Transcript Module3

Safety & Treatment in
Disaster Response
Basic Biodefense Curriculum
Module 3
2005
Modules were developed as part of a grant from the HRSA BTCDP initiative
Purpose of Module:

B-NICE / CBRNE response procedures
 Caregiver safety and protective equipment
 Decontamination
 Isolation and quarantine

Mass casualty care

Vulnerable Populations

Psychological consequences of disasters
Learning Objectives
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List key safety questions for health care providers
Describe principles of disease or exposure
containment including decontamination and
community-level actions
Describe and identify vulnerable populations
Describe appropriate personal protective equipment
for a given type of exposure
Describe the importance of psychological as well as
physical care
Key Safety Questions

Where is it (What is the setting)?
• Risks at the scene - safety of rescuers and victims
• Risks at off-site treatment centers - safety of caregivers &
patients
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What type of agent(s) are involved?
• Use CBRNE or B-NICE
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What are the routes of exposure?
• Can I become contaminated by touching or inhaling?
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Am I safe? How do I remain safe while I work?
• Where are the safety zones
• Should Personal Protective Equipment (PPE) be used
• What are the protective (prevention) procedures
Answers Will Guide Safety
Decisions

Some methods used to protect and prevent more
exposures:
 Quarantine
 Isolation
 Immunization
 Prophylaxis with medications
 Decontamination
 Evacuation or sheltering-in-place
Routes of Exposure
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Injection
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Inhalation
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Almost as direct as injection plus affects large crowds
Expect large number of casualties at same time
Ingested
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Most direct, but usually affects only one person
Exception: infectious disease that spreads over time
May affect fewer people, but easier to administer
Topical
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If agent easily absorbed through skin, like inhalation
Can affect large crowds
May see secondary wave of victims due to contamination
Factors Impacting Exposure
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Length of Time Exposed
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Longer time agent is in contact; the more that is absorbed
Decrease effects by decontaminating (cleaning) skin and
moving victims to area where air is clean
Quantity of Agent Released
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Higher quantities of agent increase overall effects.
Affected by:
• Amount of agent released
• proximity to point of origin
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Preventive Measures
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To decrease amount of exposure to an agent:
• Avoid areas where agent was released
• May leave area ahead of release (evacuate) or to stay put during
release (shelter-in-place)
Scenario: “C” Nerve Agent
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Scene: Hospital Emergency Department
Over 500 begin to swarm
Symptoms: uncontrollable secrections
Diagnosis: severe organophosphate poisoning
Plan: Immediate care is needed, but…
…STOP... ASK YOUR SAFETY QUESTIONS…
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Is the hospital away from the disaster site? YES
Which type of exposure? CHEMICAL NERVE AGENT
How were they exposed? assume TOPICAL AND INHALED
What safety measures are needed?
• NEED TO KEEP CLEAN AREAS CLEAN --- DECONTAMINATE
BEFORE TREATING
• Solution: Set up decontamination area before allowing into
hospital
Chemical Accident / Injury Event
CLEAN FIRST; THEN TREAT
For Chemical Exposures
Chemical Accident/Injury
Event Algorithm
Patient is moved to safe area upwind and away from the
hazard by Emergency Personnel wearing the appropriate PPE
Are Life Saving Procedures
Required?
YES
Are there Unknown or Potentially
Life Threatening Contaminants?
YES
Simultaneously Grossly Decontaminate (i.e. remove
clothing and big chunks), cover or wrap contaminated
areas to prevent spread to unaffected areas, initiate
stabilization / ABC’s
No
Perform Life-Saving Procedures
No
Environmental or Patient Condidtions
Prevent Further Decontamination
YES
Cover or wrap patient to prevent spread
of contamination to others
No
Decontaminate by making patient as clean as possible (ACAP - Contamination reduced to a level that is no longer a threat to patient or responder)
Further Medical Attention or
Surveillance Required
No
Report to superiors for instructions
YES
Advise Receiving Medical Facility
of Patient Status and Deliver/
Transport as Instructed
Undress and Bag Work Uniform Shower - Change into clean clothes
Decontaminate Transport Vehicle
Crowd
Control
Line
Staging Area
Drainage
Command
Post
Access
Control
Points
Decontamination
Line
Exclusion
(Hot)
Zone
Access
Control
Points
Wind
Contamination
Reduction
(Warm) Zone
Support
(Cold) Zone
Hot
Line
When the disaster victims
come to the hospital:
DECONTAMINATION ALGORITHM – AT THE HOSPITAL OR TREATMENT CENTER
DECONTAMINATION AREA
CLEAN AREA
NONAMBULATORY
Airway and antidote
administration and clothing
removal
Gurney decontamination
Initial
Triage:
Contaminated?
Airway
Compromise?
Amublatory?
Requires
decontamination
Male
Ambulatory
decontamination
AMBULATORY
Female
Antidote administration and
clothing removal
Not exposed, requires no decontamination
EXIT
Clean area:
clean clothing.
Triage again
Hospital treatment
area assigned
based upon nature
and acuity of signs
and symptoms
Contaminated Patient Video
Scenario: Patient exposed to Copper Sulfate
arrives at emergency department
Watch how personnel handle the situation
And NOTE five (5) things they do to safely
care for the patient
Chemical Exposure Pearl
Treatment of victims of a
chemical exposure
begins with provider self
protection and victim
decontamination.
Treatment Approaches for
Chemical Exposure
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Decontaminate first, then manage the symptoms
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Some chemical agents have antidotes
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Soap and water for blister agents and irritants/corrosives
Clean air or oxygen for inhaled agents (e.g., choking)
Nerve Agents: atropine, protopam, diazepam
Blood Agent (cyanide): amyl nitrite plus sodium thiopental
Vesicant (Lewisite): BAL (dimercapral) for severe cases only
Supportive care may be only option
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Suction or supplemental oxygen for breathing
Maintain blood pressure
Keep comfortable
Protection from Exposure
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Personal Protective Equipment (PPE)
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Used to protect against biological, chemical, and
radiological contamination
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Includes a range of equipment
• May be as simple as wearing gloves to avoid touching
• May be as complex as wearing full suits with SelfContained Breathing Apparatus (SCBA) to avoid inhaling
The Four Levels of PPE
Level Skin Eyes Lungs SCBA
Highest
A
B
C
Lowest
D
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Description
YES
Self-contained suit that is
water and vapor proof,
boots, gloves, hardhat
YES
Splash-resistant clothing
with hood, gloves, boots
---
Air purifying respirator with
goggles and gloves
---
Face shield, gloves,
glasses, cover clothing
PPE: Level D
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Protection includes:
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Normal work attire plus
Standard Precautions
Gloves
Goggles, glasses or face
shield
Face mask (if appropriate)
Does not protect from
corrosives or vapors
PPE: Level C
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Replace normal attire
with a chemical-resistant
suit and boots
Wear two (2) layers of
gloves
Add a full hood with mask
Add an air-purifying
respirator
Does not protect from
toxic gases
PPE: Level B
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Chemical splash suit with
hood
Inner and outer chemicalresistant gloves
Chemical-resistant boots
and covers
Add a hard hat
Add an external selfcontained breathing
apparatus (SCBA) with
positive pressure full face
piece
PPE: Level A
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Totally encapsulating chemical
protective suit that is also vapor
proof
Inner and outer chemical
resistant gloves
Chemical resistant boots
Hard hat
SCBA with positive pressure,
full face piece inside suit
Scenario: “B” Infectious Agent
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Meningococcal meningitis case
in the dormitory
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Nature of the disease:
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Contagious for close contacts
Generally treatable with
antibiotics
Vaccine available
Post-exposure prophylaxis
option
General Approaches for
Biological Agents
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What is the agent?
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Category A Biological Agents (Treatment):
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BACTERIA (antibiotics)
• Anthrax, Plague, Tularemia
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VIRUS
 Smallpox (vaccine, supportive care)
 Hemorrhagic Fever (supportive care)
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TOXIN
 Botulism (antitoxin)
 Ricin (supportive care)
Caregiver Precautions for
Infectious Diseases
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Four Types of Precautions
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Standard
Contact
Airborne
Droplet
Precautions used will vary by
mode of transmission of pathogen
Standard Precautions
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Standard Precautions used in routine practice
Assumes all bodily fluids are contaminated
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Standard Precautions involve:
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Hand washing between patients or after handling
specimen
Protective physical barriers (gloves, masks, eye
protection, face shield, gown over clothes)
Appropriate disposal of infectious wastes or specimen
Sterilization or disinfection of re-usable equipment
Elements of Standard Precautions
Contact Precautions
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Contact may be direct or indirect
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Examples of contact-borne pathogens
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Direct: person-to-person
Indirect: person-to-fomite-to-person
Methicillin-resistant Staphyloccus aureus (MRSA)
Clostridium difficile
Enterovirus
Ebola virus
Contact precautions involve
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Standard Precautions PLUS
• Disinfect inanimate objects (e.g., door knobs, telephone receivers)
• May opt to restrict movement of infected patients (i.e., isolation)
Airborne Precautions
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Limits spread of infection by small pathogen-laden
particles that remain suspended in air for long time
and are easily inhaled
Examples of airborne pathogens:
• Measles virus
• Smallpox virus
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Airborne Precautions involve
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Standard Precautions PLUS
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Negative air pressure room with vent to outside
Isolation ward or private room
Put mask on patient
Wear an N95 respirator instead of face mask
Droplet Precautions
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Use for infections spread by droplets coming into
contact with mucus membranes
Examples of droplet-borne pathogens:
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tuberculosis, pertussis (whooping cough) and mumps
Droplet Precautions involve:
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Standard precautions PLUS
Isolation ward or private room
Limit movement outside of room
Maintain at least 3 feet between patient and
caregiver
Patient wears mask or covers up when coughing or
sneezing
Community-level Precautions
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Restrict movement of infected residents
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Quarantine:
• Restricts movement of exposed but asymptomatic (i.e., not ill)
people to a room or building
• Also keeps people who are not yet exposed out of the area
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Isolation:
• Restricts movement and separation of symptomatic (ill) folks
from healthy folks
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Proper disposal of infected wastes and specimens
Mass Clinic for Immunization or
Post Exposure Prophylaxis (PEP)
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Mass Immunization or PEP Clinic
• Temporary public health clinic
• Immunization - Provides vaccinations for a large number of
residents before they are exposed
• PEP - Dispenses medications to residents who were most
likely exposed to an agent
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Clinic may offer one or both services
To activate a mass clinic, you must have:
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Confirmation of etiologic (causative) agent
Potential for further exposure or spread
Available supply of medications or vaccines
“N” or “R” Nuclear or
Radiological Exposures
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What is the agent?
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Nuclear or Radiological
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What are your local risks?
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Most radiological exposures are accidental
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Sources of radiation (may see both in one person)
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Waves (especially gamma)
Particles that are touched, inhaled, or ingested
Decontamination Needs
Vary by Type of Exposure
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Irradiation caused by physical contact with
radioactive particles:
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Need to decontaminate skin before treating injuries
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Remove clothing to eliminate 70-90% of radiation source
Wash skin and exposed areas
Removing particles ends radiation exposure
Care givers are at risk of radiation exposure if patients NOT
decontaminated
Irradiation caused by exposure to gamma rays:
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Nothing to decontaminate – treat injuries
• Move away from source of gamma radiation to end exposure
• Irradiated patients cannot contaminate healthcare providers
General Treatment Approaches
for Radiation Exposures
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For patients exposed only to irradiating
waves (no solid particles)
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For patients exposed to particles,
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Treat injuries first, then radiation exposure
Decontaminate skin, then treat injuries
followed by internal decontamination methods
Treatments for radiation poisoning
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Chelating agents to bind radioactive particles
inhaled or ingested
• Prussian Blue or DTPA
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Protect thyroid gland
• Potassium Iodide
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Treat bone marrow suppression
“E” and “I” Scenario
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Scene: At a busy metropolitan hospital in the heart of the
city
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Event: A muffled sound similar to a distant sonic boom.
Bottles of medication on the shelves rattle momentarily.
The ambulance medic says that there is smoke billowing
out of the nearby underground metro station. A bomb has
exploded.
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Key Questions:
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What are your personal safety considerations?
What kind of injuries might you expect of those affected by the
blast?
What will be your initial actions?
Will you have enough resources and how long will they last?
“E” and “I” Explosive and
Incendiary Exposures
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Injuries may be caused directly by initial blast
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Or indirectly due to:
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Collapse of structures
Flying debris
Secondary explosions
Fire
Injuries due to Explosion
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Some may be internal or delayed and not readily apparent
Types of injuries associated with explosions:
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Penetrating and blunt trauma
Blast lung or ear drum rupture
Traumatic brain Injury
Amputations
Eye Injuries
“E” and “I” Explosive and
Incendiary Exposures
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Fire-related injuries
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Most deaths related to
inhalation of smoke or fumes,
not burns
• Respiratory symptoms occur
most quickly
• Other symptoms may be
delayed
Vulnerable Populations
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What is a Vulnerable Population?
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Why are they vulnerable?
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People or animals who are at increased risk of
injury or death
Very young or very old
Physical or mental limitations
Language or cultural barriers
Pre-existing medical conditions
Domestic and wild animals
Who are the vulnerable populations in your
community? Where are they located?
Issues to Consider
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Plans and Responses need to consider people
who:
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Confined to home
Not able to communicate
Cannot understand information
Require assistance to travel
Need adjustments to treatments
Cannot advocate for themselves
Psychological Consequences
of Disasters
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Not everyone experiences physical effects
during a disaster but most will have some
psychological reaction during or after an
event
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Need to have plan for mitigating psychological
effects:
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Example: Critical Incident Stress Debriefings
(CISD)
• Minimizes post-traumatic stress disorders in first
responders
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Need to include health care workers
Community recovery will depend on
psychological and physical health
Common Symptoms of
Excessive Stress:
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If you or another responder displays some or all of
these symptoms, it may mean excessive stress:
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Easily distracted or inability to concentrate
Quick to anger
Depressed with or without anxiety
Substance abuse
Change in weight
Change in sleep patterns
Summary
Basic
BioBio-Defense
Project
Emergency Preparedness Curriculum

Safety First
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Take steps to ensure your own safety as well as that of your
patients
Care Components for B-NICE / CBRNE agents
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Use current information for controlling contamination and
treating patients exposed to these agents
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Your plan should include procedures for decontamination,
quarantine, iIsolation, and mass clinic-treatment options

Determine who the vulnerable populations are in your
community
Plan to attend to psychological as well as physical injuries
during and after a disaster

Basic
BioBio-Defense
Project
Authors
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Jean Carter
Sandra Kuntz
Earl Hall
Steven Fehrer
Steven Glow
Emergency Preparedness Curriculum

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
Jacqueline Elam
Michele Sare
Lisa Wrobel
Michael Minnick
Modules prepared as part of the Montana Basic BioDefense Curriculum
For Pharmacy, Nursing, and Allied Health
Funded by the HRSA CFDA 93.996 initiative
Photo Credits
Basic
BioBio-Defense
Project
Emergency Preparedness Curriculum

Do not reproduce individual photos or videoclips without
permission from original source.

A list of photo credits was included in the instructor’s
packet.

To request a copy of the photo credits, send an email to
[email protected]
Modules prepared as part of the Montana Basic BioDefense Curriculum
For Pharmacy, Nursing, and Allied Health
Funded by the HRSA CFDA 93.996 initiative