CategoryABiologicalEffort.pptx

Category |A| Biological Agents
Louisiana Office of Public Health
Center for Community Preparedness

Training Objectives
• Describe the CDC’s Category A biological threat agents.
• Describe the public health considerations involved in
the release of a biological threat agent.
• Discuss the recognition of potential bioterrorism
events and the formulation of an appropriate response
strategy.
OPH Center for Community Preparedness

BIOLOGICAL WEAPONS

Biological Weapons
• Biological warfare (BW), also known as germ warfare,
is the deliberate use of disease-causing biological
agents such as protozoa, fungi, bacteria, protists, or
viruses, to kill or incapacitate humans, other animals,
or plants.
• Biological weapons (bioweapons) are living
organisms or replicating entities (virus) that
reproduce or replicate within their host victims.

Biological Weapons | Uses
• Mass casualties
– Morbidity
– Mortality
• Destruction of resources
– Agriculture
– Drinking water
• Societal disruption
– Overwhelm local resources
– Breakdown of order
– Panic and fear
– Economic hardship

Biological Weapons | Historical
• Offensive biological warfare (developing and stockpiling
bioweapons) was outlawed in 1972 by the Biological Weapons
Convention (BWC). As of 2009, 163 nations had ratified the
BWC.
• The United States’ biological weapons program ran from 1943
to 1969.
– Biodefense research is now conducted by the United States Army
Medical Research Institute of Infectious Diseases (USAMRIID) at Fort
Detrick in Maryland.
• The Soviet Union’s biological weapons program began in the
1920’s and was know as Biopreparat after 1973. Program was
reportedly ended in 1992.
• Both the United Kingdom and Japan have developed
advanced bioweapon programs.

BIOLOGICAL AGENT CATEGORIES

CDC Biological Agent Categories
Category A
High-priority agents include
organisms that pose a risk to
national security because they:
– Can be easily disseminated or
transmitted from person to
person;
– Result in high mortality rates
and have the potential for
major public health impact;
– Might cause public panic and
social disruption; and
– Require special action for
public health preparedness.
Agents
• Anthrax (Bacillus anthracis)
• Botulism (Clostridium
botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella
tularensis)
• Viral hemorrhagic fevers
(Ebola, Marburg, Lassa,
Machupo)

Category B
Second highest priority agents
include those that
– Are moderately easy to
disseminate;
– Result in moderate morbidity
rates and low mortality rates;
and
– Require specific
enhancements of CDC's
diagnostic capacity and
enhanced disease
surveillance.
Agents
• Brucellosis (Brucella species)
• Epsilon toxin of Clostridium perfringens
• Food safety threats (e.g., Salmonella species,
Escherichia coli O157:H7, Shigella)
• Glanders (Burkholderia mallei)
• Melioidosis (Burkholderia pseudomallei)
• Psittacosis (Chlamydia psittaci)
• Q fever (Coxiella burnetii)
• Ricin toxin from Ricinus communis (castor
beans)
• Staphylococcal enterotoxin B
• Typhus fever (Rickettsia prowazekii)
• Viral encephalitis (alphaviruses [e.g.,
Venezuelan equine encephalitis, eastern equine
encephalitis, western equine encephalitis])
• Water safety threats (e.g., Vibrio cholerae,
Cryptosporidium parvum)

Category C
• Third highest priority
agents include emerging
pathogens that could be
engineered for mass
dissemination in the
future because of:
– Availability;
– Ease of production and
dissemination; and
– Potential for high
morbidity and mortality
rates and major health
impact.
Agents
• Emerging infectious
diseases such as Nipah
virus (found in fruit bats).

Biological Agents | Characteristics
As a bioweapon
• Effectiveness
– Morbidity and Mortality
• Transmission
– Environmental
– Person-to-person
• Ease of Use
– Special handling
– Production complexity
• Accessibility
– Commonly available
– Few legal controls
• Prevention
As a disease
• Symptoms
• Diagnosis
– Clinical
– Laboratory
• Transmission
– Environmental
– Person-to-person
• Treatment
– Curative
– Supportive

THE AGENTS

ANTHRAX

Anthrax | Description
Anthrax: An infection caused by the spore-forming
bacteria Bacillus anthracis. Also called “wool sorter’s
disease.”
Types
• Inhalational (rare)
– Acquired by inhaling anthrax spores. This is the form most likely
caused by a biological attack using aerosolized anthrax spores.
• Cutaneous (more common)
– Acquired when anthrax bacteria enter a break in the skin.
• Gastrointestinal (rare)
– Acquired by eating food contaminated with anthrax bacteria.

Inhalational Anthrax | As a Disease
Organism – Bacillus anthracis
Incubation Period – less than 1 week (range 1 to 60 days)
Symptoms -
• low-grade fever
• nonproductive cough
• malaise
• fatigue
• myalgias
• profound sweats
• chest discomfort

Later Symptoms
• 1–5 days after onset of initial symptoms .
• May be preceded by 1–3 days of improvement.
• Abrupt onset of high fever and severe respiratory
distress.
• Shock, death within 24–36 hours .

Diagnosis
• Specific chest X-Ray findings (Ex. widened mediastinum)
• Gram-positive bacilli in blood or cerebrospinal fluid.
• Aerobic blood culture growth of large, Gram-positive bacilli
provides preliminary identification of Bacillus species.
• Confirmation by polymerase chain reaction (PCR)
Treatment
• Antibiotics (doxycycline, ciprofloxacin)
• Survival chances decrease dramatically if not treated within
48 hours of exposure.

• Effectiveness
– In the 20th century, 18 cases of (natural exposure) anthrax in the US
had a case-fatality rate of 85%.
– In the 2001 anthrax attacks, where the victims received aggressive
supportive and antibiotic therapy, the case fatality rate was 45%.
– The 2001 anthrax attacks caused widespread panic and fear.
• Transmission
– No person-to-person transmission.
– Spores can survive for decades in the environment.
– Weaponized varieties remain suspended in air for substantial periods.
• Ease of Use
– Multiple distribution methods available.
Inhalational Anthrax | As a Bioweapon

• Accessibility
– Occurs naturally in the soil.
– Is a common disease in livestock in some parts of the world.
– The technology is available on the open market with few controls to
purchase.
• Prevention
– A vaccine is available, but not widely used outside the military.
– Detection methods include air-sampling machinery, and indirect
methods such as syndromic surveillance and other pattern-recognition
methods. These are only useful after an anthrax release has occurred.
Inhalational Anthrax | As a Bioweapon

Inhalational Anthrax | Public Health Actions
Detection
• Direct detection of agent
• Clinician reports to state health department.
• Syndromic detection of illness
• Laboratory confirmation
Isolation and quarantine
• Not useful for this illness (not person-to-person)
Prophylaxis
• Treatment more useful to those not yet exhibiting symptoms.
• Delays in treatment greatly increase mortality.
Decontamination
• People and clothing can be washed.
• Contaminated possessions may need to be incinerated.
• Environmental cleaning difficult and expensive.

Inhalational Anthrax | Historical Notes
• Used against Russian forces in Finland in 1916 by
Scandinavian freedom fighters (sponsored by Germany).
• First extensively developed as a bioweapon by Unit 731
(Japan) in Manchuria in the 1930’s. The USSR later captured
the labs used in this project, thus beginning that nation’s
bioweapon program.
• In 1942 the United Kingdom conducted anthrax bioweapon
trials on Gruinard Island in Scotland, making the isle
uninhabitable until it was decontaminated in 1990.
• Sverdlovsk, Russia – April 2nd 1969, weaponized anthrax
spores accidentally released in the city of Sverdlovsk. At least
94 people were infected, and at least 68 died.
• In 1990, Iraq deployed two 600 km range missiles loaded with
anthrax.

BOTULISM

Botulism | Description
Botulism – a disease caused by the toxin-producing bacteria
Clostridium botulinum.
Types
• Botulinum Intoxication occurs when a person ingests or
inhales a pre-formed toxin that leads to illness within a
few hours to days. This toxin is used in the production of
biological weapons.
• Infant botulism occurs in a small number of susceptible
infants each year who harbor C. botulinum in their
intestinal tract.
• Wound botulism occurs when wounds are infected with
C. botulinum that secretes the toxin.

Botulism | As a Disease
Organism – Clostridium botulinum
Incubation Period – 12 to 36 hours (range 6 hours to 10 days)
Symptoms –
• Double vision
• Blurred vision
• Drooping eyelids
• Slurred speech
• Dry mouth
• Muscle weakness (paralysis) moving down the body
• Paralysis of breathing muscles can lead to death

Botulism | As a Disease
Diagnosis
• Based on symptoms
– Although this disease resembles Guillain-Barré syndrome, stroke, and
myasthenia gravis.
• Neurologic tests
• Testing for botulinum toxin can be performed at some state
health departments and the CDC.
Treatment
• Supportive care (such as mechanical breathing assistance).
• Antitoxin is available from CDC (at no cost).
• Immune globulin for infant botulism is available from
California Department of Public Health ($45,300 per dose)

Effectiveness
• Botulinum toxin is the most poisonous substance known. A single gram of
crystalline toxin, evenly dispersed and inhaled, is sufficient to kill more
than 1 million people.
• Case fatality rate for untreated botulism (toxin) is 60%.
Transmission
• Not person-to-person.
• Must be ingested or inhaled.
Ease of Use
• Distribution accomplished through simple methods.
– Direct contamination of food or water.
– Spraying of aerosolized toxin.
Botulism | As a Bioweapon

Accessibility
• Bacterium occurs naturally in the soil.
• Production methods are relatively unsophisticated for contaminating food
and water sources. Aerosolization of the toxin is more difficult.
Prevention
• No vaccine available.
Botulism | As a Bioweapon

Botulism| Public Health Actions
Detection
• Clinician report to state health department.
• Syndromic detection of illness.
• Laboratory confirmation.
Prophylaxis
• Effectively none, although antitoxin might be used in some cases as
prophylaxis.
• No patient-contact prophylaxis necessary.
Decontamination
• Destruction of contaminated food.
• Standard healthcare sanitization of surfaces and durable equipment.
• Standard healthcare sanitization of bedding and clothing.

• Tested as a bioweapon by Unit 731 (Japan) in Manchuria in
the 1930’s. C. botulinum cultures were fed to prisoners.
• Aerosolized C. botulinum was dispersed on at least three
occasions in Japan by Aum Shinrikyō.
• Believing that Nazi Germany had developed weaponized
botulinum toxin, the US created 1 million doses of botulinum
toxoid vaccine to protect Allied soldiers participating in the
invasion of Normandy (June 6th 1944).
• By 1991, Iraq had produced 19,000 liters of botulinum toxin,
10,000 liters of which were in weapons. This is approximately
three times the amount necessary to kill the entire population
of the Earth.
Botulism | Historical Notes

PLAGUE

Plague | Description
A disease caused by the bacterium Yersinia pestis, which is carried by rodents
and their fleas.
• Bubonic plague occurs when an infected flea bites a person or when materials
contaminated with Y. pestis enter through a break in a person's skin. Patients
develop swollen, tender lymph glands (called buboes) and fever, headache,
chills, and weakness. Bubonic plague does not spread from person to person.
An epidemic in 14th century Europe is known as “the Black Death.”
• Pneumonic plague occurs when Y. pestis infects the lungs. This type of plague
can spread from person-to-person through the air. Pneumonic plague may also
occur if a person with bubonic or septicemic plague is untreated and the
bacteria spread to the lungs. This form of the illness will be the most likely
result of a biological attack involving Y. pestis.
• Septicemic plague occurs when plague bacteria multiply in the blood. It can be
a complication of pneumonic or bubonic plague or it can occur by itself.
Septicemic plague does not spread from person to person.

Pneumonic Plague| As a Disease
Organism – Yersinia pestis
Incubation Period – 1 to 6 days
Symptoms –
• fever
• weakness
• rapidly developing pneumonia with
– shortness of breath
– chest pain
– cough
– sometimes bloody or watery sputum
• Nausea, vomiting, and abdominal pain may also occur.
• Without early treatment, pneumonic plague usually leads to
respiratory failure, shock, and rapid death.

Pneumonic Plague| As a Disease
Diagnosis
• Lab testing of blood, sputum, or lymph node aspirate.
Treatment
– Single patient: streptomycin and gentamycin (intravenous).
– Mass casualty: doxycycline and ciprofloxacin.

Effectiveness
• The mortality rate for untreated pneumonic plague is almost 100%.
• Treatment started more than 24 hours after exposure has reduced
effectiveness.
Transmission
• Person-to-person (mainly respiratory secretions).
Ease of Use
• Aerosolized Y. pestis persists in the air for up to 1 hour after release.
• High lethality of the agent requires extreme care in handling.
Pneumonic Plague| As a Bioweapon

Accessibility
• Available commercially.
• Infects many types of rodents.
• Endemic in many areas of the world, including the Southwestern U.S.
(prairie dogs).
Prevention
• An approved vaccine exists, but is no longer commercially available.
Pneumonic Plague| As a Bioweapon

Pneumonic Plague | Public Health Actions
Detection
• Clinician report to state health department.
• Federally mandated isolation and quarantine disease.
• Can be as simple as wearing a proper mask.
• May require isolation in a hospital negative pressure room .
Prophylaxis
• Antibiotic treatment of close contacts.
Decontamination
• Y. pestis is susceptible to sunlight and drying.

• In ancient China and medieval Europe, infected carcasses
were used to contaminate enemy water supplies.
• Mongol invasion of Caffa - the bodies of plague victims were
launched by catapult into the city during the siege.
• Plague of Justinian – in the 6th and 7th centuries is the first
recorded plague outbreak. It is estimated that one half of
Europe's population died.
• Black Death – 1348 to 1350. This epidemic killed between 75
million to 100 million people.
• After World War II, both the US and USSR developed
techniques for weaponizing plague.
• In 1994, an outbreak of suspected pneumonic plague
occurred in India, resulting in 52 deaths and large internal
migrations.
Plague| Historical Notes

SMALLPOX

Smallpox | Description
A disease caused by the virus variola major. Smallpox as
a naturally occurring disease was eradicated in 1979.
Types
• Ordinary: the most frequent type, accounting for 90% or more
of cases.
• Modified: mild and occurring in previously vaccinated
persons.
• Flat: rare and very severe. Occurs more often in children.
Usually lethal.
• Hemorrhagic: rare and very severe. More common in
immuno-deficient individuals. Usually lethal.

Smallpox| As a Disease
Organism – variola major (a virus)
Incubation Period – 7 to 17 days (not contagious)
Symptoms – by phase.
• Prodrome: 2 to 4 days duration (possibly contagious)
– Fever (101 to 104 °F)
– malaise
– head and body aches
– sometimes vomiting
– During this phase, people are generally too sick to carry on daily
activities.

• Early rash: 4 days duration (most contagious phase)
– Small red spots develop on the tongue and in the mouth, which break
open and release the virus
– At this time, a rash appears on the body, concentrated on the arms
and legs, but spreading everywhere within 24 hours.
– By the third day, the spots become raised bumps.
– By the fourth day, the bumps fill with a thick, opaque fluid and often
have a depression in the center that looks like a bellybutton.
– Fever usually returns at this point and remains until the bumps scab
over.
• Pustular rash: 5 days duration (contagious)
– Bumps become pustules (sharply raised, round, and firm to the
touch).
– Pustule feels as though something like a small ball bearing is
embedded in it.

• Pustules and scabs: 5 days duration (contagious)
– The pustules begin to form a crust and then scab.
– By the end of the second week after the rash appears, most of the sores have
scabbed over.
• Resolving scabs: ~ 6 days duration (contagious)
– Scabs begin to fall off. The resulting marks on the skin will eventually become
pitted scars.
– Most scabs will have fallen off three weeks after the rash first appeared.
– The person is contagious until all of the scabs have fallen off.
• Scabs resolved (not contagious)

Diagnosis
• Clinical diagnosis: acute onset of fever >101°F (38.3°C) followed by a rash
characterized by firm, deep seated vesicles or pustules in the same stage
of development without other apparent cause.
• Laboratory confirmation: Polymerase chain reaction (PCR).
Treatment
• No proven treatment available, though antivirals may be useful in some
cases.
• Supportive care.
• Vaccination can reduce the severity of disease if given within 2 to 3 days of
exposure or decreases the symptoms if given within one week of
exposure.

Effectiveness
• In unvaccinated individuals, smallpox is fatal in 30% of cases.
• Causes severe illness (most patients are effectively incapacitated).
• Transmission rates are high – in past outbreaks, it is estimated that each
infected person infected 10 others.
Transmission
• Person-to-person transmission (mainly respiratory secretions).
• Large portions of the global population have no immunity.
Ease of Use
• Working with smallpox requires highly sophisticated equipment and
advanced knowledge.
Smallpox| As a Bioweapon

Accessibility
• Variola major is not naturally occurring. It was wiped out as a natural
disease in 1979 after a long-standing global vaccination campaign.
• Viral stocks are maintained by only (reportedly) two nations: the United
States and the Russian Federation.
Prevention
• A vaccine is available, but its use in the general public was discontinued in
1976.
• In response to concerns of bioterrorism in the US, a vaccination campaign
to immunize medical personnel and first responders was conducted in
2002 - 2003.
Smallpox| As a Bioweapon

Smallpox| Public Health Actions
Detection
• Severity of illness makes isolation at home impractical.
Prophylaxis
• Vaccination soon after exposure reduces severity of illness.
Decontamination

• In the 18th century, smallpox killed approximately 400,000
Europeans.
• In 1763, during the French and Indian War, a local trader (and
British sympathizer) gave a French-allied Native American
tribe (the Delawares) two blankets and a handkerchief from a
smallpox hospital.
• During World War II, extensive research on the weaponization
of smallpox was conducted by the United States, United
Kingdom, and Japan.
• In 1992, Soviet defector and Biopreparat scientist Ken Alibek
revealed that the USSR had stockpiled at least 20 tons of
weaponized smallpox, which may have been engineered to
reduce the effectiveness of the vaccine.
Smallpox| Historical Notes

TULAREMIA

Tularemia | Description
A disease caused by the bacterium Francisella tularensis. Also
known as “rabbit fever.”
– There are approximately 200 reported cases of tularemia in
the US each year.
– The bacterium is commonly found in rodents, rabbits, and
hares.
– Routes of infection include:
• Hunters being exposed while handling game carcasses.
• Being bitten by an infected tick, deerfly, or other insect.
• Consuming contaminated food and water.
• Inhaling the bacteria.

Tularemia| As a Disease
Organism – Francisella tularensis
Incubation Period – 3 to 5 days after exposure (range 1 to
14 days).
Symptoms
• Sudden fever
• Chills
• Headaches
• Diarrhea
• Muscle aches
• Joint pain
• Dry cough
• Progressive weakness
• Pneumonia with chest pain and bloody sputum

Tularemia| As a Disease
Diagnosis
• Symptoms are non-specific.
• Laboratory testing: F. tularensis can be identified in certain body fluids by
microscopy in properly equipped labs. Growth of the bacterium in culture
is considered a confirmed diagnosis.
Treatment
• Antibiotics
– Single patient: streptomycin and gentamycin (intravenous).
– Mass casualty: doxycycline and ciprofloxacin.

Effectiveness
• F. tularensis is one of the most infectious pathogenic bacteria known.
• Fewer than 50 organisms can cause disease. Compare to salmonella
species which require 103 to 106 organisms to cause disease.
Transmission
• Not person-to-person
• F. tularensis can survive in soil and water for several weeks.
Ease of Use
• Aerosolization of the bacteria would be the most likely scenario for use as
a bioweapon. This would require substantial technical expertise to
accomplish.
Tularemia| As a Bioweapon

Accessibility
• Naturally occurring in many species of wildlife.
• Technology to grow cultures of the bacteria relatively easy to obtain.
Prevention
• An approved vaccine was in use to protect laboratory workers, but was
discontinued.
Tularemia| As a Bioweapon

Tularemia| Public Health Actions
Detection
Prophylaxis
• Antibiotics useful in reducing risk of severe illness in exposed persons.
• No patient-contact prophylaxis necessary.
Decontamination

• Named after Tulare County in California.
• First isolated in 1912 in a US Public Health Service laboratory.
• Researched as a bioweapon by several countries as a more
desirable alternative to anthrax.
• In the US, development of F. tularensis as a bioweapon was
done at the Pine Bluff Arsenal in Arkansas.
• In September 2005, six air sampling devices around the Mall
in Washington DC detected F. tularensis. This occurred during
a well-attended anti-war rally on September 24th 2005.
100,000 to 300,000 people were present. No illnesses were
reported and it was declared a natural occurrence.
Tularemia| Historical Notes

VIRAL HEMORRHAGIC FEVER

Viral Hemorrhagic Fevers | Description
“Viral hemorrhagic fever“ (VHF) is used to describe a severe syndrome
affecting multiple organ systems that is caused by a variety of viruses.
• A common symptom of all types is hemorrhage (bleeding).
• Some of these diseases are found in rodents and can transmitted to
humans:
– by insects that have fed on infected rodents.
– through contact with the urine, feces, or saliva of infected animals.
– through contact with the body fluids of an infected person.
Viral families
• Arenaviruses (Laasa fever, Crimean-Congo Hemorrhagic Fever)
• Filoviruses (Hantavirus, Rift Valley Fever)
• Bunyaviruses (Ebola, Marburg)
• Flaviviruses (Omsk Hemorrhagic fever, tick-borne encephalitis)

Viral Hemorrhagic Fevers | Examples
• Laasa Fever
– Named after the town in Nigeria where it was first identified.
– 100,000 to 300,00 cases per year; 5000 deaths per year.
– In epidemics, case fatality can reach 50%.
• Hantavirus Pulmonary Syndrome
– First recognized in 1993 in the southwest US. In that outbreak, half of
the patients declined rapidly and died.
– Acquired by breathing air contaminated with the feces and urine of
infected mice.
• Ebola Hemorrhagic Fever
– First recognized in 1976; named after a river in the Democratic
Republic of Congo.
– The reservoir (host) animal for Ebola is unknown.

Viral Hemorrhagic Fevers | As a Disease
Organism – viruses in the families arenaviridae, filoviridae,
bunyaviridae, and flaviviridae.
Incubation Period – varies by organism, but usually one to
three weeks.
Symptoms – vary by disease.
• General
– fever, fatigue, dizziness, muscle aches, loss of strength, and
exhaustion.
• Severe cases
– Bleeding under the skin, in internal organs, or from body orifices
like the mouth, eyes, or ears.
– Shock, nervous system malfunction, coma, delirium, and
seizures.

Viral Hemorrhagic Fevers | As a Disease
Diagnosis
• Early stages of some fevers are non-specific (such as a rash or breathing
difficulty).
• The most severe forms of the illness are easily recognized, though
identification of the specific virus generally requires laboratory analysis.
Treatment
• For most diseases in this category, there is no specific treatment, other
than supportive care. In many cases, patients will require ventilator
support or other advanced forms of care.

Effectiveness
• Mortality varies by type, but most VHF agents cause severe illness and
some diseases are fatal without aggressive medical treatment.
Transmission
• Insect bites.
• Contact with infected animals.
• Contact with body fluids of infected people (person-to-person).
Ease of Use
• The highly lethal nature of these agents requires extreme caution when
handling.
• Distribution of the agent is relatively easy (low tech) for small scale
operations (which may be sufficient for causing panic and disruption).
Viral Hemorrhagic Fevers | As a Bioweapon

Accessibility
• Each disease agent is geographically limited, only occurring where the host
animals live. For some viruses (Ebola and Marburg) the host animals are
unknown.
• Laboratory stocks are tightly controlled in bio-safety level 4 containment
facilities.
Prevention
• With the exception of one disease (Argentine HF), no vaccine is available
for viral hemorrhagic fevers.
• For naturally occurring disease, the only prevention is avoidance of host
animals and insect vector control.
Viral Hemorrhagic Fevers | As a Bioweapon

Viral Hemorrhagic Fevers | Public Health Actions
Detection
• Because of the unusual presentation, this syndrome will be rapidly
identified.
• The only truly effective method of containment.
• Most cases will require hospitalization.
Prophylaxis
• None
Decontamination
• Standard healthcare sanitization of surfaces and durable equipment .
• Incineration of non-reusable equipment.

• Some researchers claim that the Black Death was actually a
VHF and not plague.
• No confirmed attempt to weaponize VHF-causing viruses is
known.
• Some former Soviet scientists have claimed that Biopreparat
attempted to engineer other bioweapons to include
characteristics of the Ebola virus.
Viral Hemorrhagic Fevers | Historical Notes

LEARNING MORE

Additional Information
• The Centers for Disease Control website has
extensive information on biological threat agents.
– General information
– Clinical guidance
– Emergency preparedness planning
– Links to many other sources of information
CDC Bioterrorism Preparedness
http://emergency.cdc.gov/bioterrorism

Other Resources
World Health Organization
http://www.who.int/en/
Responder Knowledge Base (FEMA)
http://www.rkb.gov
National Library of Medicine – PubMed
http://www.ncbi.nlm.nih.gov/pubmed/
Louisiana Office of Public Health
http://www.dhh.louisiana.gov/offices/?ID=79

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