In this presentation, we'll talk about commercial driver's license exams, drug testing, including the role of the medical review officer, emergency preparedness, and weapons of mass destruction with a focus on the CDC's classified Class A agents. Our objectives for this section of the course include reviewing the key elements of the commercial driver medical exam, recognizing that this is a brief overview and is certainly not representative of the knowledge base for someone who would be certifying as a commercial driver medical examiner. We will also review the duties and scope of practice of a medical review officer, again recognizing that there is a certification pathway for those who wish to become certified medical review officers. We will also identify resources for emergency management systems and review the CDC classified Class A bioterrorism agents. So we'll begin this part of our discussion with a case. You have a 45-year-old driver presenting for his CDL exam who reports a history of insulin-dependent diabetes with a recent hemoglobin A1C of 6.5. Is his history in exam or otherwise normal? As a CDL examiner, what may you tell the driver? May you tell him he must surrender his license? He must switch to an oral hypoglycemic medication? Is he qualified if he obtains a waiver or exemption for his insulin-dependent diabetes? Or is he qualified with a medical card you issue? For those of you who have been commercial driver medical examiners or have been following recent changes, we'll recognize that there is a waiver or currently called exemption for insulin-dependent or insulin-treated diabetes, and we'll talk about that as we go through this presentation. The correct answer at the present time is answer C. The driver is qualified if he obtains a waiver or exemption, and at the present time, that waiver or exemption is issued by the examiner and is no longer issued by the Federal Motor Carrier Safety Administration or the FMCSA. This slide illustrates the legal requirements as of May 2014 of the National Registry of Certified Medical Examiners or NRCME. It's important to note that although the original law included a requirement for periodic training and testing, the process through which examiners would go about obtaining this training and taking recertification tests has yet to be published, and so we are still waiting for this guidance from the agency. It's essential that examiners understand that it is not only operating or driving the commercial vehicle that is an essential job function for commercial drivers. In addition to the capacity to operate the vehicle safely, the driver must be able to perform a safety check of the vehicle, which includes examining the lift gate, ensuring that the cargo is in place, checking the wheelbases, tires, and attachment of the trailer, and this requires the physical ability to maneuver oneself about those areas of the vehicle. Essential job functions also may include loading and unloading of cargo and covering the cargo appropriately with a tarp, and certainly maintaining alertness for long periods, tolerance of irregular work, and irregular meal schedules. Examiners must realize that although a particular driver at the time of the exam may be operating only during daytime, only in a local area, and may have a position where he or she does not have to load or unload cargo, he or she must be able to perform all of these essential job functions. The medical certificate issued by the examiner is not specific to one place of employment nor to a specific set of job duties, and examiners cannot specify restrictions for a commercial driver other than those that are included on the medical card, which would include use of corrective lenses and that the certificate must be accompanied by a skills performance evaluation certificate. The required components of the commercial driver medical exam are listed on the exam form and include a self-reported history of medical conditions and all medications taken including non-prescription medications by the driver, as well as a review of this information with documentation by the examiner. Vision including visual acuity, visual fields, and color vision to view the traffic light signal colors is also required. A driver's hearing may be assessed via a whisper test or an audiogram, and a driver may wear hearing aids for this part of the assessment. If your clinic does not have the capacity to perform an audiogram on a driver wearing hearing aids, then this assessment may be performed elsewhere and provided to the examiner for review. Vital signs including blood pressure, pulse, and the driver's height and weight are recorded. The examiner is not required to calculate a BMI, however, some guidelines do recommend calculation of BMI. A urinalysis is not required, but a urine dip test for specific gravity, protein, sugar, and the presence of blood is required. A physical exam to the scope of that printed on the form is required, and any additional testing or records determined necessary by the examiner may be required for the examiner's review. Specific medical requirements for commercial drivers as per FMCSA regulations include best corrected distant vision of at least 20, 40, or better in each eye with a field of vision of at least 70 degrees in each eye and the ability to recognize red, green, and amber, the colors of traffic lights. Regarding hearing, drivers must be able to demonstrate that they can perceive a forced whisper at 5 feet or have their hearing assessed via an audiogram with average hearing loss in the better ear no greater than 40 decibels at 500, 1,000, and 2,000 hertz. And again, as mentioned before, hearing may be assessed using a hearing aid. The information on this slide is slightly outdated as the new medical exam form no longer includes guidance regarding hypertension. However, this evidence-based guidance is still current. As the examiner, guidance supports issuing a time-limited certificate as follows. For stage 1 hypertension, guidance recommends issuing a one-year time-limited certificate. For stage 2 hypertension, a three-month time-limited certificate. And drivers who present with stage 3 hypertension are disqualified per current guidance. Other disqualifying medical conditions contained in FMCSA regulations include a current seizure disorder, monocular vision. However, there is a federal exemption for drivers with monocular vision and the information on how to obtain that exemption from the Federal Motor Carrier Safety Administration is available on the FMCSA website. As I mentioned at the beginning of this discussion, drivers with current insulin-dependent or insulin-treated diabetes are eligible for an exemption. And as of November 2018, this exemption is issued at the examiner level rather than via an application to the agency. And information on that process is available on the agency's website. Current drug use or abuse is disqualifying. Methadone is specifically mentioned in the regulation as a disqualifying medication. However, Marinol or Dronabinol is not in and of itself considered disqualifying. It's important for examiners to evaluate not only a particular medication, but also the medical condition for which the medication is being prescribed. Therefore, it may not be that a driver is disqualified by an examiner purely because he or she has a prescription for Marinol, but one would imagine that the condition for which Marinol or Dronabinol might be prescribed is likely going to interfere with the driver's ability to safely control the vehicle or perform other essential job functions. According to FMCSA regulations, a driver is qualified if they don't use controlled substances. And those could include, but aren't limited to, Schedule I drugs, amphetamines, narcotics, or other habit-forming drugs. A noted exception is if the driver has a prescription from a physician or other licensed medical practitioner who's both familiar with the driver's medical history and assigned duties and has had a discussion with the driver on how to take that substance so that the substance or drug will not adversely infect his or her ability to safely control a motor vehicle. So you can conclude that it's really important as an examiner to be aware of the responsibilities, particularly situational awareness and other responsibilities regarding work hours of a commercial driver, and to take this into consideration when making a medical clearance determination. As the examiner, again, as I stated before, you can require additional information from the driver and or their treating healthcare provider regarding the stability and control for any condition for which the driver is taking medication, as well as for additional information such as any side effects expected or reported by the driver. When evaluating a driver for a commercial driver medical certificate, it is essential that the examiner evaluate whether the driver can perform all of the essential job functions. Given the safety-sensitive nature of this job, as well as the need for constant maintenance of situational awareness, accommodations are likely unrealistic. Remember that other than specifying that the driver must use corrective lenses or that the certificate must be accompanied by a skilled performance examination certificate, an examiner may not indicate any restrictions on the medical certificate regardless of the employee or driver's current job demands. So it is quite unrealistic to recommend any accommodations. For example, having another person in the cab perform some of the essential functions of the driver. Examiners also must consider the risk of the underlying diagnosis or treatment for each reported medical condition and medication in terms of whether or not it would affect the safe operation of the vehicle. Although many states have legalized the use of medical and or recreational marijuana, the FMCSA has been clear. Although this FAQ number as listed 88 is likely outdated due to the constant changing of things on the FMCSA website, the FMCSA, the Department of Transportation, and the Drug Enforcement Administration have been clear. So in response to the question, can a driver be qualified if taking prescribed medical marijuana, the answer is no. Drivers taking medical marijuana cannot be certified. And I will just add that that is not even if they reside in a state where medical marijuana use is legal. Furthermore, as we discussed on the previous slides, examiners must take into consideration the medical condition prompting the use of any therapy which would include medical marijuana or even prescription dronabinol. So as you can imagine, if a driver requires such treatments, it is likely that they have an underlying medical condition that would make them unfit for the commercial driver medical job position. The maximum length of certification permitted by the Federal Motor Carrier Safety Administration is two years. However, an examiner may grant a shorter time limited certificate upon the examiner's judgment. Certain guidelines such as the guidelines for blood pressure or hypertension are specific for such certificates as I discussed in an earlier slide. Certain guidelines such as those for medical conditions such as obstructive sleep apnea or cardiac conditions or diabetes additionally recommend a time limited certificate. Skill performance evaluations or SPEs may be required for an applicant that has a permanent limb impairment. This could be a result of a traumatic amputation, a congenital deformity, or a medical condition such as sclerosis or scarring or a burn. It's important to recognize that a skill performance evaluation would not be appropriate for a driver who has a medical condition that has not yet reached maximum medical improvement such as tendonitis or a bone fracture that's not yet healed. The examiner recommends, as noted on the certificate, that the driver obtain a skill performance evaluation and then the result of that evaluation is required for the driver to have a valid medical certificate. The FMCSA website lists various facilities that can perform a skill performance evaluation. This is not a service that is performed in the same time as a medical examination. It is often performed at a separate facility that has the adequate training of personnel and equipment to evaluate a driver's ability to safely control a commercial vehicle and to perform the essential functions of the job of commercial driver. Let's transition into the next section of our discussion with a review question. Alcohol and drug abuse are associated with which of the following? A. Increase work-related injuries, B. Impaired job performance, C. Increased medical costs, D. Decreased performance on specific tasks, or E. All of the above. The correct answer to this question is E, all of the above, and we'll talk about the evidence basis for this answer in the next section. According to the National Institute on Drug Abuse or NIDA, nearly 75 percent of all adult illicit drug users are employed based upon self-reported information. When compared with people who are not reporting substance abuse, those who report abuse of substances are more likely to change jobs frequently, have problems with lateness or absenteeism, be less productive, be involved in work-related accidents, and file a worker's compensation claim. And this is important information as we are thinking about medical clearance for our safety-sensitive employees in the workplace and the need for awareness in occupational medicine of the signs and symptoms and treatment for substance use disorders. The DSM-5, published in 2013, reclassified what were formerly described as substance abuse and substance dependence into a continuum under the umbrella of substance use disorders. We have 11 criteria to examine, and patients who meet 2 to 11 of those criteria are classified as having either a mild, moderate, or severe substance use disorder. In addition, the term opioid use disorder is used instead of general substance use disorder if opioids are the specific drug of abuse for a given person. This slide includes key epidemiologic facts about alcoholism. The effects of alcoholism in the workplace depend on the specific study. Up to 50 percent or more traffic fatalities, homicides, rapes, and suicides have been related to alcohol use. 3 to 13 percent of those studied who are self-reporting alcohol use would be classified as heavy drinkers, as defined as drinking 5 or more drinks on 5 or more occasions in the past 30 days. And the prevalence of heavy drinking is higher in males as compared to females. Occupations at increased risk include movers, transportation workers, bartenders, waiters, and longshoremen. Research has found that up to 6% of workers meet criteria for heavy drinking. We can use the CAGE questionnaire in clinic as an easy tool to identify workers who may be at higher risk of a substance or alcohol use disorder. If employees answer positively to two out of the four CAGE questions, this correlates very well with a diagnosis of alcohol dependence, which would now be called an alcohol use disorder under the new DSM criteria. Marijuana is the most common substance found on positive workplace drug screens. Tetrahydrocannabinol, or THC, is the active ingredient in marijuana, and that is also the substance that is tested for in federal and non-federal drug testing programs. Use of marijuana results in apathy, impaired judgment, and decrements in problem-solving ability, which can certainly affect our safety-sensitive employees. Physical health effects associated with marijuana use include bronchitis and injury to the lungs, and when smoked, the side effects, or effects of marijuana, onset within minutes. This slide includes information on naturally occurring and synthetic stimulants for the central nervous system. It includes cocaine, which is made from the coca leaf, and can be smoked in a freebase form. It can also be insufflated as a salt, and health effects resulting include increased heart rate, increased blood pressure, possible heart attack, which has been called a Casey-Jones reaction, seizures, and stroke. Amphetamines have a longer half-life than cocaine, and side effects can include psychosis and motor agitation. Side effects of methamphetamine can also include out-of-control psychosis. Methamphetamine is also associated with decreased memory and decreased psychomotor function. Opiates and opioids can collectively be referred to as narcotics, as they cause central nervous system depression. Medical use, as well as illicit use, may result in an opioid or substance use disorder. To be correct, I wanted to include the formal definitions for opiate and opioids on this slide, although they are often used interchangeably. Opiates are naturally occurring narcotics, and these include heroin, morphine, and codeine, while opioids are made synthetically and include oxycodone, hydrocodone, hydromorphone, and oxymorphone. Signs of opiate abuse may include needle tracks, meiosis, constipation, weight loss, and infectious complications due to immunocompromised state. Sedative, hypnotic drugs have many clinical uses, but can also be drugs of abuse and even when taken according to prescriptions, due to their sedation and long half-lives in some cases have significant potential for impacting worker safety and situational awareness. The barbiturates include butavital, which again, has several clinical uses, which include use for migraine headaches and some digestive disorders, for example. The benzodiazepines include many agents, which vary by their half-life. Certain benzodiazepines, including alprazolam, whose brand name is Xanax, have a relatively short half-life compared to diazepam, brand name Valium, or clonazepam, brand name Klonopin, which have extended half-lives. For example, clonazepam's half-life can extend beyond 30 hours. The benzodiazepines are used for a variety of clinical reasons, including treatment of mental health conditions like anxiety, panic disorders, and may also use to help as sleep agents and treat sleep disorders due to chronic pain. The half-lives, again, of these agents vary, and it's important to understand the pharmacology of these agents when evaluating a worker's fitness for duty. We will transition to our discussion of the role of the medical review officer and drug testing with another review question. Which type of workplace drug testing yields the highest rate of positive tests? Is it post-offer, also called pre-employment testing, post-accident testing, return to duty, or follow-up testing, or reasonable suspicion or for-cause testing? The correct answer to this review question is reasonable suspicion or for-cause testing. And that is good because what it means is that when supervisors and others identify an employee's behavior as suspicious for drug use, they are often correct. The regulations governing certification and practice of a federal medical review officer are found in Department of Transportation, Code of Federal Regulations, and a federal executive order, as noted on this slide. The requirements have changed over time, and current requirements for certification, training, and continuing education and reexamination are per the Department of Transportation. Each year, the Department of Transportation sets requirements or rates for a set percentage of workers in each agency under the Department of Transportation to undergo random urine drug and breath alcohol testing. These rates are set upon experience data, kind of like insurance rates. In other words, the higher the rates of past positive tests, the higher the required rate will be for the next year. Currently, for the Federal Motor Carrier Safety Administration governing commercial drivers, the annual required rate of random urine drug testing is 50%, and the annual required rate for breath alcohol testing is 10%. For those of you who are not certified federal medical review officers, or who have not reviewed this information since the last time you took a board certification exam, it's important to note that the federal panel, which covers both Department of Transportation and employees covered by Health and Human Services, changed as of January 1st, 2018. The current test panel includes the drugs and substances listed on this slide, and you can see that one significant change was the addition of testing for the opioids, particularly for oxycodone and hydrocodone, as well as the continuing testing for 6-monoacetylmorphine, which in the past, medical review officers had to specifically request as a confirmatory test for the presence of heroin. On the next few slides, we'll talk about the different types of workplace drug testing. Post-offer, also called pre-employment testing, is aimed at identifying and then weeding out new hires and or applicants who are using drugs. It's important to remember that a current drug user is not a qualified person with a disability under the Americans with Disabilities Act. This does not apply to people with alcoholism. Random drug testing is meant to deter employees from using illicit drugs or illicit use of prescription drugs. A percentage of employees is tested under DOT regulation for each DOT agency annually, and we discussed those percentages for the FMCSA on the prior slide. If a random drug test is positive, the Department of Transportation nor HHS do not require the employer to retain the employee. However, the employer is required to refer the employee to a substance abuse professional. Once the employee has completed recommended treatment, the employee may be eligible to return to work under a periodic testing program called a follow-up program. But again, that is up to the employer. Other types of drug testing include reasonable suspicion, otherwise known as for-cause testing. As we discussed in our review question, this is responsible for the most positive tests on employees. When supervisors or others suspect that an employee might be under the influence of drugs, they refer an employee for this type of drug test. Post-accident testing refers to testing after specific types of accidents, and the specifics for each agency are outlined by the Department of Transportation and by the agency. In some cases, there is a maximum duration of time between the event and the test. Another type of drug testing called follow-up testing or individual deterrence test programs are for those employees who have completed substance abuse treatment for a substance abuse disorder and then are returning to the workplace. These programs include a return to duty test, as well as 12 to 60 months or up to five years of follow-up testing periodically, according to the recommendations of a substance abuse professional. Up to this point, we've been discussing Department of Transportation and Health and Human Services drug testing, both referred to as federal or regulated drug testing programs. Now we're going to spend a little time talking about non-regulated testing. These are often employer-based drug testing programs when the employer is not bound by federal DOT or Health and Human Services regulations. Employers can thus use expanded test panels, and this slide is a little outdated because you can see I've mentioned oxycodone and hydrocodone, which are now, as we discussed, on the federal panel. Other substances that can be included include the benzodiazepines, the barbiturates, steroids, for example, and really any other substance that the employer desires to test for. Whereas federal specimens are all collected as a split specimen, non-regulated test specimens may be split or non-split. Whereas federal testing or HHS testing is all done on urine, non-regulated testing can use different media, including hair, oral fluid or saliva, as well as sweat or blood. The MRO process involves multiple steps aimed at preserving the integrity of the process, such as reviewing the chain of custody or custody and control form, conducting an interview with the donor to determine if a legitimate medical explanation exists for the lab result, and reporting the results of the test back to the employer via the designated employer representative. In federal testing, where a split specimen is collected, if the urine drug test is positive on initial determination, the donor is educated regarding the donor's right to request testing of the split specimen at a separate government-certified laboratory. The cost of this specimen testing might be the responsibility of the donor, and that is up to the employer's policies. When determining if a legitimate medical explanation exists for the results of the drug test, medical review officers may review prescriptions and or other supporting medical documentation, and they're also responsible for determining if a safety letter is needed, that is, if a safety concern is present. This is required by the DOT and Health and Human Services by regulations updated in the fall of 2017. If the donor or the employee is unable to provide an adequate sample, which would be 45 cc or milliliters of urine in one void, then this is called a shy bladder process. The employee or donor is given up to three hours and provided up to 40 ounces of fluid at the testing site. And then if the employer or donor is unable to provide that 45 cc's of urine in one void by the end of the three-hour period, this is then reported as a shy bladder event to the medical review officer. By federal guidance, the DOT requires a medical evaluation, which must be by a physician who is familiar with DOT regulations that apply to the shy bladder evaluation, to determine if there is a medical reason for the donor's inability to provide an adequate specimen. If there is no legitimate medical explanation, this constitutes a refusal to test, which under DOT law is the same as a violation. Regarding breath alcohol tests, under federal Department of Transportation guidance, employees are prohibited from performing safety-sensitive duties if their breath alcohol concentration is 0.02 or greater. If the breath alcohol concentration is 0.04 or greater, this is a violation of the drug and alcohol regulations. Employees are, of course, prohibited from performing safety-sensitive functions while using alcohol and within four hours after using alcohol. Under FAA guidance for flight crew, this period is extended to eight hours, sometimes referred to as the bottle-to-throttle time frame. Regarding urine drug testing, if the medical review officer determines that a drug test is positive, adulterated, or a substituted specimen, the employer must immediately remove the employee from his or her safety-sensitive position. Some employers may have stand-down authority through a waiver process from the Department of Transportation, and this stand-down process permits the employer to remove an employee from their safety-sensitive position before the medical review officer has completed his or her review. Again, this is only permitted if the employer has received this stand-down approval. As I mentioned before, the Department of Transportation does not specify whether an employer must retain an employee who has had a positive federal drug test. However, the employer is required to ensure that the employee is referred to a substance abuse professional. Let's wrap up this part of our discussion with two review questions. So here's the first one. Which, if the following, is not an acceptable explanation for a trucker who can't provide an adequate urine specimen during a shy bladder evaluation? Of the three choices listed, choices B, C, and D all describe medical problems which would certainly provide a legitimate medical explanation for a donor not being able to provide an adequate urine specimen for a urine drug collection. Choice A, new-onset anxiety, especially if this is related to the incident of the drug collection, would not be a legitimate medical explanation. Therefore, this is the correct answer to this question. If there was a circumstance where a donor had a pre-existing and well-documented anxiety disorder, that might provide a legitimate medical explanation, but that would be up to the particular circumstances and records reviewed by the reviewing physician who was conducting the shy bladder evaluation. Our second review question asks, when can an MRO determine that a test reported by the lab as positive for cocaine is negative? So choice A, if the donor alleges passive inhalation, as you recognize, would not be correct because, first of all, if this were passive inhalation, for example, of marijuana, the levels for cutoffs are set to prevent that being a cause for a positive urine test. Furthermore, cocaine is not passively inhaled. Choice B, where the donor is asserting that the positive test is due to the use of a lidoderm patch, is incorrect because lidoderm is lidocaine and this is not related to cocaine, nor is it a substance that would result in a positive urine test for cocaine. Choice C, where the donor asserts that he or she drank Inca tea, would not provide a legitimate medical explanation, as although Inca tea may be used in certain countries culturally, it is not a prescription medication and therefore would not constitute a legitimate medical explanation. If the donor provides documentation that he or she was treated with cocaine for hemostasis after an ear nose and throat procedure, then that would provide a legitimate medical explanation for the presence of cocaine or its metabolite in a urine drug test. So for this question, choice D would be the correct answer. This slide highlights two important resources for information on disaster response and emergency management and those are at the Federal Emergency Management Agency or FEMA as well as the U.S. Centers for Disease Control or the CDC. When responding or planning a public health response after a disaster, although it is tempting to send supplies or to start sending personnel resources, the first thing that needs to be done is a needs assessment and this should be completed within 24, that should say 24 to 48 hours for natural disasters or sudden impact events. Although a formal epidemiologic study is not possible in a disaster situation, one would want to select a representative sample of information sources and this may very well be a convenient sample based on who has a cell phone and can report information, for example. The needs assessment is meant to identify the needs and areas of technical assistance that are needed to respond appropriately to the disaster situation and certainly in an evolving situation, repeated assessments would be needed for ongoing long-term situations and those could include, for example, a wartime situation with displaced people as well as a pandemic situation. After an initial public health response, ongoing surveillance is necessary to continue monitoring key determinants and response to needs. Examples of metrics that one might monitor include the incidence and prevalence of vaccine preventable diseases, deaths, and the prevalence of malnutrition, for example. When displaced persons or others who have been relocated after a disaster are in crowded situations, it's important to monitor for incidences of violence. It's also important to assess the need for and provide appropriate mental health support to those who have suffered from the natural disaster or man-made incident or other public health incident. Furthermore, it's important to consider appropriate management of disaster-related occupational stressors, recognizing that it's not just the people who have been victims of the disaster, but those who respond who may be suffering from disaster-related stress. It's also important to realize that the very first responders on site at an incident might also be victims of this situation because they are located in the local area where the incident occurred. So it's important to monitor stress levels, symptoms of mental health conditions such as depression, sleep disturbance, increased substance use, irritability, and anxiety. We've discussed how critical incident stress debriefings can be important in reducing the health effects of traumatic incidents, and this applies to disasters as well. And certainly, as time goes on, we would need to assess responders for signs of post-traumatic stress disorder. On these next two slides, we'll briefly discuss some key points about emergency response focused on protecting responders in situations with potential exposure to hazardous chemicals or biological or radiological agents. The cartoon on the right-hand corner of the slide illustrates three zones, with the hot zone being the area where the hazard was deployed or the exposure is at its highest level. Only responders with full protective equipment should be entering this hot zone. There should be one way in and one way out, and there should not be any definitive healthcare or care beyond rudimentary first aid occurring in this zone. Really, in this zone, we are just grabbing any exposed people who are salvageable and removing them to the warm zone. In the warm zone, generally, we are performing decontamination. This is where the decontamination line that I'll talk about on the next slide would be present. And the purpose of the warm zone is to reduce the contamination from exposed people and to avoid contaminating the outer zone, also called the cold zone. In the cold zone, illustrated in green in the cartoon, emergency medical care, triage, and our command and control activity would be located. Again, continuing our review of some key points on the slide, in the upper right-hand photo, you see an example of a prefabricated decontamination line. You can see some first responders there who are training on decontamination of a worker who is in a level A protective suit. And then in the picture on the lower right-hand corner of the slide, you see an operation of responders who are washing off a fellow responder before removal of a hazmat or level A suit. And again, this would be part of training in preparation for a disaster response. It's important to designate your responders as a hazardous materials team and provide them appropriate training and equipment. This would certainly include medical surveillance for potential exposures, baseline testing, as well as periodic and post-exposure testing after responses. And that would be tailored to the particular agents to which the workers were potentially exposed. In addition, please remember there is an OSHA hazardous materials and hazardous responder standard, so particular training is required, as well as medical surveillance. You would need to ensure that workers are appropriately medically cleared to wear respirators using the OSHA respirator questionnaire, and as well that they were medically fit for hot work in level A suits depending on your ambient environment. We'll transition to the final part of our discussion with two review questions. So here's our first question. Which of the following biological syndromes are transmitted from person to person? A, botulism, B, anthrax, C, smallpox, or D, tularemia or rabbit fever? The correct answer is C, smallpox, which is in fact one of the most infectious in terms of its R-naught or number of people infected by a infected person of the infectious diseases. On the lower right-hand corner of the slide is an electron micrograph of Ebola virus, which we know is quite infectious and which we will discuss as we go through this presentation. So again, the correct answer here is C, smallpox. For our second review question, we have a scenario where you're preparing your hospital to receive casualties from a dirty bomb detonation. You should prepare to treat A, radiation exposure to area residents requiring potassium iodide therapy, B, shrapnel and traumatic blast injuries to those who were near the area of impact, C, both A and B, or D, neither A nor B. The aim of this review question is to highlight the fact that although this was reported as a dirty bomb detonation, the proximal hazard to those in the immediate area in the absence of evidence that this did actually contain radiation would be kinetic energy, which would be due to injuries related to flying objects or shrapnel, as well as traumatic blast injuries due to the high energy generated from an explosion. An example of a recent tragedy that exemplifies this would be the Boston Marathon bombing several years ago. In contrast, a radiation accident at a power plant or a plume-type exposure would be a situation in which we would be recommending shelter-in-place measures, as well as potentially, depending on the type of radiation, recommending potassium iodide therapy. So, again, the correct answer to this review question is B. This slide includes examples of potential chem-bio-radiation terrorism agents by category. Regarding the potential bioterrorism agents, the CDC has published a classification system that rates or classifies these agents based upon their potential mortality, morbidity, and ease of potential dissemination to large numbers of people. Class A agents are the easiest to disseminate, including potential person-to-person transmission, and have the highest risk of high mortality. Class B agents are less easy for potential spread and have moderate morbidity and lower mortality compared to the Class A agents. Class C agents include emerging agents such as Hantavirus infection. Regarding chemical agents, as you recall from other presentations in this course, these can include nerve agents, which can include the organophosphates, blood or choking agents such as cyanide, and other agents. Radiologic agents can include so-called dirty bombs or improvised explosive devices or IEDs. For your information and review, this slide illustrates the list of Class A bioterrorism agents according to the Centers for Disease Control. As information on the CDC website, there's a wealth of information including slides, photos, and potential response plans as well as educational material that you can use if you are doing any worker or leadership or preparation education around these agents. So let's just take a few minutes and review them. Smallpox is caused by the variola virus, and this is a DNA virus. Anthrax is caused by Bacillus anthracis and causes both a skin infection as well as potentially a pulmonary infection when inhaled. This is what we saw in the fall of 2000 after some weaponization of anthrax. Botulinum toxin is produced by the bacteria Clostridium botulinum, and generally exposure is via food poisoning. However, this can also be aerosolized to the point where it can be inhaled. Plague is caused by Yersinia pestis, which is another bacteria. Generally, this would be bubonic plague where our exposed workers might include those who work outdoors. However, this can also be pneumonic plague affecting the pulmonary system. Tularemia, sometimes called rabbit fever, is caused by the bacteria Francisella tularensis. And the viral hemorrhagic fevers include both Ebola and Marburg viruses, which are RNA viruses. Again, the link at the bottom of the slide will take you to a very thorough website sponsored by the CDC around the bioterrorism agents. To wrap up this section of this presentation, as well as this part of the course, I've summarized the class A bioterrorism agents with some key facts on the next two slides. Let's review them together. Smallpox infection causes a fever, a rash, and up to 30% mortality in those infected. As I mentioned before, this is one of the most highly contagious infections and is transmitted person to person. It's important to note the smallpox vaccine is based on vaccinia virus. And so although disseminated infection is an adverse effect of vaccination in immunocompromised people, this would not be smallpox infection. It would be disseminated vaccinia infection. Anthrax is caused by a bacteria, as I mentioned earlier. There is a vaccine available, and this is not a live virus or live bacteria vaccine. You cannot get anthrax infection from the anthrax vaccine. Anthrax infection is not spread person to person, and so you can cohort infected persons. Post-exposure prophylaxis for exposed personnel would include ciprofloxacin or doxycycline. Please remember these two antibiotics because you will see them again as we talk about post-exposure prophylaxis for some of the other class A agents. Botulism, whether inhaled or ingested, causes a similar syndrome of muscle paralysis. It is not spread person to person, and the treatment is antitoxin, which makes sense because the syndrome is caused by ingestion or inhalation of the botulinum toxin. Continuing our discussion of key facts of the class A bioterrorism agents, pneumonic plague consists of symptoms of fever, headache, and pneumonia. Plague is transmitted person to person by respiratory droplets, and here again are the same antibiotics which are effective as post-exposure prophylaxis, doxycycline, or ciprofloxacin. Tularemia, or rabbit fever, consists of a fever, muscle aches, and pneumonia, and is also not spread person to person. And again, here are two same antibiotics for post-exposure prophylaxis, doxycycline, or ciprofloxacin. Please refer to the CDC website or other medical evidence-based recommendations for prescription information and other necessary information for these medications. The viral hemorrhagic fevers, which as I mentioned, include both Ebola and Marburg viruses, which are RNA viruses, are exemplified by pneumonic plague. These are identified by fever, muscle aches, fatigue, bleeding, and overwhelming shock and multi-organ system failure. These are highly infectious agents and cannot only be transmitted via contact with blood and body fluids, but also by contact with remains or cremains after cremation, which is very unusual, and respiratory transmission is also possible. Currently, there is no established post-exposure prophylaxis, nor treatment, nor vaccine. However, experimental use or investigational or humanitarian use of plasma from people who have recovered from infection has shown some effectiveness in treatment, and vaccine trials are underway. This concludes this part of our course. Thank you very much.

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