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Training Future Physicians About Weaponsof Mass Destruction:Report of the Expert Panel on BioterrorismEducation for Medical Students

This report was supported in part by funding from award U36/CCU 319276 through a coopera-tive agreement with the Centers for Disease Control and Prevention, U.S. Department ofHealth and Human Services.

To request additional copies of this publication, please contact:

Rika Maeshiro, M.D., M.P.H.Association of American Medical Colleges

2450 N Street, NWWashington, DC 20037-1134E-mail: [email protected]

Copyright 2003 by the Association of American Medical Colleges. All rights reserved.

The events of September 11, 2001, the follow-ing month’s anthrax outbreaks, and the rein-stitution of smallpox vaccinations have calleddramatic attention to the need for physiciansto be prepared for the health consequencesof the use of weapons of mass destruction(WMD). WMD include biologic, chemical,physical (i.e., explosive), and radiologicalagents. Polls have shown that the generalpublic prefers to turn to their doctors forguidance on how to protect themselves andtheir families in case of public health emer-gencies, such as a bioterrorism attack.1,2 Inorder to meet the expectations of their patientsand of their communities, physicians mustnot only become familiar with rare clinicalsyndromes and exotic offending agents butmust also develop an understanding of theirroles in the public health systems’ prepared-ness and response to the use of WMD.

Since the autumn of 2001, considerable efforthas been given to assess the capacities of thesystems and individuals that are expected toprevent, detect, and respond to terror incidentsinvolving WMD. Public health agencies3, 4 aca-demic health centers5, public health workers6,and specific physician specialists in practice7, 8, 9

have been the focus of activities to identifycompetencies that help to assure their readi-ness. Medical schools have also responded byintegrating WMD-related topics into their cur-ricula, but no guidance has existed regardingthe content and the teaching methods thatwould be most appropriate for medical students.

The Association of American Medical Colleges(AAMC) convened a multi-disciplinary groupof experts to share their insights about thelearning objectives and educational experiencesthat they would recommend. The group includedrepresentatives with expertise in medical,nursing, and public health education, as wellas experts in WMD preparedness, from schoolsof medicine, nursing, and public health, theCenters for Disease Control and Prevention(CDC), and the Uniformed Services Universityof the Health Sciences (USUHS). They werespecifically tasked to respond to two questions:

Report of the Expert Panel on Bioterrorism Education for Medical Students

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1 Harvard School of Public Health/Robert Wood Johnson Foundation Survey Project on Americans’ Response to Biological Terrorism, 2002.

2 Lake Snell Perry & Associates Inc. Americans Speak Out On Bioterrorism and U.S. Preparedness to Address Risk. Commissioned by the RobertWood Johnson Foundation, 2002. (www.RWJF.org/special/changingworld).

3 Fraser, MR and VS Fisher. Elements of Effective Bioterrorism Preparedness: A Planning Primer for Local Public Health Agencies. NationalAssociation of County and City Health Officials (NACCHO): Washington, DC, 2001.

4 Centers for Disease Control and Prevention. Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response. MMWR. 2000;48(No. RR-4).

5 Rubin ER, Osterweis M, Lindeman LM editors. Emergency Preparedness:Bioterrorism and Beyond. Association of Academic Health Centers:Washington DC, 2002.

6 Columbia University School of Nursing Center for Health Policy. Bioterrorism & Emergency Readiness: Competencies for All Public Health Workers.Columbia University: New York, 2002.

7 American Academy of Pediatrics. AAP Task Force on Terrorism to Help Prepare Pediatricians for Disaster Response. AAP News. 2002;20:4.

8 American College of Emergency Physicians. Positioning America’s Emergency Health Care System to Respond to Acts of Terrorism. October, 2002.

9 American College of Surgeons. Disasters from Biological and Chemical Terrorism—What Should the Individual Surgeon Do?: A Report from theCommittee on Trauma. 2001.

1. What should medical students learn about bioterrorism (learning objec-tives)?

2. What kind of educational experienceswould allow students to achieve those learning objectives?

The expert panel broadened the scope of theirdiscussion beyond bioterrorism to includeother potential WMD. Their deliberationsidentified medical student competencies thatshould prepare students to identify and torespond specifically to WMD incidents. Thepanel agreed that an integral component ofthe curriculum should focus on physicians’interactions with the public health system inorder to help facilitate effective and coordi-nated medical and public health responses toWMD, as well as to more common threats tohealth, including chronic and infectious dis-eases, injuries, and substance abuse. Panelistsacknowledged that better coordinationbetween medicine and public health wouldimprove the management of public healthchallenges ranging from food-borne illnessesto natural disasters to emerging infectiousdiseases such as Severe Acute RespiratorySyndrome and West Nile Virus. They recog-nized that in the absence of WMD incidents,conventional public health threats help “drill”the coordinated systems that are central to aneffective medical and public health responsein the event of a WMD incident. Panelists alsoconcluded that because the science associatedwith WMD-related topics is evolving, medicalstudents should adopt a life-long learningperspective with regard to this subject.

Many of the subjects in a WMD curriculumare part of traditional medical school teaching.Pathophysiology, toxicology, infectious dis-eases, emergency preparedness/disasterresponse, biostatistics, and epidemiologyintroduce concepts and topics that are thefoundation for information more specific toWMD preparedness and response. Buildingupon these familiar concepts should help toassure that medical school graduates arearmed with the necessary knowledge andskills to become competent and preparedphysicians who will practice effectively in atransformed societal and clinical environment,where the theoretical potential of a WMDevent has become a real possibility. Dependingon the characteristics of a WMD event, physi-cians may play critical roles in identifying,responding to, and recovering from the WMD.

Physicians may be the first to recognize theuse of a WMD, particularly in the case of acovert (unannounced) release of a biologicagent. Unusual clinical presentations or clus-ters of cases, particularly in vulnerable popu-lations such as the very young, very old, andthe immunocompromised, should raise suspi-cion. Physicians will also need to routinelyconsider the possibility of WMD in their dif-ferential diagnoses of more typical clinicalpresentations because many of the earlysigns and symptoms of exposure to biologicWMD mimic common viral syndromes.Clinicians’ abilities to efficiently analyze signs,symptoms, and basic diagnostic tests thatlessen or rule out the possibility of a WMDwill also be critical. Once the possibility of aWMD event is raised, physicians must knowhow to elicit critical data from patients, how


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to record these data, and how to report theirsuspicions to their public health agency. Aftercontacting public health authorities, physiciansshould be prepared to proceed clinically inconsultation with their public health colleagues.

During the response to a WMD event, physi-cians’ responsibilities will vary by their prac-tices and their institutional affiliations. Somephysicians may not care for any patients whoare directly affected by the WMD but shouldunderstand the rationale behind the publichealth and medical interventions that may beimplemented to treat and contain the morbid-ity and mortality associated with the WMDevent. Public health interventions can includeepidemiologic investigations, environmentaltesting, public health education campaigns,immunization programs, and quarantines.Physicians may find that they are identifiedas the experts in their community and may beasked to help explain and clarify theseresponse activities, regardless of their levelof involvement, usual practice, or specialty.Physicians may also find that their patientswho did not suffer physical exposure orinjury are nevertheless concerned about theirhealth and welfare. In addition to understand-ing when and how to withhold inappropriatediagnostic tests and treatments, clinical prac-titioners must know how to recognize andcare for those suffering from psychologicaltrauma following a WMD event. Physicianswho are directly involved with physicallyinjured or exposed populations must have amore intimate knowledge of treatment proto-

cols and their roles in any public health oremergency management interventions thatmay be implemented. While the details ofresponse plans will vary with regard to physi-cian roles, medical students must be awarethat they may have both explicit and impliedroles in these plans as practicing physicians,including leadership roles in interdisciplinaryteams. As students, they should also beaware of any responsibilities they may havewithin their medical school and/or teachinghospital’s response plans.

Unique to the WMD context is the illicit andpurposeful exposure of individuals and com-munities to harmful agents. Because of theunlawful nature of the exposures and thepotential population-wide impact, physiciansmay be interacting with law enforcement,emergency personnel, public health agencies,the media, and their communities in a man-ner that is qualitatively different from theirtypical day-to-day practice. In addition toclinical knowledge and skills, medical schoolswill need to equip their students with theskills to interact within multi-disciplinaryteams in the context of WMD preparednessand response, including the collection andpreservation of forensic evidence.


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General PrinciplesAlthough the meeting of the expert panel wasentitled “Bioterrorism Education for MedicalStudents”, the group determined that focus-ing only on biologic agents of terrorism wasinappropriately limiting. Because physiciansin practice should be prepared to respond toany event that may result in mass casualties,the expert panel agreed to adopt an “all-agents”approach by considering biologic, chemical,physical, and radiological agents.

1. In the medical school curriculum, WMDeducation should be considered in thecontext of any threats that may resultin mass casualties, including the use of biologic, chemical, physical, and radiological agents.

The expert panel acknowledged that withthis broader perspective, the list of potentialagents of terrorism, particularly when consid-ering chemical agents, is extensive. Requiringmedical students to memorize the character-istics of all possible agents was not thought tobe a productive activity. Focusing on generalconcepts that distinguish particular classes ofagents, their mechanisms of injury, and theircontainment/treatment options was recom-mended.

2. General concepts should be empha-sized rather than details regarding every potential agent.

The expert panel stressed that in addition tobecoming familiar with potential WMD agents,medical students needed to augment their

clinical knowledge with an understanding oftheir roles in the implementation of WMDpreparedness and response interventions. Thepanel identified working in multidisciplinaryteams and working in coordination with publichealth systems as critical aspects of a physi-cian’s responsibility.

3. The roles and responsibilities of physicians during a WMD event shouldbe presented, including the need to work in multidisciplinary teams and in coordination with the public healthsystem.

Learning ObjectivesThe expert panel identified learning objectivesthat could be integrated into the traditionalbasic science and clinical curricula, as well aslearning objectives that focus on the publichealth system, the emergency managementsystem, the physicians’ roles in the publichealth and emergency management response toa WMD event, and professional ethics, topicsthat may not be included in existing course-work at all schools.

Basic SciencesThe basic science curriculum includes natu-ral opportunities to discuss WMD examplesin the presentation of core concepts of bio-chemistry, microbiology, pathology, patho-physiology, physiology, pharmacology, andradiation physiology.

For its part the medical school must ensurethat before graduation a student will havedemonstrated, to the satisfaction of the faculty,the following:


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� Knowledge of the biochemical, infectious, physical, and radiological mechanisms andproperties that characterize potential WMD

� An understanding of the multiple routes of potential exposure to WMD and the associ-ated pathophysiology of injuries and illnesses

� Knowledge of the pharmaceutics and phar-maceuticals used to combat WMD (e.g., burn therapies, biochemical antidotes, antibiotics)

� An understanding of the epidemiology of classes of WMD

� Knowledge of prevention strategies associ-ated with WMD

� Knowledge of specific Category A and B biologic agents and general classes of chemicals identified as potential WMD

Clinical SciencesDuring clinical training, medical studentsshould learn how to recognize and treatpatients who have been exposed to WMD,along with the precautions they should taketo protect the safety and health of otherpatients, staff, and themselves.

For its part the medical school must ensurethat before graduation a student will havedemonstrated, to the satisfaction of the facul-ty, the following:� The ability to take medical histories that:

� Determine the absence or presence of symptoms that are characteristic of exposure to WMD

� Identify patients who may have psycho-logical trauma following a WMD event

� Identify occupational and psychosocial risks for exposure to potential WMD

� Characterize exposures to potential WMD,including type of agent, timing, and lengthof exposure

� The ability to conduct physical exams that:� Are guided by exposure or potential

exposure to WMD� Determine the absence or presence of

physical signs that are characteristic of exposure to WMD

� The ability to identify patterns of signs andsymptoms likely to be associated with occult exposure to WMD

� The ability to incorporate evidence-based diagnostic procedures and laboratory studiesto confirm the diagnoses and/or causative agents

� The ability to consider WMD exposure when establishing differential diagnoses and developing problem lists

� The ability to interpret results of the medicalhistory, physical exam, and diagnostic workup to rule out, when possible, the likelihood of WMD exposure

� The ability to interpret results of the medicalhistory, physical exam, and diagnostic workup to determine an accurate diagnosisof WMD exposure

� The ability to consider critical aspects of treatment plans for patients who may havebeen affected physically and/or psychologi-cally by WMD, including:� Acute care management� Long-term management� Secondary and tertiary prevention� Attention to mental health concerns� Referrals� Awareness of concomitant psychosocial

issues� Consultation with public health authorities

� The ability to use appropriate precautions to prevent WMD exposure to other patients,care providers, and themselves (e.g., isola-tion, decontamination, personal protective equipment, appropriate waste disposal)


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� The ability to utilize risk communication skills when informing patients and their families about WMD

� The ability to recognize the need for, and to collect and preserve, forensic evidence from patients who may be victims of a WMD event

Public Health SystemInformation regarding public health is not yeta standard part of medical school curricula.Nevertheless, medical students should under-stand the structure and function of their pub-lic health system, including the linkagesbetween the medical care and public healthsystems during public health emergencies,such as one involving a WMD. As physicians,they may be asked to explain and to clarifypublic health policies and programs to theirpatients and to their communities.

For its part the medical school must ensurethat before graduation a student will havedemonstrated, to the satisfaction of the faculty,the following:� An understanding of public health system

interventions that prepare for public healthemergencies, such as the use of WMD (e.g.,public health education, disease and syn-dromic surveillance, vaccination programs and their rationale, risk communication, public health laws)

� An understanding of public health inter-ventions that are part of the response to public health emergencies such as the use of WMD (e.g., mass vaccination, quarantine,epidemiologic investigations, environmentaldecontamination, public health laws)

Emergency Management SystemInformation regarding emergency manage-ment systems is also not a standard part ofmedical school curricula. Medical studentsshould understand the structure and functionof emergency management systems, includ-ing the rationale for incident command sys-tems.

For its part the medical school must ensurethat before graduation a student will havedemonstrated, to the satisfaction of the faculty,the following:� An understanding of community emergency

response systems� An understanding of the incident command

system� An understanding of community and hospital

all hazards planning� An understanding of state and federal

resources that contribute to emergency management and response at the local level

Public Health and EmergencyManagement Roles and ResponsibilitiesMedical students should also be aware of thespectrum of roles and responsibilities ofphysicians within the public health and emer-gency management systems to prepare forand respond to emergencies.

For its part the medical school must ensurethat before graduation a student will havedemonstrated, to the satisfaction of the faculty,the following:� Knowledge of local and national resources

that provide information about WMD� Knowledge of unusual clinical scenarios

that may represent sentinel cases of victimsof an unannounced use of WMD


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� An understanding of procedures used to collect patient data for surveillance or tracking

� An understanding of procedures for report-ing cases that are suspicious for WMD

� An understanding of their assignment, if any, within the community response plan, the incident command system, and their school or hospital’s emergency response plan

� An understanding of their community’s public health and medical response systemand its interactions with law enforcement, National Guard, emergency medical system,etc.

� An understanding of the methods and ration-ale for environmental decontamination

� An understanding of the importance of riskcommunication skills when informing communities or the media about WMD

Professional EthicsPhysicians may confront a variety of moraland ethical issues regarding their professionalobligations to treat and protect their patientsand themselves in the face of a WMD event.Medical students should understand theframework and limitations of the professionalethics that guide their actions.

For its part the medical school must ensurethat before graduation a student will havedemonstrated, to the satisfaction of the faculty,the following:� An understanding of their professional

obligations to treat� An understanding of their rights to protect

their personal safety� An understanding of their responsibilities

and rights as a volunteer� An understanding of professional liability

issues in the context of WMD events

General PrinciplesThe existing medical school curriculumincludes opportunities to introduce WMDtopics throughout the four-year curriculum,building upon and augmenting the students’growing knowledge and skill base. The panelagreed that WMD-related learning objectivesshould be integrated into the existing curricu-lum across all four years.

1. WMD-related learning objectives shouldspan all four years of medical school.

WMD-related topics cut across a variety ofsubjects that are part of the standard medicalschool curriculum. The expert panel agreedthat WMD-related topics should be integratedacross subjects such as microbiology, pathol-ogy, and toxicology. Horizontal integrationmay also be achieved in the clinical sciencesacross specialties such as emergency medi-cine, primary care specialties, and infectiousdiseases.

2. WMD-related learning objectives shouldbe integrated horizontally through thecurriculum.

The panel agreed that the most effectivemethods of teaching should be used to teachthe WMD-related topics. For early, basic knowl-edge acquisition, didactic methods could beutilized; however, for later learning objectivesthat require the integration of knowledge andskills, experiential learning is preferred.


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3. A combination of didactic sessions andexperiential learning exercises should be used.

Educational StrategiesThe panel described a spectrum of teachingstrategies that correspond to the varying lev-els of knowledge and skill desired of stu-dents. Many medical students may achieveWMD-associated competencies through acombination of didactic and experientiallearning exercises that are folded into exist-ing curricula. The integration of WMD exam-ples in their basic science and clinical experi-ences, the inclusion of information regardingthe public health system, and the use ofWMD case scenarios for discussions regard-ing professional ethics may provide a mini-mum level of competency for medical stu-dents. Alternatively, schools with a specialinterest or obligation to train physicians forthe military and the U.S. Public HealthService, such as the Uniformed ServicesUniversity of the Health Sciences, can requirelarge-scale disaster drills in their curriculum.Other schools could also consider fourth-yearcapstone activities to help consolidate theinformation from all four years, such as atabletop exercises or case study discussions.

Educational strategies to help students achievethe necessary competencies in the area ofWMD preparedness and response include:

� Lectures� Directed reading� Use of standardized patients� Objective structured clinical examinations� Review and discussion of case studies� Use of existing distance-learning courses,

including those developed by the Centersfor Disease Control and Prevention

� Research in WMD and WMD-related healthcare delivery

� Seminars to address student anxiety and fears regarding their responsibilities

� Tabletop exercises� Disaster drills� Participation in public health emergency

planning activities� Participation in community emergency

planning activities

In addition to the development of curricularresources, the expert panel agreed thatincreasing the cadre of faculty prepared toteach WMD topics, and including WMD topicsin student and institutional evaluation activitieswill be critical to the successful integrationof this subject into the medical school cur-riculum.

Development of Curricular ResourcesThe panel identified a need to develop curric-ular resources, such as standardized patients,on-line study modules, and elective opportu-nities that could be shared by institutions anddepartments.

Faculty DevelopmentAlthough a paucity of medical school facultycurrently identify themselves as “WMDexperts”, a desire to quickly impart this infor-mation to medical students exists. The expertpanel identified a variety of opportunities inwhich their faculty could be trained in WMDcompetencies. These range from distance-


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based, self-study experiences to fellowshipexperiences at institutions with expertise inWMD.

Activities that would facilitate faculty devel-opment in the topic of WMD preparednessand response include:� Establishing distance-based self-study

modules for medical school faculty� Establishing “train the trainer” symposia

for medical school faculty� Requiring faculty to participate in medical

school/teaching hospital disaster drills� Establishing partnerships with Veterans

Administration Centers, Department of Defense medical facilities, and Centers for Public Health Preparedness to facilitate faculty development

� Establishing month-long “faculty-in-resi-dence” programs that allow faculty to observe and learn at institutions with a robust WMD curriculum

� Establishing year-long fellowship programs inWMD preparedness and response for faculty

Evaluation ActivitiesThe panel agreed that students’ competencyin WMD topics and medical schools’ teachingof WMD topics should be assured throughthe existing evaluation systems. Writtenexaminations as well as the evaluation of stu-dents’ clinical skills should include cases ofWMD use. WMD content should also be con-sidered for inclusion in national examina-tions and in reviews and evaluations of med-ical school curricula.

Almost immediately after the events ofSeptember 11, medical schools across thecountry began to include or enhance informa-tion regarding mass casualty events, includingthe use of WMD, in their curriculum. Manyschools sponsored grand rounds lectures orother special presentations on the identifica-tion and treatment of potential biologic agentsof terrorism. While not a comprehensive list-ing, the following schools have developededucational opportunities beyond the inser-tion of isolated lectures on WMD, and mayserve as models for other schools:

Medical College of OhioThe Medical College of Ohio offers an eight-hour mandatory course, “Basic Anti-TerrorismEmergency Lifesaving Skills”, to their students.The course includes an overview of disastermanagement and focuses on preparedness.Medical students cover topics such as triage,treatment of blast and crush injuries, hazardousmaterials situations, biological and chemicalagents, and mass casualty management. Themulti-disciplinary faculty also presents infor-mation regarding epidemiology, surveillance,and public health. A case scenario of a smallpoxoutbreak in their area is featured. This courseis a cooperative effort between the MedicalCollege of Ohio and the University of FindlayCenter for Terrorism Preparedness.

Uniformed Services University of theHealth SciencesThe Uniformed Services University of theHealth Sciences (USUHS) was established in1972 with a mission to educate health profes-


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sionals dedicated to career service in theDepartment of Defense and the United StatesPublic Health Service. Because topics thatare unique to military medicine have beenwoven into typical medical school courses,students at USUHS are provided with morethan 28 hours of training in WMD-related sub-jects throughout the four years of the cur-riculum. These experiences range from theinclusion of WMD information in pharmacol-ogy, biochemistry, and microbiology curriculato extensive field operations. Topics in thecurriculum include the medical effects ofnuclear, biological, and chemical agents onthe human body; the response to suspectedexposure, including detection, decontamina-tion, and medical countermeasures; and thepsychological stresses of combat and trauma.

The University of Arizona College ofMedicineThe University of Arizona College of Medicine,in collaboration with the other colleges with-in the University of Arizona Health SciencesCenter, developed and presented an “inter-professional” seminar, Bioterorrism andConsequence Management, in the spring of2002. The Colleges of Medicine, Nursing,Pharmacy, and Public Health developed a four-hour program that highlighted the clinical,environmental, public health, and emergencyresponse issues associated with the use ofWMD. Faculty from all four colleges, alongwith members of the local emergencyresponse and public health communities,contributed to the development of the pro-gram and participated as speakers. The audi-ence consisted of third-year medical students,graduate students in public health and epi-

demiology, fifth-semester and graduate nursingstudents, and third-year pharmacy studentsand residents. The format of the seminarincluded didactic sessions as well as a case-based, interprofessional small-group discus-sion. The University of Arizona HealthSciences Center plans to repeat the seminarin an intercollegiate setting as a method offostering the interprofessional teamwork nec-essary to respond to public health emergencies.

University of Pittsburgh School ofMedicineThe University of Pittsburgh School of Medicineoriginally introduced a small-group case-based workshop, “The Medical Managementof Biological and Chemical Exposures”, intothe required third-year clinical curriculum inthe summer of 2000. Emergency Medicinefaculty taught the workshops during the stu-dents’ integrated clerkship in InternalMedicine/Emergency Medicine/Critical CareMedicine. The workshops focused on mecha-nisms of toxicity, common agents used asweapons, differential diagnoses, syndromerecognition, decontamination, and treatment.Although student feedback was positiveregarding the relevance of the topics and theteaching method prior to September 11, 2001,their perception regarding the relevance ofWMD subjects increased after the identifica-tion of the Florida anthrax cases in October2001. In 2003, WMD topics have been inte-grated throughout the curriculum as a four-year longitudinal theme, titled “BiologicThreats to Society”. WMD issues are presentedin a variety of courses ranging from neuro-science to ethics.


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University of Tennessee College of MedicineAt the University of Tennessee College ofMedicine, a group of first-year medical studentsestablished the “University of TennesseeCommunity Disaster Response Unit” as theirLongitudinal Community Program project, arequirement in their first and second years.The goal of the project was to identify and trainstudent volunteers to participate in disasterresponse activities, should any WMD or gen-eral disaster events occur in their community.Since its establishment in spring 2002, studentshave prepared and delivered two two-hourtraining modules on biological agents andchemical agents to medical students at theiruniversity. Future plans include the develop-ment of modules on general disaster responseand radiological agents, as well as participa-tion in a disaster drill. Students interacted withtheir local Emergency Management Agency, theTennessee Emergency Management Agency, andhospital administrators in the development ofthis program, and hope to sustain this effortbeyond their participation in the LongitudinalCommunity Program course.

University of Utah School of MedicineThe University of Utah School of Medicineaddresses bioterrorism through activities thatspan the four-year curriculum. The topic ofbioterrorism is introduced to first-year stu-dents by the inclusion of potential agents ofbioterrorism in their medical microbiologycourse. After potential agents have been pre-sented individually, a one-hour summary lecture is offered on bioterrorism. During students’ third-year clerkships, bioterrorismcases are included in their “Topics in Medicine”discussions. Bioterrorism cases are also indevelopment for their fourth-year requiredpublic health rotation.

Internet Resources (Please note that this list is not exhaustive.Many medical and scientific professionalsocieties have included information relatedto WMD that is most relevant for their mem-bership on their websites.)

Agency for Toxic Substances and DiseaseRegistry (ATSDR)www.atsdr.cdc.gov/HEC/primer.htmlA Primer on Health Risk CommunicationPrinciples and Practices

Agency for Healthcare Research andQuality (AHRQ)www.ahrq.gov/clinic/tp/biotrtp.htmTraining Clinicians for Public Health EventsRelevant to Bioterrorism Preparedness, anevidence report by the Johns Hopkins UniveristyEvidence-based Practice Center regardingeffective methods of training health careproviders about bioterrorism preparedness

American Academy of Dermatology(AAD)www.aad.org/BioInfo/BioInfo.htmlAAD educational materials that focus on thecutaneous manifestations of WMD

American Academy of Family Physicians(AAFP)www.aafp.org/btresponse.xmlAAFP activities, press releases, and educa-tional resources on WMD preparedness andresponse


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American Academy of Pediatrics (AAP)www.aap.org/terrorism/index.html“Children, Terrorism, and Disasters”, a com-pilation of resources and materials on disas-ters, bioterrorism, and psychological supportof children

American College of EmergencyPhysicians (ACEP)www.acep.org/1,4634,0.htmlACEP reports and guidelines regardingbioterrorism

American College of Physicians (ACP) www.acponline.org/bioterro/index.htmlACP activities, press releases, and education-al resources on WMD preparedness andresponse. Strong emphasis on anthrax andother biologic agents

American College of Surgeons (ACS)www.facs.org/civiliandisasters/intro.htmlACS reports: Disasters from Biological andChemical Terrorism—What Should theIndividual Surgeon Do?: A Report from theCommittee on Trauma and Statement onUnconventional Acts of Civilian Terrorism:A Report from the Board of Governors

American Medical Association (AMA)www.ama-assn.org/go/DisasterPreparednessAMA activities, press releases, and JAMAarticles related to WMD preparedness andresponse

American Psychiatric Association (APA)www.psych.org/pract_of_psych/disaster_psych.cfmEducational resources for psychiatrists inpreparing for and responding to disasters andother traumatic events

American Public Health Association(APHA)www.apha.org/united/APHA activities, press releases, and educa-tional resources on WMD preparedness andresponse from a public health perspective

American Society of Microbiology (ASM)www.asmusa.org/pasrc/bioprep.htmASM resources, including articles and reportsassociated with biologic agents

Association of American MedicalColleges (AAMC)www.aamc.org/newsroom/bioterrorism/AAMC activities, press releases, and sum-maries of federal activities associated withWMD preparedness and response

Association of Medical SchoolMicrobiology and Immunology Chairs(AMSMIC)www.amsmic.org/educational_links.htmlPresentation on a study of the opinions ofmicrobiology chairs with regard to teachingbioterrorism related topics to medical students

Association of State and TerritorialHealth Officials (ASTHO)www.astho.org/index.php?template=1bioterrorism.htmlASTHO activities, press releases, and educa-tional resources on WMD preparedness andresponse from the perspective of state healthdepartments

Association for Professionals in InfectionControl and Epidemiology (APIC)www.apic.org/bioterror/Links to a broad range of WMD educationalresources from government agencies andprofessional societies


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Center for Civilian Biodefense Strategieswww.hopkins-biodefense.org/index.htmlAn independent, non-profit organization ofthe Johns Hopkins Bloomberg School ofPublic Health and the School of Medicine, theCenter for Civilian Biodfense Strategiesaddresses a broad spectrum of science andpolicy issues associated with bioterrorism.The Clinician’s Biodefense Network, a free,not-for-profit email and web-based systemthat was created to facilitate communicationand information exchange among cliniciansin the event of a bioterrorism event, ishoused here.

Centers for Disease Control andPrevention (CDC)www.bt.cdc.gov/CDC activities, press releases and educationalresources on WMD preparedness and response

Federal Emergency Management Agency(FEMA)www.fema.govCurricular materials and other informationregarding emergency management systems

Food and Drug Administration (FDA)www.fda.gov/oc/opacom/hottopics/bioterrorism.htmlFDA counter-terrorism initiatives and infor-mation on food safety

Infectious Diseases Society of America(IDSA)www.idsociety.org/BT/ToC.htmIDSA educational materials, including medicalsummaries and clinical pathways, slide sets,and other images associated with bioterrorismagents

National Association of County and CityHealth Officials (NACCHO)www.naccho.org/NACCHO-RespondsToBT.cfmNACCHO activities, press releases and educa-tional resources on WMD preparedness andresponse from the perspective of local healthdepartments

National Library of Medicinewww.nlm.nih.gov/medlineplus/biodefenseandbioterrorism.htmlLinks to updated Internet references fromgovernment, academic, and other sources

Society for Healthcare Epidemiology ofAmerica (SHEA)www.shea-online.org/BTprep.htmlSummaries of CDC updates on bioterrorism-related clinical issues and links to other sites.

Uniformed Services University of theHealth Scienceswww.usuhs.milDisaster/terrorism care resources from theirCenter for the Study of Traumatic Stress, aswell as an online version of the MedicalManagement of Radiological CasualtiesHandbook, Second Edition, published inApril 2003

U.S. Army Medical Research Institute ofInfectious Diseases (USAMRIID) www.usamriid.army.mil/education/bluebook.htmlOnline version of USAMRIID’s February 2001edition of Medical Management of BiologicCasualties Handbook


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U.S. Army Medical Research Institute ofChemical Defense (USAMRICD)http://ccc.apgea.army.mil/products/handbooks/books.htmOnline versions of many handbooks andguides, including USAMRICD’s August 1999edition of Medical Management of ChemicalCasualties Handbook and Medical Managementof Radiological Casualties Handbook.

Virtual Naval Hospitalwww.vnh.org/Providers.html#NBCComprehensive list of links for informationon biological, chemical and nuclear warfareand radiation safety

WaterHealthConnection.orgwww.waterhealthconnection.orgRecognizing Waterborne Disease and theHealth Effects of Water Pollution, a compre-hensive on-line reference designed for physi-cians on water quality, safety, and healthissues. Includes a section titled PhysicianPreparedness for Acts of Water Terrorism,with direct links to many of the resourceslisted above. Topics range from clinical sub-ject areas, to epidemiology, to risk communi-cation. CME offering sponsored by theAmerican College of Preventive Medicine.

Published ResourcesDarling RG, Eitzen EM, Mothershead JL andWaeckerle JF, ed. May 2002 EmergencyMedicine Clinics of North America:Bioterrorism. WB Saunders and Co:Philadelphia, PA, 2002.

Knobler SL, Mahmoud AAF and Pray, LA, ed.Biological Threats and Terrorism: Assessingthe Science and Response Capabilities.National Academy Press: Washington, DC,2002.

Novick LF, Marr JS, ed. Public Health Issuesin Disaster Preparedness: Focus onBioterrorism. Aspen Publishers, Inc: NewYork, NY, 2001.


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Although integrating WMD subjects into thealready-full curriculum of medical students isa challenge, the insertion of WMD-basedexamples and cases into the existing basicscience and clinical curriculum may be aneffective and relatively uncomplicated firststep. The current focus on WMD preparednessand response also highlights what has been adeficit in the education of many medical stu-dents—-an understanding of their role in theirpublic health system. An effective responseto a public health emergency, such as the useof a WMD, requires a physician workforce thatis familiar with the resources and interven-tions of their local and state health agencies.The learning objectives and learning activi-ties for medical students should reflect theneed for a greater familiarity with potentialWMD agents, as well as an understanding oftheir roles and responsibilities as physicianswithin the public health system. Because thescience, scope, and context of WMD-relatedtopics will continue to evolve, medical stu-dents must be encouraged to stay abreast ofnew developments as they continue theirtraining and begin their practices.


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Bioterrorism Education for Medical StudentsExpert Panel

Jean Bartels, Ph.D., R.N.Chair and Professor of Nursing

Georgia Southern University School of Nursing

Ronald Blanck, D.O.President

University of North Texas Health Science CenterTexas College of Osteopathic Medicine

Luciana Borio, M.D.Senior Fellow

Johns Hopkins Center for Civilian Biodefense Strategies

Jacqueline Cattani, Ph.D.Center Director

Center for Biologic Defense University of South Florida College of Public Health

Richard Coico, Ph.D.Professor and Chairman

Department of Microbiology and ImmunologyCity University of New York Medical School

N. Lynn Eckhert, M.D., Dr.P.H.Professor of Family Medicine and Community Health

University of Massachusetts Medical School

R. Gregory Evans, Ph.D., M.P.H.Director

Center for the Study of Bioterrorism and Emerging InfectionsSaint Louis University School of Public Health

Tee L. Guidotti, M.D., M.P.H.Director

Division of Occupational Medicine and ToxicologyDepartment of Medicine

School of Medicine and Health SciencesThe George Washington University Medical Center


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Gabor D. Kelen, M.D.Professor and Chair

Johns Hopkins University Department of Emergency MedicineDirector

Johns Hopkins Office of Critical Event Preparedness and Response

Maureen Y. Lichtveld, M.D., M.P.H.Associate Director for Workforce Development

Public Health Practice Program OfficeCenters for Disease Control and Prevention

Mack Lipkin, Jr., M.D.Director, Division of Primary Care

Department of MedicineNew York University School of Medicine

John F. Mahoney, M.D.Assistant Dean for Medical Education

University of Pittsburgh School of Medicine

David Mallott, M.D.Associate Dean, Medical Education

University of Maryland School of Medicine

Lois Margaret Nora, M.D., J.D. (Chair of the Panel)President and Dean

Northeastern Ohio Universities College of Medicine

CDR Barry A. Wayne, M.D.Assistant Professor

Department of Military and Emergency MedicineUniformed Services University of the Health Sciences

Kevin Yeskey, M.D.Director

Office of Emergency ResponseEmergency Preparedness and Response Directorate

Department of Homeland Security


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AAMC Staff

Deborah Danoff, M.D.Associate Vice President

Division of Medical EducationAssociation of American Medical Colleges

Rika Maeshiro, M.D., M.P.H.Senior M.D. Research AssociateDivision of Medical Education

Association of American Medical Colleges

Rajeev Sabharwal, M.P.H.Staff Associate

Division of Medical EducationAssociation of American Medical Colleges


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