21st Century U.S. Military Manuals: Treatment of Biological Warfare Agent Casualties Field Manual - FM 8-284 (Value-Added Professional Format Series)
U.S. Army, U.S. Military, Department of Defense
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TREATMENT OF BIOLOGICAL WARFARE AGENT CASUALTIES FIELD MANUAL
ARMY FM 8-284 * NAVY NAVMED P-5042 * AIR FORCE AFMAN (I) 44-156 * MARINE CORPS MCRP 4-11.1C
HEADQUARTERS, DEPARTMENTS OF THE ARMY, THE NAVY, AND THE AIR FORCE, AND COMMANDANT, MARINE CORPS
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PREFACE
Purpose
This publication serves as a guide and a reference for trained members of the Armed Forces Medical Services and other medically qualified personnel on the recognition and treatment of biological warfare (BW) agent casualties. Information contained in this publication may also be relevant for the diagnosis and treatment of patients with naturally acquired diseases or illnesses due to pathogens with BW potential.
Scope
a. This publication—
(1) Classifies and describes potential BW agents.
(2) Provides procedures for collecting, handling and labeling, shipping, and identifying potential BW agents.
(3) Describes procedures for medical diagnosing, treating, and management of BW casualties.
(4) Describes medical management and treatment in BW operations.
b. The material in this publication is applicable to both the conventional battlefield and the integrated environment of the battlefield. (For the purpose of this publication, the "integrated environment" is intended to mean warfare and/or contingency operations where nuclear, biological, and chemical [NBC] weapons/agents are being employed or have a high probability of being employed in addition to conventional weapons.)
c. The treatment modalities contained in this manual differ from standard textbooks in that they apply to BW agent exposures. The method of exposure for most BW agents is by inhalation; whereas, the endemic disease exposure (if applicable) is by other means. Some are by ingestion, some by arthropod bites, and others by dermal contact with the agent. This does not preclude service members becoming BW casualties by these means.
d. The use of the term "level of care" in this publication is synonymous with "echelon of care" and "role of care." The term "echelon of care" is the old North Atlantic Treaty Organization (NATO) term. The term "role of care" is the new NATO and American, British, Canadian, and Australian (ABCA) term.
Standardization Agreements
This manual is in consonance with the following NATO Standardization Agreements (STANAGs) and ABCA Quadripartite Standardization Agreements (QSTAGs):
TITLE / NATO STANAG / QSTAG
Warning Signs for the Marking of Contaminated or Dangerous Land Areas, Complete Equipments Supplied and Stores / 2002 / -
Reporting Nuclear Detonations, Biological and Chemical Attacks, and Predicting and Warning of Associated Hazards and Hazard Areas / 2103 / 187
First Aid and Hygiene Training in NBC Operations / 2358 / -
User Comments
Users of this publication are encouraged to submit recommendations to improve the publication. Comments should be keyed to the page, paragraph, and line(s) of the text where the change is recommended. The proponent for this publication is the United States (US) Army Medical Department Center and School (AMEDDC8S). Comments should be forwarded to: Commander, AMEDDC&S, ATTN: MCCS-FCD, 1400 East Grayson Street, Fort Sam Houston, Texas 78234-6175.
Gender Statement
Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to men.
Use of Trade Names/Trademarks
Use of trade names/trademarks in this publication is for illustrative purposes only. Their use does not constitute endorsement by the Department of Defense (DOD).
References
References listed should be consulted for details beyond the scope of this publication.
1-1. The Threat of Biological Warfare Agents Against United States Forces and Civilian Populations
a. Biological warfare is the intentional use of viruses, bacteria, other microorganisms, or toxins derived from living organisms to cause death or disease in humans, animals, or plants.
b. In 1943, the US began research in and experimentation with several human and plant pathogens for use as BW weapons. In 1969, the US adopted a policy to cease offensive BW research and never again to produce, stockpile, weaponize, or use biological agents. By 1970 all offensive BW research was terminated. The Us biological arsenal was destroyed by the end of 1972. In addition, the US is a party of the 1972 Biological Weapons Convention (BWC), which prohibits offensive BW agent research, stockpiling, weaponization, and use. However, several foreign governments and terrorist organizations have continued to develop offensive BW programs. The US conducts research to develop vaccines, chemoprophylaxes, diagnostic tests, and therapies to minimize the potential impact of a BW attack.
c. Biological warfare has interested several foreign governments and terrorist organizations for a number of reasons—
• Biological warfare agents are relatively easy to obtain. Naturally occurring viruses and bacteria which cause disease are obtainable from soil, water, animal reservoirs, clinical specimens, and clinical and research laboratories. Also, the development of recombinant genetic engineering has introduced the potential to genetically modify viruses and bacteria to enhance their ability to cause disease. Such modifications may include antibiotic resistance, enhanced invasiveness or toxin production, or enhanced ability to evade host immune defenses.
• Biological warfare agents are relatively easy and inexpensive to produce. The technology used to produce antibiotics, vaccines, and other industrial and food products can easily be converted to BW agent production. Such technology is readily available and is commonly used by industry; therefore, production of BW agents may be easily concealed.
1-2. Modes of Delivery
a. Biological warfare agents are unconventional weapons and can be delivered by unconventional means. Conventional explosive munitions are inefficient delivery systems for BW; the heat generated by the explosion will inactivate most of the BW agent. In addition, an explosion will generate a wide range of particle sizes with only a fraction of the weaponized BW agent being aerosolized in particles of a size suitable for deposition in the lower respiratory tract. The efficiency of explosive munitions delivering a viable BW agent is in the range of 1 to 2 percent.
b. Biological warfare agents are most effectively delivered as an aerosol. Aerosolized particles 1 to 5 microns in diameter are most efficiently delivered to their target (the air sacs of the lung). Larger particles either settle onto environmental surfaces, or are deposited in the upper respiratory tract and eliminated by mucociliary clearance. Due to the aerodynamics of particle flow through the respiratory tract, most particles smaller than 1 micron in diameter are exhaled and result in inefficient delivery to the lung.
c. Aerosol generators capable of generating particles of optimal size are easily constructed by adapting available agricultural and industrial sprayers. Aerosols may be delivered via point source (stationary release point, bomblets, or other devices equipped with sprayers) or from a line source (such as a moving vehicle or cruise missile releasing agent).
d. Biological warfare agents may be used to contaminate food or water systems/supplies. Heat destroys most pathogens and toxins; thus, to be effective most agents would have to be used on food that will be served raw or added after the food is prepared and presented for serving. Dilution can reduce the concentration of pathogens and toxins below an effective level. Standard water purification methods (chlorination and filtration) inactivate most pathogens and toxins. Therefore, a successful BW attack on a water system would have to occur after treatment.
e. Biological warfare agents have been delivered by covert injection.
1-3. Employment of Biological Warfare Agents
a. Nuclear, biological, and chemical weapons/agents, and radiological dispersal devices are classified as weapons of mass destruction (WMD). Aerosols of BW agents may deliver incapacitating or lethal inocula over large geographic areas and produce mass casualties. The epidemic produced by the BW agent can quickly overwhelm the supporting military health service support (HSS) system or public health capabilities; thus reducing the ability of emergency response teams and emergency medical providers to respond. Limited medical resources (such as intensive care units) can quickly become overloaded with special medications being quickly exhausted early in a BW incident.
b. The BW agents may be plant pathogens used to destroy crops, devastate the food chain, and cause famine. Livestock and other animals of economic importance may be targeted. Contamination of water systems/supplies and the food chain with potential human pathogens is another mode of delivery to a targeted population.
c. The threatened use of BW agents can result in fear and panic in a population (whether under attack or being threatened to gain political advantage in political activities). The potential psychological impact of BW agents adds to an adversary's strategic threat.
d. Most BW agents are probably poor tactical weapons on a modern battlefield. Given that most BW agents have incubation times of several days to weeks duration, the outcome of a rapidly developing battle will be determined before the effects of a BW attack are realized. However, rapid-acting toxins (such as saxitoxin) may have tactical utility. Potential targets for delayed-onset BW agents may include areas with relatively fixed positions (logistics support facilities, aerial ports of debarkation, and seaports of debarkation).
e. Biological warfare agents are adaptable for terrorist operations. A BW agent with its delivery system can be easily concealed and transported. Given the difficulties in identifying a BW agent attack and the incubation periods for most BW agents, the perpetrators can escape before the BW release is apparent. The employment of BW agents is not limited to war; the potential for BW agent use exists and can occur at anytime, anyplace, and by anyone with an intent to cause injury, disturbance, or create political discord. The employment of BW agents during political events (especially during multinational events) is a major threat.
1-4. Classification of Biological Warfare Agents
Biological warfare agents may be classified according to—
• Their effects.
• Lethal agents produce death in all or most victims.
• Incapacitating agents produce severe disease, but not death. The potential adverse effects of an incapacitating agent on a military unit's ability to perform its mission equals or surpasses those of a lethal agent; casualties are unable to perform their mission and place high demands on available HSS assets.
• Their taxonomy. However, such a classification system is probably of limited value in a battlefield situation.
• Their mode of delivery (aerosol, food- or waterborne, vectorborne, or injection.)
• The clinical syndrome they produce (such as pneumonia agents and systemic disease agents). However, this classification system is of questionable value since many BW agents are delivered via aerosol, resulting in both pneumonic and systemic disease. The clinical syndromes of many BW agents are similar during the early stages of disease development; classic disease-specific syndromes may not present until later in the clinical course.
1-5. Portals of Entry
a. Biological warfare agents enter the body via the "portals of entry" of naturally occurring infectious diseases. These include the respiratory tract following inhalation of an aerosolized BW agent; the exposed mucosal surfaces (the moist surfaces of the nose, mouth, and eyes); the digestive tract following ingestion of contaminated food or water; or the inadvertent swallowing of an agent delivered as an aerosol. Intact skin provides an effective barrier against most BW agents, except mycotoxins. However, traumatic wounds, superficial abrasions, and cuts can provide portals of entry. The protective barrier of the skin can also be bypassed by injection (a technique which has been used in covert assassination).
b. In most instances, the disease produced by a BW attack mimics the naturally occurring infectious disease caused by the same pathogen. The delivery of a toxin to a portal of entry different from the natural portal of entry can result in a different clinical presentation. For example, staphylococcal enterotoxin B when ingested in food causes acute gastrointestinal (GI) illness; however, when delivered via aerosol to the respiratory tract, it produces respiratory disease.
1-6. Environmental Detection
a. Adequate and accurate intelligence is required in order to develop effective defenses against BW. Following the release of a BW agent aerosol, detection of the aerosol prior to its arrival over the target will enable commanders to instruct personnel to take defensive protection measures.
b. Aerosols of BW agents or contamination of food or water supplies are not detectable by human senses. Systems for the rapid detection and presumptive identification of several BW agent aerosols are fairly new and to date have limited fielding. Several point and standoff detection devices are planned, under development, or are being field-tested.
(1) Biological Integrated Detection System (BIDS) is a multi-component system that provides monitoring, sampling, detection, and presumptive identification. The BIDS is vehicle-based and must be located in the BW aerosol cloud to detect the agent. These technologies use components that automatically count and size particles, determine if the particles are living organisms, classify some basic cell characteristics, and use antigen-antibody analysis for presumptive identification. Improvements to this system are ongoing to increase BW agent detection and identification through the pre-planned product improvement program. See Field Manual (FM) 3-101-4 for detailed information.
(2) A Short-Range Biological Standoff Detection System (SRBSDS) is in development. This unit will employ ultraviolet and laser-induced fluorescence to detect aerosol clouds of possible BW origin at distances up to 5 kilometers (km).
(3) A Long-Range Biological Standoff Detection System (LRBSDS) employs a laser system mounted in a helicopter to scan a designated area of interest and find large, man-made aerosols suspected of containing BW agents. It enhances situational awareness and allows for early force protection. These systems are available for fixed site application or for transport platforms including fixed wing aircraft. These units will be used to provide early warning, enhance decontamination efforts, and cue other detection efforts. See FM 3-101-6 for additional information on the technical aspects of environmental detection.