Novel EIDs or deliberately released biowarfare agents will be extremely difficult to recognize via clinical presentation alone, in an initial casualty or set of casualties. This is because these agents will not fit into the typical clinical reasoning paradigm and the downstream effects of delayed diagnosis can be significant, especially in an austere, deployed environment (Figure 3). Other health threats to consider include DNBI and environmental/occupational exposures.
A deliberate release of a biowarfare agent will likely be completed before the local commander or medical advisor are aware that it has taken place.25 However, a well-trained and vigilant medical staff, force health protection measures, preventive medicine services IAW JP 4-02 and optimal use of laboratory assets can help aid earlier recognition/mitigation and be potentially instituted even before a definitive diagnosis is made. The approach in the following sections integrates the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) steps in the management of potential biological casualties,25,27 current JTS CPGs, U.S. doctrinal documents, and NATO resources. The overall approach is summarized in Figure 4, Figure 5, and Figure 6 below.