Medical NBC Briefing Series Medical NBC Aspects of Pneumonic Plague

1. 12 June 2012 1 Medical NBC Briefing SeriesMedical NBC Aspects ofPneumonic Plague This presentation is part of a series developed by the Medical NBC Staff at the Office of The Surgeon General for the Army. Technical production has been provided by the Chemical and Biological Defense Information Analysis Center (CBIAC). CBIAC is a Department of Defense Information Analysis Center operated by Battelle Memorial Institute and sponsored by the Defense Technical Information Center (DTIC-AI), Fort Belvoir, VA 22060-6218. This report is a work prepared for the United States Government by Battelle. In no event shall either the United States Government or Battelle have any responsibility or liability for any consequences of any use, misuse, inability to use, or reliance upon the information contained herein, nor does either warrant or otherwise represent in any way the accuracy, adequacy, efficacy, or applicability of the contents hereof.This presentation is part of a series developed by the Medical NBC Staff at the Office of The Surgeon General for the Army. Technical production has been provided by the Chemical and Biological Defense Information Analysis Center (CBIAC). CBIAC is a Department of Defense Information Analysis Center operated by Battelle Memorial Institute and sponsored by the Defense Technical Information Center (DTIC-AI), Fort Belvoir, VA 22060-6218. This report is a work prepared for the United States Government by Battelle. In no event shall either the United States Government or Battelle have any responsibility or liability for any consequences of any use, misuse, inability to use, or reliance upon the information contained herein, nor does either warrant or otherwise represent in any way the accuracy, adequacy, efficacy, or applicability of the contents hereof.

2. 12 June 2012 2 Purpose

3. 12 June 2012 3 Outline Background Battlefield Response Medical Response Command and Control Summary References Reference for picture: www.bath.ac.uk/~bssgjs/ravi/super.html Reference for picture: www.bath.ac.uk/~bssgjs/ravi/super.html

4. 12 June 2012 4 Background Disease Background General Background Pneumonic Plague Disease Course Summary Signs and Symptoms Diagnosis Treatment Current Situation Weaponization Reference for picture: www.bayonet.netReference for picture: www.bayonet.net

5. 12 June 2012 5 Disease Background Bacteria: Yersinia pestis Vector: flea (Xenopsylla cheopis) Three forms of Plague: Bubonic, Primary septicemic, Pneumonic Yersinia pestis, a rod-shaped, non-motile, non-sporulating, gram-negative, bipolar staining, facultative anaerobic bacterium. It causes plague, normally a zoonotic disease of rodents (e.g., rats, mice, ground squirrels). Plague normally appears in three forms in man: bubonic, primary septicemic, and pneumonic. An additional pharyngeal form resembling acute tonsillitis occurs among Southeast Asian women who pick fleas out of each other�s hair and bite them to kill them. This presentation is on Pneumonic Plague. Bubonic plague is the most common type of plague. The disease is spread by the flea (Xenopsylla cheopis). Outbreaks tend to occur when rodents and humans come into close contact. The other common form of the disease, pneumonic plague, is spread by respiratory droplet transmission. A small percentage of patients with bubonic or septicemic plague develop secondary pneumonic plague and can then spread the disease by respiratory droplet. Persons contracting the disease by this route develop primary pneumonic plague. The pneumonic form is an infection of the lungs due to inhalation of the organisms (primary pneumonic plague), or organisms spread to the lungs from septicemia (secondary pneumonic plague). The mortality of untreated bubonic plague is approximately 50 percent, whereas in pneumonic plague, the untreated mortality rate is 100 percent. Yersinia pestis, a rod-shaped, non-motile, non-sporulating, gram-negative, bipolar staining, facultative anaerobic bacterium. It causes plague, normally a zoonotic disease of rodents (e.g., rats, mice, ground squirrels). Plague normally appears in three forms in man: bubonic, primary septicemic, and pneumonic. An additional pharyngeal form resembling acute tonsillitis occurs among Southeast Asian women who pick fleas out of each other�s hair and bite them to kill them. This presentation is on Pneumonic Plague. Bubonic plague is the most common type of plague. The disease is spread by the flea (Xenopsylla cheopis). Outbreaks tend to occur when rodents and humans come into close contact. The other common form of the disease, pneumonic plague, is spread by respiratory droplet transmission. A small percentage of patients with bubonic or septicemic plague develop secondary pneumonic plague and can then spread the disease by respiratory droplet. Persons contracting the disease by this route develop primary pneumonic plague. The pneumonic form is an infection of the lungs due to inhalation of the organisms (primary pneumonic plague), or organisms spread to the lungs from septicemia (secondary pneumonic plague). The mortality of untreated bubonic plague is approximately 50 percent, whereas in pneumonic plague, the untreated mortality rate is 100 percent.

6. 12 June 2012 6 History Ancient � first cited in I Samuel V:6,9 - 1320 BC Major Pandemics 541 AD - Plague of Justinian 1346 AD - �Black Death� 1894 AD - Modern Pandemic 200,000,000 deaths have been attributed to plague Pneumonic plague has rarely been the dominant manifestation Plague is an ancient disease. The first reference of bubonic plague is cited in the biblical book of I Samuel as the Philistinian plague of 1320 B.C. Y. pestis has caused three great pandemics of human disease during the 6th, 14th, and 20th centuries. Since the same bacteria causes both bubonic and pneumonic plague, outbreaks of bubonic plague have created outbreaks of pneumonic plague. Although pneumonic plague has rarely been the dominant manifestation of the disease, large outbreaks of pneumonic plague have occurred. In an outbreak in Manchuria in 1910-1911, as many as 60,000 persons developed pneumonic plague; a second large Manchurian pneumonic plague outbreak occurred in 1920-1921. As would be anticipated in the preantibiotic era, nearly 100% of these cases were reported to be fatal. Reference: Inglesby, T, et al., Plague as a Biological Weapon. Journal of the American Medical Association. Vol 283, No 17, May 3, 2000.Plague is an ancient disease. The first reference of bubonic plague is cited in the biblical book of I Samuel as the Philistinian plague of 1320 B.C. Y. pestis has caused three great pandemics of human disease during the 6th, 14th, and 20th centuries. Since the same bacteria causes both bubonic and pneumonic plague, outbreaks of bubonic plague have created outbreaks of pneumonic plague. Although pneumonic plague has rarely been the dominant manifestation of the disease, large outbreaks of pneumonic plague have occurred. In an outbreak in Manchuria in 1910-1911, as many as 60,000 persons developed pneumonic plague; a second large Manchurian pneumonic plague outbreak occurred in 1920-1921. As would be anticipated in the preantibiotic era, nearly 100% of these cases were reported to be fatal. Reference: Inglesby, T, et al., Plague as a Biological Weapon. Journal of the American Medical Association. Vol 283, No 17, May 3, 2000.

7. 12 June 2012 7 In primary pneumonic plague, the incubation period is 2 to 3 days. The onset is acute and fulminant with malaise, high fever, chills, headache, myalgia, cough with production of a bloody sputum, and toxemia. The pneumonia progresses rapidly, resulting in dyspnea, strider, and cyanosis. In fatal cases, death results in about four days. In untreated patients, the mortality is 100 percent with the terminal event being respiratory failure, circulatory collapse, and extensive internal bleeding.In primary pneumonic plague, the incubation period is 2 to 3 days. The onset is acute and fulminant with malaise, high fever, chills, headache, myalgia, cough with production of a bloody sputum, and toxemia. The pneumonia progresses rapidly, resulting in dyspnea, strider, and cyanosis. In fatal cases, death results in about four days. In untreated patients, the mortality is 100 percent with the terminal event being respiratory failure, circulatory collapse, and extensive internal bleeding.

8. 12 June 2012 8 Signs and Symptoms 2 to 3 day incubation period High fever, chills, headache, and cough with bloody sputum Development of severe difficulty breathing and eventual circulatory collapse Rapid onset of symptoms After an incubation period varying from 2 to 3 days for primary pneumonic plague, presumably dependent upon the dose of inhaled organisms, onset is acute and often fulminate. The presentation is one of malaise, high fever, chills, headache, myalgia, cough with production of a bloody sputum, and toxemia. The pneumonia progresses rapidly, resulting in dyspnea, stridor, and cyanosis. Chest w-ray findings are variable and may reveal a patchy or consolidated bronchopneumonia, cavitation, hilar adenopathy, and pleural effusions. The terminal event is one of respiratory failure and circulatory collapse. Although laboratory findings may suggest, DIC, hemorrhage is rare. The photo on left shows right, middle, and lower lobe consolidation in pneumonic plague. Post-mortem lung on right shows necrotic nodules with intense hyperemia and intervening compensatory emphysema in pulmonary parenchyma, hemorrhage in the lower lobe. Pneumonic plague includes severe pneumonia accompanied by high fever, labored breathing, and the production of bloody sputum. If immediate treatment is not rendered, rapid shock and death may result.After an incubation period varying from 2 to 3 days for primary pneumonic plague, presumably dependent upon the dose of inhaled organisms, onset is acute and often fulminate. The presentation is one of malaise, high fever, chills, headache, myalgia, cough with production of a bloody sputum, and toxemia. The pneumonia progresses rapidly, resulting in dyspnea, stridor, and cyanosis. Chest w-ray findings are variable and may reveal a patchy or consolidated bronchopneumonia, cavitation, hilar adenopathy, and pleural effusions. The terminal event is one of respiratory failure and circulatory collapse. Although laboratory findings may suggest, DIC, hemorrhage is rare. The photo on left shows right, middle, and lower lobe consolidation in pneumonic plague. Post-mortem lung on right shows necrotic nodules with intense hyperemia and intervening compensatory emphysema in pulmonary parenchyma, hemorrhage in the lower lobe. Pneumonic plague includes severe pneumonia accompanied by high fever, labored breathing, and the production of bloody sputum. If immediate treatment is not rendered, rapid shock and death may result.

9. 12 June 2012 9 Laboratory Diagnosis Cultures from blood and sputum Requires a minimum BL-2 laboratory with respiratory isolation protection Handling specimens should be with glove and mask precautions Culturing the organism from blood and sputum can make a definitive diagnosis. The organism grows slowly at normal incubation temperatures. Plague can be misidentified by automated systems because of its delayed biochemical reactions. Blood agar, MacConkey agar, or infusion broth are the preferred media in which plague may be cultured. When examining the cultures, tiny 1- to 3-mm "beaten-copper" colonies will appear on blood agar within 48 hours. Cultures may appear negative at 24 hours. Y. pestis is a pathogen in biohazard risk group III and should be handled in an appropriate containment laboratory. Standard bacteriological practices of biosafety level 2 are usually sufficient for clinical laboratories, but special precautions must be used if aerosols are produced or dead animals are handled. Such activities, as well as procedures with cultures of Y. pestis, should be performed in a class III biological safety cabinet. Laboratory staff must be protected against skin contact and inhalation of aerosols by wearing gloves and a face mask. Culturing the organism from blood and sputum can make a definitive diagnosis. The organism grows slowly at normal incubation temperatures. Plague can be misidentified by automated systems because of its delayed biochemical reactions. Blood agar, MacConkey agar, or infusion broth are the preferred media in which plague may be cultured. When examining the cultures, tiny 1- to 3-mm "beaten-copper" colonies will appear on blood agar within 48 hours. Cultures may appear negative at 24 hours. Y. pestis is a pathogen in biohazard risk group III and should be handled in an appropriate containment laboratory. Standard bacteriological practices of biosafety level 2 are usually sufficient for clinical laboratories, but special precautions must be used if aerosols are produced or dead animals are handled. Such activities, as well as procedures with cultures of Y. pestis, should be performed in a class III biological safety cabinet. Laboratory staff must be protected against skin contact and inhalation of aerosols by wearing gloves and a face mask.

10. 12 June 2012 10 Treatment - Prophylaxis Plague vaccine 3doses: Initial dose 1 month 6 months Efficacy against aerosolized Y. pestis has not been established A licensed, killed whole cell vaccine is available for use in those considered to be at risk of exposure. The primary series consists of three doses. The initial dose of 1.0 ml IM followed by 0.2 ml IM at 1 and 6 months. Three booster doses of 0.2 ml IM are given at 6 month intervals following the third dose of the primary series and then every 1-2 years thereafter. The current vaccine offers protection against bubonic plague, but its efficacy against aerosolized Y. pestis has not been established. Presently, 8-10 percent of inoculations result in local reactions which include erythema, induration, tenderness and edema at the site of injection. These typically resolve within 48 hours. Approximately 7-10 percent of inoculations will result in systemic symptoms including malaise, lymphadenopathy, fever and very rarely anaphylaxis, tachycardia, urticaria, or hypotension. Reference: National Research Council and Institute of Medicine, Chemical and Biological Terrorism, Research and Development to Improve Civilian Medical Response, Washington DC: National Academy Press, 1999.A licensed, killed whole cell vaccine is available for use in those considered to be at risk of exposure. The primary series consists of three doses. The initial dose of 1.0 ml IM followed by 0.2 ml IM at 1 and 6 months. Three booster doses of 0.2 ml IM are given at 6 month intervals following the third dose of the primary series and then every 1-2 years thereafter. The current vaccine offers protection against bubonic plague, but its efficacy against aerosolized Y. pestis has not been established. Presently, 8-10 percent of inoculations result in local reactions which include erythema, induration, tenderness and edema at the site of injection. These typically resolve within 48 hours. Approximately 7-10 percent of inoculations will result in systemic symptoms including malaise, lymphadenopathy, fever and very rarely anaphylaxis, tachycardia, urticaria, or hypotension. Reference: National Research Council and Institute of Medicine, Chemical and Biological Terrorism, Research and Development to Improve Civilian Medical Response, Washington DC: National Academy Press, 1999.

11. 12 June 2012 11 Treatment - Clinical Early recognition and treatment is paramount Fatality rate of treatment delayed more than 24 hours after onset of symptoms if high Quarantine of known cases for at least 48 hours Supportive care � substantial advanced medical supportive care is necessary Oxygen Hydration (IV therapy) Ventilation support for severe cases Support for possible multi-organ failure The high mortality rate of pneumonic plague makes early diagnosis and early treatment critical. Patients must be readily identified, quarantined, and treatment begun within 24 hours of onset of symptoms. Patients that are symptomatic must be isolated for at least the first 48 hours of therapy. Patients may deteriorate rapidly with the progression of the disease. Extensive intensive care facilities may be required to support these patients. The possibility for severe respiratory compromise and organ failure is high and must considered in planning for health service support. Substantial supplies for oxygen therapy, hydration, ventilatory support, and associated organ failure support may be necessary. IV therapy and beds will be required for all patients that are symptomatic.The high mortality rate of pneumonic plague makes early diagnosis and early treatment critical. Patients must be readily identified, quarantined, and treatment begun within 24 hours of onset of symptoms. Patients that are symptomatic must be isolated for at least the first 48 hours of therapy. Patients may deteriorate rapidly with the progression of the disease. Extensive intensive care facilities may be required to support these patients. The possibility for severe respiratory compromise and organ failure is high and must considered in planning for health service support. Substantial supplies for oxygen therapy, hydration, ventilatory support, and associated organ failure support may be necessary. IV therapy and beds will be required for all patients that are symptomatic.

12. 12 June 2012 12 Treatment - Clinical (cont.) Antibiotic therapy - Bubonic or Pneumonic Gentamicin - 5 mg/kg I.V. q 24 hr X 10 days Streptomycin (age-old favorite) - 15 mg/kg I.M. bid X 10 days Sulfadiazine 2-3 gm I.V. q 12 hr X 10 days Chloramphenicol Streptomycin, tetracycline, chloramphenicol, and gentamicin are highly effective, especially if begun early (within 24 hours of onset of symptoms). Plague pneumonia is almost always fatal if treatment is not initiated within 24 hours of the onset of symptoms. Streptomycin is given on doses of 15 milligram (mg)/kilogram (kg) bid, for ten days. Gentamicin dose is 5 mg/kg lean body mass IV q 24 hr x 10 days. While the patient is typically not feverish after three days, the extra week of therapy prevents relapses. Results obtained from laboratory animal experience, not human experience, indicate that quinolone antibiotics such as oflaxacin and ciprofloxacin may also be effective. Streptomycin, tetracycline, chloramphenicol, and gentamicin are highly effective, especially if begun early (within 24 hours of onset of symptoms). Plague pneumonia is almost always fatal if treatment is not initiated within 24 hours of the onset of symptoms. Streptomycin is given on doses of 15 milligram (mg)/kilogram (kg) bid, for ten days. Gentamicin dose is 5 mg/kg lean body mass IV q 24 hr x 10 days. While the patient is typically not feverish after three days, the extra week of therapy prevents relapses. Results obtained from laboratory animal experience, not human experience, indicate that quinolone antibiotics such as oflaxacin and ciprofloxacin may also be effective.

13. 12 June 2012 13 Current Situation Worldwide Cases 1980 - 89 861 / year 11% mortality 1990 - 94 1974 / year 8% mortality There has been an annual average of around 1,000 to 1,500 cases over the last 25 years, with a 5 to 10 percent mortality rate. A small percentage of the cases are pneumonic. In the United States, 390 cases of plague were reported from 1947 to 1996, 84% of which were bubonic, 13% septicemic, and 2% pneumonic. Picture:http://www.who.int/emc-documents/surveillance/docs/whocdscsrisr2001.html/plague/ plague.htm#Prevention Reference: Inglesby, T, et al., Plague as a Biological Weapon. Journal of the American Medical Association. Vol 283, No 17, May 3, 2000. There has been an annual average of around 1,000 to 1,500 cases over the last 25 years, with a 5 to 10 percent mortality rate. A small percentage of the cases are pneumonic. In the United States, 390 cases of plague were reported from 1947 to 1996, 84% of which were bubonic, 13% septicemic, and 2% pneumonic. Picture:http://www.who.int/emc-documents/surveillance/docs/whocdscsrisr2001.html/plague/ plague.htm#Prevention Reference: Inglesby, T, et al., Plague as a Biological Weapon. Journal of the American Medical Association. Vol 283, No 17, May 3, 2000.

14. 12 June 2012 14 Weaponization As a biological warfare agent, Y. pestis poses a significant threat to ground troops Highly transmissible Infectious Lethal Easily dispersible to ground troops and vector animals in theater May remain viable in 68 % humidity for up to 2 days An adversary could conceivably choose plague as a biological warfare agent because of its ability to affect individuals and vectors by air drop, its stability, its incapacitating effects, and its speed of interaction. Plague would most likely be dispersed as an aerosol. As an aerosol, agent only lasts for 3 to 4 hours in direct sunlight. In rotating aerosol chambers that keep the aerosol relatively stable, Y. pestis was capable of multiplying for 32 hours at 68-percent relative humidity. Aerosols containing particles ranging 1-2 mm remained viable under these chamber conditions for up to 2 days. Larger particles ranging 2 to 6 mm remained viable for only 9 hours. The bubonic form of the disease has been used on a number of occasions as a bilogical weapons through the intentional dissemination of infected fleas. Since WWII, biological weapons research has focused on the Pneumonic form of the disease.An adversary could conceivably choose plague as a biological warfare agent because of its ability to affect individuals and vectors by air drop, its stability, its incapacitating effects, and its speed of interaction. Plague would most likely be dispersed as an aerosol. As an aerosol, agent only lasts for 3 to 4 hours in direct sunlight. In rotating aerosol chambers that keep the aerosol relatively stable, Y. pestis was capable of multiplying for 32 hours at 68-percent relative humidity. Aerosols containing particles ranging 1-2 mm remained viable under these chamber conditions for up to 2 days. Larger particles ranging 2 to 6 mm remained viable for only 9 hours. The bubonic form of the disease has been used on a number of occasions as a bilogical weapons through the intentional dissemination of infected fleas. Since WWII, biological weapons research has focused on the Pneumonic form of the disease.

15. 12 June 2012 15 Weaponization (cont.) Operation Cauldron: U.S. offensive program �1952 Soviet program Aerosolization Inhalation threat Delivery systems can be simple Spray systems Sub munitions Detonation containers Crop duster or boat Bomblets Aircraft The United States worked with Y. pestis as a potential BW agent in the 1950s, before the old offensive BW program was terminated. During Operation Cauldron in 1952, 40 milliliters (mL) of Y. pestis was released in an aerosol cloud upwind of a large test pontoon in the South Pacific. Twelve percent of the guinea pigs and thirty eight percent of the monkeys on the pontoon became infected. Plague was then abandoned by the U.S. because of low infectivity. Other countries have been, or are suspected of weaponizing this organism. Yersinia pestis is difficult to grow into weaponizable quantities without loss of virulence. Aerosolized bacteria exhibit a 20 to 25 percent per hour biological decay rate if unstabilized. Nevertheless, the former Soviet Union manufactured metric tons of plague as a wet BW agent because of its high secondary infection capability. Dissemination in the atmosphere is possible with spray systems, sub-munitions (bomblets), and detonation of the container. Spray systems can be ground based or aircraft types analogous to agricultural cropdusters. Bomblets are designed to cover a large area on the ground, after which the agent is aerosolized or released through detonation. BW agents can be disseminated as a dry material or powder, liquid aerosol, or slurry. Particle size will vary depending on the agent, weapon system type, and conditions. In general, particles in the respirable size range 2 to 15 microns. Particles smaller than 5 microns will penetrate deeply into lower respiratory tract and pass into the bloodstream via the pulmonary alveoli. The United States worked with Y. pestis as a potential BW agent in the 1950s, before the old offensive BW program was terminated. During Operation Cauldron in 1952, 40 milliliters (mL) of Y. pestis was released in an aerosol cloud upwind of a large test pontoon in the South Pacific. Twelve percent of the guinea pigs and thirty eight percent of the monkeys on the pontoon became infected. Plague was then abandoned by the U.S. because of low infectivity. Other countries have been, or are suspected of weaponizing this organism. Yersinia pestis is difficult to grow into weaponizable quantities without loss of virulence. Aerosolized bacteria exhibit a 20 to 25 percent per hour biological decay rate if unstabilized. Nevertheless, the former Soviet Union manufactured metric tons of plague as a wet BW agent because of its high secondary infection capability. Dissemination in the atmosphere is possible with spray systems, sub-munitions (bomblets), and detonation of the container. Spray systems can be ground based or aircraft types analogous to agricultural cropdusters. Bomblets are designed to cover a large area on the ground, after which the agent is aerosolized or released through detonation. BW agents can be disseminated as a dry material or powder, liquid aerosol, or slurry. Particle size will vary depending on the agent, weapon system type, and conditions. In general, particles in the respirable size range 2 to 15 microns. Particles smaller than 5 microns will penetrate deeply into lower respiratory tract and pass into the bloodstream via the pulmonary alveoli.

16. 12 June 2012 16 Battlefield Response toPlague Detect Protect Individual protection Collective protection

17. 12 June 2012 17 Detection Possible methods of detection Detection of agent in the environment Clinical (differential diagnosis) Medical surveillance (coordination enhances detection capability) Diagnosis of plague is not presumptive of a BW attack � plague may be endemic to the area The three general methods of detecting any release of a biological agent are detection of the agent in the environment, clinical diagnosis of the disease caused by the agent, or detection of the increase in the number of patients through DNBI (Disease Non-Battle Injury Reports). The detection capability of the theater is greatly enhanced through the coordination and the training of the various units responsible for detection such as coordination of a medical treatment unit with the 520th Theater Army Medical Laboratory (TAML) for testing procedures of samples from patients possibly exposed to plague. Since the same bacteria causes all three forms of the disease, appearance of a vector-borne disease in the absence of natural vectors or reservoir hosts (i.e., rabbits, rodents, or fleas) may signal a potential biological warfare attack with plague. Diagnosis of plague is not presumptive of a BW attack. A plague may be a result of vectors in the area. The three general methods of detecting any release of a biological agent are detection of the agent in the environment, clinical diagnosis of the disease caused by the agent, or detection of the increase in the number of patients through DNBI (Disease Non-Battle Injury Reports). The detection capability of the theater is greatly enhanced through the coordination and the training of the various units responsible for detection such as coordination of a medical treatment unit with the 520th Theater Army Medical Laboratory (TAML) for testing procedures of samples from patients possibly exposed to plague. Since the same bacteria causes all three forms of the disease, appearance of a vector-borne disease in the absence of natural vectors or reservoir hosts (i.e., rabbits, rodents, or fleas) may signal a potential biological warfare attack with plague. Diagnosis of plague is not presumptive of a BW attack. A plague may be a result of vectors in the area.

18. 12 June 2012 18 Current military detection systems for Y. pestis include antigen capture chromatography, ELISA, and PCR. Smart tickets are hand-held point detectors based on antigen capture chromatography. These test are similar to pregnancy tests in that the biological agent chemically binds to the agent-specific antibodies on the test strip, inducing a color change that can be observed by the naked eye. These devices are strictly screening assays, and the analyses are subject to error from the introduction of other contaminants. Therefore, positive results need to be confirmed with more sensitive tests. According to the National Research Council�s Chemical and Biological Terrorism (1999), smart tickets are available for Y. pestis, F. tularensis, B. anthracis, V. cholerae, SEB, ricin, botulinum toxins, and Brucella species, but not for smallpox. ELISA is a biological assay based on the specificity of the antigen-antibody reaction. These immunoassays are laboratory procedures used to detect specific antibodies that are developed by the body's immune system when the person is exposed to that biological agent. Antibodies can be found in serum or other body fluids from humans, animals, arthropods, or mosquitoes. The 520th TAML and USAMRIID currently operate this system in the field. ELISA is capable of detecting plague given the lab has the proper reagents. PCR is a method for synthesizing and amplifying defined sequences of DNA. The PCR process uses temperature to separate the two targeted DNA strands and then reproduce that strand millions of times for detection. The system is currently fielded to the 520th TAML. PCR is capable of detecting plague given the lab has the proper reagents. Since the field of the above equipment and units such as the 520th will greatly vary, the medical NBC officer should keep in close contact with the CINC for the for information on the capability in theater.Current military detection systems for Y. pestis include antigen capture chromatography, ELISA, and PCR. Smart tickets are hand-held point detectors based on antigen capture chromatography. These test are similar to pregnancy tests in that the biological agent chemically binds to the agent-specific antibodies on the test strip, inducing a color change that can be observed by the naked eye. These devices are strictly screening assays, and the analyses are subject to error from the introduction of other contaminants. Therefore, positive results need to be confirmed with more sensitive tests. According to the National Research Council�s Chemical and Biological Terrorism (1999), smart tickets are available for Y. pestis, F. tularensis, B. anthracis, V. cholerae, SEB, ricin, botulinum toxins, and Brucella species, but not for smallpox. ELISA is a biological assay based on the specificity of the antigen-antibody reaction. These immunoassays are laboratory procedures used to detect specific antibodies that are developed by the body's immune system when the person is exposed to that biological agent. Antibodies can be found in serum or other body fluids from humans, animals, arthropods, or mosquitoes. The 520th TAML and USAMRIID currently operate this system in the field. ELISA is capable of detecting plague given the lab has the proper reagents. PCR is a method for synthesizing and amplifying defined sequences of DNA. The PCR process uses temperature to separate the two targeted DNA strands and then reproduce that strand millions of times for detection. The system is currently fielded to the 520th TAML. PCR is capable of detecting plague given the lab has the proper reagents. Since the field of the above equipment and units such as the 520th will greatly vary, the medical NBC officer should keep in close contact with the CINC for the for information on the capability in theater.

19. 12 June 2012 19 The BIDS and IBADS are field military equipment that detect biological agents and may be deployed in theater. Again, the fielding of such equipment greatly varies and the medical NBC officer should keep in close contact with the CINC for the information on the capability in theater. The M31E1 Biological Integrated Detection System (BIDS). The BIDS consists of a shelter mounted on a dedicated vehicle and equipped with a biological detection suite that employs complementary technologies to detect large-area biological attacks. The biological detection suite links aerodynamic particle sizing, bioluminescence, flow cytometry, mass spectrometry, and immunoassay technologies in a complementary, layered manner to increase detection confidence. The particle sizing and bioluminescence instrumentation gives the BIDS the ability to determine if an aerosol is of biological material. The agent specific antibody test that can be accomplished by the BIDS is distribution restricted information and can be found in FM 3-101-4 (Biological Detection Platoon Operations Tactics, Techniques, and Procedures). The BIDS is a corps-level asset. The Interim Biological Agent Detector (IBADS) program will provide Naval forces a contingency capability, warning of the presence of biological and toxicological warfare agents. The IBADS is a point detector system designed for shipboard use. It is composed of a particle size counter, particle wet cyclone sampler, and a manual identifier (improved membrane calorimetric ticket flow-through assay). The antibody-antigen tickets are used for BW agent identification in the ship's medical bay. The IBADS probably has similar detection capability as the BIDS. The Navy has a total of 25 rapid prototypes that can be deployed with the fleet on short notice. The same technology is being used in the development of biological detectors for ports and airfields. Reference: Department of Defense. Chemical and Biological Defense Program, Annual Report to Congress, March 2000.The BIDS and IBADS are field military equipment that detect biological agents and may be deployed in theater. Again, the fielding of such equipment greatly varies and the medical NBC officer should keep in close contact with the CINC for the information on the capability in theater. The M31E1 Biological Integrated Detection System (BIDS). The BIDS consists of a shelter mounted on a dedicated vehicle and equipped with a biological detection suite that employs complementary technologies to detect large-area biological attacks. The biological detection suite links aerodynamic particle sizing, bioluminescence, flow cytometry, mass spectrometry, and immunoassay technologies in a complementary, layered manner to increase detection confidence. The particle sizing and bioluminescence instrumentation gives the BIDS the ability to determine if an aerosol is of biological material. The agent specific antibody test that can be accomplished by the BIDS is distribution restricted information and can be found in FM 3-101-4 (Biological Detection Platoon Operations Tactics, Techniques, and Procedures). The BIDS is a corps-level asset. The Interim Biological Agent Detector (IBADS) program will provide Naval forces a contingency capability, warning of the presence of biological and toxicological warfare agents. The IBADS is a point detector system designed for shipboard use. It is composed of a particle size counter, particle wet cyclone sampler, and a manual identifier (improved membrane calorimetric ticket flow-through assay). The antibody-antigen tickets are used for BW agent identification in the ship's medical bay. The IBADS probably has similar detection capability as the BIDS. The Navy has a total of 25 rapid prototypes that can be deployed with the fleet on short notice. The same technology is being used in the development of biological detectors for ports and airfields. Reference: Department of Defense. Chemical and Biological Defense Program, Annual Report to Congress, March 2000.

20. 12 June 2012 20 Clinical Detection Sudden presentation of Respiratory syndromes with a bloody cough, high fevers, chills, and headaches presenting in groups Rapid progression of symptoms When used as a BW agent of plague may manifest itself as rapidly occurring respiratory syndromes with a bloody cough involving groups of individuals. Other syndromes may include high fevers, chills, and headaches. Symptoms will progress rapidly causing the troops to become incapacitated.When used as a BW agent of plague may manifest itself as rapidly occurring respiratory syndromes with a bloody cough involving groups of individuals. Other syndromes may include high fevers, chills, and headaches. Symptoms will progress rapidly causing the troops to become incapacitated.

21. 12 June 2012 21 Division medical assets lack the ability to test for plague. Once plague is suspected, a sample must be sent to a medical treatment facility or other laboratory for biological testing. Biological samples from affected individuals will be used for both medical and legal reasons. General policies for collecting samples in order to facilitate identification of biological agents are essential. Unit SOP�s should address the collection, handling, and shipping of biological samples. In a possible BW event, the MTF or appropriate receiving lab should be contacted in order to assure proper specimen handling. The laboratory officer has the responsibility of assuring this handling. Yersinia pestis can be readily cultured from blood, sputum, and bubo aspirates. Most naturally occurring strains of Y. pestis produce an �Fl� antigen in vivo which can be detected in serum samples by immunoassay. A fourfold rise of Y. pestis antibody levels in patient serum is also diagnostic. Presumptive diagnosis can be made by identification of the gram-negative coccobacillus with safety-pin bipolar staining organisms in Giemsa or Wayson�s stained slides from a lymph node needle aspirate, sputum, or cerebrospinal fluid (CSF) samples. When available, immunofluorescent taining is very useful. Elevated levels of antibody to Y. pestis in a nonvaccinated patient may also be useful.Division medical assets lack the ability to test for plague. Once plague is suspected, a sample must be sent to a medical treatment facility or other laboratory for biological testing. Biological samples from affected individuals will be used for both medical and legal reasons. General policies for collecting samples in order to facilitate identification of biological agents are essential. Unit SOP�s should address the collection, handling, and shipping of biological samples. In a possible BW event, the MTF or appropriate receiving lab should be contacted in order to assure proper specimen handling. The laboratory officer has the responsibility of assuring this handling. Yersinia pestis can be readily cultured from blood, sputum, and bubo aspirates. Most naturally occurring strains of Y. pestis produce an �Fl� antigen in vivo which can be detected in serum samples by immunoassay. A fourfold rise of Y. pestis antibody levels in patient serum is also diagnostic. Presumptive diagnosis can be made by identification of the gram-negative coccobacillus with safety-pin bipolar staining organisms in Giemsa or Wayson�s stained slides from a lymph node needle aspirate, sputum, or cerebrospinal fluid (CSF) samples. When available, immunofluorescent taining is very useful. Elevated levels of antibody to Y. pestis in a nonvaccinated patient may also be useful.

22. 12 June 2012 22 The following assets are possible points of contact for assistance in the handling of biological samples: Corps (or appropriate) Chemical Officer - in charge of NBC defense for the unit. Technical Escort Unit - transportation of suspected biological agents and samples. AFMIC (Armed Forces Medical Intelligence Center) - to obtain medical intelligence of naturally occurring disease or enemy capabilities. 520th TAML (Theater Army Medical Laboratory) - first theatre level laboratory that can provide specific assistance in sample collection and analysis. USAMRIID (U.S. Army Medical Research Institute of Infectious Disease) - Assistance in specimen collection and analysis. Expertise in pathogenesis and treatment. WRAIR (Walter Reed Army Institute of Research) - assistance with diagnostic testing, disease pathogenesis, and treatment of patients with BW illnesses. CDC (Center for Disease Control and Prevention) - expertise with diagnostic testing, sample management, disease pathogenesis, and treatment.The following assets are possible points of contact for assistance in the handling of biological samples: Corps (or appropriate) Chemical Officer - in charge of NBC defense for the unit. Technical Escort Unit - transportation of suspected biological agents and samples. AFMIC (Armed Forces Medical Intelligence Center) - to obtain medical intelligence of naturally occurring disease or enemy capabilities. 520th TAML (Theater Army Medical Laboratory) - first theatre level laboratory that can provide specific assistance in sample collection and analysis. USAMRIID (U.S. Army Medical Research Institute of Infectious Disease) - Assistance in specimen collection and analysis. Expertise in pathogenesis and treatment. WRAIR (Walter Reed Army Institute of Research) - assistance with diagnostic testing, disease pathogenesis, and treatment of patients with BW illnesses. CDC (Center for Disease Control and Prevention) - expertise with diagnostic testing, sample management, disease pathogenesis, and treatment.

23. 12 June 2012 23 The medical officer must be keenly aware of bio-warfare and the identification of the disease in WMD-risk areas. Daily medical disposition reports, specifically those reporting disease non-battle illnesses/injuries, are an invaluable tool in determining whether an event is occurring. Rapid identification of a pneumonic plague outbreak is imperative to reduce mortality among the affected troops. Diligence in reporting symptomatic patients and possible syndromes is the key in medical surveillance. A BW attack will most likely be completed before the local commander will be aware that it is has taken place. Consequently, when the signs of illness occur that lead one to suspect a BW attack, the first task of the medical officer is to attempt to distinguish between a possible BW attack and a disease outbreak of a natural origin. There are clues to a possible attack using plague: High numbers of high fevers, chills, headache, and respiratory syndromes with a bloody cough.The medical officer must be keenly aware of bio-warfare and the identification of the disease in WMD-risk areas. Daily medical disposition reports, specifically those reporting disease non-battle illnesses/injuries, are an invaluable tool in determining whether an event is occurring. Rapid identification of a pneumonic plague outbreak is imperative to reduce mortality among the affected troops. Diligence in reporting symptomatic patients and possible syndromes is the key in medical surveillance. A BW attack will most likely be completed before the local commander will be aware that it is has taken place. Consequently, when the signs of illness occur that lead one to suspect a BW attack, the first task of the medical officer is to attempt to distinguish between a possible BW attack and a disease outbreak of a natural origin. There are clues to a possible attack using plague: High numbers of high fevers, chills, headache, and respiratory syndromes with a bloody cough.

24. 12 June 2012 24 The M40 mask and MOPP suit, gloves, and boots will provide protection against a biological agent attack delivered by the aerosol route. Currently, fielded respirators equipped with standard NBC filter canisters will protect the respiratory system against particles greater than 1-1.5 micrometers in size (mass median diameter). Biological agents are generally released in aerosols of particle size 2-10 microns, for retention in the lungs. While the IPE clothing employed against chemical agents will also protect against biological agents, it is important to note that even standard uniform clothing of good quality affords a reasonable protection against dermal exposure these agents. Protective clothing provides a barrier between a soldier and potentially hazardous agents. The various levels of protective clothing are dependent upon the anticipated presence of the agent. Those casualties unable to continue wearing PPE should be held and/or transported within casualty wraps designed to protect the patient against chemical or biological agent exposure. Addition of a filter blower unit to provide overpressure enhances protection and provides cooling. Decontamination may be necessary. Chemical neutralization/ detoxification is the most versatile decontamination methods. The greatest advantage of chemical neutralization is that the biological agent/toxin is rendered harmless against people, material, and the environment. The three major chemical methods used for decon are water/soap washes, oxidation, and acid/base hydrolysis. Decontaminating Solution No. 2 (DS2) is a standard decontaminant that is readily available in US military supply systems. Dermal exposure to BW agents should be immediately treated with soap and water. Careful washing removes a large amount of the agent population from skin surfaces. It is important to use a brush to ensure mechanical loosening from skin surfaces and then to rinse with copious amounts of water. This method is often sufficient to avert contact infection. Contaminated areas should then be washed with a 0.5 percent hypochlorite solution, with a contact time of 10 to 15 minutes. The M40 mask and MOPP suit, gloves, and boots will provide protection against a biological agent attack delivered by the aerosol route. Currently, fielded respirators equipped with standard NBC filter canisters will protect the respiratory system against particles greater than 1-1.5 micrometers in size (mass median diameter). Biological agents are generally released in aerosols of particle size 2-10 microns, for retention in the lungs. While the IPE clothing employed against chemical agents will also protect against biological agents, it is important to note that even standard uniform clothing of good quality affords a reasonable protection against dermal exposure these agents. Protective clothing provides a barrier between a soldier and potentially hazardous agents. The various levels of protective clothing are dependent upon the anticipated presence of the agent. Those casualties unable to continue wearing PPE should be held and/or transported within casualty wraps designed to protect the patient against chemical or biological agent exposure. Addition of a filter blower unit to provide overpressure enhances protection and provides cooling. Decontamination may be necessary. Chemical neutralization/ detoxification is the most versatile decontamination methods. The greatest advantage of chemical neutralization is that the biological agent/toxin is rendered harmless against people, material, and the environment. The three major chemical methods used for decon are water/soap washes, oxidation, and acid/base hydrolysis. Decontaminating Solution No. 2 (DS2) is a standard decontaminant that is readily available in US military supply systems. Dermal exposure to BW agents should be immediately treated with soap and water. Careful washing removes a large amount of the agent population from skin surfaces. It is important to use a brush to ensure mechanical loosening from skin surfaces and then to rinse with copious amounts of water. This method is often sufficient to avert contact infection. Contaminated areas should then be washed with a 0.5 percent hypochlorite solution, with a contact time of 10 to 15 minutes.

25. 12 June 2012 25 A dedicated hardened or unhardened shelter equipped with an air filtration unit (AFU) providing overpressure can offer collective protection (Colpro) for personnel in the biologically-contaminated environment. An airlock ensures that no contamination will be brought into the shelter. All personnel must be decontaminated prior to entering Colpro. In the absence of a dedicated structure, enhanced protection can be afforded within most buildings by sealing cracks and entry ports and providing air filtration within existing ventilation systems. Due to the requirement to continue operations in a contaminated environment, a good deal of medical treatment will likely take place in Colpro. Standard universal precautions should be employed as patients are brought to and treated in the Colpro. Chlorine is commonly used for disinfecting water. Utilize standard SOP for decontamination of water (Reference: FM 21-10-1 sec 2-6.). Food products requiring refrigeration should be stored at a temperature of 45� F (7� C) or below. All food products must be cooked to standard SOP temperatures (Reference: FM 21-10-1 sec 2-6 to 2-1). Contaminated articles can be decontaminated using 0.05% hypochlorite solution (1 tbps. Bleach per gallon of water).A dedicated hardened or unhardened shelter equipped with an air filtration unit (AFU) providing overpressure can offer collective protection (Colpro) for personnel in the biologically-contaminated environment. An airlock ensures that no contamination will be brought into the shelter. All personnel must be decontaminated prior to entering Colpro. In the absence of a dedicated structure, enhanced protection can be afforded within most buildings by sealing cracks and entry ports and providing air filtration within existing ventilation systems. Due to the requirement to continue operations in a contaminated environment, a good deal of medical treatment will likely take place in Colpro. Standard universal precautions should be employed as patients are brought to and treated in the Colpro. Chlorine is commonly used for disinfecting water. Utilize standard SOP for decontamination of water (Reference: FM 21-10-1 sec 2-6.). Food products requiring refrigeration should be stored at a temperature of 45� F (7� C) or below. All food products must be cooked to standard SOP temperatures (Reference: FM 21-10-1 sec 2-6 to 2-1). Contaminated articles can be decontaminated using 0.05% hypochlorite solution (1 tbps. Bleach per gallon of water).

26. 12 June 2012 26 ProtectVaccinations Plague vaccine Efficacy against aerosolized Y. pestis has not been established While a vaccine for plague exist, its efficacy against aerosolized Y. pestis has not been established. While a vaccine for plague exist, its efficacy against aerosolized Y. pestis has not been established.

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28. 12 June 2012 28 Patients with plague will not be returning to duty within 72 hours and will require intravenous fluid therapy and p[possibly respiratory support when they are severely symptomatic. Therefore, evacuation in Echelons I and II should be as soon as assets allow. Patients in Echelons III and IV may have intravenous therapies established and maintained in theater until they return to duty. All severely symptomatic patients should return to CONUS for long term care and follow up as soon as assets allow. Triage categories will vary according to the severity of the illness, available resources, and personnel. All patients presenting classified as Immediate. Since these patients are not expected to recover in the 15 days required in theater, they will be evacuated. Evacuation will be METT-T dependent. The availability of isolation facilities for symptomatic patients must be considered prior to evacuation. Communication with the MTF will be essential prior to evacuation. Considerations must be made on evacuation based on the availability and resources at the MTFs. If possible, all patients should be evacuated from theater. Communication with MTFs regarding all patients is essential prior to evacuation to prevent disease spread out of theater. Patients may be evacuated using both ground and air evacuation assets. Standard infection control precautions for medical patients should be observed during transport.Patients with plague will not be returning to duty within 72 hours and will require intravenous fluid therapy and p[possibly respiratory support when they are severely symptomatic. Therefore, evacuation in Echelons I and II should be as soon as assets allow. Patients in Echelons III and IV may have intravenous therapies established and maintained in theater until they return to duty. All severely symptomatic patients should return to CONUS for long term care and follow up as soon as assets allow. Triage categories will vary according to the severity of the illness, available resources, and personnel. All patients presenting classified as Immediate. Since these patients are not expected to recover in the 15 days required in theater, they will be evacuated. Evacuation will be METT-T dependent. The availability of isolation facilities for symptomatic patients must be considered prior to evacuation. Communication with the MTF will be essential prior to evacuation. Considerations must be made on evacuation based on the availability and resources at the MTFs. If possible, all patients should be evacuated from theater. Communication with MTFs regarding all patients is essential prior to evacuation to prevent disease spread out of theater. Patients may be evacuated using both ground and air evacuation assets. Standard infection control precautions for medical patients should be observed during transport.

29. 12 June 2012 29 Since plague patients would probably not be able to return to duty (RTD) in the normal theater evacuation policy of 15 days, strict interpretation of the doctrine would then call for evacuation. However, since plague is contagious, one may want to limit the spread of the bacteria by imposing a quarantine instead of allowing evacuation. Unlike smallpox, plague is already endemic to various parts of the world. Therefore the evacuation of patients is not as large of an issue as it is for smallpox. Before evacuating patients suspected of plague, guidance should be sought from the CINC. Consideration for evacuation or quarantine should include the current spread of the disease and the ability of the medical units in the area to treat the sick. If the outbreak is limited to a small area, quarantine would probably be the wisest choice. However, if the disease has already spread throughout the region, then evacuation of the patients should be considered. Reference for evacuation: FM 8-10-6.Since plague patients would probably not be able to return to duty (RTD) in the normal theater evacuation policy of 15 days, strict interpretation of the doctrine would then call for evacuation. However, since plague is contagious, one may want to limit the spread of the bacteria by imposing a quarantine instead of allowing evacuation. Unlike smallpox, plague is already endemic to various parts of the world. Therefore the evacuation of patients is not as large of an issue as it is for smallpox. Before evacuating patients suspected of plague, guidance should be sought from the CINC. Consideration for evacuation or quarantine should include the current spread of the disease and the ability of the medical units in the area to treat the sick. If the outbreak is limited to a small area, quarantine would probably be the wisest choice. However, if the disease has already spread throughout the region, then evacuation of the patients should be considered. Reference for evacuation: FM 8-10-6.

30. 12 June 2012 30 Even though the vaccine has not been established as efficacy against aerosolized plague, mass immunization should be considered to prevent any possible outbreak of bubonic plague and attempt to prevent the further spread of pneumonic plague. Not only contacts of the patients with pneumonic plague but also individuals who have been exposed to aerosols should be treated with Doxycycline 100 mg administered twice daily and a prophylaxis. Hospital personnel who are observing the recommended isolation procedures do not require prophylactic therapy. However, people who were in the same environment and who were potentially exposed to the same source of infection as the contact cases should be given prophylactic antibiotics. In addition, previously vaccinated individuals should receive prophylactic antibiotics if they have been exposed to plague aerosol. In a health care environment, standard precautions should be taken and patients with plague should be placed in strict isolation. Drainage and bodily secretions should not be handled until the patient has received antibiotic therapy for 48 hours and has demonstrated a favorable response to the antibiotics. To avoid aerosolizing infectious material, care must be taken when handling or aspirating buboes (swollen lymph nodes). Bodies of plague-infected people and animal carcasses should be handled using aseptic precautions. The plaque bacteria may remain viable in water and moist meals and grains for several weeks. At near freezing temperatures, it will remain alive from months to years but is killed by 15 minutes exposure to 72 � C. Control of the rodent population is paramount to reduce the vector population and the prevention of a possible secondary bubonic outbreak. Even though the vaccine has not been established as efficacy against aerosolized plague, mass immunization should be considered to prevent any possible outbreak of bubonic plague and attempt to prevent the further spread of pneumonic plague. Not only contacts of the patients with pneumonic plague but also individuals who have been exposed to aerosols should be treated with Doxycycline 100 mg administered twice daily and a prophylaxis. Hospital personnel who are observing the recommended isolation procedures do not require prophylactic therapy. However, people who were in the same environment and who were potentially exposed to the same source of infection as the contact cases should be given prophylactic antibiotics. In addition, previously vaccinated individuals should receive prophylactic antibiotics if they have been exposed to plague aerosol. In a health care environment, standard precautions should be taken and patients with plague should be placed in strict isolation. Drainage and bodily secretions should not be handled until the patient has received antibiotic therapy for 48 hours and has demonstrated a favorable response to the antibiotics. To avoid aerosolizing infectious material, care must be taken when handling or aspirating buboes (swollen lymph nodes). Bodies of plague-infected people and animal carcasses should be handled using aseptic precautions. The plaque bacteria may remain viable in water and moist meals and grains for several weeks. At near freezing temperatures, it will remain alive from months to years but is killed by 15 minutes exposure to 72 � C. Control of the rodent population is paramount to reduce the vector population and the prevention of a possible secondary bubonic outbreak.

31. 12 June 2012 31 Resource requirements for a large scale bubonic plague outbreak will focus mainly on the need for evacuation assets and supportive therapies in the form of IV therapy, hemodynamic monitoring, antibiotics, pain relievers, and ICU facilities for severely-respiratory compromised patients. Infected patients will require isolation. In Echelon I and II, therapy started prior to evacuation to higher Echelons may significantly reduce impact to the medical system as well as decreasing mortality and morbidity. Echelon III and above must be prepared to receive patients with respiratory compromise and to accommodate the need for additional long term (14 days or more) bed space as well as isolation facilities. The goal of theater assets will be to evacuate severely symptomatic patients to CONUS facilities for long term care and return other patients to duty. Consequently, Echelon III assets may be heavily taxed.Resource requirements for a large scale bubonic plague outbreak will focus mainly on the need for evacuation assets and supportive therapies in the form of IV therapy, hemodynamic monitoring, antibiotics, pain relievers, and ICU facilities for severely-respiratory compromised patients. Infected patients will require isolation. In Echelon I and II, therapy started prior to evacuation to higher Echelons may significantly reduce impact to the medical system as well as decreasing mortality and morbidity. Echelon III and above must be prepared to receive patients with respiratory compromise and to accommodate the need for additional long term (14 days or more) bed space as well as isolation facilities. The goal of theater assets will be to evacuate severely symptomatic patients to CONUS facilities for long term care and return other patients to duty. Consequently, Echelon III assets may be heavily taxed.

32. 12 June 2012 32 Intelligence regarding a bubonic plague BW event will generally come from medical companies. An aerosol attack may be detected and symptoms will begin to appear in large numbers of people 1-3 days post-exposure. Medical surveillance and medical intelligence reporting to command levels are the keys to responding to a plague BW event. Aerosolized plague is highly transmissible when aerosolized. Quarantine and restriction of troops who are symptomatic will be necessary after the �all clear� has been called. Since plague patients would probably not be able to return to duty (RTD) in the normal theater evacuation policy of 15 days, strict interpretation of the doctrine would then call for evacuation. However, since plague is contagious, one may want to limit the spread of the bacteria by imposing a quarantine instead of allowing evacuation. Unlike smallpox, plague is already endemic to various parts of the world. Therefore the evacuation of patients is not as large of an issue as it is for smallpox. Movement of troops not infected or symptomatic should not be affected. Additional Class VIII supplies, specifically 6404 items, will be necessary to reduce morbidity and mortality. Supply and evacuation routes will be heavily utilized. An aerosol dissemination has the potential for infecting large numbers of individuals at one time. Significant numbers of patients at one time may present themselves reducing manpower suddenly. Evacuation of all effected individuals will also require additional manpower and assets.Intelligence regarding a bubonic plague BW event will generally come from medical companies. An aerosol attack may be detected and symptoms will begin to appear in large numbers of people 1-3 days post-exposure. Medical surveillance and medical intelligence reporting to command levels are the keys to responding to a plague BW event. Aerosolized plague is highly transmissible when aerosolized. Quarantine and restriction of troops who are symptomatic will be necessary after the �all clear� has been called. Since plague patients would probably not be able to return to duty (RTD) in the normal theater evacuation policy of 15 days, strict interpretation of the doctrine would then call for evacuation. However, since plague is contagious, one may want to limit the spread of the bacteria by imposing a quarantine instead of allowing evacuation. Unlike smallpox, plague is already endemic to various parts of the world. Therefore the evacuation of patients is not as large of an issue as it is for smallpox. Movement of troops not infected or symptomatic should not be affected. Additional Class VIII supplies, specifically 6404 items, will be necessary to reduce morbidity and mortality. Supply and evacuation routes will be heavily utilized. An aerosol dissemination has the potential for infecting large numbers of individuals at one time. Significant numbers of patients at one time may present themselves reducing manpower suddenly. Evacuation of all effected individuals will also require additional manpower and assets.

33. 12 June 2012 33 For operations in which biological warfare is considered possible, each case of illness on the battlefield could be attributed to a biological attack; even minor symptoms might be interpreted as the initial signs of an artificially-produced disease. This reaction will significantly burden the medical system. Additionally since plague is contagious, soldiers may try to isolate themselves or isolate anyone exhibiting plague-like symptoms in a hope to prevent the spread of the disease. Therefore control of panic and misinformation thus assumes a significant role. An education of the threat, together with the implementation of defensive measures, will help to prevent panic. This can be achieved only by adequate preparation (for example, standard operating procedures) and by training prior to such an attack. Many positive defensive measures can be taken prior to, or in anticipation of, this contingency. Food chains and water sources should be protected. The control of rodents and insects should be a hygienic priority. Available biological detection equipment and decontamination equipment should be fielded. Soldiers must be trained in the proper use and rapid deployment of protective equipment. Attention to such preparatory measures will increase confidence and enable the BW threat to be met by reducing the psychological impact. Reference: FM 8-9 pp 2-5 to 2-6.For operations in which biological warfare is considered possible, each case of illness on the battlefield could be attributed to a biological attack; even minor symptoms might be interpreted as the initial signs of an artificially-produced disease. This reaction will significantly burden the medical system. Additionally since plague is contagious, soldiers may try to isolate themselves or isolate anyone exhibiting plague-like symptoms in a hope to prevent the spread of the disease. Therefore control of panic and misinformation thus assumes a significant role. An education of the threat, together with the implementation of defensive measures, will help to prevent panic. This can be achieved only by adequate preparation (for example, standard operating procedures) and by training prior to such an attack. Many positive defensive measures can be taken prior to, or in anticipation of, this contingency. Food chains and water sources should be protected. The control of rodents and insects should be a hygienic priority. Available biological detection equipment and decontamination equipment should be fielded. Soldiers must be trained in the proper use and rapid deployment of protective equipment. Attention to such preparatory measures will increase confidence and enable the BW threat to be met by reducing the psychological impact. Reference: FM 8-9 pp 2-5 to 2-6.

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