from the suspected route of exposure, presence of infected or dying animals, and the discovery of suspicious actions or potential delivery systems Most of the primary biologic threat agents can be categorized as causing the subacute onset of effects (e.g., days after exposure); those effects can be divided into predominantly respiratory, neurologic, or dermatologic syndromes Thus, with a careful medical and epidemiologic history, physical examination, and limited, routine laboratory evaluation, an early suspicion of a biologic attack might be raised, and initial diagnostic impression considered, as outlined in Figure 132.1 This in turn could trigger appropriate requests for infectious disease consultation and more definitive laboratory testing, as well as early empiric therapy A similar approach, applied in the setting of unusual increases in patient volume or illness presentations, might also help practitioners to participate in the early recognition of a new or reemerging natural infectious disease (e.g., West Nile disease, severe acute respiratory syndrome [SARS], Middle East Respiratory Syndrome [MERS], monkeypox, Ebola, and pneumonic tularemia, to name some recent examples) If a pediatrician or emergency medicine physician recognizes, or even suspects, any such natural or intentional outbreak, immediate reporting to local and regional public health authorities is appropriate, even before a specific diagnosis can be confirmed Triage Considerations: Minimizing Spread of Infection As soon as ED staff suspect that a patient may be the victim of biologic terrorism, appropriate steps must take place to prevent or minimize exposure to limit the spread of disease The level of ED mitigation and preparedness activities will largely depend on the level of awareness of the disease outbreak For example, faced with a known release of smallpox by terrorists, EDs would need to take dramatic steps to protect staff and patients Such steps might include setting up screening stations outside of the hospital, staffed by clinicians wearing gowns, gloves, N-95 respirators, and eye protection If a child suspected to have smallpox were encountered at the screening station, he or she would need to be covered with a sheet, provided a mask, and escorted directly to a negative-pressure room for further evaluation and treatment Infection Prevention and Control specialists would need to provide guidance on specimen collection, handling, and testing Patients suspected to have smallpox should be moved to a specialized biocontainment facility as soon as possible In the event of a large outbreak, when the supply of scarce biocontainment beds is likely to be exhausted, airborne infection isolation rooms might be an acceptable alternative Should these also prove inadequate for the number of affected patients, the cohorting of patients in designated “smallpox wards” might be necessary