|
Items in cart [0] |
Questions? Call 888-624-8373 |
| Copyright © 2010. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page R1
Chemical and Biological Terrorism Research and Development to Improve Civilian Medical Response Committee on R&D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents Health Science Policy Program INSTITUTE OF MEDICINE and Board on Environmental Studies and Toxicology Commission on Life Sciences NATIONAL RESEARCH COUNCIL NATIONAL ACADEMY PRESS Washington, D.C. 1999
OCR for page R2
Page ii
NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, NW • Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
Support for this project was provided by the Office of Emergency Preparedness, Department of Health and Human Services (Contract No. 282-97-0017). This support does not constitute an endorsement of the views expressed in the report.
Library of Congress Cataloging-in-Publication Data
Chemical and biological terrorism: research and development to improve civilian medical response / Committee on R&D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents, Health Science Policy Program, Institute of Medicine, and Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council. p. cm. Includes bibliographical references and index. ISBN 0-309-06195-4 (hardcover) 1. Chemical warfare—Health aspects. 2. Biological warfare—Health aspects. 3. Civil defense—United States. 4. Terrorism—Government policy—United States. 5. Disaster medicine—United States. I. Institute of Medicine (U.S.). Committee on R & D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents. II. National Research Council (U.S.). Board on Environmental Studies and Toxicology. RA648 .C525 1999 358'.3—dc21 98-58069
Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area).
This report is also available online at http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at http://www2.nas.edu/iom.
Copyright 1999 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
OCR for page R3
Page iii
Committee on R&D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents PETER ROSEN (Chair), Director, Emergency Medicine Residency Program, School of Medicine, University of California, San Diego
LEO G. ABOOD, Professor of Pharmacology, Department of Pharmacology and Physiology, University of Rochester Medical Center*
GEORGES C. BENJAMIN, Deputy Secretary, Public Health Services, Department of Health and Mental Hygiene, Baltimore, Maryland
ROSEMARIE BOWLER, Assistant Professor and Fieldwork Coordinator, Department of Psychology, San Francisco State University
JEFFREY I. DANIELS, Leader, Risk Sciences Group, Health and Ecological Assessment Division, Earth and Environmental Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California
CRAIG A. DeATLEY, Associate Professor, Department of Emergency Medicine and Health Care Sciences Program, The George Washington University, Washington, D.C.
LEWIS R. GOLDFRANK, Director, Emergency Medicine, New York University School of Medicine and Bellevue Hospital Center, New York
JEROME M. HAUER, Director, Office of Emergency Management, City of New York
KAREN I. LARSON, Toxicologist, Office of Toxic Substances, Washington Department of Health, Olympia
MATTHEW S. MESELSON, Thomas Dudley Cabot Professor of the Natural Sciences, Department of Molecular and Cellular Biology, Harvard University, Cambridge, Massachusetts
DAVID H. MOORE, Director, Medical Toxicology Programs, Battelle Edgewood Operations, Bel Air, Maryland
DENNIS M. PERROTTA, Chief, Bureau of Epidemiology, Texas Department of Health, Austin
LINDA S. POWERS, Professor of Electrical and Biological Engineering, and Director, National Center for the Design of Molecular Function, Utah State University, Logan
PHILIP K. RUSSELL, Professor of International Health, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland
JEROME S. SCHULTZ, Director, Center for Biotechnology and Bioengineering, University of Pittsburgh
ROBERT E. SHOPE, Professor of Pathology, University of Texas Medical Branch, Galveston
ROBERT S. THARRATT, Associate Professor of Medicine and Chief, Section of Clinical Pharmacology and Medical Toxicology, Division of Pulmonary and Critical Care Medicine, University of California, Davis Medical Center, Sacramento
*Deceased, January 1998.
OCR for page R4
Page iv
Committee Liaisons
JUDITH H. LAROSA, Professor and Chair, Department of Community Health Services, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, and Liaison to the Board on Health Science Policy
WARREN MUIR, President, Hampshire Research Institute, Alexandria, Virginia, and Liaison to the Board on Environmental Studies and Toxicology
Study Staff
FREDERICK J. MANNING, Project Director
CAROL MACZKA, Senior Program Officer
C. ELAINE LAWSON, Program Officer
JENNIFER K. HOLLIDAY, Project Assistant (May 1997 through May 1998)
THOMAS J. WETTERHAN, Project Assistant (June 1998 through November 1998)
Institute of Medicine Staff
CHARLES H. EVANS, JR., Head, Health Sciences Section
ANDREW POPE, Director, Health Sciences Policy Program
LINDA DEPUGH, Section Administrative Assistant
JAMAINE TINKER, Financial Associate
National Research Council Staff
JAMES REISA, Director, Board on Environmental Studies and Toxicology
OCR for page R5
Page v
Independent Report Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report:
JOHN D. BALDESCHWIELER, Professor of Chemistry, California Institute of Technology, Pasadena
DONALD A. HENDERSON, University Distinguished Professor, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland
DAVID L. HUXSOLL, Dean, School of Veterinary Medicine, Louisiana State University, Baton Rouge
JOSHUA LEDERBERG, Sackler Foundation Scholar, Rockefeller University, New York
H. RICHARD NESSON, Senior Consultant, Partners Health Care System, Inc., Boston
MICHAEL OSTERHOLM, Chief, Acute Disease Epidemiology Section, Minnesota Department of Health, Minneapolis
OCR for page R6
Page vi
ANNETTA P. WATSON, Research Staff, Health and Safety Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee
MELVIN H. WORTH, Clinical Professor, State University of New York-Brooklyn and Uniformed Services University of Health Sciences, and Institute of Medicine Scholar-in-Residence
The committee would also like to thank the following individuals for their technical reviews of single chapters of the draft report:
ROBERT E. BOYLE, Formerly Technical Advisor, Chemical Warfare and NBC Defense Division, Office of the Deputy Chief of Staff for Operations, Plans, and Policy, Department of the Army, Washington, D.C.
GREGORY G. NOLL, Hildebrand and Noll Associates, Inc., Lancaster, Pennsylvania
ROBERT S. PYNOOS, Professor and Director, Trauma Psychiatry Service, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
JOSEPH J. VERVIER, Senior Staff Scientist, ENSCO, Inc., Melbourne, Florida, and formerly Technical Director, Edgewood Research, Development and Engineering Center, Aberdeen Proving Ground, Maryland
Although the individuals listed above have provided many constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests solely with the authoring committee and the institution.
OCR for page R7
Page vii
Preface American military forces have been struggling with the issue of chemical and biological warfare for decades—a 1917 National Research Council Committee laid the groundwork for the Army Chemical Warfare Service—but it was the attack of the Tokyo subway with the nerve gas sarin in March 1995 that suddenly put the spotlight on the danger to civilians from chemical and biological attacks. The Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services' Office of Emergency Preparedness (OEP), which is responsible for medical services, have an admirable record of helping state and local governments cope with floods, storms, and other disasters, including terrorism, but, fortunately, no direct experience with the consequences of chemical or biological terrorism. In May 1997, the Institute of Medicine was asked to help OEP prepare for the possibility of chemical or biological terrorism, and, with help from the National Research Council's Board on Environmental Studies and Toxicology, formed this committee to provide recommendations for priority research and development (R&D).
In the ensuing year and a half, the committee met four times, heard presentations on existing technology and ongoing R&D, attempted to absorb a virtual mountain of information, and formulated their recommendations. In the process, a number of things became clear to me. I suspect the rest of the committee would agree, but I will exercise the chair's prerogative at this point, and share the view from my perspective.
First, there is no way to prepare in an optimal fashion for a terror incident. There is too low an incidence to justify the enormous financial
OCR for page R8
Page viii
outlay it would take to optimally prepare every community for every possible incident. Furthermore, there are not enough incidents for any community to acquire enough experience to make a significant impact on response to the next episode.
Second, although there is a sophisticated technology, described within the body of the report, for in-line detection of an opposing forces chemical agent, it will not be possible to select the sites to protect in a civilian setting with such technology, even if the expense could be borne. At best, it might be possible to selectively protect a public arena where the President was to give an address.
Third, there is no guarantee that the terrorist will announce the attack. Without such an announcement, there will be no recognition that a biological attack is occurring until enough cases, including a number of fatalities, are observed and reported to allow recognition of an epidemic of an unusual disease. Since exposed victims will almost certainly not seek medical care in the same facility, the problem becomes compounded even more greatly. *
Fourth, virtually all the militarily important biologic agents present with early clinical symptoms that resemble viral flu syndromes. Since these are the most common form of acute illness, and since they are usually mild and nonserious, it is probable that the early victims of the attack will be unrecognized, and sent home from a physician's office or Emergency Department as a mild viral syndrome. Therefore, in any response planning, it has to be acknowledged that it will be impossible to prevent ALL mortality, no matter how good a technology can be developed, and no matter how much money we are willing to spend to enhance our response.
Fifth, there is a huge gap between detection technology and therapy. There are many biologic agents, and certainly many chemical agents for which there are no known treatments. We should not expect that terrorists will choose the agents for which we are prepared, and for which we have effective treatment, even if they are the easiest to create and disperse, such as anthrax or sarin.
Sixth, the approach that the committee found most useful to consider in making its recommendations was considering how to superimpose a response
* For example, in Wyoming this year (Summer 1998), there has been an epidemic of E. coli diarrhea from a contaminated spring that fed the water supply of the small town of Alpine. There were well over a hundred cases that involved 12 states since the tourists who acquired the disease were from many different locations. It took at least two months to find the source of the contamination, and the only reason that the epidemic was recognized as early as it was, is that there were only a small number of medical facilities available to the victims.
OCR for page R9
Page ix
to a terror attack upon the systems that are already in place to deal with nonterror events. For example, an earthquake, or a chemical spill, or a flu epidemic will all stress and often overload existing medical facilities. There must be systems in place to deal with these problems, not only on a local basis, but when help must be brought in from outside the afflicted area. These are the systems that will be most appropriate to build on for an effective response to an incident of chemical or biological terrorism.
Seventh, communication between the medical community and agencies that gather and analyze intelligence about potential terrorists and attacks is critical. As alluded to above, it will not only shorten the identification issues and lead to more effective responses, but will clearly lower mortality.
There are a number of areas that will not be covered in this report. For example, it was not possible for the committee to discuss every conceivable biological and chemical weapon that might be used in an attack. It is probable that to prepare only for the list of known weapons and most likely agents will take a commitment and a financial expenditure that will exceed the resources of virtually all communities.
The committee's charge did not include making recommendations on organization and training of individuals and groups faced with managing the consequences of a chemical or biological incident, nor on how to equip such persons or groups, nor on what therapeutic options they should choose. Nevertheless, as noted in our interim report, the committee believes that it would be irresponsible to focus solely on R&D while ignoring potentially simpler, faster, or less expensive mechanisms, such as organization, staff, training, and procurement. Examples from our interim report include:
•
Survey major metropolitan hospitals on supplies of antidotes, drugs, ventilators, personal protective equipment, decontamination capacity, mass-casualty planning and training, isolation rooms for infectious disease, and familiarity of staff with the effects and treatment of chemical and biological weapons.
•
Encourage the CDC to share with the states its database on the location and owners of dangerous biological materials. State health departments in turn should be encouraged, perhaps by education or training on the effects of the agents and medical responses required, to add infections by these materials to their lists of reportable diseases.
•
Convene discussions with FDA on the use of investigational products in mass-casualty situations and on acceptable proof of efficacy for products where clinical trials are not ethical or are otherwise impossible.
•
Develop incentives for hospitals to be ambulance-receiving hospitals, to stockpile nerve-agent antidotes and selected antitoxins and put
OCR for page R10
Page x
them in the hands of first responders (this may require changes to existing laws or regulations in some states), to purchase appropriate personal protective equipment and expandable decontamination facilities and train emergency department personnel in their use.
•
Supplement existing state and federal training initiatives with a program to incorporate existing information on possible chemical or biological terror agents and their treatment into the manuals, SOPs, and reference libraries of first responders, emergency departments, and poison control centers. Professional societies and journal publishers should be recruited to help in this effort.
•
Intensify Public Health Service efforts to organize and equip Metropolitan Medical Strike Teams in high-risk cities throughout the country. Although MMSTs are designed to cope with terrorism, because they use local personnel and resources, they also increase the community's general ability to cope with industrial accidents and other mass-casualty events.
Even though the tasks of being prepared and responding adequately appear at times to contain insurmountable obstacles, the committee does believe that by utilizing the resources that are present, along with improvements in communications, monitoring capabilities, detection, and therapeutics, it will be possible to minimize the damage that a terror attack will cause. It is not our intent to leave the readers of this report with feelings of hopelessness. Even if preparation for certain attacks only forces the attackers to choose a weapon that we have not prepared for, we will have developed a system with which we can improvise. The goal, as always in medicine, is to reduce morbidity and mortality and minimize suffering.
In closing I would like to offer my sincere thanks to the staff of the Institute of Medicine, who made our meetings as comfortable and efficient as possible and pulled our sometimes splintered efforts into a coherent whole, and to the members of the committee, busy professionals who volunteered precious time and energy in a highly collegial manner. It was a privilege to work with this outstanding group.
PETER ROSEN, M.D. CHAIR
OCR for page R11
Page xi
Abbreviations AChE
Acetylcholinesterase
AEL
Acceptable exposure limit
AIDS
Acquired immune deficiency syndrome
APA
American Psychological Association or American Psychiatric Association
ANL
Argonne National Laboratory
ASTM
American Society for Testing and Materials
ATP
adenosine 5'-triphosphate
ATSDR
Agency for Toxic Substances and Disease Registry
BAL
British antiLewisite
BChE
Butyrylcholinesterase
BDO
Battle Dress Overgarment
BIDS
Biological Integrated Detection System
BW
Biological warfare or biological weapon
CAHBS
Civilian Adult Hood Blower System
CAM
Chemical agent monitor
CAPS
Civilian Adult Protective System
CBDCOM
Chemical Biological Defense Command
CBIRF
Chemical Biological Incident Response Force
CBMS
Chemical Biological Mass Spectrometer
CBNP
Chemical and Biological Nonproliferation Program
CBPSS
Chemical Biological Protective Shelter System
OCR for page R12
Page xii
C/B-RRT
DoD Chemical/Biological Rapid Response Team
CBWCA
Chemical and Biological Weapons Control Act
CCHF
Crimean Congo hemorrhagic fever
CCP
Crisis Counseling Assistance and Training Program
CDC
Centers for Disease Control and Prevention
cDNA
Complementary (or copy) deoxyribonucleic acid
ChE
Cholinesterase
CISD
Critical incident stress debriefing
CLS
Commission on Life Sciences
CMHS
Center for Mental Health Services
CN-
Cyanide anion
CNS
Central nervous system
CSEPP
Chemical Stockpile Emergency Preparedness Program
CSTE
Council of State and Territorial Epidemiologists
CW
Chemical warfare or chemical weapon
CWA
Chemical warfare agent
4-DMAP
4-Dimethylaminophenol
DARPA
Defense Advanced Research Projects Agency
DHHS
Department of Health and Human Services
DMAT
Disaster Medical Assistance Team
DNA
Deoxyribonucleic acid
DNTB
5,5'-dithio-bis (2-nitrobenzoic acid)
DoD
Department of Defense
DoE
Department of Energy
DRN
Disaster Response Network
dsRNA
Double-stranded ribonucleic acid
DSWA
Defense Special Weapons Agency
EDTA
Ethylene diamine tetraacetic acid (dicobalt)
EEE
Eastern equine encephalomyelitis
EF
Edema factor
EIDI
Emerging Infectious Disease Initiative
EIS
Epidemic Intelligence Service
ELISA
Enzyme-linked immunosorbent assay
EMCR
Electronic medical care record
EMS
Emergency Medical Service
EMT
Emergency medical technician
EPA
Environmental Protection Agency
ERDEC
Edgewood Research, Development and Engineering Center, U.S. Army
OCR for page R13
Page xiii
FABS
Force-amplified biological sensor
Fab
Antibody fragment
FBI
Federal Bureau of Investigation
Fc
Crystallizable fragment (of antibody)
FDA
Food and Drug Administration
FEMA
Federal Emergency Management Agency
FOWG
Fiber-optic evanescent wave guide
FTIR
Fourier Transform Infrared Spectrometry
GA
Tabun
GB
Sarin
GC/FTIR
Gas Chromatography Fourier Transform Infrared Spectrometry
GC/MS
Gas Chromatography Mass Spectrometry
GC-MS-MS
Gas Chromatography Tandem Mass Spectrometry
GD
Soman
GF
Cyclosarin
HAZMAT
Hazardous materials
HD
Sulfur mustard
HIV
Human immunodeficiency virus
HMT
Hexamethylene tetramine
HPAC
Hazard prediction and assessment capability
HPLC
High-performance liquid chromatography
HSEES
Hazardous substances emergency events surveillance
IDLH
Immediately dangerous to life and health
IMS
Ion mobility spectrometry
IND
Investigational new drug
IOM
Institute of Medicine
IPDS
Improved Chemical Agent Point Detection System
IU/L
International units per liter
JCAD
Joint Chemical Agent Detector
JCAHO
Joint Commission on Accreditation of Healthcare Organizations
JCBAWM
Joint Chemical Biological Agent Water Monitor
JLIST
Joint Service Lightweight Integrated Suit Technology
JPOBD
Joint Program Office for Biological Defense
JPOCD
Joint Program Office for Chemical Defense
OCR for page R14
Page xiv
JSLSCAD
Joint Service Lightweight Standoff Chemical Agent Detector
JUN
Junin virus
LANL
Los Alamos National Laboratory
LCR
Ligase chain reaction
LD50
Dose lethal to 50 percent of the population exposed
LF
Lethal factor
LIDAR
Light detection and ranging
LLNL
Lawrence Livermore National Laboratory
MALDI-MS
Matrix-assisted laser desorption mass spectrometry
MANAA
Medical aerosolized nerve agent antidote
MARCORSYSCOM
Marine Corps Systems Command
MiniCAD
Miniature chemical agent detector
MMST
Metropolitan Medical Strike Team
NAME
Nitroarginine methylester
NARAC
National Atmospheric Release and Advisory Center
NBC
Nuclear, biological, chemical
NDA
New Drug Application
NDMS
National Disaster Medical System
NFkB
Nuclear factor-kappa B transcription factor
NFPA
National Fire Protection Association
NIAID
National Institute of Allergy and Infectious Diseases
NIH
National Institutes of Health
NIOSH
National Institute for Occupational Safety and Health
NIPAC
National Infrastructure Protection Center
NMRI
Naval Medical Research Institute
NOAA
National Oceanic and Atmospheric Administration
NRC
National Research Council or Nuclear Regulatory Commission
NRL
Naval Research Laboratory
NSWC
Naval Surface Warfare Center
OEP
Office of Emergency Preparedness
OP
Organophosphate
ORNL
Oak Ridge National Laboratory
OSHA
Occupational Safety and Health Administration
2-PAM
Pralidoxime chloride
PA
Protective antigen
OCR for page R15
Page xv
PAHP
para-aminoheptanophenone
PAOP
para-aminooctanoylphenone
PAPP
para-aminopropiophenone
PAPR
Powered air purifying respirator
PBB
Polybrominated biphenyls
PCB
Polychlorinated biphenyls
PCC
Poison control center
PCR
Polymerase chain reaction
PDD
Presidential Decision Directive
PHS
Public Health Service
PID
Photo ionization detector
PIRS
Photoacoustic infrared spectroscopy
PPE
Personal protective equipment
ProMED
Program for Monitoring Emerging Diseases
PTSD
Post traumatic stress disorder
RBC
Red blood cell
RDEC
Research, development, and engineering center
RNA
Ribonucleic acid
RT
Reverse transcriptase
RVF
Rift Valley fever
SAW
Surface acoustic wave
SBIR
Small business innovative research
SciPUFF
Second-order Closure Integrated Puff
SCBA
Self-contained breathing apparatus
SCPS
Simplified Collective Protection System
SDA
Strand displacement amplification
SEB
Staphylococcal enterotoxin B
SFAI
Swept frequency acoustic interferometry
SOF
Special Operations Forces
SOPs
Standard operating procedures
STEPO
Self-contained Toxic Environment Protective Outfit
TAS
Transcription-based amplification system
TDG
Thiodiglycol
TOF-MS
Time-of-flight mass spectrometry
TSP
Topical Skin Protectant
TSWG
Technical Support Working Group
UAV
Unmanned aerial vehicle
UPT
Up-converting phosphor technology
OCR for page R16
Page xvi
USAMRICD
US Army Medical Research Institute of Chemical Defense
USAMRIID
US Army Medical Research Institute of Infectious Diseases
UV
Ultraviolet
VA
Veterans Affairs (Department of)
VEE
Venezuelan equine encephalomyelitis
VIG
Vaccinia-immune globulin
VX
Persistent nerve agent (o-ethyl S-[2-(diisopropylamino)ethyl]-methylphosphorofluoridate)
WEE
Western equine encephalomyelitis
WHO
World Health Organization
WMD
Weapons of mass destruction
WWW
World Wide Web
YF
Yellow fever
OCR for page R17
Page xvii
Contents Executive Summary
1
1 Introduction
15
Legislative Background
16
Charge to the Committee
18
Data Collection
19
Assumptions and Parameters of This Report
20
Current Civilian Capabilities
23
2 Pre-Incident Communication and Intelligence: Linking the Intelligence and Medical Communities
29
R&D Needs
33
3 Personal Protective Equipment
34
Types of PPE and Regulatory Standards
34
Access to PPE
35
Potential Advances
36
R&D Needs
42
4 Detection and Measurement of Chemical Agents
43
Chemical Warfare Agents in the Environment
43
Clinical Laboratory Analysis for Exposure to Chemical Warfare Agents
59
R&D Needs
64
OCR for page R18
Page xviii
5 Recognizing Covert Exposure in a Population
65
Surveillance and Investigation of Biological Agents
66
Laboratory Capacity and Surveillance
71
Chemical/Toxin Surveillance
74
Aids for Clinical Diagnosis Based on Signs and Symptoms
75
R&D Needs
77
6 Detection and Measurement of Biological Agents
78
Detection of Biological Agents in Clinical Samples (Patient Diagnostics)
79
Detection of Biological Agents in the Environment
86
R&D Needs
95
7 Patient Decontamination and Mass Triage
97
Decontamination
97
Mass-Casualty Triage Procedures
107
R&D Needs
108
8 Availability, Safety, and Efficacy of Drugs and Other Therapies
110
Chemical Agents
112
Biological Agents
131
Summary of R&D Needs
161
9 Prevention, Assessment, and Treatment of Psychological Effects
165
Long-Term Effects of Terrorism (Post Traumatic Stress Disorder)
165
Short-Term Effects of Terrorism (Acute Needs)
166
First Responders
167
Neurological vs. Psychological Responses
169
Treatment Methods
169
Training
170
Community Effects
172
R&D Needs
172
10 Computer-Related Tools for Training and Operations
174
Medical Vigilance and Dose Reconstruction
175
Models Facilitating Assessment and Planning
176
Support for Decontamination and Reoccupation Strategies
182
R&D Needs
182
OCR for page R19
Page xix
11 Conclusions and Recommendations
184
Recommendations for Research and Development
189
References
195
Appendixes
A Committee and Staff Biographies
215
B Inventory of Chemical and Biological Defense Technology, with Gap and Overlap Analysis
221
C Lethal and Incapacitating Chemical Weapons
260
D Centers for Disease Control and Prevention List of Restricted Agents
263
Index
265
OCR for page R20
OCR for page R21
Chemical anc] Biological
OCR for page R22
