eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Personal Protective Equipment

Author: Kermit D Huebner, MD, FACEP, Research Director, Carl R Darnall Army Medical Center
Coauthor(s): Eric J Lavonas, MD, FACEP, Associate Director, Rocky Mountain Poison and Drug Center; Assistant Professor, University of Colorado School of Medicine; Jeffrey L Arnold, MD, FACEP, Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Jun 16, 2008

Introduction

Personal protective equipment (PPE) refers to the respiratory equipment, garments, and barrier materials used to protect rescuers and medical personnel from exposure to biological, chemical, and radioactive hazards. The goal of PPE is to prevent the transfer of hazardous material from patients or the environment to health care workers. Different types of PPE may be used depending on the hazard present.

The types of hazards addressed in this article include biological warfare agents (BWAs), chemical warfare agents (CWAs), and radioactive agents. The most common routes of exposure to these hazards include inhalation, dermal contact, and ingestion.

Routes of Exposure to Hazards

Routes of exposure to biological warfare agents

Exposure to BWAs is most likely to occur by inhalation of biological aerosols. BWA particles of 1-5 µm in diameter are inhaled most efficiently into the pulmonary alveoli. Mucous membranes or abraded skin are also vulnerable and require protection against BWAs. Conversely, dermal contact does not pose a significant risk because intact skin provides an effective barrier to all BWAs except trichothecene mycotoxins. An insignificant amount of aerosolized BWA particles adhere to clothing or skin after open-air dissemination.

In general, environmental contamination and generation of secondary aerosols pose minimal risks with this method of delivery. Release of aerosolized BWA particles in an enclosed space can result in significant contamination and an increased potential for the formation of secondary aerosols. Other possible routes of exposure for BWA include ingestion and percutaneous delivery, depending on the biological agent used. Ingestion is a minor route of exposure but inadvertently may occur with hand-to-mouth contact or by swallowing contaminated secretions.

Routes of exposure to chemical warfare agents

Exposure to chemicals and CWAs occurs by inhalation of chemical gas or vapor. Exposure also occurs by direct contact of the eyes or skin to chemical vapor or liquid. Mucous membranes are particularly vulnerable because moisture promotes the absorption of many chemicals. Ingestion is a minor route of exposure.

Routes of exposure to radioactive agents

Patients exposed to beams of ionizing radiation (eg, patients receiving diagnostic radiography) do not emit radiation and, therefore, pose no radiation danger to others. In the setting of an explosion, fire, or spill of radioactive material, victims can become contaminated with radiation-emitting material. External contamination occurs when radioactive material gets on a victim's clothing, skin, or hair. Victims can also become contaminated internally if radioactive material enters the body through the GI tract, an open wound, or less likely, inhalation of highly radioactive dust. In any situation, the goal of personal protective equipment (PPE) is to prevent the transfer of radioactive material from the victim to the rescuer until the victim is decontaminated.

Civilian Personal Protective Equipment

Civilian personal protective equipment (PPE) refers to the PPE typically worn by civilian rescue or emergency care workers. The goal of civilian PPE is to protect emergency personnel while they perform essential response functions in contaminated environments or with contaminated patients. Various types of emergency personnel require PPE, including first responders working in the hot zone (exclusion zone or contaminated area), emergency medical personnel involved in field decontamination, and hospital personnel involved in decontamination at the hospital. Physicians rarely require high level PPE unless they are participating in prehospital response (usually as part of a specialized team) or providing medical care to contaminated patients at the hospital. Standard precautions are required when caring for all patients. Transmission-based precautions should be instituted based on the patient's disease.

Many types of PPE are currently available, ranging from maximum protection with a positive pressure respirator and total body encapsulation to minimum protection with a simple surgical mask and a pair of latex gloves. The various types of protective respiratory devices and clothing are described below.

Protective Respiratory Devices

Two basic types of respirators are available: atmosphere supplying (self-contained breathing apparatus [SCBA], supplied-air respirator [SAR]) and air purifying respirator (APR).

Self-contained breathing apparatus

SCBA consists of a full facepiece connected by a hose to a portable source of compressed air. The open-circuit, positive-pressure SCBA is the most common type. This SCBA provides clean air under positive pressure from a cylinder; the air then is exhaled into the environment. Negative-pressure SCBAs are prohibited by Occupational Safety and Health Administration (OSHA) regulations for hazardous materials (HAZMAT) incidents.¹ SCBA provides the highest level of respiratory protection.

Supplied-air respirator

SAR consists of a full facepiece connected to an air source away from the contaminated area via an airline. Because SARs are less bulky than SCBA, they can be used for longer periods. SARs are also easier for most hospital personnel to use. Although negative-pressure SARs are available, positive-pressure SARs are recommended for HAZMAT incidents. SARs, like SCBA, provide the highest level of respiratory protection.

Air-purifying respirator

An APR consists of a facepiece worn over the mouth and nose with a filter element that filters ambient air before inhalation. Three basic types of APRs are available: powered, disposable, and chemical cartridge or canister. Powered air-purifying respirators (PAPRs) deliver filtered air under positive pressure to a facepiece mask, helmet, or hood, which provides respiratory and ocular protection. Nonpowered APRs operate under negative pressure, depending on the inspiratory effort of the wearer to draw air through a filter. Because PAPRs function under positive pressure, they provide the greatest degree of respiratory protection. Various chemical cartridges or canisters, which eliminate various chemicals including organic vapors and acid gases, are available.

Disposable APRs are usually half masks, which do not provide adequate eye protection. This type of APR depends on a filter, which traps particulates. The use of a high-efficiency particulate air (HEPA) filter or use in combination with a chemical cartridge enhances disposable APRs.

One measure of respiratory filtration efficiency relevant to BWA exposures is the percent penetration of droplet nuclei into the facepiece. For exposures to biological aerosols, PAPRs with HEPA filters are most efficient, followed by elastomeric half-mask HEPA filter respirators and non-HEPA disposable APRs.

All APRs are limited by the adequacy of their face seals. Accordingly, APRs do not provide adequate respiratory protection in environments immediately dangerous to life or health (IDLH).²

High-efficiency particulate air filter

HEPA filters remove particles of 0.3-15 µm diameter with an efficiency of 98-100%, efficiently excluding aerosolized BWA particles in the highly infectious 1- to 5-µm range. HEPA filters are incorporated into various protective respiratory devices including PAPRs and elastomeric half-mask respirators (see Air-purifying respirator). This type of filtration is required when caring for a patient infected with a disease requiring "airborne precautions" such as smallpox and viral hemorrhagic fevers.

Surgical mask

Surgical masks are designed to protect the sterile field of the patient from contaminants generated by the wearer. Although surgical masks filter out large-size particulates, they offer no respiratory protection against chemical vapors. These masks are effective against respiratory droplets and are used when treating infected patients who require "droplet precautions" such as pneumonic plague.

Protective Clothing

Most protective clothing is aimed at protection against chemicals and CWAs because intact skin provides an effective barrier against all BWAs except the trichothecene mycotoxins.

Chemical-protective clothing

Chemical-protective clothing (CPC) consists of multilayered garments made out of various materials that protect against various hazards. Because no single material can protect against all chemicals, multiple layers of various materials are usually used to increase the degree of protection. Aluminum-lined, vapor-impermeable garments increase the level of protection. Protection is maximized by total encapsulation. An assortment of types of chemical-protective hats, hoods, gloves, and boot covers complements the garments.

Barrier gown and latex gloves

Barrier gowns are waterproof and protect against exposure to biological materials, including body fluids, but do not provide adequate skin or mucous membrane protection against chemicals. Latex gloves also protect wearers from biological materials but are inadequate against most chemicals. Barrier gowns, latex gloves, and leg and/or shoe covers together comprise "contact precautions" and are useful for agents such as viral hemorrhagic fevers.

Military Personal Protective Equipment

Military personal protective equipment (PPE) refers to the protective respiratory devices, garment ensembles, gloves, and footwear covers worn by military personnel. The purpose of military PPE is to protect military personnel from chemical, biological, and radioactive hazards, while enabling these personnel to accomplish their assigned missions. In general, military PPE used for CWA exposures also protects against BWAs. The PPE used by the US military is not available for civilian use.

M40 mask

The M40 mask is a full-face chemical and biological protective mask that protects the respiratory tract, eyes, and mucous membranes in a manner similar to a nonpowered APR. Available in 3 sizes, the M40 mask combines the protective mechanisms of a charcoal filter against CWA vapors (especially nerve agents and vesicants) and a HEPA filter against BWA particles in 1 screw-on filter canister. Maintenance of this filter canister is critical. Filter canisters must be replaced every 30 days, whenever filter elements are damaged physically or immersed in water, or when excessive breathing resistance is encountered. Other features include 2 voicemitters for communication, optical inserts for visual correction, and a drinking tube.

Battledress overgarments

Battledress overgarments (BDOs) are 2-layered chemical protective overgarments that contain an inner layer of activated charcoal to adsorb penetrating chemical liquids and vapors. BDO also protects against BWAs and radioactive alpha and beta particles. Available in 8 sizes and woodland or desert camouflage patterns, BDOs may be worn up to 24 hours in a contaminated environment. Contaminated BDOs must be incinerated or buried.

Joint Service Lightweight Integrated Suit Technology

The Joint Service Lightweight Integrated Suit Technology (JSLIST) is a replacement for the battle dress overgarment. This 2-piece garment is composed of high waist trousers and a waist length jacket that has an integral hood. A selectively permeable membrane replaces the activated charcoal layer used in the BDO. JSLIST can be worn in an uncontaminated environment for 45 days with up to 6 launderings or 120 days with no laundering. In contaminated environments, the JSLIST may be worn for 24 hours.

Chemical-protective gloves

Chemical-protective glove sets consist of a protective outer glove made out of butyl rubber and an inner glove for absorption of perspiration. Glove sets are available in 4 sizes and 3 thicknesses (7, 14, and 25 mL) with varying tactile sensitivities. Gloves may be worn for 12 hours in the contaminated environment. After visual inspection, gloves may be reused for another 12 hours. After use, gloves may be decontaminated and reused.

Chemical-protective footwear covers

Chemical-protective footwear covers (CPFC) are single-sized butyl rubber footwear covers that protect combat boots against all agents. Vinyl overboots are also available.

Patient protective wraps

Patient protective wraps (PPWs) or casualty wraps are chemical-protective and biological-protective wraps for casualties in contaminated environments in which personnel are unable to wear BDOs. The top of the PPW has a charcoal lining similar to the BDO, whereas the bottom is constructed of impermeable rubber. Breathing occurs through the permeable PPW top, which functions as a protective respiratory mask.

Wartime personal protective equipment for civilians

The chemical infant protective system (CHIPS) is a semiclosed hoodlike system designed to protect infants in contaminated environments.³ This protective device delivers filtered air via a battery-operated blower. CHIPS is available for civilian use in Israel.

Levels of Personal Protective Equipment

Civilian Personal Protective Equipment

Level A

Level A PPE consists of a SCBA and a totally encapsulating chemical-protective (TECP) suit. Level A PPE provides the highest level of respiratory, eye, mucous membrane, and skin protection.

Level B

Level B PPE consists of a positive-pressure respirator (SCBA or SAR) and nonencapsulated chemical-resistant garments, gloves, and boots, which guard against chemical splash exposures. Level B PPE provides the highest level of respiratory protection with a lower level of dermal protection.

Level C

Level C PPE consists of an APR and nonencapsulated chemical-resistant clothing, gloves, and boots. Level C PPE provides the same level of skin protection as Level B, with a lower level of respiratory protection. Level C PPE is used when the type of airborne exposure is known to be guarded against adequately by an APR.

Level D

Level D PPE consists of standard work clothes without a respirator. In hospitals, Level D consists of surgical gown, mask, and latex gloves (universal precautions). Level D PPE provides no respiratory protection and only minimal skin protection.

Military Personal Protective Equipment

Military PPE also has been graded into levels, which are known as mission-oriented protective postures (MOPP). Seven levels of MOPP have been defined, ranging from MOPP ready (prepared to use MOPP gear within 2 h) to MOPP 4 (maximum protection in protective respiratory mask and BDO). The higher the level of MOPP, the greater is the level of protection (and greater is the negative impact on individual performance).

Choice of Personal Protective Equipment

Emergency care personnel who provide medical care to victims of hazardous incidents have the responsibility of first protecting themselves by wearing adequate PPE. Whenever possible, select the level of PPE based on the known properties of the hazard. When the type of hazard is unknown, assume a "worst case" exposure and use the highest level of adequate PPE.

The primary consideration in selecting appropriate PPE is whether it will be worn in the hot zone (exclusion zone or contaminated area) or in the warm zone (contamination reduction zone or area where decontamination of patients takes place). Because patients and equipment should be decontaminated thoroughly before leaving the warm zone, PPE is unnecessary in uncontaminated areas (except as noted below).

Hot Zone

The hot zone is IDLH. Accordingly, Level A PPE with SCBA or SAR is required for first responders or other personnel working inside the hot zone, where contact with HAZMAT is likely, including chemical gas or vapors, biological aerosols, or chemical and/or biological liquid or powder residua. Incidents occurring in enclosed spaces with poor ventilation increase the risk of inhalation.

Warm Zone

The warm zone is an uncontaminated environment into which contaminated victims, first responders, and equipment are brought. In classic HAZMAT response, the warm zone is adjacent to and upwind from the hot zone. However, experience with previous disasters indicates that contaminated victims capable of fleeing the hot zone are likely to bypass emergency medical services (EMS) and go directly to the nearest hospital, in which case the warm zone may occur outside the emergency department or even inside the hospital.

Accordingly, the warm zone poses the risk of contaminated victims and equipment, which in turn depends on the type and route of exposure. In general, early recognition of the type of exposure is based on the clinical presentation of victims. The PPE required depends on whether victims were exposed to a BWA, CWA, radiological agent, or agent(s) of unknown identity. The route of exposure may be inferred from the presence of contaminant on the clothing and skin of victims.

Vapor or aerosol exposure leaves no or minimal contaminant on victims, and off gassing from the lungs does not occur. Liquid or powder exposures leave visible residua. For example, in the Tokyo subway sarin attack in 1995, approximately 90% of victims exposed to sarin vapor reported to medical facilities by private or public transportation without notable contamination of others. Secondary injury to hospital staff was minimal (mostly miosis) and did not necessitate specific treatment. In a similar manner, handling patients exposed to biological aerosols poses little risk to emergency care personnel outside the hot zone.

Known biological warfare agent hazards

• Personnel handling patients contaminated with BWAs require respiratory protection. Dermal protection is largely unnecessary because BWAs are not dermally active (with the single exception of the mycotoxins).
• Personnel handling victims who have been exposed to a known BWA aerosol are not required to wear PPE because secondary aerosolization of residual agent from clothing, skin, or hair is insignificant.
• When victims are contaminated with a known BWA liquid or powder, Level D PPE (universal precautions) and PAPR with HEPA filter are required until decontamination is complete. Level C PPE and PAPR with HEPA filter may be considered if residua on victims is suspected of containing mycotoxins.

Known chemical warfare agent hazards

• Personnel handling patients contaminated with CWAs require respiratory and dermal protection.
• When victims are exposed to a known CWA gas at standard temperature and pressure (eg, chlorine, phosgene, oxides of nitrogen, cyanide), no PPE is required, because off gassing is insignificant.
• When victims are exposed to a known CWA vapor from volatile liquid (eg, nerve agent, vesicant vapor), PPE is required because off gassing may result in low-level exposure of responders.
• When victims are contaminated with a known CWA volatile liquid (eg, nerve agent liquid, vesicant liquid), Level C PPE with PAPR and chemical cartridge is required until decontamination is complete. In general, Level C PPE is used when the inhalation risk is known to be below the concentration-time product expected to harm personnel and when eye, mucous membrane, and skin exposures are unlikely.

Known radiation hazards

• When victims are exposed to external radiation but not contaminated with a radiation-emitting source, no PPE is required. If any doubt surrounds whether victims or their clothing are contaminated, they should be surveyed with a Geiger-Müller counter.
• When victims are contaminated externally with radioactive material (skin, hair, wounds, clothes), use Level D PPE (ie, waterproof barrier materials, such as surgical gown, mask, gloves, leg, and/or shoe coverings; universal precautions) until decontamination is complete. Double layers of gloves and frequent changes of the outer layer help reduce the spread of radioactive material. Handle radioactive materials with tongs whenever possible. Lead aprons are cumbersome and do not protect against gamma or neutron radiation. For this reason, experts currently recommend against their use when caring for a radiation-contaminated patient. Health care workers should also wear radiological dosimeters while working in a contaminated environment. The health care facility radiation safety officer usually supplies these devices.
• When victims are contaminated internally with radioactive material, wear latex gloves when handling body fluids (urine, feces, wound drainage). The health care facility radiation safety officer or health physicist can determine when the amount of radioactivity in the patient's body secretions has fallen to a nondangerous level.

Unknown hazards (BWA, CWA, or both)

According to current US OSHA regulations, Level B PPE is required for emergency medical personnel responding to an unknown hazard. For hospital personnel using Level B PPE, SAR is recommended because SCBA is more cumbersome to use. Some experts maintain that Level C PPE with PAPR (with organic vapor cartridge and HEPA filter) provides adequate protection until decontamination is complete. Unfortunately, no single ensemble of PPE can protect emergency care personnel against all hazards.

Cold Zone

By definition, the cold zone should be completely uncontaminated. Nevertheless, patients exposed to certain BWAs may develop transmissible disease, which then poses a risk of secondary spread to medical personnel. The type of PPE required depends on the route of transmission of these infectious diseases.

Respiratory droplet/airborne particles

PAPR with HEPA filter provides the greatest degree of respiratory protection against BWA-associated disease spread by respiratory droplet (ie, smallpox, pneumonic plague) or airborne particles (possibly smallpox) when treating patients with overt disease. Disposable HEPA filter masks also suffice. Evidence suggests that smallpox may be transmitted by airborne particles under certain circumstances. Some patients develop a very dense confluent rash and severe cough when infected with variola. These patients are also likely to have many lesions involving the oral mucosa and pharynx. During bouts of severe cough, they may shed virus as an airborne aerosol. One well-documented episode of this form of transmission occurred at the Meschede Hospital in Germany in January 1970.^4,5 Medical personnel should wear latex gloves while handling the skin of patients with smallpox because smallpox is also transmitted by contact with pox lesions that have not yet crusted over.

Blood or body fluid

While in contact with patients with BWA-associated disease spread by blood or body fluid contact (ie, hemorrhagic fever viruses), wear Level D PPE (contact precautions).

Limitations of Personal Protective Equipment

Personal protective equipment (PPE) is associated with numerous potential limitations, as listed below. In general, higher levels of PPE are more difficult to use.

• Takes time to put on: Level A PPE takes the longest time to put on.
• Impaired dexterity: Some first responders or emergency care personnel may experience difficulty in performing some life-saving interventions.
• Impaired mobility: Mobility decreases with weight. Mobility is also limited by using a SAR because the wearer must retrace his or her steps along the supplied airline to exit hot zone.
• Impaired communication: Wearing a facepiece or mask commonly results in poor speech intelligibility.
• Impaired vision: Facepieces may also limit the wearer's visual field.
• Heat stress: Encapsulation and moisture-impermeable CPC material lead to heat stress.
• Increased weight: Level A with SCBA is the heaviest PPE.
• Psychological stress: Encapsulation increases the psychological stress to wearers and patients.
• Limited duration of use: Wearing Level A PPE for longer than 30 minutes is difficult.
• Limited oxygen availability: SCBAs only can be used for the period of time allowed by the air in the tank. APRs only can be used in environments in which the ambient air provides sufficient oxygen.

PPE is also associated with potential "hazards" or risks to wearers, as follows:

• Improper use: Protective respiratory devices and CPC must be properly fitted, tested, and periodically checked before use. An improper fit is an avoidable cause of penetration.
• Penetration: Penetration refers to the process by which HAZMAT may penetrate openings in protective respiratory equipment or clothing. The risk of penetration increases with the use of negative-pressure respirators.
• Permeation: Permeation refers to the process by which HAZMAT cross through protective barriers. Permeation depends on both the properties of the protective garment (or equipment) and concentration of chemical at surface. Permeation is measured in terms of the breakthrough time.
• Degradation: Degradation refers to the process by which structural characteristics of PPE are degraded by contact with chemical substances. Degradation allows permeation or penetration.
• Recontamination: Wearers may become contaminated during PPE removal unless decontamination and PPE removal protocols are followed systematically.

Personal Protective Equipment Training, Regulation, and Conclusion

Personal Protective Equipment Training

The use of any type of personal protective equipment (PPE) requires adequate training. The overall goals of PPE training are to protect the wearer from physical hazards (biological, chemical, radioactive) and to prevent injury from improper use or equipment malfunction. Appropriate training topics include hazard identification, medical monitoring, environmental surveillance, and the selection, use, maintenance, and decontamination of PPE.

Personal Protective Equipment and US Regulatory Agencies

Occupational Safety and Health Administration

US OSHA requires that first responders participating in community emergency response plans to HAZMAT incidents comply with hazardous waste operations emergency response (HAZWOPER) standards. Accordingly, emergency medical personnel responding to a HAZMAT incident in the US are required to wear an appropriate level of PPE. Furthermore, OSHA regulations require that a minimum of Level B PPE be used for emergency medical personnel responding to an unknown hazard. New OSHA standards also require that employees who serve as first responders to HAZMAT incidents receive 8 hours of initial training in the use of PPE.

OSHA's Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances provides PPE guidelines for hospital-based personnel. Minimum PPE for personnel involved in the hospital decontamination zone includes a NIOSH approved PAPR with a protective factor of 1,000 in combination with a HEPA/organic vapor/acid gas respirator cartridge, double layer protective gloves, chemical-resistant suit, and chemical-protective boots with all suit openings sealed with tape. Employees in the hospital post-decontamination zone require normal work clothes and PPE, as necessary, for infection control purposes, such as gloves, gown, and appropriate respiratory protection.

Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that accredited healthcare institutions in the US have emergency procedures that define the use of PPE during HAZMAT exposures. JCAHO specifically requires that every institution with an emergency department have a plan for treating at least 1 contaminated patient.

National Institute for Occupational Safety and Health

The US National Institute for Occupational Safety and Health (NIOSH) establishes the technical criteria for certification of respiratory protective equipment and makes recommendations for its use.

Conclusion

This article is intended as an introduction to the types and levels of PPE currently available. The optimal choice of PPE remains challenging because little scientific evidence is available to guide selection. Even OSHA regulations and expert recommendations may disagree at times, and neither is supported by demonstrations of increased safety or improved outcomes. Furthermore, higher levels of protection also increase costs, physical stress, and training requirements. Nevertheless, 2 important principles remain to guide the optimal choice of PPE. Whenever possible, choose the level of PPE based on the known properties of the hazard. When the types or properties of the hazard are unknown, assume a "worst case" exposure and use the highest level of adequate PPE.

For excellent patient education resources, visit eMedicine's Bioterrorism and Warfare Center. Also, see eMedicine's patient education article Chemical Warfare, Biological Warfare, and Personal Protective Equipment.

Multimedia

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Media file 1: Rescuer wearing Occupational Safety and Health Administration (OSHA) Level A protection. Note that he is encapsulated completely with a self-contained breathing apparatus (SCBA). This type of suit provides the highest degree of both dermal and respiratory protection and is appropriate for wear in an immediate danger to life and health (IDLH) environment (ie, hot zone). However, the garment severely limits communication and provides a great deal of heat stress (photo credit: Tom Blackwell, MD).

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Media file 2: Rescuer wearing Occupational Safety and Health Administration (OSHA) Level A protection, rear view. By definition, Level A protection incorporates either a self-contained breathing apparatus (SCBA, shown here) or a supplied-air respirator (SAR). The wearer is encapsulated completely (photo credit: Tom Blackwell, MD).

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Media file 3: Rescuer wearing Occupational Safety and Health Administration (OSHA) Level B protection. This type of suit provides excellent splash protection from the front, but the wearer is not encapsulated completely. Air is supplied by a self-contained breathing apparatus (SCBA, shown here) or supplied-air respirator (SAR). Level B protection is appropriate for workers performing patient care and decontamination in the warm zone, in which the victims and their clothing possibly are contaminated with a chemical that could evaporate or be absorbed through the skin (photo credit: Tom Blackwell, MD).

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Media file 4: Rescuer wearing Occupational Safety and Health Administration (OSHA) Level C protection. The dermal protection is the same as with Level B, but the rescuer now is breathing filtered air from a powered air-purifying respirator (PAPR) rather than supplied air from a tank. Because it avoids the weight and complexity of a self-contained breathing apparatus (SCBA) system, Level C protection is much easier to wear and causes less heat stress. Level C protection is appropriate for most activities in the warm zone, unless droplet and/or vapor levels are very high (photo credit: Tom Blackwell, MD).

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Media file 5: Bioterrorist Agents. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/bioterrorism.html.

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Media file 6: Chemical Terrorism Agents and Syndromes. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/chemical.html.

Keywords

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