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In the event of a bioterrorist attack anywhere, clinicians everywhere will assume significant roles in the public health and medical response in their communities. In 2002, Secretary of the Department of Health and Human Services Tommy Thompson stated that "Physicians today need to be ready to recognize and respond to unusual symptoms that might signal a bioterror attack. Primary care doctors might be the first to spot the danger signs, and their knowledge and rapid action could be crucial for the nation." We agree with this assessment and find it a cause of concern that so little attention has been given to the bioterrorism preparedness needs of community-based physicians. Although emergency response efforts warrant the investments of money and resources that are currently underway, failing to look beyond emergency issues means preparation is incomplete. Since community practitioners form the point of first contact with the health care system for most Americans and are key sentinels in the nation's public health system, they have significant responsibilities in meeting the challenge of bioterrorism preparedness and response.

The Bioterrorism Sourcebook was written first and foremost by two general internists for our clinical and public health colleagues. One of the authors (MRG) was involved in two of the more significant public health events in recent memory relating to bioterrorism—the 2001 U.S. Postal Service anthrax attacks—as well as a number of local and state-based bioterrorism preparedness efforts, including the smallpox vaccination program that began in Connecticut on January 24, 2002. Such experiences brought home the realization that any clinician may find him or herself drawn into the issue of bioterrorism. If this could occur in a small state like Connecticut—where Ottilie Lundgren, a 94-year-old resident of a rural town died of inhalational anthrax two months after the September 11th attacks—it could occur anywhere. Our goal in writing The Bioterrorism Sourcebook has been to synthesize and integrate information into a substantive yet practical resource for community-based practitioners that is concise, lucid, and accessible.

We faced several challenges along the way. Bioterrorism is a dynamic area of medical and public health science. It is complex, highly technical, and intrinsically multidisciplinary, operating at the nexus of applied and basic research and encompassing fields as diverse as toxicology, pharmacology, engineering, public health, and health policy. Recent events in the United States and elsewhere in the world have accelerated interest in the field and a rapidly expanding reservoir of information on bioterrorism has resulted, including Websites, journal articles, and online and distance learning courses.

There are several problems with this growing reservoir of information, however. First, much of it focuses on emergency triage or the acute management of biologic, chemical, or nuclear events. For reasons alluded to already and discussed elsewhere in the text, such focus is shortsighted. Further, a large majority of these resources provide information on the so-called "Big Six" biologic agents: smallpox, anthrax, tularemia, viral hemorrhagic fevers, plague, and botulism. A host of other biologic agents as well as chemical and radiologic agents are thus given relatively short shrift. Another concern is that although a great deal of information is accessible electronically to any resourceful individual, clinicians are typically hard-pressed to find the time to efficiently comb through such disparate sources, whose quality and comprehensiveness vary greatly, just to find what they really need. Nothwithstanding the many advantages that today's information technology brings to the practice of medicine, in certain circumstances books retain a familiarity, efficiency, and accessibility that newer technologies simply cannot match.

The primary purpose of this book is to fill a void that exists for frontline clinicians and public health workers who will be called on to respond quickly, knowledgeably, and sensibly should a bioterrorist event occur in their community. So much emphasis to date has been on both emergency response and acute care facilities—and not without justification—that we sought to focus instead on educating and preparing community-based physicians, health care workers, and local public health officials for the responsibilities they will assume in the event of a bioterrorist attack as a complement to the care of these victims in hospitals and emergency rooms.

Creating a singular resource for practicing physicians, medical students, residents, and public health officials who work in the outpatient setting that is detailed, practical, and easy to use. To date, no such resource exists despite the enormous amounts of information available on the Internet and medical literature addressing bioterrorism. The vast amount of information available is of varying scope and credibility, but again, no single resource exists that is comprehensive, practical, and meaningful to clinicians. As noted earlier, the Centers for Disease Control and Prevention (CDC) website crashed after the anthrax cases in 2001, underscoring the need for built-in redundancy in our information technology systems, surge capacity, and the value of a hands-on manual such as The Bioterrorism Sourcebook.

Organization of the Book

The Bioterrorism Sourcebook is divided into four main sections, the first setting out basic principles and providing background for addressing the class-specific sections that follow. Section I emphasizes relevant clinical and public health issues as they relate to biologic, chemical, and nuclear (BCN) terrorism and provides the foundation for approaching Sections II through IV. We considered separating the more public health-oriented chapters from the more clinical-oriented chapters; however, the threat of bioterrorism requires clinicians to know the clinical aspects of bioterrorism as well as their role in the nation's public health response. For this reason, we hope that our readers will view the cross-disciplinary approach of the introductory section as a foundation from which to best approach the agent-specific chapters that form the bulk of the book.

The introduction proper begins with a brief discussion of terrorism, including derivations and definitions of the term as well as a short overview of the history of terrorism in the ancient and modern world. Terrorism evokes different views depending on the perspective with which one views it, and at the risk of sounding trite, it is reasonable to make the point that one person's terrorist may be another person's freedom fighter or religious martyr. Our short review of terrorism writ large makes the simple point that acts of planned violence against individuals, groups, organizations, or governments for political, religious, or ideologic purposes— what some have offered as a reasonable definition of terrorism—is not a modern phenomenon.

Chapter 2 moves directly into a discussion of the clinical approach to bioterrorism. Recent experiences with public health emergencies, such as the SARS epidemic or Hurricane Katrina, demonstrate that practicing clinicians will be drawn into medical or public health emergencies and yet they remain largely ill-equipped to do so. Practitioners must be prepared to assess patients presenting with potential bioterrorist syndromes, be capable of taking a bioterror history and be comfortable at least initially with triage, treatment, and prophylaxis. This chapter provides one approach to clinical diagnosis in this area. Among the points stressed are that clinicians need to include certain questions traditionally relegated to the social history—if asked at all—to find those clues that might indicate a potential bioterrorism diagnosis. An obvious example of what is meant here is that obtaining a detailed travel or work history may prove critical to the early identification of a bioterrorist event. In addition to providing one approach to the targeted bioterror history, Chapter 2 summarizes likely responsibilities that will devolve to clinicians in the event of a bioterrorist attack. This includes familiarity with initial triage of patients, antibiotic prophylaxis and medical surveillance of primary and secondary contacts, collecting samples, infection control procedures, and the importance of recognizing psychologic sequelae to bioterror events in victims, near victims, and those who were not exposed but nonetheless present for medical evaluation and require knowledgeable reassurance. It bears restating that cumulative and fairly recent experience with bioterrorism and other significant public health issues suggests that for every exposed individual somewhere between 15 and 200 nonexposed individuals will present for medical evaluation. Clinicians will assume a central role in distinguishing between individuals requiring medical triage, treatment, prophylaxis, or expectant surveillance and those requiring only reassurance. Finally, clinicians also must be aware that they have a duty to notify key public health officials in their community in the event they are entertaining or have made a diagnosis consistent with a bioterrorist event.

As noted previously, the introductory section also addresses the public health responsibilities of community-based physicians in the event of a BCN event or, for that matter, any public health emergency. Chapter 3 summarizes clinicians' public health responsibilities, beginning with an overview of existing public health infrastructure as it relates to BCN terrorism and disaster management. This includes the specific roles played by federal and state health and law enforcement agencies, and strategic components of the national bioterrorism response, such as communication strategies, pharmaceutical stockpiling, and the laboratory response network (LRN). This chapter introduces the concept of the incident command system—an organizational approach to disaster management broadened to include BCN specific concerns. The chapter also reviews applicable principles of occupational health and safety and the role of personal protective equipment as they relate to BCN terrorism. If this information seems somewhat far afield from bioterrorism, it is worth pointing out that multiple reviews and analyses of the response to the September 11th attacks found a critical need to develop standardized protocols to maximize safety while enabling rescue workers, first responders, health care workers, and workers responsible for "cleaning up" to do their jobs.

The historical schism between medicine and public health is unacceptable in today's global village. Infectious diseases or environmental and occupational health threats do not respect national boundaries and can therefore intrude—often with sudden and massively disruptive consequences—into ordinary medical practice. One need only mention SARS, Chernobyl, or anthrax to be reminded of how significant these international public health issues can become for practicing physicians. And yet, few clinicians have had substantive medical training or experience in the field of public health. Indeed, one of the lessons driven home time and again whenever a major public health emergency looms is that most public health units in this country are understaffed when it comes to individuals with substantive clinical experience and, more importantly, that this dearth has negative consequences for a well-crafted and effective public health response. This point finds expression in several places throughout the book.

Chapter 4 picks up on the public health theme of the previous chapter by discussing potential environmentally based terrorist threats. The chapter begins with a discussion of the potential risk to the nation's food manufacturing and agricultural sectors and from there moves on to consider how indoor air environments—specifically ventilation systems—offer opportunities for terrorists to disseminate a variety of BCN agents within buildings, as well as options for protecting buildings from such threats. The final subsection of this chapter includes a discussion of water-borne terrorist threats, a possibility that the nation's water industry takes very seriously. Additional details relating to specific water-borne threats are included in agent-specific chapters, particularly the chapter on Category B agents.

Several chapters in the introductory section focus on areas where clinical medicine and public health come face to face in meeting the threat of bioterrorism. Chapter 5 addresses BCN surveillance systems. The term refers variously to approaches encompassing environmental, clinical, or laboratory-based reporting systems designed for early identification of potential bioterrorist events and rapid communication to key individuals or organizations forming the basis of the nation's emergency public health response system. Syndromic surveillance is one of the most rapidly developing areas in the field of bioterrorism. During the 2004 Republican National Convention, for example, state health departments throughout the northeast collaborated with regional hospitals, urgent care centers, and laboratory facilities to create a system by which emergency room encounters and hospital admissions diagnoses were entered into a clinical database programmed to identify selected clinical symptoms or diagnoses as a means of identifying potential BCN events. The goal of surveillance is to be able to facilitate the early identification of emerging public health threats—whether influenza or anthrax, for example— and to promulgate that information quickly to the medical and public health community so that steps may be taken to contain its public health impact. The chapter considers the purposes and capabilities that well-designed surveillance systems would entail. Many surveillance models are being investigated and field tested, including those that use primarily clinical data (such as noted earlier with the 2004 political conventions) to those that use fixed site environmental monitoring, such as exists for radiation worldwide (see Section IV: Radiation Syndromes). The current limitations of existing surveillance strategies and the generalizable value of improved surveillance models for non-BCN health issues are also discussed.

Chapter 5 also presents several of the clinical tools developed or promoted as a means for clinicians to differentiate between naturally occurring and intentional outbreaks. The chapter includes discussion of clinical syndromes—sometimes referred to as toxidromes—as well as clinical algorithms that may aid clinicians in making the diagnosis of a bioterror event. One of the greatest challenges to the community physician is diagnosing an index bioterror case following a small-scale attack with a BCN agent. Infectious diseases take days or even weeks to evolve, but even nuclear or chemical attacks can be subtle in their presentation unless the attack is large enough to generate a sudden cluster of sick individuals presenting geographically and/or temporally with similar clinical syndromes. Further, as noted previously, in the overview of the toxicology chapter, the stereotypical pathophysiologic response of organs and tissues to a variety of insults means that signs and symptoms can be frustratingly nonspecific.

Chapter 5 suggests several clinical tools to aid clinicians in the difficult task of identifying a BCN diagnosis. The first tool is the concept of the sentinel health event or sentinel health data. In the context of BCN terrorism, sentinel data are any information that by its very presence demands consideration of a BCN exposure in the differential diagnosis.

An example might best serve to illustrate this point. A person presenting with a black eschar on their arm might not elicit consideration of cutaneous anthrax, but the identical clinical finding in a person who works in a mailroom of the Pentagon, Senate Office Building, or a U.S. Postal Office should—in today's world—prompt consideration of anthrax. This chapter also considers epidemiologic clues that can raise or lower one's index of suspicion for a BCN event such as travel, atypical presentations of common diseases, or "at-risk" jobs, buildings, and organizations.

The second half of Chapter 5 builds on the clinical utility of sentinel data by suggesting strategies by which clinicians can begin to distinguish sporadic illness caused by indigenous or naturally occurring infectious diseases from planned terrorist attacks.

For example, naturally occurring plague is not unheard of in the Western United States so that an occasional diagnosis would not be unexpected. In contrast, a spate of plague diagnoses in this same region would have very different implications, whereas even a single case of plague in a nonendemic area would have equally serious implications. Weaponization of biologic and chemical agents as a means of amplifying their potential for causing harm is also considered in the section on distinguishing natural from deliberate attacks. For infectious diseases, weaponization usually involves genetic manipulation to add virulence, infectivity, or biopersistence. The anthrax used in the U.S. Post Office bioterrorist attacks was weaponized by greatly increasing its ability to remain airborne, a property that enabled the microbe to be widely distributed in contaminated buildings and lowered the infective dose required to cause disease. Analogous strategies can be applied to both chemical and nuclear agents. For example, adding solvents to chemical agents may increase lipid solubility and therefore dermal absorption, which in turn enhances toxicity.

The next set of chapters covers areas that are important to clinicians and public health workers in preparing for bioterrorism. These include clinically-oriented chapters covering topics such as vulnerable populations (Chapter 6), the psychologic consequences of bioterrorism (Chapter 7), toxicology (Chapter 8), as well as a selected overview of medicolegal and ethical concerns (Chapter 9).

The concept of vulnerable populations may be somewhat unfamiliar to some readers. It refers to the fact that by virtue of preexisting medical, psychologic, or social factors, certain groups are uniquely vulnerable to the adverse effects bioterrorism. Although the individual agent-specific chapters also include small subsections summarizing vulnerable groups as they related to that particular agent or class of agents, Chapter 6 sketches out the general principles behind this concept, one that has much wider applicability in the health and welfare of our society.

There has been a great deal of emphasis on the acute medical issues surrounding bioterrorist events in the medical literature as well as in the media and other information sources. Although this focus is certainly appropriate—particularly for the emergency response system, hospitals, and local, state, and federal public health agencies—community-based clinicians may be expected to address several areas that, to date, have received somewhat less attention. Two areas given only passing attention in most existing resources are the chronic effects of the biologic, chemical, and nuclear agents and whether some individuals are by virtue of medical, psychologic, or social factors uniquely vulnerable to various bioterrorist agents. There is much less literature on which to draw to answer these two questions, but they are questions to which practicing physicians will want answers or at least some guidance. After all, many exposed and nonexposed individuals will continue to seek out the opinion and care of their own physicians following a bioterrorist event and what, if any, possible long-term health consequences are reasonable concerns. Although the chronic health effects of bioterrorist agents and vulnerable groups are dealt with in each agent-specific chapter, we dedicated Chapter 6 to a longer discussion of the medical, psychologic, and socioeconomic factors that may conspire to make some individuals more vulnerable to bioterrorist agents.

Chapter 7 addresses psychologic aspects of bioterrorism and offers clinicians strategies by which they can begin to understand and manage its psychologic consequences. The emotional impact of disasters is an area that is too often given less attention than is warranted. Numerous epidemiologic studies support the view that 70% of all mental health problems in the United States are managed by primary care doctors. Nearly three-fourths of all physician visits are motivated by substantial or wholly psychosocial factors. In the aftermath of the September 11 terrorist attacks, clinicians reported a surge in terrorism-related psychosocial complaints in their patients. This statistic was even higher the closer the practice came to the epicenter of the attacks. There is little doubt that individuals and communities experience profound emotional and psychologic consequences following any disaster, be it natural or deliberate, and that the psychologic fallout usually far exceeds the medical consequences. Clinicians working in communities with large Russian émigré populations will no doubt recall how some of their patients remember vividly the impact of the Chernobyl Nuclear Power Plant disaster not only on individuals living in the region but also on all of Russian society. Many of these individuals were not themselves directly exposed to nuclear material, and yet long after they have left their native country, many still experience profound worry or frank anxiety, depression, or posttraumatic stress. Similar psychologic outcomes will result from any sizeable bioterrorist event. In any given situation, community practitioners will be confronted with a surge in psychosocial complaints in their patients, regardless of their proximity to the actual event or degree of exposure.

Chapter 8 introduces the reader to some of the more relevant principles of toxicology. This chapter is of particular relevance to understanding the health consequences of chemical agents. It is a fundamental precept of toxicology that most organs or tissues respond in only a limited number of ways to toxic insults. This stereotypic tissue response explains why it is not always possible to distinguish pathophysiologically the root cause of any given end organ damage. For example, ARDS can result from numerous specific respiratory insults, ranging from infectious causes (e.g., influenza) to occupational or environmental exposures (chlorine gas) to pulmonary agents, such as phosgene. Elucidating the cause requires careful inquiry as to preexisting conditions, occupational or environmental exposures, or in the case of BCN terrorism, where the person works, has traveled, or with whom they have been in contact, to name a few. Clinicians' understanding of toxicology is generally related to basic pharmacology. In fact, pharmacology and toxicology share many general principles in terms of kinetics, target organ effects, metabolism, and excretion. Although a detailed review of toxicology is well beyond the scope of this book, Chapter 8 offers a quick overview of basic toxicology, including how physical properties, routes of exposure, toxicokinetics, biotransformation, and detoxification influence the toxicity of any given chemical. Understanding these issues will facilitate readers' awareness of the pathways by which chemical agents enter the body as well as the body's response to these particular toxins. Because toxicology has broad applicability to other areas of medicine—for example, poisonings and occupational health—we hope that this "mountain top" approach will enable clinicians to apply this knowledge to other areas of their practice.

The final chapter in Section I focuses selectively on the legal and ethical issues raised by medical and public health preparedness and response. Chapter 9 includes brief discussions on the historical, legal, and regulatory framework in which bioterrorism preparedness and response operates and some of the ethical dilemmas posed by such efforts.

Taken as a whole we hope that the introductory chapters in Section I of The Bioterrorism Sourcebook provide a concise foundation by which to understand subsequent chapters focused on the clinical syndromes caused by various BCN agents.

Sections II through IV form the bulk of The Bioterrorism Sourcebook and provides detailed information on biologic, chemical, and nuclear agents, respectively. Each major section begins with a brief historical summary of the class's use as warfare or terrorist agents, an overview of basic terminology, and consideration as to why this particular class of agent is a viable threat within the context of bioterrorism preparedness. Readers are encouraged to expand their knowledge by going directly to the sources cited for each chapter and are included in the bibliography. Our aim is to summarize succinctly from authoritative sources the core topics that must form the foundation of our understanding of biologic, chemical, and nuclear agents.

One of the initial decisions was to determine how to categorize the various agents to provide a sensible and coherent structure to the text. Two options were considered.

The first—and the one eventually used—was the approach promulgated most commonly by the CDC and the U.S. military. In this categorization, infectious agents are classified into Category A, B, and C agents, and chemical agents by their dominant clinical presentation, for example, blistering agents, nerve agents, and the like. Alternatively, a syndromic approach across the BCN categories could have been used. A syndromic approach might include a "rash-fever" syndrome such as Category A agents smallpox and viral hemorrhagic fevers, as well as the Category B agents Psittacosis and Typhus fever. Similarly, an "ARDS and fever" syndrome might incorporate not only Category A agents (e.g., anthrax and plague) and Category B biotoxins (e.g., ricin and staphylococcal enterotoxin B), but chemical agents that cause serious pulmonary injury, such as chlorine gas or phosgene gas.

There are compelling advantages and disadvantages to either approach. In the end, the Categories A, B, and C approach to infectious agents is emphasized, chemical agents are classified into four designations used by the CDC and the U.S. military (nerve agents, pulmonary agents, blistering agents [or vesicants], and blood agents), and nuclear agents were left to stand alone in their own section. However, because there is clinical and public health utility for clinicians to appreciate the value of syndrome recognition, Chapter 5 in Section I is dedicated to syndromic surveillance, and whenever appropriate, whichever syndrome a particular agent would fall is noted for each agent or class-specific chapter. In this way, the most common nosologic approach to bioterrorism is emphasized—of value to readers as they look at other sources of information, both text-based and electronic—and a complementary and clinically useful method of making biologic, chemical, and nuclear diagnoses is provided.

Section II is the first of three large sections addressing the major categories of bioterrorism agents. Perhaps because the United State's first experience with bioterror in the post–September 11 era came in the form of a biologic attack with anthrax, the scientific and medical literature, media attention, and much of the national preparedness effort emphasizes the threat of biologic agents. The agent specific sections in the The Bioterrorism Sourcebook begins with biologic agents for several reasons, including that quite a bit more is known about these agents, experience with them is much more recent, and they are of particular concern to the public. Section II includes 10 chapters: five on the Category A infectious agents smallpox (Chapter 12), Viral Hemorrhagic Fevers (Chapter 13), Anthrax (Chapter 14), Plague (Chapter 15), Tularemia (Chapter 16), a long chapter on the numerous Category B and C agents (Chapter 19), and finally several chapters on biotoxins, in particular the Category A agent botulinum toxin and ricin.

Category A agents—smallpox, viral hemorrhagic fevers, plague, tularemia, and anthrax—are considered by most authorities to pose the most significant public health threat if used in a terrorist attack. These agents—along with botulinum, technically a biotoxin and not a microbe—are classified by the CDC as Category A agents. This term was adopted in 1999 through a consensus conference held under the auspices of the CDC. The conference drew together public health and infectious disease experts, government representatives, as well as civilian and military intelligence experts and law enforcement officials from around the country. The group identified three categories reflecting graded public health importance: Category A, B, and C agents.

Category A agents have the greatest potential for serious public health impact for three distinct reasons. First, these agents are capable of causing mass casualties, have a contagiousness that enables wide dissemination, and are likely to instill widespread public fear and anxiety. Second, preparedness training and planning for each of these agents necessitates broad multistaged public health approaches. For example, identification and management of an epidemic caused by any of the Category A agents require effective disease and syndrome surveillance systems, diagnostic laboratories trained and equipped for rapid and accurate identification, stockpiling and planning to distribute antidotes, antibiotics and other equipment needed to manage an outbreak, and improved systems of communication among the nation's public health, law enforcement, and health care communities.

Like Category A agents, Category B agents are disseminated easily, but they cause moderate morbidity and only infrequently cause death. Consequently, Category B agents are less likely to cause widespread public panic and require less investment in terms of preparedness. The last category, Category C agents, are emerging pathogens whose absolute risk remains uncertain at this point, but they are not viewed as a high public health threat based on current public health risk assessment. An example of the latter is the Hanta virus. Categories B and C agents are included in their own chapter within the biologic agent section.

Section III addresses the chemical agents that pose the greatest threat as weapons of terror. Once again, this section begins with brief chapters covering the class of agents and their historical use as weapons. The four major categories of chemical agents—pulmonary agents, vesicant or blistering agents, nerve and incapacitating agents, and blood agents—each include sections on the pathophysiology of various chemical agents, laboratory and radiologic findings, the clinical presentation, recommended management, existing sources, vulnerable populations, and the consideration of long-term or chronic effects from exposure.

Section IV begins with a brief historical chapter on the Atomic Age and nuclear issues, followed by a chapter that addresses basic definitions and issues relating to nuclear physics. The subsequent chapter (Chapter 28) on nuclear terrorism begins with a review of the likely scenarios for nuclear terrorism, the pathophysiology of nuclear injury, laboratory, and radiologic findings, the clinical presentation, recommended management, vulnerable groups, and consideration of long-term or chronic effects from exposure.

What follows next for each class of agent is the expected discussion of epidemiology, pathophysiology, clinical manifestations, laboratory and radiographic findings, and treatment. These topics are certainly covered in great depth in the extant literature and on many websites, such as that of the CDC.

Finally, the book includes a series of appendices and a bibliography of useful sources and resources. The first appendix provides detailed dosing regimens based on the latest consensus recommendations for management of BCN diagnoses. The second appendix contains a glossary of key terms, abbreviations, and concepts. The final appendix includes the Quick Reference Guides from the agent-specific chapters. The intent of this duplication is to enable readers' quick access to information that is already contained in various formats within the main text in its most concise format as quickly as possible without having to return to reading through individual chapters. The book closes with a selected bibliography of citations and websites used in the writing of this book, and a list of useful information sources, including key phone numbers and websites.

Readers will noticed that within each chapter are several sections that are not commonly included in standard references and sources but that we feel have particular relevance to practicing physicians. This includes a discussion of the sources of the agents and "at-risk" occupations where exposure to these agents is possible even without a deliberate terrorist attack. Our purpose in providing this information is to reinforce the point that clinicians should have a rough inventory of what facilities or industries in their community could be targets for terrorists or, perhaps even more relevant, where individuals might be exposed to the agent in the absence of a deliberate biologic, chemical, or nuclear attack. The latter adds emphasis to the importance of considering environmental and occupational factors in approaching not only BCN terrorism but also our routine clinical practice. Whenever possible we also summarize what is known about the long-term or chronic effects of these agents. Information on sources of exposure, at-risk occupations, vulnerable groups, and chronic effects also affords clinicians and public health officials with information that might be of use in their roles both during an emergency and in its aftermath.

After all, survivors of any BCN event—be they directly or indirectly exposed—will be confronted with a host of potential physical, psychologic, and social sequelae that cannot be given justice simply by summarizing the acute clinical manifestations, diagnostic approaches, management strategies, and preventive issues.

Creating an off-the-shelf resource for practicing physicians and public health practitioners was the primary goal in writing this book. Therefore, within each chapter are tables providing critical information for each agent in a readily accessible format. These tables address critical medical and public health information for that agent, syndrome-based diagnostic strategies, and public health responsibilities respectively. The Quick Reference Guide, Making the Diagnosis, and Critical First Steps each attempt to live up to their name—the salient points organized for quick access and ease of use.

Final Thoughts

Readers will likely notice aspects of organization, style, or content in this book that differ from many, but not all, medical textbooks. For example, a strategy to make more apparent the relevance of BCN terrorism to community practitioners was adopted by including clinical or public health vignettes at the beginning of each chapter that have—it is confessed—somewhat "headline grabbing" attributes. Some of these vignettes focus on a particular agent as a terrorist threat, whereas others present naturally occurring, occupational, or accidental case histories, the latter purposefully intended to underscore that episodic and occupational/environmental exposures can also lead to disease that mimics bioterrorism diagnoses. Although some of the vignettes are fictionalized accounts of potential clinical encounters, whenever possible actual or newsworthy events underscore the point that bioterrorism is a fact of modern life and requires vigilant awareness on the part of the medical and public health community, as well as of the general public. These vignettes were crafted to illustrate key clinical or public health aspects of that particular agent or class of agents, but they are also intended to stimulate the interest and attention of the reader. For similar purposes, readers will also note the liberal use of historical vignettes, literary excerpts, and quotes throughout the text. As the French novelist Albert Camus in his 1947 postwar novel The Plague wrote: "The plague had killed all colors, vetoed all pleasures." These excerpts are not mere leavening— although again it is hoped that they enliven the readers' experience—but are chosen because they speak to the text itself, illuminating evocatively various scientific, social, or psychologic themes as only historians or novelists can do.

The Bioterrorism Sourcebook does its best to provide state-of-the-art information, but it is also fair to point out that bioterrorism—not unlike the HIV/AIDS literature of 10 years ago—is a moving target. Further, knowledge of the health effects of most of the biologic, chemical, and nuclear weapons derives largely from historical experience and therefore firm evidence-based recommendations are few. Extrapolations from other sources, including toxicology studies and military research programs, accidents, and deliberate uses of these weapons do not necessarily provide all that we would like to know about the health impact of these agents. Given this situation, it is not hyperbole to suggest that clinical acumen and early diagnosis might mean the difference between early, controlled interventions and mass casualties.

Two caveats relating to terminology are in order, both of which were adopted largely in the interests of brevity and convenience. First, rather than repeat the phrase "biologic, chemical, nuclear," or combine the first letters of these words into one of several commonly used acronyms (e.g., BCN, NBC, or CNBR), we either use the term of "bioterrorism" to mean all three, or BCN. When referring specifically to one class of bioterrorist agent, we will use terms such as biologic weapons, chemical agents, or nuclear events. Second, although our primary target audience is practicing clinicians—a group we feel has been underrepresented in current preparedness efforts—the book's format, accessibility, and approach should prove equally valuable to individuals from the many disciplines that comprise the nation's health care and public health infrastructure and that are essential components in our preparedness efforts, in particular, first responders, law enforcement officials, local public health officials, and, of course, learners in the medical, allied health, and public health educational system. We ask readers to forebear with our admittedly arbitrary use of "clinicians," "physicians," or "community-based practitioners," rather than our full intended audience, for the simple reason of avoiding repetition of a string of professions within the text. We acknowledge here that our colleagues from many disciplines and professions share responsibility for the nation's bioterrorism preparedness efforts that is certainly equal to that of physicians and other health care providers.

In making a commitment to write The Bioterrorism Sourcebook, we asked ourselves two compelling questions. First, does biologic, chemical, and nuclear terrorism pose a threat to our society? Second, do practicing clinicians have unavoidable and unique responsibilities in meeting these threats? We believe the answer to both questions is an unqualified yes. The threat of bioterrorism is real. Just ask congressional staffers in the offices of Senators Bill Frist or Tom Daschle, the victims and families of the anthrax attacks, or the thousands of U.S. postal workers placed on prophylactic antibiotics as a result of the anthrax attacks. The impact on our country of even these few bioterrorist attacks has been enormous and lasting.

Today, the nation's health care system is a critical component of our national security apparatus, a new and historically unprecedented development whose ultimate impact remains to be seen. It is imperative that the nation's medical community increase its familiarity with the clinical and public health aspects of bioterrorism and it needs accurate, accessible, and concise information to better prepare for addressing the concerns of patients and the public health needs of our communities. The Bioterrorism Sourcebook represents our contribution to the educational needs of these medical and public health professionals, our colleagues in the vital effort to improve our nation's preparedness for the next—and sadly, probably inevitable—bioterrorist attack.

Michael R. Grey, M.D., M.P.H.
Springfield, Massachusetts

Kenneth R. Spaeth, M.D., M.P.H.
New York, New York

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