Transcript UCLA Center for Public Health and Disasters 10911 Weyburn

UCLA Center for Public Health and Disasters
Bioterrorism Training for Physicians
Updated March 2003
Over 1700 Downloads Since Going Online October 2001
Available at: http://www.ph.ucla.edu/cphdr/bioterrorism
BIOTERRORISM:
Are You
Prepared?
Bioterrorism 101
Why is this a problem?
Who and what
are the agencies worrying about?
Biological Terrorism
Intentional or threatened use of viruses,
bacteria, fungi or toxins from living
organisms to produce death or disease in
humans, animals or plants
Anthrax Mail Attacks - 2001
Biological Terrorism – Why?
Small amounts – devastating effects
Invisible, odorless, tasteless
Easy to obtain
Difficult to detect
Civilian populations unprotected
Delayed onset - difficult to trace
Publicity, fear, chaos
What Happens in a
Bioterrorism Incident?
That depends on whether the attack is:
OVERT
or
COVERT
Overt Attack
Threat Validation
Coordinated System Response
Traditional First Responders: Fire, Police, EMS
Hospitals
Community Practitioners
Public Health - Information Management
Law Enforcement
Overt Attack
Problems:
Verifying if an attack has taken place
Fear, chaos
Large numbers of “worried well”
Decontamination
Limited supply of treatment, prophylactic drugs, and
vaccines
Real or Hoax?
Public health and law
enforcement will determine
credibility, and need for
decontamination or prophylaxis
Test results may take 24-48
hours
Covert Attack
EMS system may be used by cases (not yet
recognized as a bioterrorist event)
Likely detected through hospitals, medical
care practitioners
Clinical labs contact local PH department
PH department refers to State or CDC
Covert Attack
Problems with recognition:
Symptoms overlap common illnesses
Delayed onset of symptoms
Victims present to different centers
Secondary spread may occur before attack is
recognized
Likely Scenarios
Aerosol release
Major city, large event, or key function
Victims presenting to different centers
Recognition of attack through symptoms,
epidemiologic patterns or microbio lab
Aerosol Delivery
Considered the most likely route for BT
Aim is to generate invisible clouds of
particles 0.5-10 microns in diameter
Can stay suspended for long periods of time
Perfect size to reach the alveoli in lungs
Aerosols of most agents produce systemic
disease
Key Indicators of a BT Event
Sudden increase in severity or incidence of
illness
Appearance of unusual (non-endemic) illness
or syndrome in your community
Geographic and/or temporal pattern of illness
Occurrence of vector-borne disease where
there is no vector
Key Indicators of a BT Event
Cluster of sick or dead animals
Atypical seasonality
Unusual expression of endemic disease
Multi drug-resistant pathogens
Bioterrorism: The Agents
Category A:
Top Priority
Easily disseminated or
transmitted
High mortality
Causes social disruption
Special preparation
needed
Category A Agents:
Anthrax
Botulism
Plague
Smallpox
Tularemia
Viral Hemorrhagic
Fevers
Bioterrorism: The Agents
Category B
Q Fever
Brucellosis
Viral encephalitides
Staphylococcal
enterotoxin B
Food/Waterborne
Ricin
Category C
Nipah virus
Hantavirus
Tickborne
hemorrhagic fever
Yellow fever
Multidrug-resistant TB
Overview of the Agents:
Clinical Manifestations
and Treatment
Pneumonic Syndromes:
Inhalational Anthrax
Pneumonic Plague
Pneumonic/Typhoidal Tularemia
Anthrax
Source: Bacillus
anthracis
Bacterial spores and
toxins
Cutaneous,
inhalational and
intestinal
Cutaneous Anthrax
Cutaneous Anthrax
Incubation 1-12 days
Papule > vesicle or ulcer > black center
over several days
Diagnosis: Gram stain and culture of
unroofed vesicle, base of ulcer,
under edge of eschar
Usually responds well to treatment
Inhalational Anthrax
Incubation: 1 - 6 days (rarely up to > 60 days)
Prodrome: 1-2 d fever, malaise, dry cough
Severe respiratory distress, septic shock, may
have meningitis
Diagnosis
Hemorrhagic mediastinitis – wide on CXR
Isolation
Standard; not contagious
Inhalational
Anthrax:
Mediastinal
Widening
Anthrax vs. Viral Illness
Anthrax
Elev. Temp
70%
Cough
90
SOB
80
Pleuritic Pain
60
Headache
50
Sore Throat
20
Rhinorrhea
10
Nausea / Vom. 80
MMWR Nov 9 2001;50:984
Flu
Other Viral
68-77%
40-73%
84-93
72-80
6
6
35
23
84-91
74-89
64-84
64-84
79
68
12
12
Evaluation of Possible Inhalation Anthrax
History of exposure or risk + Symptoms:


WBC (bandemia), Blood culture – highest yield
CXR – wide mediastinum, effusion, or infiltrate
Consider CT if CXR normal
If results abnormal or pt. seriously ill:
Multi-drug treatment
If results normal and pt mildly ill:
Observe and initiate single-drug prophylaxis
Anthrax - Treatment
Combination Rx for seriously ill:
Cipro or Doxy + other drug(s)
Other drugs with activity include:
Rifampin, Vancomycin, Clindamycin, Imipenem,
Clarithromycin, PCN
Post-Exposure Prophylaxis:
Cipro or Doxy X 60 d
(X 30 d if given with vaccine)
Anthrax Exposure?
Most patients need only reassurance
Higher risk:
Threatening message
Sandy brown color powder
Suspicious letter or package
High-profile person or postal worker
If exposure is credible, contact police
Nasal swab NOT sensitive enough to r/o exposure
for an individual
Plague
Source
Bacterium: Yersinia pestis
Forms
Bubonic, septicemic, and pneumonic**
** Suspect Bioterrorism
Pneumonic
Plague
Incubation: 2-3 d
Symptoms
Fulminant pneumonia, bloody sputum, septic shock,
high fever, chills, headache, possible disseminated
intravascular coagulation
Diagnosis
Laboratory: Gram stain blood, sputum, node
Small, Gram-neg, bipolar (‘safety-pin’), poorly staining
coccobacilli
Pneumonic Plague
Isolation
Highly contagious
Strict respiratory isolation until Rx for 3d
Followed by standard respiratory droplet
precautions (masks, gown, gloves, eye protection)
Treatment
Streptomycin, doxycycline, or chloramphenicol
High mortality, but may respond to early
treatment
Tularemia
Source
Bacterium: Francisella
tularensis
Gram neg. coccobacillus
Zoonotic (‘rabbit fever’)
Forms
Ulceroglandular and typhoidal/pneumonic**
**Suspect Bioterrorism
Tularemia
Incubation: 2-10 days
Prodrome:
Fever, headache, chills, myalgia, cough, nausea, vomiting,
diarrhea
May present as pneumonia
Diagnosis
Laboratory: Culture/Gram stain blood, sputum, node
Culture can be difficult and is risky to lab personnel
Tularemia
Isolation
Standard; not contagious
No human-human transmission
Treatment
Streptomycin, gentamicin, or doxycycline
If exposed: watch for 7 days, treat if fever develops
Vaccine under review by FDA
Mortality 30% untreated; < 10% treated
Paralytic Syndrome:
Botulism
Botulism
Source:
Clostridium botulinum
neurotoxin
Types A, B, E, and F
Most potent toxin known
Lethal dose 1 ng/kg
100,000 times more toxic than sarin
Botulism
Incubation: 1-5 days
Symptoms
Blocks cholinergic synapses
Dry mouth, blurred/diplopia, muscle weakness, dysphagia
Descending flaccid paralysis can last for weeks to months
Diagnosis
Clinical
A few labs can do serum toxin assay
Death from respiratory failure
Botulism
Isolation
Standard; not contagious
No human-human transmission
Decontaminate clothing, skin with soap and water
Treatment
Ventilatory support
Botulinum antitoxin - equine
Skin test for horse serum sensitivity
More effective if given early – will not reverse paralysis
that has already occurred
Rash and Fever Syndromes:
Smallpox
Viral Hemorrhagic Fevers
Smallpox: Variola major
Smallpox: Presentation
Incubation: ~ 12 days (up to 17 days)
Early symptoms nonspecific
Fever, malaise, aches for 2-4 days; then severe illness
Rash then appears on extremities with uniform
appearance
Scabs over in 1-2
weeks
Contagious until ALL
scabs have fallen off
Smallpox
Notify Public Health IMMEDIATELY
Diagnosis
Laboratory
Rule out chickenpox – PCR
Isolation
Strict contact and respiratory isolation (negative pressure)
Trace contacts up to 17 days prior to illness
Treatment
None known effective
Questionable effectiveness of Cidofovir
Mortality ~ 30%
Smallpox vs. Chickenpox
Incubation
Prodrome
Distribution
Progression
Scab formation
Scab separation
Variola
7-17 d
2- 4 d
extremities
similar growth
10-14 d p rash
14-28 d p rash
Varicella
14-21 d
minimal/none
trunk
dissimilar growth
4-7 d p rash
<14 d p rash
Smallpox vs Chickenpox
Rash: extremities, uniform size
Rash: trunk, different
stages of development
Smallpox
Vaccine
Live Vaccinia virus
Given intradermal on bifurcated needle
Pustule – scab in ~ 1 week, mild fever
Can potentially spread to others until scab is gone
Lifelong immunity is questionable
Vaccinated persons probable reduced risk of mortality
Vaccine is effective up to several days AFTER
exposure
Administering the Vaccine
Administering the Vaccine
Vaccinia: Common Reactions
Sore arm
Adenopathy
Fever
Up to 1/3 may have reactions severe
enough to miss work, school, or usual
activities
Smallpox Vaccine - Reactions
Risks for primary vaccinees:
Accidental Inoculation: > 500 / million
Generalized Vaccinia: 242 / million
Eczema Vaccinatum: 12 – 39 / million
Progressive Vaccinia: 1 – 2 / million
Encephalitis: 3 – 12 / million
Death: 1 - 2 / million
Risks are much less if previously vaccinated
Vaccinia Immune Globulin-VIG
Primary treatment for
adverse reactions
Produced from plasma
of vaccinated
individuals
Stored at CDC
IM forms only at
present
Indications for use
Eczema vaccinatum
Progressive vaccinia
Accidental implantations
(extensive lesions)
Generalized
vaccinia(severe)
Not recommended in
vaccinia keratitis
Accidental
Inoculation
Generalized
Vaccinia
Eczema
Vaccinatum
Progressive
Vaccinia
Progressive
Vaccinia
Fetal
Vaccinia
Viral Hemorrhagic Fever (VHF)
Ebola
Lassa
Marburg
Sabia: Brazilian HF
Machupo: Bolivian HF
Rift Valley Fever
Crimean-Congo HF
Ebola virus
Viral Hemorrhagic Fever
Incubation: 4-21 days
Symptoms vary between viruses
Fever, myalgia, prostration
Petechiae, hemorrhage, shock
Neurologic, pulmonary, hepatic
involvement
Mortality varies: 10 – 90%
Viral Hemorrhagic Fever
Diagnosis
Primarily clinical
Viral isolation, serology, immunohist. at CDC
Isolation
Strict contact isolation
Strict respiratory isolation
Strict bodily fluid isolation
Viral Hemorrhagic Fever
Treatment
Supportive
Fluids, transfusion
Watch for pulmonary edema
Avoid unnecessary lines, procedures, etc.
Ribavirin may be effective for Lassa, Bolivian
HF, Crimean-Congo HF, Rift Valley Fever
Risk of Secondary
Transmission
Agents to worry about:
Smallpox
Plague
Viral Hemorrhagic
Fever
Isolation is critical if
any of these are
suspected
Notify hospital
infection control
immediately
Bioterrorism Agents: Decon
For most agents, it is very unlikely that anyone
would be infected from clothing, skin, etc.
Decon when there is:
Gross contamination by dust, powders, spray, etc.
A body fluid agent, such as in the case of Ebola
Generally, no special equipment needed
Remove clothing and seal it in plastic bag
Shower with soap & water
Laboratory Risks of BT Agents
Agent
BSL
Laboratory Risk
B. anthracis
Y. pestis
2
low
2
medium
Botulinum toxin
2
medium
F. tularensis
2/3
high
Smallpox
4
high
Viral Hemorrhagic Fever 4
high
Laboratory Response Network for
Bioterrorism
LEVEL D: CDC
LEVEL C: Typing Labs, Public Health Labs
LEVEL B: Public Health Labs
LEVEL A: Clinical Labs
Special Problems with BT
Identifying a covert attack
Social disruption
Prophylaxis for large populations
National Pharmaceutical Stockpile (NPS)
Vaccination plans
Secondary transmission
Special Problems with BT
Specialized labs needed for some agents
Risks to laboratory workers
Communication between agencies
Limited Health Care Resources
Isolation rooms
Ventilators
Protective Equipment
Medications
Vaccines
Morgue facilities
Challenges in Recognizing
a Bioterrorist Attack
Delayed onset - hours to weeks
Early signs/symptoms nonspecific
Physicians/laboratorians not familiar
with rare diseases/organisms
Current public health surveillance may
not be adequate for early detection
Early Detection of a BT Event:
Finding a Zebra Among Horses
Early detection and control of bioterrorism will
depend on alert clinicians reporting unusual
illnesses or patterns of illness to Public Health
BEFORE definitive diagnosis
When you hear hoof beats, think “zebras”
(as well as horses)
Public Health Bioterrorism
Surveillance Plan
Enhance traditional surveillance for all
potential BT agents and unusual illnesses
Novel surveillance methods
Hospital diversion data
Medical examiner data
Syndrome-based ER/ICU admissions
School absences
Animal disease surveillance
Pharmacy sales
Agencies Responding to a
BT Attack
Local
Public Health
Police, Fire, EMS
State
Public Health
Disaster management
National Guard
Federal
CDC
FBI, Dept of Justice
Homeland Security,
FEMA
Dept of Defense
BT Hospital Preparedness Issues
Develop plans for:
Infection control
Lab support
A large influx of patients: triage, pt
placement, pt transport
Pharmacy inventories
Psychological aspects of BT
BT Hospital Preparedness Issues
Develop plans for:
Hospital Emergency Incident Command
System (HEICS)
Internal and external communication
Evidence collection
Discharging or post-mortem care
Decon
Preparation for a BT Attack
Familiarize medical staff with BT agents
Incorporate into disaster planning
Infection control and decontamination
Communication plan with key agencies:
Public Health Dept
Laboratory, CDC, police, FBI, etc.
Identify contacts to obtain stockpiled supplies:
antibiotics, immune sera, vaccines, antidotes,
decon equipment, PPEs, etc.
Security preparations
Local Health Department Actions
Determine whether situation is “unusual”
Case finding/case investigation
Laboratory confirmation
Alert medical community
Identify source of outbreak and at-risk persons
Coordinate with State DHS, CDC, FBI, and other
authorities
Public Health’s Role in
Bioterrorism Event
Incorporation of State Epidemiology BT Materials
Epi/surveillance
Labs
Notification
Media/Public Information Officer (PIO)
Integration with FBI
Integration with CDC
Public Health’s Role in
Bioterrorism Event
Infectious Disease/epidemiology tracks infectious
diseases
Public Health Laboratories identify agents (either
in-house or through referral to State or CDC)
Environmental Health assesses sanitation and
safety of food and water
Public Health’s Role in
Bioterrorism Event
Health Officer coordinates information for the
public and medical providers
Community Health and PH nurses provide
education, information to the public and to
community providers
Treatment and prophylaxis
Quarantine
What To Do if You Suspect a
Bioterrorist Disease
IMMEDIATELY NOTIFY:
Hospital Infection Control
Isolation: Smallpox, plague, hemorrhagic fevers
Laboratory
Hospital Administration
Local Public Health Department
Case Studies
Case 1 - Dyspnea, Hypotension
46 year old stock trader
Fever, malaise, cough 2 days prior
Abrupt onset severe dyspnea
38.1o 115
86/40 32 O2sat 83%
Diaphoretic, Disoriented
CXR - no infiltrate, + small pleural eff.
Mediastinal
Widening
Case 1 - Dyspnea, Hypotension
Patient admitted to ICU:
Fluids, Intubation, Ceftriaxone, Vanco., Gent.
Later the same day a similar patient presents
Also a stock trader in the same building
Both patients deteriorate and die the next day
Case 2 - Rapid Progressive
Pneumonia
10 y/o boy with fever, dry cough for 1 day
8 y/o sister also ill
VS
38.6o
110
96/60
91% sat
Scattered crackles in both lungs
CXR - Bilateral infiltrates
Later develops severe dyspnea, hemoptysis,
shock
Case 3 - Fever
52 y/o male c/o 3 days malaise, fever,
vomiting, myalgias
39.1o
92/50
124
28
WBC 18
platelets 45
BUN 48
Creatinine 2.9
Within hours becomes confused, vomits
blood
Case 4 – Vesicular Rash
34 y/o woman
with fever,
malaise X 2 days
Today, a rash
appeared
39.4o 106/78
116
18
A & O X 3 Lungs
clear
Case 5 - Overt Attack
A terrorist group says they have
released 10 kg of botulinum toxin over
your city
Clostridium botulinum neurotoxin
Lethal dose 1 ng/kg
Bioterrorism Addendum A:
Selected Category B and C Agents
Q Fever
Source
Bacterium: Coxiella burnetii
Resistant to heat, drying and many common disinfectants
Incubation 10-40 d
Sx variable - Fever, HA, myalgia, malaise
Occ. cough, rales, CXR infiltrate
WBC usually normal, but LFTs common
Low mortality, but malaise may last months
Q Fever
Diagnosis
Laboratory: serology, antibody or ELISA
Isolation: Standard
Treatment
Antibiotics will shorten course
Tetracyclines
Erythromycin, azithromycin, quinolones,
Chloramphenicol, TMP/SMX
Brucellosis
Source
Brucella species
Zoonotic
Slow-growing gram negative rod
Presentation: Incubation 5-60 d or longer
May last weeks or months, but rarely fatal
Brucellosis
Diagnosis
Serology; Culture of bone marrow, liver or spleen tissue
Isolation
Standard
Contact if open lesions
Treatment
Combination antibiotics
Most recover even without antibiotics
Viral Encephalitis
Alphaviruses: Venezuelan, Eastern, Western
Equine Encephalitis
Presentation: Incubation 2-14 d
Fever, HA, myalgia, photophobia, vomiting
Small % of VEE progress to neurologic Sx
Delirium, coma, seizures
Viral Encephalitis
Diagnosis
Viral isolation or serology, PCR for some
Isolation: Standard
Treatment
Supportive analgesics, anticonvulsants
Vaccines available, but poorly immunogenic
Ricin
Ricin
Source
Derived from castor beans (Ricinus communis)
1 million tons of castor beans produced
annually worldwide
5% ricin by weight
Stable
Inhibits protein synthesis via ribosome
Toxic via inhalation, ingestion, injection
Ricin
Ricin was used to
assassinate Bulgarian
exile Georgi Markov in
London in 1978.
A weapon disguised as
an umbrella was used
to implant a ricincontaining pellet
Ricin
Symptoms begin in 4-8 hours:
Weakness, fever, cough, hypothermia, sweating
Inhalation
Severe respiratory symptoms from necrosis and edema,
hypoxia with respiratory failure in 36-72 hours
Ingestion
Nausea, vomiting, diarrhea, GI hemorrhage, vascular
collapse, death in 3 d
May cause DIC, multi-organ failure
Ricin
Diagnosis
Serum ELISA available in few labs
Treatment
Primarily supportive:O2, hydration
If ingested:
Gastric lavage
Activated charcoal
Staphylococcal Enterotoxin B
Presentation: Incubation 1-6 hrs
Diagnosis
Clinical and epidemiological
Isolation: Standard
Treatment
Supportive
Clostridium perfringens Toxin
Source
Episilon toxin of Clostridium perfringens
Organism ubiquitous in soil
Present in stool of every vertebrate
Can produce gas gangrene, necrotizing
enterocolitis, food poisoning
Secretes > 12 toxins
Could be toxic if inhaled or ingested
C. perfringens Toxin
Symptoms within hours
GI symptoms prominent, rare fever
If inhaled, could cause resp. distress
Mortality
Death is rare
Could result from vascular leaks, lung damage
C. perfringens Toxin
Diagnosis: Clinical
Stool tests for enterotoxin are not widely
available
Treatment
Supportive
Antibiotics active against organism:
penicillin, clindamycin
Trichothecene Mycotoxins
Source
Group of > 40 fungal toxins
Produced by Fusarium, other common fungi
Stable to heat and UV
Inhibits protein and nucleic acid synthesis
affecting rapidly proliferating tissues
If aerosolized, appears as yellow droplets,
“yellow rain”
Toxic via inhalation, ingestion, and skin
Trichothecene Mycotoxins
Symptoms: onset minutes to 4 hours
Skin blistering, eye irritation, nose/throat pain,
Cough, dyspnea, chest pain, hemoptysis
Abdominal pain, vomiting, bloody diarrhea
Bone marrow suppression can lead to diffuse
hemorrhage
If severe: prostration, ataxia, shock and death in
hours to days
Trichothecene Mycotoxins
Diagnosis:
Urine, blood, tissue samples for liquid chromatographymass spectrometry in specialized labs
Treatment: Supportive
Remove and isolate clothing, irrigate eyes, wash with
soap/water
If ingested, Activated charcoal
? Benefit of ascorbic acid, dexamethasone
Case 1 – Headache, Vomiting
39 y/o woman presents with 2 d worsening HA,
nausea, vomiting, fever, malaise
Better after fluids, acetaminophen and is released
Returns following day with confusion, seizure
Case 2 – Vomiting, Diarrhea
Multiple patients present to ER with:
Vomiting, diarrhea, headache, myalgias,
malaise, fever, chills, cough
All had been at a large outdoor festival
Case 3: Malaise
High numbers of people present to ERs and
clinics over several weeks in Nov. - Dec.
Fevers, malaise, cough, headaches
Some have pneumonia on CXR
Most have elevated LFTs
Public health department finds no influenza
or other pathogens
Bioterrorism Addendum B:
Additional Resources and References
Additional Web Resources
Centers for Disease Control and Prevention (CDC)
www.bt.cdc.gov
US Army Medical Research Institute on Infectious
Disease (USAMRIID)
www.usamriid.army.mil
World Health Organization (WHO) Communicable
Disease Surveillance and Response (CSR)
www.who.int/emc/
Additional Print Resources
Emergency Medicine Clinics of North America May 2002 (entire
issue devoted to bioterrorism)
Kortepeter MG and Parker GW. Potential biological weapons
threats. Emerging Infectious Diseases. 1999; 5: 523-27.
Inglesby TV et al. Anthrax as a Biological Weapon, 2002:
Updated Recommendations for Management. JAMA. May 01,
2002;287(17): 2236-2252.
Arnon SS et al. Botulinum Toxin as Biological Weapon:
Medical and Public Health Management. JAMA. Feb 8,
2001;285(8): 1059-1070, 2081.
Inglesby TV et al. Plague as a Biological Weapon: Medical and
Public Health Management. JAMA. May 03,2000;283(17):
2281-2290.
Additional Print Resources
Henderson DA et al. Smallpox as a Biological Weapon:
Medical and Public Health Management. JAMA. June 09,
1999; 281(22):2127-2137.
Dennis DT et al. Tularemia as a Biological Weapon: Medical
and Public Health Management. JAMA. June 02, 2001;
285(21):2763-2773.
Borio L et al. Hemorrhagic Fever Viruses as Biological
Weapons: Medical and Public Health Management. JAMA.
May 08, 2002; 287(18): 2391-2405.
Franz DR, Jahrling PB, Friedlander DJ et al. Clinical
recognition and management of patients exposed to
biological warfare agents. JAMA. 1997;278(5):399-411.
Additional Print Resources
Bryan JL, Fields HF. An ounce of prevention is worth a
pound of cure – shoring up the public health infrastructure
to respond to bioterrorist attacks. Amer J of Infection Control.
1999;27:465-7.
CDC. Biological and Chemical Terrorism: Strategic Plan for
Preparedness and Response. Recommendations of the CDC
Strategic Planning Workgroup. MMWR. April 21,2000, Vol
49, No. RR-4.
Wetter DC, Daniell WE and Treser CD. Hospital
preparedness for victims of chemical or biological terrorism.
Amer J of Public Health. 2001;91(5):710-16.
Additional Print Resources
Pavlin J. Epidemiology of bioterrorism. Emerging Infectious
Diseases. 1999;5:528-530
Macintyre AG, Christopher GW, Eitzen E et al. Weapons of
Mass Destruction Events with Contaminated Casualties:
Effective Planning for Health Care Facilities. JAMA. 2000;
283:242-249.
Meltzer MI, Damon I, LeDuc JW, and Millar JD. Modeling
potential responses to smallpox as a bioterrorist weapon.
Emerging Infectious Diseases. 2001;7(6):959-969.
DiGiovanni C Jr . Domestic terrorism with chemical or
biological agents: psychiatric aspects. Am J Psychiatry
1999;156:1500-5.
UCLA Center for Public Health
and Disasters
1145 Gayley Avenue, Suite #304
Los Angeles, CA 90024
Tel: 310/794-0864
Fax: 310/794-0889
Email: [email protected]
http://www.ph.ucla.edu/cphdr