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Response to Bioterrorism Incidents

By Drew Fried, EMT-B

In October 2001, as we recovered from the events of 9/11, a new emergency began to take shape. The biological agent anthrax surfaced in the state of Florida. It soon spread to New Jersey, Washington D.C., and New York City. Since this was a new type of emergency, the response in most cases was uncoordinated for those involved. Information on anthrax was incomplete, and most fire or EMS agencies were not prepared. Responses have been changed or updated. Most EMS agencies have developed procedures that not only cover anthrax and other biological emergencies but also include chemical and radiological emergencies.

Initial Assessment
Initial assessment does not begin with the first-arriving units. Sometimes it begins by interviewing the caller. The caller might be Joe Citizen, a worker in the office building where the incident is taking place, or security. We must educate the public and companies within our service areas to ensure a coordinated response. It is best to treat this not only as a crime scene but also as a haz-mat incident. The dispatchers should be trained to give instructions to the caller, as they might with other emergencies.

A call is received from security of a large company stating that an employee has opened an envelope and found white powder inside. he employee panicked and threw the envelope in the garbage. An employee in the next cubicle called security to report the incident.

Two years ago, this was not a common type of incident, so there were no policies or procedures in place. On October 18, 2003, the New York State Bureau of Emergency Medical Services issued policy statement 01-08, "Advisory for Response to Patients Exposed to Unknown Substances." This advisory was issued to give New York State EMS agencies a policy to guide them in cases where dry unknown substances are indicated.

New York State Department of Health
Bureau of Emergency Medical Services
Supercedes/Updates: New
No. 01-08
Date: 10/18/01
Re: Unknown Dry Substance/Suspected Anthrax Response Advisory


This advisory is being sent to you to assist when responding to an emergency call involving a package, envelope or substance suspected of being Anthrax. Also attached are Anthrax advisories/protocols developed by the Department of Health to assist you in understanding what Anthrax is, mail handling protocols, recommended patient/equipment, decontamination guidelines, specimen handling and criteria for lab testing.

There are some primary things to understand about responding to an emergency medical response, which involves a call site alleged to contain Anthrax or involving an unknown powder/substance:

  1. Confirm scene safety and type of incident. Responding EMS agencies are NOT advised to enter an affected area until a competent authority has determined the scene to be safe.
  2. If you arrive on the scene first, notify the competent authority.
  3. If an unknown substance has been found in the air handling system, evacuate the premises immediately and notify the competent authority.
  4. Anthrax is NOT contagious. Person to person transmission has never been reported.
  5. There will be little or no need for prehospital medical care. Do not transport the individual to a hospital, unless other medical conditions need to be addressed (i.e., chest pain, severe anxiety). Patients should not be transported to a hospital.
  6. If patient insists on being transported to the hospital, contact medical control for physician consultation.
  7. If you transport to the hospital, notify the receiving hospital that you are bringing a patient who has been exposed to a powder/unknown substance and request the hospital to have staff meet you outside of the Emergency Department.
  8. Create a list of individuals who were in area of exposure to be given to the incident commander or local police and shared with local public health officials. All, or most, individuals should be released home with the self-monitoring instructions attached.
  9. The need for testing of the substance will be determined by appropriate authorities following risk assessment.
  10. Unless a lab test confirms the nature of the powder substance, there is no need to immediately initiate prehospital medical treatment. These lab tests take at least 24 hours to complete. There is no harm to an individual waiting for lab results before beginning appropriate medical treatment.
  11. The Centers for Disease Control (CDC) has advised that no treatment is necessary for Anthrax in an otherwise healthy person exposed to an unknown powder/substance.
  12. If you arrive at the scene and patient(s) have been decontaminated; you should follow the above guidelines, but assist in addressing individual concerns about infection and treatment.
  13. If you enter a scene and the patient has not been decontaminated and there is an observable substance, contact a competent authority and perform the following:
    • If the patient has a powder or other substance on their skin or clothing, ask the patient to remove their outer clothing. If the patient is not able to undress themselves, put on PPE1 and remove the patient's outer or exposed clothing.
    • Provide the patient with a disposable garment or a sheet.
    • The patient's clothing should be secured by the patient (if possible) in a clear plastic bag and left with the competent authorities on the scene.
    • See attached Decontamination Advisory. This should be followed by the appropriate local agency responsible for decontamination. EMS is not generally responsible for decontamination.
  14. Remember you are considered health care providers who the public expects will be knowledgeable about Anthrax. Often, you will be the highest medical authority at the scene. Please review the attached materials and be prepared to work with local or state public health officials in calming public fears regarding these incidents.

NOTE: This guideline is being provided to your local REMAC
for incorporation into local protocol.

1 Personal Protective Equipment (PPE) - Gloves, mask and eye protection. These may not be necessary on every call. Use the appropriate PPE based on the patient assessment and the presence of blood or body fluids and pertinent past medical history.

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