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By definition, the cold zone should be completely uncontaminated. Nevertheless, victims exposed to certain biological warfare agents may develop disease that can be transmitted to others. This situation then poses a risk of secondary spread to medical personnel. The type of protective equipment 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 biological-associated disease spread by respiratory droplet (such as smallpox or pneumonic plague) or airborne particles (possibly smallpox) when treating victims with obvious disease. Disposable HEPA filter masks also work.
  • Evidence exists that smallpox may be transmitted by airborne particles under certain circumstances. Some people develop a very dense rash and severe cough when infected with smallpox. These victims are also likely to have many lesions involving the mouth and throat. During bouts of severe cough, they may shed virus into the air. One well-documented episode of this form of transmission occurred at the Meschede Hospital in Germany in January 1970.
  • Medical personnel should wear latex gloves while handling the skin of people with smallpox, because smallpox may potentially be transmitted by contact with pox lesions that have not yet crusted over.
• Blood or body fluid
  • While in contact with victims with biological-associated disease spread by blood or body fluid contact (hemorrhagic fever from Ebola, for example), level D PPE (standard precautions) is generally protective. Higher levels of protection may be necessary, however, if such victims have coughing or extensive bleeding.

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