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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
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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 warfareHealth aspects. 2. Biological warfareHealth aspects. 3. Civil defenseUnited States. 4. TerrorismGovernment policyUnited States. 5. Disaster medicineUnited 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'.3dc21 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.
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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.
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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
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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
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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.
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Page vii Preface American military forces have been struggling with the issue of chemical and biological warfare for decadesa 1917 National Research Council Committee laid the groundwork for the Army Chemical Warfare Servicebut 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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Chemical anc] Biological
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