By Alan Melnick

Emergency preparedness for the first care general practitioner -- organic terrorism -- Chemical terrorism -- Radiological terrorism -- psychological wellbeing and fitness and terrorism -- the first care physician's function in helping the general public well-being reaction to organic, chemical, and radiological terrorism

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The outbreak in Northern India caused 1,400 deaths. Studies of the Manchurian outbreaks suggested that indoor exposure, cold temperature, increased 34 2 Biological Terrorism humidity and crowding were risk factors for transmission (23). More recently, in 1997 one patient in Madagascar with pneumonic plague transmitted the infection to 18 others, resulting in eight deaths (23). Plague remains a rare but reportable disease in the United States, with 390 cases reported from 1947 to 1996. Of these cases, 84% were bubonic, 13% septicemic, and 2% were pneumonic (23).

Los Angeles was the site of the last person-toperson transmission in the United States in 1924 (23). In the United States, most plague cases naturally occur in the summer, when exposure to infected fleas is most likely. Most cases, especially in the Southwest, occur at or near the case’s residence, and are associated with conditions that provide food and shelter for potentially infected rodents. Participation in recreational activities, especially in California, has also resulted in plague cases, although less frequently (22).

An infected flea can transmit thousands of plague bacilli through the skin. Once inoculated, the bacilli migrate through lymphatics to regional lymph nodes, where they resist destruction by phagocytosis. Instead, they proliferate, destroying the node architecture and causing bacteremia, septicemia and endotoxemia, leading to shock, disseminated intravascular coagulation (DIC) and coma (22,23). Bubonic plague symptoms develop 2–8 days after the fleabite. Patients experience a sudden onset of fever, chills, and weakness.

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