preparing for and responding to bioterrorism: information for the public health workforce

Northwest Center for Public Health PracticeUniversity of Washington School of Public Health and Community Medicine

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Preparing for and Responding to Preparing for and Responding to Bioterrorism: Bioterrorism:

Information for the Public Health Information for the Public Health WorkforceWorkforce

UW Northwest Center for Public Health Practice

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Acknowledgements Acknowledgements Acknowledgements Acknowledgements

This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for thepurpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouragedto freely use all or portions of the material for its intended purpose.

The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide.

Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention

Judith YarrowDesign and Editing Health Policy and Analysis; University of WA

Washington State Department of Health

Jeff Duchin, MD Jane Koehler, DVM, MPHCommunicable Disease Control, Epidemiology and Immunization Section

Public Health - Seattle and King County

Ed Walker, MD; University of WADepartment of Psychiatry


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Consequence Management Consequence Management For Other Public Health StaffFor Other Public Health Staff

Module CModule C

Consequence Management Consequence Management For Other Public Health StaffFor Other Public Health Staff

Module CModule C


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Consequence ManagementConsequence ManagementLearning ObjectivesLearning Objectives


Describe the role of local public health in Describe the role of local public health in consequence management following a consequence management following a public health emergencypublic health emergency

Describe the roles of state and federal health Describe the roles of state and federal health agencies in consequence managementagencies in consequence management

Describe the role of local public health in Describe the role of local public health in consequence management following a consequence management following a public health emergencypublic health emergency

Describe the roles of state and federal health Describe the roles of state and federal health agencies in consequence managementagencies in consequence management


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Identify factors determining the need for Identify factors determining the need for isolation or quarantine and describe the isolation or quarantine and describe the potential adverse consequencespotential adverse consequences

Identify the potential psychological Identify the potential psychological responses, on individual and community responses, on individual and community levels, following a BT event, threat, or other levels, following a BT event, threat, or other public health emergencypublic health emergency

Identify factors determining the need for Identify factors determining the need for isolation or quarantine and describe the isolation or quarantine and describe the potential adverse consequencespotential adverse consequences

Identify the potential psychological Identify the potential psychological responses, on individual and community responses, on individual and community levels, following a BT event, threat, or other levels, following a BT event, threat, or other public health emergencypublic health emergency


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Consequence Management Consequence Management Legal Basis for Local EffortsLegal Basis for Local Efforts

Consequence Management Consequence Management Legal Basis for Local EffortsLegal Basis for Local Efforts

State police powers give states the authority State police powers give states the authority to prescribe within the limits of state and to prescribe within the limits of state and federal constitutions, reasonable laws federal constitutions, reasonable laws necessary to preserve the public order, necessary to preserve the public order, health, safety, welfare, and morals.health, safety, welfare, and morals.

RCW 70.05.070 gives the local health officer RCW 70.05.070 gives the local health officer power to “take such measures as he or she power to “take such measures as he or she deems necessary in order to promote the deems necessary in order to promote the public health.”public health.”

State police powers give states the authority State police powers give states the authority to prescribe within the limits of state and to prescribe within the limits of state and federal constitutions, reasonable laws federal constitutions, reasonable laws necessary to preserve the public order, necessary to preserve the public order, health, safety, welfare, and morals.health, safety, welfare, and morals.

RCW 70.05.070 gives the local health officer RCW 70.05.070 gives the local health officer power to “take such measures as he or she power to “take such measures as he or she deems necessary in order to promote the deems necessary in order to promote the public health.”public health.”


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Consequence Management Consequence Management Federal SupportFederal Support

Consequence Management Consequence Management Federal SupportFederal Support

Federal Response Plan, Emergency Support Federal Response Plan, Emergency Support Function #8Function #8 Provides “federal assistance to supplement Provides “federal assistance to supplement

state and local resources in response to state and local resources in response to public health and medical needs following a public health and medical needs following a major disaster or emergency, or during a major disaster or emergency, or during a developing potential medical situation”developing potential medical situation”

Directed by DHHS Directed by DHHS CDC lead for protecting health and safetyCDC lead for protecting health and safety

Federal Response Plan, Emergency Support Federal Response Plan, Emergency Support Function #8Function #8 Provides “federal assistance to supplement Provides “federal assistance to supplement

state and local resources in response to state and local resources in response to public health and medical needs following a public health and medical needs following a major disaster or emergency, or during a major disaster or emergency, or during a developing potential medical situation”developing potential medical situation”

Directed by DHHS Directed by DHHS CDC lead for protecting health and safetyCDC lead for protecting health and safety


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Consequence ManagementConsequence ManagementRole of Public HealthRole of Public Health


Education and information updatesEducation and information updates Between staff/agency divisionsBetween staff/agency divisions With other coordinating agencies With other coordinating agencies With the media and public With the media and public

Evaluation and referral of phone calls and Evaluation and referral of phone calls and requests for information or services requests for information or services

Follow-up of cases/victims and contactsFollow-up of cases/victims and contacts

Education and information updatesEducation and information updates Between staff/agency divisionsBetween staff/agency divisions With other coordinating agencies With other coordinating agencies With the media and public With the media and public

Evaluation and referral of phone calls and Evaluation and referral of phone calls and requests for information or services requests for information or services

Follow-up of cases/victims and contactsFollow-up of cases/victims and contacts


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In cooperation with other agencies: In cooperation with other agencies: Mass antibiotic prophylaxis and Mass antibiotic prophylaxis and

immunization immunization Quarantine and isolationQuarantine and isolation Closure of public places/institutions when Closure of public places/institutions when

indicatedindicated Evaluating and referring reports of Evaluating and referring reports of

suspicious packages or substancessuspicious packages or substances

In cooperation with other agencies: In cooperation with other agencies: Mass antibiotic prophylaxis and Mass antibiotic prophylaxis and

immunization immunization Quarantine and isolationQuarantine and isolation Closure of public places/institutions when Closure of public places/institutions when

indicatedindicated Evaluating and referring reports of Evaluating and referring reports of

suspicious packages or substancessuspicious packages or substances


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CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation

Isolation Isolation The separation of a person or group of The separation of a person or group of

persons from other people to prevent the persons from other people to prevent the spread of infection spread of infection

Quarantine Quarantine Restriction of activities or limitation of Restriction of activities or limitation of

freedom of movement of those freedom of movement of those presumed presumed exposedexposed to a communicable disease in to a communicable disease in such a manner as to prevent effective such a manner as to prevent effective contact with those not so exposedcontact with those not so exposed

Isolation Isolation The separation of a person or group of The separation of a person or group of

persons from other people to prevent the persons from other people to prevent the spread of infection spread of infection

Quarantine Quarantine Restriction of activities or limitation of Restriction of activities or limitation of

freedom of movement of those freedom of movement of those presumed presumed exposedexposed to a communicable disease in to a communicable disease in such a manner as to prevent effective such a manner as to prevent effective contact with those not so exposedcontact with those not so exposed


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CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation

Quarantine measures may include: Quarantine measures may include:

Suspension of public gatheringsSuspension of public gatherings

Closure of public placesClosure of public places

Restriction of travelRestriction of travel

Cordon sanitaireCordon sanitaire

Quarantine measures may include: Quarantine measures may include:

Suspension of public gatheringsSuspension of public gatherings

Closure of public placesClosure of public places

Restriction of travelRestriction of travel

Cordon sanitaireCordon sanitaire


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QuarantineQuarantineLegal authority – Local LevelLegal authority – Local Level

QuarantineQuarantineLegal authority – Local LevelLegal authority – Local Level

When confined to a specific locale When confined to a specific locale (community, state) – rests with local and/or (community, state) – rests with local and/or state health authorities (police power)state health authorities (police power)

Few states have specific policies/procedures Few states have specific policies/procedures for deciding whether quarantine is for deciding whether quarantine is warranted warranted in a specific situationin a specific situation

Be familiar with the laws pertaining to Be familiar with the laws pertaining to quarantine or that might be interpreted as quarantine or that might be interpreted as applying to quarantine existing in your stateapplying to quarantine existing in your state

When confined to a specific locale When confined to a specific locale (community, state) – rests with local and/or (community, state) – rests with local and/or state health authorities (police power)state health authorities (police power)

Few states have specific policies/procedures Few states have specific policies/procedures for deciding whether quarantine is for deciding whether quarantine is warranted warranted in a specific situationin a specific situation

Be familiar with the laws pertaining to Be familiar with the laws pertaining to quarantine or that might be interpreted as quarantine or that might be interpreted as applying to quarantine existing in your stateapplying to quarantine existing in your state


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Quarantine and Isolation Quarantine and Isolation Factors to ConsiderFactors to Consider

Quarantine and Isolation Quarantine and Isolation Factors to ConsiderFactors to Consider

Is there a scientific basis? Is there a scientific basis? Among “Category A” agents, only Among “Category A” agents, only

smallpox, pneumonic plague, and some smallpox, pneumonic plague, and some VHFs transmitted person-person VHFs transmitted person-person

Is it practical and feasible? Is it practical and feasible? Defined geographic area of riskDefined geographic area of risk Resources to enforce and maintain Resources to enforce and maintain Time period required Time period required

Do the potential benefits outweigh the risks?Do the potential benefits outweigh the risks?

Is there a scientific basis? Is there a scientific basis? Among “Category A” agents, only Among “Category A” agents, only

smallpox, pneumonic plague, and some smallpox, pneumonic plague, and some VHFs transmitted person-person VHFs transmitted person-person

Is it practical and feasible? Is it practical and feasible? Defined geographic area of riskDefined geographic area of risk Resources to enforce and maintain Resources to enforce and maintain Time period required Time period required

Do the potential benefits outweigh the risks?Do the potential benefits outweigh the risks?


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Quarantine Quarantine Potential Adverse ConsequencesPotential Adverse Consequences

Quarantine Quarantine Potential Adverse ConsequencesPotential Adverse Consequences

Increased risk of disease transmission in Increased risk of disease transmission in quarantined population quarantined population

Mistrust of governmentMistrust of government Civil disobedience Civil disobedience violence violence

Social stigmatization Social stigmatization Economic impacts Economic impacts

Businesses in quarantined area Businesses in quarantined area Businesses relying on goods and services Businesses relying on goods and services

from quarantined area from quarantined area

Increased risk of disease transmission in Increased risk of disease transmission in quarantined population quarantined population

Mistrust of governmentMistrust of government Civil disobedience Civil disobedience violence violence

Social stigmatization Social stigmatization Economic impacts Economic impacts

Businesses in quarantined area Businesses in quarantined area Businesses relying on goods and services Businesses relying on goods and services

from quarantined area from quarantined area

National Pharmaceutical StockpileNational Pharmaceutical StockpilePurposePurpose

National Pharmaceutical StockpileNational Pharmaceutical StockpilePurposePurpose

Provides resources to respond to both Provides resources to respond to both biologic and chemical attacksbiologic and chemical attacks

Requested by governorRequested by governor

Managed by Centers for Disease Control Managed by Centers for Disease Control and Preventionand Prevention

Provides resources to respond to both Provides resources to respond to both biologic and chemical attacksbiologic and chemical attacks

Requested by governorRequested by governor

Managed by Centers for Disease Control Managed by Centers for Disease Control and Preventionand Prevention

More on NPS... 15

http://www.cdc.gov/nceh/nps/synopses.htm


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Psychological Response toPsychological Response toA Public Health EmergencyA Public Health Emergency Psychological Response toPsychological Response toA Public Health EmergencyA Public Health Emergency

Reaction to the event itself Reaction to the event itself Anticipation of future events Anticipation of future events Reaction to public health measures taken to Reaction to public health measures taken to

manage/control disease and injury manage/control disease and injury Isolation and quarantine Isolation and quarantine Prophylactic measures Prophylactic measures Prioritization/rationing of resources Prioritization/rationing of resources

Reaction to misinformation (e.g., myths, Reaction to misinformation (e.g., myths, rumors)rumors)

Reaction to the event itself Reaction to the event itself Anticipation of future events Anticipation of future events Reaction to public health measures taken to Reaction to public health measures taken to

manage/control disease and injury manage/control disease and injury Isolation and quarantine Isolation and quarantine Prophylactic measures Prophylactic measures Prioritization/rationing of resources Prioritization/rationing of resources

Reaction to misinformation (e.g., myths, Reaction to misinformation (e.g., myths, rumors)rumors)


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Psychological Aftermath of Crisis: Psychological Aftermath of Crisis: Role of Public HealthRole of Public Health

Psychological Aftermath of Crisis: Psychological Aftermath of Crisis: Role of Public HealthRole of Public Health

Educating and informing clinicians and the Educating and informing clinicians and the public about current risks and protective public about current risks and protective measuresmeasures

Coordination of and referral to medical and Coordination of and referral to medical and social support resources social support resources

Ensuring the needs of populations at-risk for Ensuring the needs of populations at-risk for psychological sequelae are addressedpsychological sequelae are addressed

Educating and informing clinicians and the Educating and informing clinicians and the public about current risks and protective public about current risks and protective measuresmeasures

Coordination of and referral to medical and Coordination of and referral to medical and social support resources social support resources

Ensuring the needs of populations at-risk for Ensuring the needs of populations at-risk for psychological sequelae are addressedpsychological sequelae are addressed


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Key Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental Health

Two types of disaster trauma Two types of disaster trauma IndividualIndividual CommunityCommunity

Most people pull together and function during Most people pull together and function during and after a disaster, but their effectiveness is and after a disaster, but their effectiveness is diminisheddiminished

Social support systems are crucial to recoverySocial support systems are crucial to recovery

Two types of disaster trauma Two types of disaster trauma IndividualIndividual CommunityCommunity

Most people pull together and function during Most people pull together and function during and after a disaster, but their effectiveness is and after a disaster, but their effectiveness is diminisheddiminished

Social support systems are crucial to recoverySocial support systems are crucial to recovery

Source: US DHHS. Key Concepts Of Disaster Mental Health


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Key Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental Health

Disaster stress and grief reactions are normal Disaster stress and grief reactions are normal responses to an abnormal situation.responses to an abnormal situation.

Many emotional reactions of disaster survivors Many emotional reactions of disaster survivors stem from living problems brought about by the stem from living problems brought about by the disaster.disaster.

Most people do not see themselves as needing Most people do not see themselves as needing mental health services following disaster and mental health services following disaster and will not seek such services.will not seek such services.

Disaster stress and grief reactions are normal Disaster stress and grief reactions are normal responses to an abnormal situation.responses to an abnormal situation.


Most people do not see themselves as needing Most people do not see themselves as needing mental health services following disaster and mental health services following disaster and will not seek such services.will not seek such services.

Source: US DHHS. Key Concepts Of Disaster Mental Health


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Psychological and Behavioral Responses to Psychological and Behavioral Responses to Trauma and DisasterTrauma and Disaster


DepressionDepression Sadness Sadness DemoralizationDemoralization Isolation/withdrawalIsolation/withdrawal Difficulty Difficulty

concentratingconcentrating Sleep and appetite Sleep and appetite

disturbancesdisturbances

DepressionDepression Sadness Sadness DemoralizationDemoralization Isolation/withdrawalIsolation/withdrawal Difficulty Difficulty

concentratingconcentrating Sleep and appetite Sleep and appetite

disturbancesdisturbances

Physical ComplaintsPhysical Complaints FatigueFatigue Aches and painsAches and pains Stomach and Stomach and

intestinal complaintsintestinal complaints HeadacheHeadache Skin rashesSkin rashes

Physical ComplaintsPhysical Complaints FatigueFatigue Aches and painsAches and pains Stomach and Stomach and

intestinal complaintsintestinal complaints HeadacheHeadache Skin rashesSkin rashes


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AnxietyAnxiety Re-experiencingRe-experiencing NumbingNumbing Hyperarousal Hyperarousal

Shock and disbeliefShock and disbelief FearFear PanicPanic AngerAnger IrritabilityIrritability

AnxietyAnxiety Re-experiencingRe-experiencing NumbingNumbing Hyperarousal Hyperarousal

Shock and disbeliefShock and disbelief FearFear PanicPanic AngerAnger IrritabilityIrritability

Behavioral Behavioral ↑↑ substance use substance use

alcohol, caffeine, alcohol, caffeine, tobacco tobacco

Interpersonal Interpersonal conflictconflict

Impaired Impaired work/school work/school performanceperformance

Behavioral Behavioral ↑↑ substance use substance use

alcohol, caffeine, alcohol, caffeine, tobacco tobacco

Interpersonal Interpersonal conflictconflict

Impaired Impaired work/school work/school performanceperformance


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Responses to Trauma - ChildrenResponses to Trauma - ChildrenResponses to Trauma - ChildrenResponses to Trauma - Children

After any disaster, After any disaster, children are most afraid children are most afraid that: that: The event will happen The event will happen

againagain Someone will be injured Someone will be injured

or killedor killed They will be separated They will be separated

from the familyfrom the family They will be left aloneThey will be left alone

After any disaster, After any disaster, children are most afraid children are most afraid that: that: The event will happen The event will happen

againagain Someone will be injured Someone will be injured

or killedor killed They will be separated They will be separated

from the familyfrom the family They will be left aloneThey will be left alone


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Helping Children Cope After TraumaHelping Children Cope After TraumaHelping Children Cope After TraumaHelping Children Cope After Trauma

Assume they know a disaster has occurredAssume they know a disaster has occurred Talk with them calmly and openly at their levelTalk with them calmly and openly at their level Ask what they think has happened, and about Ask what they think has happened, and about

their fearstheir fears Share your own fears and reassureShare your own fears and reassure Emphasize the normal routineEmphasize the normal routine Limit media re-exposureLimit media re-exposure Allow expression in private ways (i.e., drawing)Allow expression in private ways (i.e., drawing)

Assume they know a disaster has occurredAssume they know a disaster has occurred Talk with them calmly and openly at their levelTalk with them calmly and openly at their level Ask what they think has happened, and about Ask what they think has happened, and about

their fearstheir fears Share your own fears and reassureShare your own fears and reassure Emphasize the normal routineEmphasize the normal routine Limit media re-exposureLimit media re-exposure Allow expression in private ways (i.e., drawing)Allow expression in private ways (i.e., drawing)


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Psychological Responses Following a Psychological Responses Following a Biological Terrorist AttackBiological Terrorist Attack

Psychological Responses Following a Psychological Responses Following a Biological Terrorist AttackBiological Terrorist Attack

Magical thinking Magical thinking about microbes and about microbes and virusesviruses

Fear of invisible Fear of invisible agentsagents

Fear of contagionFear of contagion

Magical thinking Magical thinking about microbes and about microbes and virusesviruses

Fear of invisible Fear of invisible agentsagents

Fear of contagionFear of contagion

Attribution of arousal Attribution of arousal symptoms to symptoms to infectioninfection

ScapegoatingScapegoating Panic and paranoiaPanic and paranoia Loss of faith in Loss of faith in

social institutionssocial institutions

Attribution of arousal Attribution of arousal symptoms to symptoms to infectioninfection

ScapegoatingScapegoating Panic and paranoiaPanic and paranoia Loss of faith in Loss of faith in

social institutionssocial institutions

Source: Holloway et al. JAMA 1997;278(5):425-7


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Stress Management for Stress Management for Public Health WorkersPublic Health Workers

Stress Management for Stress Management for Public Health WorkersPublic Health Workers

Take care of yourself: Take care of yourself: Get sufficient sleep Get sufficient sleep Eat regular mealsEat regular meals Keep caffeine and alcohol consumption Keep caffeine and alcohol consumption

moderatemoderate Talk through your feelings with a safe Talk through your feelings with a safe

confident confident Family memberFamily member Mental health or other health care provider Mental health or other health care provider

Seek help when feelings overwhelm or Seek help when feelings overwhelm or interfere with your ability to function interfere with your ability to function

Take care of yourself: Take care of yourself: Get sufficient sleep Get sufficient sleep Eat regular mealsEat regular meals Keep caffeine and alcohol consumption Keep caffeine and alcohol consumption

moderatemoderate Talk through your feelings with a safe Talk through your feelings with a safe

confident confident Family memberFamily member Mental health or other health care provider Mental health or other health care provider

Seek help when feelings overwhelm or Seek help when feelings overwhelm or interfere with your ability to function interfere with your ability to function


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Summary of Key Points Summary of Key Points Summary of Key Points Summary of Key Points

The initial and primary response to the The initial and primary response to the consequences of a terrorist event occurs at the consequences of a terrorist event occurs at the local level. local level.

ESF 8 provides for federal assistance to ESF 8 provides for federal assistance to supplement state and local efforts in response supplement state and local efforts in response to a public health emergency.to a public health emergency.

Medical, practical, and feasibility considerations Medical, practical, and feasibility considerations are important in the decision to implement are important in the decision to implement quarantine.quarantine.

The initial and primary response to the The initial and primary response to the consequences of a terrorist event occurs at the consequences of a terrorist event occurs at the local level. local level.

ESF 8 provides for federal assistance to ESF 8 provides for federal assistance to supplement state and local efforts in response supplement state and local efforts in response to a public health emergency.to a public health emergency.

Medical, practical, and feasibility considerations Medical, practical, and feasibility considerations are important in the decision to implement are important in the decision to implement quarantine.quarantine.


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Summary of Key PointsSummary of Key PointsSummary of Key PointsSummary of Key Points

Individual, community, and event-specific Individual, community, and event-specific factors influence the psychological response to factors influence the psychological response to a public health emergency.a public health emergency.

Most individuals will function adequately Most individuals will function adequately following a traumatic event, but a few will need following a traumatic event, but a few will need psychological and/or medical intervention. psychological and/or medical intervention.


Individual, community, and event-specific Individual, community, and event-specific factors influence the psychological response to factors influence the psychological response to a public health emergency.a public health emergency.

Most individuals will function adequately Most individuals will function adequately following a traumatic event, but a few will need following a traumatic event, but a few will need psychological and/or medical intervention. psychological and/or medical intervention.



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Summary of Key PointsSummary of Key PointsSummary of Key PointsSummary of Key Points

Anxiety responses are most likely following a Anxiety responses are most likely following a biological attack, but depression, physical biological attack, but depression, physical symptoms, and substance use may also occur.symptoms, and substance use may also occur.

Anxiety responses are most likely following a Anxiety responses are most likely following a biological attack, but depression, physical biological attack, but depression, physical symptoms, and substance use may also occur.symptoms, and substance use may also occur.


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Resources Resources Resources Resources

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Barbera J, et al. Large-scale quarantine Barbera J, et al. Large-scale quarantine following biological terrorism in the United following biological terrorism in the United States. States.

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Barbera J, et al. Large-scale quarantine Barbera J, et al. Large-scale quarantine following biological terrorism in the United following biological terrorism in the United States. States.

http://www.bt.cdc.gov

JAMA. 2001;286:2711-2717


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ResourcesResourcesResourcesResources

American Psychiatric Association American Psychiatric Association

info on disaster psychiatryinfo on disaster psychiatry Federal Emergency Management Agency Federal Emergency Management Agency

DHHS/SAMHSA - disaster mental health info, and links to publications

American Psychiatric Association American Psychiatric Association

info on disaster psychiatryinfo on disaster psychiatry Federal Emergency Management Agency Federal Emergency Management Agency

DHHS/SAMHSA - disaster mental health info, and links to publications

http://www.psych.org

http://www.mentalhealth.org/cmhs/EmergencyServices/

http://www.fema.gov

preparing for and responding to bioterrorism: information for the public health workforce

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