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An adequate response to a bioterrorist event of any magnitude requires early recognition and effective coordination of many disparate health and medical entities beyond the ED. Although the emergency physician plays a critical role in these types of events, many other essential functions must be addressed by individuals and organizations representing public health, mental health, law enforcement, emergency management, and others. Emergency physicians may find themselves working closely with organizations that are not traditionally encountered in everyday emergency medical practice.


A bioterrorist incident is the release, or the threat of a release, of a biologic agent among a civilian population for the purpose of creating fear, illness, and death. Such an occurrence is a low-probability, high-impact incident. For example, in the U.S. anthrax dissemination incident, the U.S. Postal Service was used to deliver letters containing spores of Bacillus anthracis. Although the environmental contamination was widespread, only 22 diagnosed cases of anthrax infection occurred: 11 cases of inhalational and 11 cases of cutaneous anthrax. Five patients died as a direct result of the anthrax exposure.1 Communities on the Eastern Seaboard of the U.S. were severely affected, with thousands receiving prophylaxis for anthrax.2 Fear then spread across the nation, as concern increased for a wider delivery of anthrax. Much of this national anxiety may have been exacerbated by the perception of an inadequate public health response capability, with the deficiencies demonstrating a critical need to integrate acute care medicine and the public health response.


Biologic agents are classified into two groups: biologically produced toxins and infectious organisms. Biologic toxins usually act as chemical agents in their human impact. The recognition and response requirements for these are very similar to those for chemical incidents (see Chapter 9, Chemical Agents and Mass Casualties), and this chapter focuses on infectious agents. Infectious agents are subdivided into two categories: contagious (propagating person to person) and noncontagious. Contagious agents have additional ramifications, both for protection of the health care workforce as well as propagation of the disease beyond the initially exposed population. The contagious agents of greatest concern, such as smallpox, plague (pneumonic), and certain viral hemorrhagic fevers, are person-to-person infectious through airborne or droplet transmission. Suspected agents should be treated as contagious until proven otherwise.


Certain characteristics make individual organisms particularly attractive as weapons for generating widespread fear, illness, and death among civilian populations. The Centers for Disease Control and Prevention (CDC) identified select organisms and the diseases they cause as the priority for focused preparation.3 Infectious agent selection was based on four general criteria:


  1. 1. Potential for public health impact

    2. Delivery potential (an estimation of the ease for development and dissemination, including the potential for person-to-person transmission of infection)

    3. Public perception (fear) of the agent

    4. Special requirements for public health preparedness (diagnostic, logistic, etc.)


The selected agents were then ranked in three categories, based on their overall potential for adverse ...

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