By Philip K. Russell
Johns Hopkins University, Baltimore, Maryland
The growing awareness of the possibility that a terrorist organization might use a biologic agent in an attack on a civilian target in the United States raises important questions about our capability as a nation to respond effectively to the threat and to deal with the consequences of an attack. The article by Kaufmann et al. in this issue of Emerging Infectious Diseases describes three possible biologic attack scenarios and uses an economic analysis to describe the benefits of a rapid medical response and early intervention. The authors conclude that major reductions in morbidity and mortality and consequent cost savings can be achieved by early intervention. The effectiveness of postattack intervention depends on a rapid response which requires prior planning, preparation, and training. Achieving the level of preparedness implied by the assumptions stated in the article will require a major national effort. This discussion of possible bioterrorist attack scenarios adds to a growing concern about our willingness as a nation to commit the effort and resources necessary to protect our citizens.
Biologic warfare and use of biologic weapons by terrorists have only recently been discussed openly and realistically. The fall of the Soviet Union and the defeat of Iraq uncovered extensive biologic weapons programs of surprising sophistication and diversity. The threat to the nation from biologic weapons is no longer a debate issue. Now the questions are how immediate and serious is the threat and how do we respond effectively?
Protecting the armed forces against biologic weapons, although complex and difficult, is less challenging than protecting the civilian population. The armed forces are relatively small populations that can be vaccinated against the major threat agents. Aerosols containing biologic materials can be detected at a distance, and protective masks and suits are effective. Military medical personnel are trained to recognize and treat casualties, and antibiotics, antiviral drugs, and antitoxins can be stockpiled for military contingencies. The preponderance of scientific expertise for many of the threat agents is within the military medical research laboratories, although this capability is now being seriously compromised by budget cuts and personnel reductions.
The civilian population cannot be protected in the same manner as the armed forces. We must rely heavily on our intelligence and criminal investigation agencies and on international efforts to identify specific threats and deter terrorists. We must also recognize the possibility that a determined terrorist organization may not be deterred, may evade detection, and may succeed in releasing an aerosol of a virulent bacterium, virus, or toxin in a susceptible target area such as an airport or stadium. Our current capability to effectively respond to such a scenario and minimize the impact is far less than needed.
The U.S. Armed Forces and the Department of Defense have the greatest capability in biologic defense, but the responsibility for dealing with the threat of biologic weapon use by a terrorist falls on multiple federal, state, and municipal agencies and the civilian health care community. Most of the organizations are inadequately prepared to deal effectively with the problem.
The organizational aspects of dealing with an attack on our civilian population are daunting. Responsibility for recognizing an unusual outbreak of illness that may be the result of the deliberate release of a biologic warfare agent will fall on the health care community. Early recognition will be an important factor in determining the overall outcome and will depend on the level of suspicion and knowledge of the health care providers that see the initial cases. Rapid, precise, and reliable diagnosis will be the responsibility of the federal and state public health laboratory system with help from their military colleagues. Organizing and managing the care of patients and mounting the appropriate public health response will involve local health care and municipal agencies and authorities and state public health authorities. The effectiveness of coordination, support, and leadership at the federal level may make huge differences in reducing death rates and containing the possible secondary spread of a communicable disease. The Federal Emergency Management Agency has the major responsibility for planning and coordinating the consequences phase of a federal response, but the level of preparedness at all levels will ultimately determine the outcome.
If we take the biologic warfare threat seriously, a major effort will be needed to develop contingency plans and initiate coordinated and mutually supportive programs in all involved agencies. Training and education of the health care community will require a major effort involving several major professional organizations. Developing and improving diagnostic and identification capability is essential for medical care, public health, intelligence, and law enforcement agencies and should be a national priority.
The science base needed to deal with the broad spectrum of agents on the threat list, bacteria, viruses, toxins, and parasites, is widely distributed among several federal laboratories in the Department of Health and Human Services, the Department of Defense, and the Department of Energy, as well as in universities and state public health laboratories.
In addition, since many of the biologic agents are not normally large public health problems or popular subjects of scientific research, critical areas have inadequate research capability and limited expert personnel. Deficiencies in our scientific knowledge and a paucity of experts will ultimately limit our capability to rapidly and precisely identify agents and respond effectively in a crisis. For example, the global molecular epidemiology of the agents at the top of the threat list is critically important for identifying the organisms accurately and differentiating local from exotic strains. Current databases are inadequate, and no organized effort is being made to fill in the gaps.
The current public discussion of the threat of biologic terrorism is an opportunity to evaluate our collective capabilities and to assess weaknesses and vulnerabilities. Raising the level of national preparedness will require leadership and action by responsible federal agencies. A thoughtful analysis of the consequences of unpreparedness provides a mandate for action.
Source: Emerging Infectious Diseases Journal
National Center for Infectious Diseases
Centers for Disease Control and Prevention
v Bioterrorism: How Prepared Are We?
Richard Preston’s The Cobra Event, which he dedicates to public health professionals, weaves a chilling, but compelling tale about a lone terrorist’s attack on Manhattan with a genetically engineered virus. Preston’s thought-provoking novel raises a logical question: How do we successfully contain and combat the threat of bioterrorism? To meet this emerging threat, we must address four important challenges.
The first challenge is to be aware that an act of bioterrorism could happen. Its likelihood is entirely unknown, and an attack may never occur. However, we have seen terrorism emerge as one of the thorniest problems of the post-cold war era, and we have seen that terrorists are always searching for new weapons. We have already seen sarin nerve gas released in the Tokyo subway. Somewhere, sometime in the future, terrorists may well threaten to use, or attempt to use, a biological weapon against the United States. When discussing the possibility of a terrorist attack in the next few years, the president unequivocally stated, "This is not a cause for panic. It is cause for serious, deliberate, disciplined, long-term concern." In other words, we must not be afraid, but we must be aware.
To increase our level of preparedness, the initiative is expanding its activities in a number of key areas: surveillance, medical and public health response, building a stockpile of drugs and supplies, and research and development. We are improving and strengthening the U.S. public health surveillance network by enhancing our capability to detect and report outbreaks, conduct epidemiologic investigations, perform laboratory tests to identify biological agents, and communicate necessary information and advisories rapidly through electronic technology.
We are enhancing our medical and public health response capacity by spearheading an administrationwide effort to develop infrastructure at the local level by establishing in major American cities medical response teams to deal with the consequences of bioterrorism. We are also expanding our capacity to provide prophylaxis, medical care, and infection control on a massive scale. We are creating, and will be maintaining, an unprecedented national stockpile of drugs and vaccines for civilian use in case of a bioterrorist attack.
Finally, we are accelerating our research and development of rapid diagnostics, drugs, and vaccines, so we can more effectively address the threats and consequences of a bioterrorist attack. In addition, we will continue our work on the genome sequencing of organisms most likely to be used as bioweapons, so that we can not only quickly identify the biological agent, but also develop effective therapies. Our efforts in surveillance, medical and public health response, stockpile provision, and research and development will increase significantly our preparedness for bioterrorism.
If we want to be truly prepared, our third challenge is for the public health and medical communities to take the lead in our fight against bioterrorism. In a conventional terrorist attack, local "first responders," such as the police, firefighters, and paramedics, constitute the first line of defense. With bioterrorism, the public health and medical communities stand directly on the front lines. How well we respond to a threat or attack will depend on the preparedness of our public health and medical communities. For example, if a bioterrorist threat is issued—perhaps someone claims to have released a deadly pathogen in a public place—physicians must be able to recognize and report cases that come to attention in emergency rooms and doctors’ offices; public health officials must be able to conduct investigations to establish the likely site/time of exposure, the size and location of the exposed population, and the prospects for secondary transmission; and appropriately traned laboratory personnel must be available to identify the biological agent.
Whether the release of a bioweapon is announced or surreptitious, affected persons may not have symptoms for days or even weeks, and by then they would be geographically dispersed. Quarantine is not practical because only one of the major biological agents—smallpox—is communicable. Even with smallpox, it would be impossible to know whom to quarantine because of the spread of disease by secondary transmission and the difficulty in accurately identifying those who have been exposed. A strong electronic communications network would be needed to piece together early reports, as well as epidemiologic and laboratory data, to determine what had happened so that public health and law enforcement officials can take prompt action. The Centers for Disease Control and Prevention would play an important role in this process because of its particular expertise in surveillance, infectious disease, and public health. Everyone from the physicians who first see victims to the scientists who identify the infectious agents must coordinate their efforts.
That brings me to the fourth, and final, challenge: We must all work together. In the fight against bioterrorism, the federal government, particularly HHS, has a leadership role. Among other things, we need to support state and local planning efforts, provide training at every level, develop an infrastructure for delivering mass medical care, and offer expertise to our communities.
This is a fight we certainly cannot win by ourselves. Across the board, we must forge new working partnerships among health, public safety, and intelligence agencies. We need unprecedented cooperation among the federal government, state and local health agencies, and the medical community. We must ensure that plans for managing the medical consequences of terrorist acts are well integrated and coordinated with other emergency response systems.
Close collaborative efforts are necessary also because microbes do not respect boundaries of culture, language, or territory. An act of bioterrorism cannot be contained by any national border or barrier. When it comes to microbes, we are not protected, in the words of the Indian poet Tagore, "by narrow domestic walls." Since these organisms recognize no boundaries, in our battle against them, neither can we. Because we share a common future, we must share a common resolve. As Dr. Gro Bruntland, the director-general of the World Health Organization, has said, when it comes to public health and safety, "Solutions, like the problems, have to be global..." As we work together to counter bioterrorism, we must pool our will and our resources to meet the challenges.
Source: Emerging Infectious Diseases Journal
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Donna E. Shalala
Ex-U.S. Secretary of Health and Human Services