Operational Medicine 2001
Field Medical Service School
Student Handbook

BIOLOGICAL AGENT CASUALTIES

FMST 0416

17 Dec 99

TERMINAL LEARNING OBJECTIVES:

1.  Given a biological warfare agent casualty in a combat environment (day or night) and the standard Field Medical Service Technician supplies and equipment, manage biological  warfare casualties, per the references.  (FMST.04.17)

ENABLING LEARNING OBJECTIVES:

1.  Without the aid of reference materials and given a list of definitions, select the correct  definition of biological warfare, per the student handbook.  (FMST.04.17a)

2.  Without the aid of reference materials and given a list of biological agents, identify the

     characteristics of the agents, per the student handbook.  (FMST.04.17b)

3.  Without the aid of reference materials and given a list of biological agents, identify the

     symptoms of exposure, per the student handbook.  (FMST.04.17c)

4.  Without the aid of reference materials and given a list of biological agents, identify the

     incubation period of the infectious agent, per the student handbook.  (FMST.04.17d)

5.  Without the aid of reference materials and given a list of biological agents, identify the

     treatment of the infectious disease, per the student handbook.  (FMST.04.17e)

6.  Without the aid of reference materials and given a list of biological agents, identify the

     methods of dissemination, per the student handbook.  (FMST.04.17f)

7.  Without the aid of reference materials and given a list of four phases of biological attack,

     select the appropriate defensive measure for each phase, per the student handbook.

     (FMST.04.17g)

8.      Without the aid of references and given a FMST MOLLE Medic bag, and a simulated casualty identify, decontaminate, treat and monitor the casualty, per the student hanbbook.  (FMST.04.17h)

OUTLINE:

A.  A BRIEF HISTORY OF BIOLOGICAL WARFARE

      1.  The potential use of biological agents on the future battlefield is based on numerous                    

            historical precedents.  The use of smallpox as a weapon has been well documented.  The         

            British  Army used smallpox against the Native Americans who were loyal to the French

            during the French and Indian War with devastating results.

2.  The American Army, during the subjugation of the Native Americans of Great Plains used

     smallpox infected blankets in the same way the British had with similar devastating 

           results.

      3.  The end of World War II brought the revelation of the intensive research effort by the

           Imperial Japanese army into the effective means of biological agent production, the

           medical effects of agent exposure, and the best method for delivering the agent to the

           target.

               4.   The most recent indication of offensive biological warfare capability came from Team 7

           of the United Nations Special Commission, which was conducting inspections of Iraqi

           biological warfare research and development.  The Iraqi government announced that prior

           to Operation Desert Storm, research had been conducted into the use of Bacillus Anthracis

           (anthrax), Botulinum toxins, and Clostridium Perfringens raising the potential that had the

           air war not been so effective, Coalition ground forces may have faced biological warfare

           agents.

B.  BIOLOGICAL WARFARE

     1.  DEFINITION - Biological Warfare (BW) is the intentional use of living infectious

          microrganisms (except toxins) to reduce or destroy the military effectiveness of personnel.

     2.  CLASSIFICATION OF BIOLOGICAL AGENTS:

          a.  Pathogens - Disease producing microorganisms. These microorganisms may be

               naturally occurring or "engineered" by manipulation of recombinant deoxyribonucleic

               acid (DNA).

          b.  Toxins - Poisons naturally produced through the activities of living organism.  Toxins

               can be produced by plants, microorganisms, and animals.  Due to the feasibility of       

               using some form of biochemical engineering to produce toxins, the United States has

               also classified toxins as a biological agent.  Examples of theses naturally occurring

               organic chemical compounds are proteins, polypeptides and alkaloids.

C.  BIOLOGICAL AGENT CONSIDERATIONS

      1.  ANTHRAX:

           a.  DEFINITION - An acute bacterial disease usually affecting the skin, but may rarely

                involve the mediastinum or intestinal tract.

           b.  CAUSES:

                1.  Primarily a disease of herbivores, with cattle, sheep and horses being the usual

                     domesticated animal hosts.

                2.  Cutaneous exposure occurs when handling infected animal tissue, contaminated

                     hair, wool, hides, or products made from infected slaughtered animals.

                3.  Respiratory exposure results from inhaling anthrax spores; an extraordinarily rare

                     form of the naturally occuring disease.

                4.  Intestinal exposure is from unknowingly ingesting infected meat.

           c.  SIGNS / SYMPTOMS:

                1.  Signs appear in most cases within 48 hours.  The incubation period for anthrax is

                     hours to 7 days, dependent upon the exposure dose.

                2.  Symptoms:

                     a)   Skin - itching of exposed skin surface, followed by a lesion which at first

                           becomes a papule followed by formation of a blister-like fluid-filled vesicle, and

                           in 2 - 6 days develops into a depressed black eschar (coal-black scab).  This

                           eschar is usually surrounded by mild to moderate edema and sometimes with

                           small secondary vesicles.

b)      Initial symptoms are followed in 2 to 3 days by the abrupt development of  severe respiratory distress with dyspnea, diaphoresis, stridor, and cyanosis.

c)      Unless properly treated, septic shock, respiratory distress, and death usually   

                            follows within 24 - 36 hours.

           d.  TREATMENT: (as directed)

                1.  Penicillin (4 million units IV) every 4 hours. 

                2.  Tetracyclines and erythromycin are also effective for penicillin-sensititve patients.

3.      Ciprofloxacin 1000mg initially, followed by 750mg by mouth twice daily.

                4.  Employ standard precautions for handling, treating, and moving all active cases

           e.  PREVENTION:

                1.  Prophylaxis of Purified B. Anthracis in a six-dose series (0,2,4, weeks then 6,12,18

                     months). An annual booster is required.

      2.  SMALLPOX:

            a.  DEFINITION - This systemic viral disease was declared globally eradicated in 1977

                 by the World Health Organization.  The only known samples of the disease causing

                 the Variola virus are in the research labs at the Center for Disease Control (CDC), in

                 Atlanta, GA and in the CDCs counterpart in Koltsovo, Russia.

            b.  CAUSES:

                 1.  Infected respiratory discharge.

                 2.  Infectious bed linens or clothing of the patients.

                 3.  Contact with the scabs. 

            c.  SIGNS / SYMPTOMS:

                 1.  Signs: Incubation period is typically 12 days (range: 10-17 days).

                 2.  Sudden onset of fever, headache, and backache that last 2-3 days.

                 3.  Rash:  After 3 - 4 days temperature falls and rash appears.  The rash develops into

                      macules, papules, vesicles, pustules, and finally scabs.

                 4.  Infectious:  During the entire term of the disease (usually 3 -4 weeks in length) the

                      patient is infectious.

           d.  TREATMENT: (as directed)

                 1.  Complete sterile handling should be enforced and complete quarantine for up to

                      four weeks after the rash appears.

                 2.  Supportive care.

            e.  PREVENTION:    

                1.  Prophylaxis: Vaccination of Vaccinia Virus that induces strong cross-protection

                     against smallpox for at least 5 years and partial protection for 10 years or more.

                     (a)  There are no routine immunizations of US forces for smallpox. When the threat

                            indicates, senior leadership may direct vaccination of personnel.

3.  CHOLERA:

           a.  DEFINITION - An acute bacterial enteric disease.

           b.  CAUSE:  Primary source is ingestion of bacteria thru infected water sources or by

                ingestion of contaminated food.

           c.  SIGNS / SYMPTOMS OF CONDITIONS:

                1.  Signs from a few hours to 5 days, usually 2 - 3 days.

                2.  Profuse watery stools with fluid losses exceeding 5 to 10 liters or more per day.

                3.  Vomiting.

                4.  Circulatory collapse.

           d.  TREATMENT: (as directed)

                1.  Prompt fluid therapy.

                    (a)  Oral hydration is warranted, when mild to moderate fluid loss has occurred.

                    (b)  IV fluid replacement is required for patients with persistant vomiting or high

                           rates of stool loss.

                2.  Antibiotics:  Tetracycline 250mg (po) every 6 hours for 3 - 5 days, or Doxycycline

                     200mg (po) initially, followed by 100mg every 12 hours for 3 - 5 days is adequate.

           e.   PREVENTION:      

                1.  Prophylaxis:  Vaccination of Vibrio cholerae with two injections given at least 1

                     week apart and booster doses every 6 months.

      4.  BUBONIC PLAGUE:

a.       DEFINITION - A specific zoonosis (a disease of animals that may be transmitted to man), involving rodents and their fleas, which transfers the bacterial infection to animals and humans.

b.      CAUSES: 

               1.  Being bitten by infected fleas is the primary mode of transmission.

               2.  A secondary source is the areosolized droplets of sputum from a patient (coughing

                    or sneezing).

           c.  SIGNS / SYMPTOMS OF CONDITIONS:

               1.  Signs from 2 - 6 days in unvaccinated individuals and a few days longer for

                    vaccinated individuals.  Incubation period for primary plague pneumonia 2 - 3 days. 

               2.  Inguinal Lymphadenitis.

               3.  High fever.

               4.  Edema and tenderness at the site of the bite.

               5.  Bubonic plague may progress spontaneously to the septicemic form with organisms

                    spreading to the lungs producing pneumonic disease.

           d.  TREATMENT: (as directed)

                1.  Quarantine the patient and maintain strict sterile procedures.

                2.  Intravenous Doxycycline 200mg initially, followed by 100mg every 12 hours and

                     Streptomycin 1g (IM) every 12 hours. 

                3.  Intravenous Chloramphenicol 1g every 6 hours for 10 - 14 days

           e.   PREVENTION:   

                1.  Prophylaxis:  Vaccination of Yersinia pestis in a three-dose primary series at 0,1, 

                     and 4 - 7 months with a booster every 1 - 2 years.

D.  METHODS OF DISSEMINATION OF BIOLOGICAL AGENTS

a.  DEFINITION - The ability to produce biological agents and the means of employment is feasible with minimal resources.

           b. METHODS: 

               1.  Aerosol:

                   a)  A live microorganism cultured in a moist environment can be introduced into the

                        air as a wet aerosol.  This is the most likely method.

               2.  Large Liquid Drops:

                    a)  Using large liquid drops of an agent, usually toxins, will cause ground

                         contamination which is similar to a persistent chemical agent.

               3.  Dry Powder:

                    a)  By employing a process similar to freeze drying, microbiological materials can

                         be stored as a dry powder.  This dry powder state causes a drastic increase in the

                         stability of the agent in an open environment and makes dissemination easier.  In

                         addition to dry powder, a pathogen can be protected by micro-encapsulation and 

                         its use would be similar to a dry powder.

               4.  Arthropod Vector:

                    a)  Least likely used method of dissemination. Difficulty in controlling the vector,            

                         (ie. mosequetos or fleas) natural predators which may destroy the vector, and the

                         cost of producing the vector.  This method of dissemination can circumvent

                         protective clothing and the protective mask.

               5.  Covert:

                    a)  Using any of the above mentioned methods. This is felt to be a threat which

                         terrorist organizations could employ. This would create a serious disruption of a

                         target population or an activities ability to wage war, with minimal planning or

                         expenditure of personnel and resources.

      6.  FOUR PHASES OF DEFENSE OR PROTECTIVE MEASURES AGAINST BW

           AGENTS

           a.  PRE-ATTACK PHASE OF BIOLOGICAL WARFARE

               1.  Train and inform personnel of possible agents.

               2.  Discourage rumors.

               3.  Practice good sanitation and hygiene.

               4.  Ensure immunizations are up to date.

               5.  Protect supplies and equipment.

           b.  ATTACK PHASE OF BIOLOGICAL WARFARE 

               1.  Observed aircraft spraying or dropping objects.

               2.  Observed lobbing of low blast shells or bombs.

               3.  Observed smokes and mists of unknown origin.

               4.  Observed dead animals with no visible cause.  (Probably too late)

               5.  Patients may experience unexpected disease.

               6.  You may have a doubling in the number of sickcall illnesses in a 48 hour period.

               7.  Stop breathing and don protective mask.

               8.  Give the alarm.

               9.  Remain undercover, and move outside only after cloud has passed or "ALL CLEAR" 

                    is sounded .

             10.  Cover exposed skin.

           c.  POST ATTACK PHASE OF BIOLOGICAL WARFARE

               1.  Practice a high order of good health, field sanitation, and hygiene discipline.

               2.  Keep wounds, cuts, and scratches clean by using soap, water, and available first aid.

               3.  Don't consume local foods.

               4.  Eat and drink only approved food and water.

               5.  Do not bathe in lakes, ponds, and streams.

               6.  Do not touch animals, especially dead ones.

               7.  Observe BW contamination markers.

           d.  DECONTAMINATION PHASE

               1.  Establish area for the decontamination station.

               2.  Set up and operate the station.

               3.  Provide personnel for monitoring teams.

               4.  Post the NATO Biological Warning Marker.

                    a)  A triangular shaped marker measuring 11" x 8" x 8" with blue background and   

                         red letters spelling "BIO".

 STUDENT REFERENCE (S):

1.  NBC Defense (FMFM 11-1)

2.  USAMRICD Management of Chemical Casualties Handbook

3.  Department of the Army Field Manual (FM 8-9)

4.  Handbook of the Hospital Corps

5.  Medical Management of Chemical Casualties, NCO Handbook

Field Medical Service School
Camp Pendleton, California

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Operational Medicine 2001
Health Care in Military Settings

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