates the need to educate emergency services personnel about how to best ensure patient and worker safety in the case of suspected exposure to biological threat agents. There are very few data to support the methods being used or the variation in current care. Emergency physicians, first responders, and hazardous materials response teams need a standardized approach to the management of patients who may have been exposed to biological threat agents. Currently recommended hospital infection control procedures seem appropriate for the level of risk involved with aerosolized biological threat agents. Such recommendations include standard and transmission-based precautions. These groups need a working knowledge of the isolation and infection control measures recommended for the treatment of patients exposed to those biological threat agents at outlined in the Centers for Disease Control and Prevention Guideline for Isolation Precautions in Hospitals.
Mark Keim, MD
*‡
Arnold F Kaufmann, DVM
*
From the National Center for
Environmental Health, Centers
for Disease Control and Prevention,
*
and the Department of Emergency
Medicine, Emory University,
Atlanta, GA.
Received for publication
May 7, 1999. Revision
received May 14, 1999.
Accepted for publication
May 14, 1999.
Address for reprints: Mark Keim,
MD, Emergency Preparedness &
Response Branch, Centers for Disease
Control and Prevention, 4770 Buford
Highway MS-F38, Atlanta, GA
30041; E-mail mjk9@cdc.gov.
Copyright © 1999 by the American
College of Emergency Physicians.
0196-0644/99/$8.00 + 0
47/1/11
DISASTER MEDICINE/SPECIAL CONTRIBUTION
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE 177
The recent occurrence of a series of anthrax-related hoaxes
illustrates the need to educate emergency services personnel
about how to best ensure patient and worker safety in the case
of suspected exposure to biological threat agents. There are very
few data to support the methods being used or the variation in
current care. Emergency physicians, first responders, and
hazardous materials response teams need a standardized
approach to the management of patients who may have been
exposed to biological threat agents. Currently recommended
hospital infection control procedures seem appropriate for the
level of risk involved with aerosolized biological threat agents.
Such recommendations include standard and transmission-
based precautions. These groups need a working knowledge of
the isolation and infection control measures recommended for
the treatment of patients exposed to those biological threat
agents at outlined in the Centers for Disease Control and
Prevention
Guideline for Isolation Precautions in Hospitals.
[Keim M, Kaufmann AF: Principles for emergency response to
bioterrorism.
Ann Emerg Med
August 1999;34:177-182.]
INTRODUCTION
In 1992, a Virginia man was arrested for spraying his
roommates with a fluid that he claimed was “anthrax,” an
infectious disease caused by Bacillus anthracis. Responding
officials placed the house under quarantine, and while
awaiting test results, began a regimen of chemoprophy-
laxis for 20 people. No trace of a pathogenic biological
agent was ever found.
1
On April 24, 1997, the B’nai B’rith headquarters in
Washington DC received a package leaking a red fluid.
The package contained a threatening note and a Petri
dish that was labeled “Anthracis Yersinia.”
2
During the
response to the incident, 2 downtown city blocks were
cordoned off, 109 occupants of the building were quar-
antined, and 30 people underwent hazardous materials
Principles for Emergency Response to
Bioterrorism
sure warranted decontamination on multiple occasions,
starting chemoprophylaxis would seem a logical next step
in a treatment regimen.
The inconsistent public health and EMS responses to
these anthrax hoaxes support the view that medical, pub-
lic health, and emergency personnel throughout the
nation are simply not consistently trained to respond to
an incident of biological terrorism. The associate director
of 1 poison control center noted that, “We treated it [the
anthrax threat] as a chemical response because everyone
knew how that system worked.”
7
In response to the increase in bioterrorism threats
alleging the use of anthrax, the Centers for Disease
Control and Prevention (CDC) published interim guide-
lines to assist in the management and response to these
threats.
8
The directives for hazard recognition, decon-
tamination, and personal protection involving suspected
chemical exposures have been well described.
9
In the
case of exposures to unknown substances, which could
also include chemicals, then the existing doctrines for
hazardous materials response should be followed. This
process of risk assessment includes hazard identification,
an evaluation of routes and extent of exposure, and an
assessment of potential toxicity caused by the chemical
agent. This article discusses in greater detail infection
control measures for use in managing the care of patients
exposed to microbiological aerosols, and focuses on the
role of decontamination in reducing the risk of secondary
transmission.
DECONTAMINATION: RISKS VERSUS BENEFITS
In the American hospital infection control community,
decontamination is a process that ensures an item is
“safe to handle” by a health care worker without protec-
tive clothing or equipment.
10
According to the
Occupational Safety and Health Guidance Manual for
Hazardous Waste Site Activities, decontamination is “the
process of removing or neutralizing contaminants that
have accumulated on personnel and equipment.”
9
Decontamination may be as simple as manual cleaning
alone or may include the additional steps of disinfec-
tion (elimination of most or all pathogenic microorgan-
isms except bacterial endospores) or sterilization (com-
plete elimination of all microbiological life). The
purpose of decontamination after exposure to an
aerosolized biological weapon is to remove or lessen
any potential contaminant from the patient’s body or
clothing and thus prevent reaerosolization and further
respiratory exposure.
EMERGENCY RESPONSE TO BIOTERRORISM
Keim & Kaufmann
178 ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
decontamination. No biological or chemical agent was
detected in laboratory tests of the package and its contents.
During 1998 and early 1999, nearly 6,000 persons
across the United States were affected by a series of
anthrax-related threats.
3
Most of these threats were made
by letter or telephone, and a substance purported to con-
tain B anthracis was sometimes present in the letter.
Abortion clinics and government buildings were the most
common targets, but retail establishments, office buildings,
schools, hospitals, and a nightclub were also involved. All
of these threats were proved to be hoaxes.
3
The emergency medical response that followed many
of these threats included scene isolation, quarantine, haz-
ardous materials decontamination of threat victims,
emergency medical evaluation, chemoprophylaxis, and
expert consultation. News reports have cited the estimated
cost of one response at nearly one-half million dollars.
4
In
addition to the direct economic impact, an important
undefined cost is the diversion of public safety and EMS
resources from other community needs. These hoaxes
occupy time and effort of emergency responders who may
be needed elsewhere. The long-term psychologic effect
on the threat recipients also remains undefined.
THE NEED FOR A STANDARD APPROACH TO
CARE
As would be expected in the case of a real biological
attack, emergency physicians became an important com-
ponent of the first response during these anthrax hoaxes.
5
The patients who presented to emergency medical
providers expected a consistent and rational approach to
care, but the approach to case management varied
remarkably from incident to incident despite the similar-
ity. Some patients were provided with no intervention
and were sent home from a threat scene by EMS or public
safety officials without any accompanying documenta-
tion of care. In other incidents, people were removed
from their workplace, disrobed, scrubbed in portable
hazardous materials showers with brushes and a solution
of .5% sodium hypochlorite, and then referred for clinical
evaluation, postexposure prophylaxis with expensive
antibiotics, and public education measures. Treatment
regimens were often uncoordinated, and patient care
strategies did not follow a consistent logic, even for the
same incident. At 1 event, a group of patients underwent
3 consecutive “decontamination” procedures, twice in
the prehospital setting plus a third time in the emergency
department, but were then discharged home without
starting chemoprophylactic therapy.
6
If the level of expo-
EMERGENCY RESPONSE TO BIOTERRORISM
Keim & Kaufmann
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE 179
skin decontamination would be of minimal or no benefit
in contributing to the prevention of disease.
The benefit of full-body skin-surface decontamination
with sodium hypochlorite solution as a method of per-
son-to-person infection control against biological threat
agents has not been well documented in the medical liter-
ature. Sodium hypochlorite has been described as a safe
and effective environmental surface and equipment
decontaminant,
14
but it is not recommended for decon-
tamination of human skin. Sodium hypochlorite is not
used for skin or wound decontamination in hospitals,
and its recent use in prehospital settings has been very
limited. The actual efficacy of disinfection with sodium
hypochlorite in cases of bioterrorism is questionable.
D.A. Henderson, director of the Johns Hopkins Center for
Civilian Biodefense, reports that “decontamination of
patients and environment,” while “critically important in
most cases” of chemical terrorism, is “not necessary in
most cases” of biological terrorism.
5
The Association for Professionals in Infection Control
and Epidemiology Bioterrorism Task Force, working in
association with the CDC Hospital Infections Program
Bioterrorism Working Group, has recently developed a
set of planning guidelines for health care facilities. These
guidelines discourage the use of external patient decon-
tamination for aerosol exposure.
15
The Working Group
on Civilian Biodefense is composed of 21 representatives
from US academic medical centers and research, govern-
ment, military, public health, and emergency manage-
ment institutions and agencies. This group has recently
published guidelines for the management of anthrax.
Those discussions also recommend washing with soap
and water for such exposures and further state that
“decontamination of directly exposed individuals or of
others is not indicated.”
16
It is important to note that there are risks associated
with dermal and inhalational exposure to solutions of
sodium hypochlorite. Some people experienced hyper-
sensitivity reactions after inhaling vapors of sodium
hypochlorite. The causticity of moderately alkaline solu-
tions of sodium hypochlorite also may be hazardous to
patients. Household bleach solutions are skin and
mucosal irritants. Failure to remove or rinse these moder-
ately alkaline solutions from skin may result in chemical
burns. Corneal abrasions can occur as a result of eye
exposure.
17
People with grossly visible evidence of a direct skin con-
tact exposure to substances contaminated by an etiologic
agent present a different decontamination problem.
These individuals have much greater risk for infection
To be an effective biological weapon, airborne pathogens
such as B anthracis must be dispersed as fine-particle (less
than 5-µm diameter) aerosols, which cannot be detected
without special equipment. Once such agents are dis-
persed, infection with the agent usually requires deep
respiration of an infectious dose. Primate studies sug-
gest that the lethal dose sufficient to kill 50% of human
beings exposed to B anthracis is about 2,500 to 55,000
spores.
10
Exposure of intact skin to the primary aerosol
presents insignificant risk. Most agents will not pene-
trate unbroken skin, and few organisms will adhere to
the skin or clothing in any instance. In one study, the
expected whole-body deposition of B anthracis–bearing
particles (average diameter 7.6 µm) on a person with
15,000-cm
2
body surface who is exposed to a primary
aerosol cloud containing 125,000 particles/m
3
was cal-
culated to be 120 particles.
11
Because the expected
number of deposited particles is directly correlated
with the average particle diameter, fewer particles
would be deposited if the average particle diameter was
3.5 µm, the optimal diameter for biological warfare
agent aerosol delivery.
12
In other words, the aerosols
presenting the greatest risk for infection through the
respiratory tract present the least risk for surface con-
tamination.
Even in a situation where the patient has been exposed
to aerosols consisting of relatively large-diameter parti-
cles, simple removal of clothing would eliminate a high
proportion of the surface contamination. Thorough
showering with soap and water (potentially at home)
would be expected to remove 99.99% of the few organ-
isms left on the patient’s skin after disrobing.
9
Few
organism-bearing particles would be present on the
clothing, and any organism-bearing particles that were
present would tend to adhere to fibers and larger parti-
cles because of van der Waals and electrostatic forces. As
a result, the few organism-bearing particles that
remained would have a much reduced potential for being
respirable even if dislodged.
13
Therefore removal and
subsequent handling of the clothing is unlikely to gener-
ate a significant secondary fine-particle aerosol of
anthrax spores and pose a major threat to others. This
suggests that very few biological particles could
reaerosolize to levels that are necessary for subsequent
transmission to others. In the case of aerosol exposure to
anthrax spores, the relatively high dose required for pul-
monary infection makes the risk for person-to-person
transmission of disease from these low-concentration
secondary aerosols even less likely. The potential for clin-
ically significant reaerosolization is minimal. Therefore
2. That hazardous material emergency responders will
actually operate within a detectable and manageable inci-
dent “scene.” A biological attack might involve an area
encompassing many square miles.
3. That local responders would have the capacity to
decontaminate the entire population that was exposed. In
fact, in the plausible setting of a massive aerosol exposure
of 100,000 people,
19
any subsequent emergency decon-
tamination program would require 3,312 person-hours
of operational work time if each person could be decon-
taminated in just 2 minutes. Even if only 2 to 3 gallons of
fresh solution were used per patient, the total procedure
would call for an emergency delivery of more than a quar-
ter of a million gallons of properly prepared solution.
These demands are well beyond the capacity of any US
hazardous materials, EMS, or ED response system. There
is a need for such reasonable population-based recom-
mendations for decontamination that do not require peo-
ple to depend on treatment through the ED or EMS system.
A more effective public health recommendation would be
for these same 100,000 people to be directed to disrobe,
seal clothing in a plastic bag, and then shower at home
with soap and water, resulting in an acceptable level of
decontamination of the entire group within an hour or so.
Currently recommended hospital infection control
procedures seem appropriate for the level of risk involved
with aerosolized biological threat agents.
20
Such recom-
EMERGENCY RESPONSE TO BIOTERRORISM
Keim & Kaufmann
180 ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
through skin breaks than do those exposed only to fine-
particle aerosols. In these particular cases of visible con-
tamination, the specific area of contaminated skin
affected by such exposure should be thoroughly washed,
sterilized by swabbing with a sporicidal/bactericidal solu-
tion (eg, .5% sodium hypochlorite or other approved
products), and then rinsed with water to minimize cuta-
neous irritation by the solution. Only the area of skin that
has been grossly contaminated should be treated. Eye and
inhalational exposures to the solution should be avoided.
Eyes may be rinsed with water or saline solution. Clothing
should be removed and disinfected or discarded. Decisions
about whether people exposed in such incidents require
chemoprophylaxis depend on additional considerations,
particularly the suspected identity of the agent.
DECONTAMINATION OF LARGE POPULATIONS
The feasibility of mass public decontamination after a
biological attack is based on a set of tenuous assumptions:
1. That a biological release would actually be detected
in the first place. However, as officials from the Bureau of
Alcohol, Tobacco, and Firearms have noted, “a terrorist
attack using an aerosolized agent could occur without
warning, and the first sign of attack might be hundreds or
thousands of ill or dying patients, since biological clouds
are not visible.”
18
Table 1.
Standard precautions for infection control.
1. Hand washing after touching potentially contaminated materials, regardless
of whether gloves were worn
2. Wearing gloves when touching potentially contaminated materials
3. Wearing a mask and eye protection or a face shield to protect mucous
membranes of the eyes, nose, and mouth during procedures and patient
care activities that are likely to produce potentially infectious splashes or
sprays
4. Wearing a gown to prevent soiling of clothing during procedures and
patient care activities that are likely to produce potentially infectious
splashes or sprays
5. Handling patient care equipment soiled with potentially infectious mate-
rial in a manner that prevents secondary transmission
6. Routinely using environmental surface cleaning and disinfecting
7. Handling, processing, and transporting used linen that has been soiled
with potentially infectious materials in a manner that prevents secondary
transmission
8. Following occupational health and bloodborne pathogens requirements
to reduce the risk for infection from contaminated equipment and inher-
ently risky patient care procedures
9. Placing patients who present risk environmental contamination in a pri
vate or cohort room
Table 2.
Transmission-based precautions for infection control.
Airborne precautions
include (in addition to
Standard Precautions
):
1. Patient placement in a negative-pressure room.
2. Respiratory protection including N95 high-efficiency particulate air filter
respirators.
3. Limit patient transport. When transport is necessary, place a surgical mask on
the patient.
4. Additional guidlines for specific prevention of tuberculosis.
Droplet precautions
include (in addition to
Standard Precautions):
1. Patient placement in a private or cohort room.
2. Wearing masks, eye protection, and face shield when within 3 feet of patient.
3. Limit patient transport. When transport is necessary, place a surgical mask on
the patient.
Contact precautions
include (in addition to
Standard Precautions
):
1. Patient placement in a private or cohort room.
2. Gloves and hand washing.
3. Gown.
4. Limit patient transport. When transport is necessary, place a surgical mask on
the patient.
5. Dedicate use of patient care equipment to one patient whenever possible. If
common use of equipment among patients is unavoidable, clean and disinfect
equipment before use on another patient.
6. Additional requirements specifically for preventing the spread of vancomycin
resistance.
EMERGENCY RESPONSE TO BIOTERRORISM
Keim & Kaufmann
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE 181
precautions are the first and most important tier and are
designed for use during the care of prehospital and hospi-
tal patients regardless of their diagnosis or presumed
infection status. Standard precautions are designed to
reduce the risk of transmission of microorganisms from
both recognized and unrecognized sources of infection in
hospitals (Table 1).
The second tier of guidelines, transmission-based pre-
cautions, are disease-specific and are designed only for
the care of those patients known or suspected to be infected
with epidemiologically important pathogens that can be
transmitted by airborne or droplet transmission or by con-
tact with dry skin or contaminated surfaces.
20
The type of
transmission-based precaution recommended depends
on the route of patient-source transmission for a specific
agent (ie, airborne, droplet, and/or contact precautions).
Table 2 provides a summary of transmission-based pre-
cautions. However, it also should be noted that infections
with most biological threat agents are not easily transmitted
person to person. Of the diseases of concern for bioterror-
ism, secondary person-to-person transmission is possible
with smallpox and pneumonic plague. Patients infected
with smallpox require aerosol and contact precautions.
Recommendations for patients infected with pneumonic
plague involve droplet precautions. Table 3 lists specific
transmission-based precautions for diseases caused by
major biological threat agents.
In summary, the recent occurrence of a series of anthrax-
related hoaxes illustrates the need to educate emergency
services personnel about how to best ensure patient and
worker safety in the case of suspected exposure to biolog-
ical threat agents. There are very little data to support the
methods being used or the variation in current care.
Emergency physicians, first responders, and hazardous
materials response teams need a standardized approach
to the management of patients who may have been exposed
to biological threat agents. These same groups need a
working knowledge of the isolation and infection control
measures recommended for the treatment of patients
exposed to those biological threat agents as outlined in
the CDC Guideline for Isolation Precautions in Hospitals.
The challenge now confronting the discipline of emer-
gency medicine is to educate emergency care providers
regarding the safety and efficacy of treatment options
incorporating existing guidelines and regulations and
assimilating new knowledge as it becomes available.
Emergency physicians confronted with the situation of
an alleged community-based biological agent exposure of
persons should immediately notify an infectious disease
consultant, the hospital laboratory officer, the local public
mendations include instructing people who may have
been exposed to contaminated materials to (1) wash their
hands; (2) change their clothing and place potentially
contaminated clothing in a sealed plastic bag; (3) conduct
prehospital decontamination by showering at home with
soap and water.Although the risk of reaerosolization of an
infective level of B anthracis spores from clothing or
human body is negligible, these simple methods will
reduce the potential for secondary transmission of bio-
logical threat agents.
ISOLATION AND INFECTION CONTROL
US emergency care providers already operate under a
very specific set of regulations and guidelines. These
include the CDC Guideline for Isolation Precautions in
Hospitals.
20
The guideline details policies and procedures
for the handling, housing, and care of individuals in
whom contagious disease or contamination with infec-
tious agents is suspected. The guideline does not recom-
mend hazardous materials decontamination as a means of
infection control, but instead stresses administrative con-
trols and environmental isolation.
The CDC Guideline for Isolation Precautions in Hospitals
includes 2 tiers of recommended precautions. Standard
Table 3.
Summary of infection control precautions for diseases caused by
potential biological threat agents.
Disease Precaution Type
Lassa fever S, A, C
Ebola S, A, C
Marburg virus S, A, C
Smallpox S, A, C
Chickenpox* S, A, C
Pneumonic plague S, D
Mycoplasma
pneumonia* S, D
Inhalational anthrax S
Venezuelan equine encephalitis S
Botulism S
Brucellosis S
Cholera S
Q fever S
Pulmonary tularemia S
Streptococal pneumonia* S
A, Airborne; C, contact; D, droplet; S, standard.
*This is a rather common ED illness that is provided here for comparison.
From Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isola-
tion procedures in hospitals.
Infect Control Hosp Epidemiol
1996;17:53-80.
From Centers for Disease Control and Prevention: Management of patients with suspected viral
hemorrhagic fever—US, 06/30/1995.
MMWR Morb Mortal Wkly Rep
1995;44:475.
EMERGENCY RESPONSE TO BIOTERRORISM
Keim & Kaufmann
182 ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
health department, and appropriate law enforcement
personnel. At a minimum, a second tier of notification,
either directly or through local or state resources, should
include the Federal Bureau of Investigation and CDC.
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... Exposure ofintact skin to the primary aerosol presents insignifıcant risk, except for mycotoxins. However, traumatic wounds, superfıcial abrasions and cuts can provide portals of entry (Keim and Kaufınann, 1999). To be maximally effective, an agent must have some of the following properties (Kortepeter and Parker, 1999;Kortepeter et al., 2001;Dembek et al., 2006): ...
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... Delayed includes Casualties with severe injuries who are in need of major or prolonged surgery or other care and who will require hospitalization, but delay of this care will not adversely affect the outcome of the injury and minimal includes casualties who have minor injuries, can be helped by nonphysician medical personnel, will not be evacuated, and will be able to return to duty shortly Emergency Medical Treatment (EMT and decontamination may be performed in rapid sequence. Treatment follows the universally accepted breakthrough of first ensuring the adequacy of airway breathing and circulation (Keim and Kaufmann, 1999).The physical process of removing residual chemicals from persons, equipment and the environment is known as decontamination. Every person arriving at Medical Treatment Facility (MTF) from biological warfare contaminated area is considered contaminated unless there is positive proof to contrary (Tucker, 1997;Richards et al., 1999).After the identification and decontamination of casualties, measures must be taken to prevent contamination of ambulance and air evacuation assets. ...
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Today the whole world is in an endeavor to deal with a newly arrived pandemic, COVID-19 which has all the potential to be catastrophic to mankind at its worst. This is not new; the world faced many pandemics earlier. According to the WHO, the worldwide spread of a new disease is called a pandemic that is if an infection becomes widespread in several countries at the same time, it may turn into a pandemic. Pandemic may be a result of new infection resulting from the evolution or change of an existing pathogen/parasite resulting in a change of host range, vector, pathogenicity or strain; or the occurrence of a previously unrecognised infection or disease or due to a known or endemic disease that either shifts its geographical setting or expands its host range, or significantly increases its prevalence. Whenever a new bacterial or viral strain is formed or the existing ones undergoes genetic variation due to mutation like genetic shift, genetic drift or genetic reassortment and have a capability of rapid transmission and infecting large population then they have a potential to cause pandemic. Man has constantly altered its ecosystem by its activities. Tracing of the origins of emerging infectious diseases back to first emergence in the human population, lead to the revelation of some distinctive patterns. There are a number of agents present in the environment to which our body is exposed all the time. Not everyone exposed to these agents develops disease. Immunity is a major factor that governs susceptibility of individual towards any disease and thus governs health. People with low immunity are very susceptible to any disease and even a mild disease can take severe form in such individuals while people with strong immune system are comparatively resistant to infection. In today‘s scenario, the lifestyle of people is exposing them to various chemicals in a way that now chemicals are part and partial of our life, be it flavoring agents, food colours, skin lotions, cleansers, disinfectants, fertilizers, pesticides, medicines, washing powder or soaps etc. Many of these chemicals either singly or in combination are proved to be a major cause behind the decreased immunity of people now days. As people around the globe are exposed to such chemicals around the clock hence it may be a major cause of mass immunosuppression. Due to which population immunity goes down and the resistance towards coming infection decreases hence they become susceptible to coming infection. This may be a major cause of an endemic disease firstly becoming epidemic then pandemic as well as a possible reason behind progression of any novel infection within the population. Being too clean might be making us sick due to development of immunologically virgin population. Even the obsessive washing of hands and excessive hygienic measures because may result in developing immunologically virgin population which is not exposed to the environment. For containment of any pandemic an amalgamation of rapid diagnosis, prevention and control, case management i.e. treatment and mass vaccination is required. Because of their changing antigenic type vaccine development is strenuous job. Additionally, it has been proved now beyond any doubt that the allopathic system of medicine alone may not be able to control any such pandemic or epidemic. It includes ayurveda which gives prime importance to prophylaxis. Ayurveda have several strong points in preventive care like scope of prevention is very large, no or very minimum side or after ill effects are seen. It also includes cowpathy which is an age old system of medicine described in ancient Indian literature and also known as ‗Panchgavya Chikitsa‖. In order to reduce the immunodeficiency, some of the nutrients like vitamins, roughages, antioxidants, lipids, Carbohydrates, Proteins, Ionophores, Carotenoids, Bioflavenoids, Omega-3 fatty acids, etc. and crude preparations of some microorganisms are also used which are necessary for the development of the body to improve the nonspecific and specific immunity. There is a need to explore novel therapeutic approach like convalescent plasma treatment which has been shown to be effective in treatment of COVID-19, swine influenza, SARS etc. The pandemics we have experienced so far have shown a number of deficiencies and defects, including vulnerabilities in global, national, and local public health capacities; difficulties in decision making under conditions of uncertainty; limitations of scientific knowledge; complexities in international cooperation; and challenges in communication among experts, policymakers, and the public. Pandemics can be contained only by an amalgamation of rapid diagnosis, prevention, control, case management and mass vaccination. Global surveillance of emerging and previously unknown infections in both human beings and other species should be done. Preparation beyond planning, with advance protocols and agreements, the commitment of ready reserves of public health experts and a financial line of credit, and the fulfillment of the international health regulation requirements can all help. Besides, the known therapeutic and preventive measures in our own traditional system and are proven on the standards of the modern scientific parameters must be used instantly without any doubt and wasting time in further research in order to save the population at large and minimize their sufferings.
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... (H2/9 -médico) Em síntese, como em outras metrópoles com altos índices de violência, podemos mesmo afirmar que no Rio de Janeiro a violência constitui um fenômeno que contribui diretamente para o incremento do saber médico na área de trauma. Artigos recentes (Solberg et al, 1998;Keim & Kaufmann, 1999;Hogan et al., 1999) indicam um campo ainda não abordado por nós, por não fazer parte de nossa realidade atual -os desafios aos conhecimentos médicos e de emergência que representam o atendimento às vítimas de atentados terroristas (sejam incidentes de grandes proporções envolvendo explosivos ou o bioterrorismo, que utiliza agentes químicos e biológicos, como o caso do envenenamento das tubulações do metrô japonês com gás sarin). ...
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To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population. The working group included 21 representatives from staff of major academic medical centers and research, government, military, public health, and emergency management institutions and agencies. MEDLINE databases were searched from January 1966 to April 1998, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of references identified by this search led to identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. Members of the working group provided formal written comments which were incorporated into the second draft of the statement. The working group reviewed the second draft on June 12, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. Specific consensus recommendations are made regarding the diagnosis of anthrax, indications for vaccination, therapy for those exposed, postexposure prophylaxis, decontamination of the environment, and additional research needs.