Bioterrorism In The United States: Threat, Preparedness, And Response
Over the last several years, a confluence of events – the World Trade Center bombing, the Tokyo subway sarin gas attack by the Aum Shinrikyo, and the bombing of the Murrah Federal Building in Oklahoma City – focused attention on the growing threat of terrorist use of chemical, biological, radiological, or nuclear (CBRN) weapons in the
United States. These developments gave rise to a set of perceptions – among policy makers and the public alike – that the United States is vulnerable to terrorist attack; that such attacks could entail the use of CBRN weapons; and that the United States has not been well prepared to deal effectively with such a challenge. Biological terrorism differs from other types of CBRN terrorism in that it would impose particularly heavy demands on the nation’s public health and health care systems. Although a chemical attack would also tax these systems, bioterrorism would impose especially stressful burdens. Yet, that same public health system is the crucial factor in an effective response. A highly effective public health system should make an important contribution to deterring the threat by demonstrably diminishing the gains of a potential attack. It also constitutes the “first line of defense” in the event deterrence or prevention fails. Ultimately, it will be the public health system that will be called on to mitigate and ameliorate the consequences of a terrorist attack using biological weapons.
A number of programs are underway to improve the health and medical dimensions of the national response to the threat of bioterrorism. Uncertainty exists, however, as to whether current programs are those that are most needed or whether they are being implemented in the most effective way possible. This uncertainty exists because to date there have been insufficient means to judge the efficacy of existing programs. This lack of criteria is the product of not having an analytic framework that establishes national requirements for an effective response derived from a comprehensive threat assessment. The development and application of a strategic framework is urgently needed. Making a contribution to the development of that framework is the purpose of this project.
Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response
The U.S. national civilian vulnerability to the deliberate use of biological and chemical agents has been highlighted by recognition of substantial biological weapons development programs and arsenals in foreign countries, attempts to acquire or possess biological agents by militants, and high-profile terrorist attacks. Evaluation of this vulnerability has focused on the role public health will have detecting and managing the probable covert biological terrorist incident with the realization that the U.S. local, state, and federal infrastructure is already strained as a result of other important public health problems. In partnership with representatives for local and state health departments, other federal agencies, and medical and public health professional associations, CDC has developed a strategic plan to address the deliberate dissemination of biological or chemical agents. The plan contains recommendations to reduce U.S. vulnerability to biological and chemical terrorism — preparedness planning, detection and surveillance, laboratory analysis, emergency response, and communication systems. Training and research are integral components for achieving these recommendations. Success of the plan hinges on strengthening the relationships between medical and public health professionals and on building new partner-ships with emergency management, the military, and law enforcement professionals.
Bioterrorism Readiness Plan: A Template for Healthcare Facilities
The Association for Professionals in Infection Control and Epidemiology (APIC) recognizes the importance of awareness and preparation for bioterrorism on the part of healthcare facilities. In cooperation with the Centers for Disease Control and Prevention (CDC), APIC offers this Bioterrorism Readiness Plan to serve as a reference document and initial template to facilitate preparation of bioterrorism readiness plans for individual institutions. This document is not intended to provide an exhaustive reference on the topic of bioterrorism. Rather it is intended to serve as a tool for infection control (IC) professionals and healthcare epidemiologists to guide the development of practical and realistic response plans for their institutions in preparation for a real or suspected bioterrorism attack. Institution-specific response-plans should be prepared in partnership with local and state health departments. Many of the facility bioterrorism planning components may be incorporated into existing disaster preparedness and other emergency management plans. These components may also be useful for identifying and responding to other infectious disease outbreaks in the community. Individual facilities should determine the extent of their bioterrorism readiness needs, which may range from notification of local emergency networks (i.e. calling 911) and transfer of affected patients to appropriate acute care facilities, to activation of large, comprehensive communication and management networks.
Hospitals and clinics may have the first opportunity to recognize and initiate a response to a bioterrorism-related outbreak. Healthcare facilities should have IC policies in place authorizing the healthcare epidemiologist, IC committee chairman, or designee to rapidly implement prevention and control measures in response to a suspected outbreak. Should a bioterrorism event be suspected, a network of communication must be activated to involve IC personnel, healthcare administration, local and state health departments, the Federal Bureau of Investigation (FBI) field office, and CDC (see Reporting Requirements and Contact Information below). Existing local emergency plans should be reviewed, and a multidisciplinary approach outlined that includes local emergency medical services (EMS), police and fire departments, and media relations in addition to healthcare providers and IC professionals. Annual disaster preparedness drills held at many facilities can improve response capacity by incorporating a bioterrorism scenario to test and refine Bioterrorism Readiness Plans at each individual facility.
USAMRIID’s Medical Management of Biological Casualties Handbook
The purpose of this Handbook is to provide concise supplemental reading material to assist in education of biological casualty management. Although every effort has been made to make the information in this handbook consistent with official policy and doctrine (see FM 8-284), the information contained in this handbook is not official Department of the Army policy or doctrine, and it should not be construed as such. As you review this handbook, you will find specific therapies and prophylactic regimens for the diseases mentioned. The majority of these are based on standard treatment guidelines; however some of the regimens noted may vary from information found in standard reference materials. The reason for this is that the clinical presentation of certain biological weapon diseases may vary from the endemic form of the disease. For ethical reasons, human challenge studies can only be done with a limited number of these agents. Therefore, treatment and prophylaxis regimens may be derived from in vitro data, animal models, and limited human data. Occasionally you will find various investigational new drug (IND) products mentioned. They are often used in the laboratory setting to protect healthcare workers. These products are not available commercially, and can only be given under a specific protocol with informed consent. They are mentioned for scientific completeness of the handbook, and are not necessarily to be construed as recommendations for therapy.
California Hospital Bioterrorism Response Planning Guide
The California Hospital Bioterrorism Response Planning Guide was developed by the Department of Health Services (DHS) to assist hospitals in preparing for a possible bioterrorism event. Reducing the incidence of transmission of infectious agents such as plague, smallpox and viral hemorrhagic fevers to staff, patients, and the community will depend on how rapidly victims, including the worried-well, can be triaged, diagnosed, isolated when necessary, and treated. Early verbal and/or electronic communication with local health departments will be essential in controlling or preventing, not only disease transmission, but also to provide public assurance. This bioterrorism-planning guide should be modified to fit each hospital’s structure, function, and patient population and should be integrated into the hospital’s existing emergency management plan. As information related to recognizing, diagnosing, treating, and preventing bioterrorism is updated at the federal and state level, hospitals should revise existing response plans accordingly.
The Public Health Response to Biological and Chemical Terrorism: Interim Planning Guidance for State Public Health Officials
Across the country, state health department officials are considering the capabilities of their departments to respond to a biological or chemical terrorism incident. Traditionally, the responsibilities of the state health departments have been disease surveillance and management. Health departments now are defining their roles to respond effectively to an intentional release of biological organisms or hazardous chemicals into an unsuspecting population.
In federal fiscal year 1999, the Centers for Disease Control and Prevention (CDC) received congressionally-appropriated funds to enter into multi-year cooperative agreements aimed at upgrading state and local health department preparedness and response capabilities relative to bioterrorism. A portion of these funds was used to facilitate preparedness and readiness assessments. Grantees receiving the Focus Area A Funds must develop terrorism response plans. In return, CDC committed to developing planning guidance. The Public Health Response to Biological and Chemical
Terrorism: Interim Planning Guidance for State Public Health Officials fulfills that commitment. This Planning Guidance is designed to help state public health officials determine the roles of their departments in response to biological and chemical terrorism and to understand the emergency response roles of local health departments and the emergency management system. The Planning Guidance also can be used to help state health departments coordinate their efforts with the many agencies and organizations at all levels of government that ultimately would respond to a biological or chemical terrorism event.
Response efforts differ according to each state=s size, population, risks, needs, and capabilities. Rather than establishing a Aone size fits all@ model, this document provides general guidance that can be tailored to meet the needs of individual jurisdictions.
The objective of the Department of Defense (DoD) Chemical and Biological Defense Program (CBDP) is to enable our forces to survive, fight, and win in a chemically or biologically contaminated warfare environment. The DoD CBDP provides development and procurement of systems to enhance the ability of U.S. forces to deter and defend against CB agents during regional contingencies. The probability of U.S. forces encountering CB agents during worldwide conflicts remains high. An effective defense reduces the probability of a CB attack, and if an attack occurs, it enables U.S. forces to survive, continue operations, and win. Scientific, technological, and resource limitations remain in preventing U.S. forces from having complete full dimensional protection and meeting all requirements for two nearly simultaneous Major Theater Wars. The unique physical, toxicological, destructive, and other properties of each threat requires that operational and technological responses be tailored to the threat. Never-theless, significant progress has been made in overcoming these limitations since the establishment of the DoD CBDP. Still, U.S. forces remain the best protected forces in the world for surviving and conducting operations in chemically or biologically contaminated environments.
In summary, we found that federal departments and agencies are participating in a variety of research and preparedness activities, from improving the detection of biological agents to developing a national stockpile of pharmaceuticals to treat victims of disasters. Federal departments and agencies have engaged in a number of efforts to coordinate these activities on a formal and informal basis, such as interagency work groups. Despite these efforts, we found evidence that coordination between departments and agencies is fragmented. We did, however, find recent actions to improve coordination across federal departments and agencies. In addition, we found emerging concerns about the preparedness of state and local jurisdictions, including insufficient state and local planning for response to terrorist events, inadequacies in the public health infrastructure, a lack of hospital participation in training on terrorism and emergency response planning, insufficient capabilities for treating mass casualties, and the timely availability of medical teams and resources in an emergency.
Combating Terrorism Considerations For Investing Resources In Chemical And Biological Preparedness
In summary, the nature of the terrorist threat appears to be more uncertain since the September 11 attacks. Preparing for all possible contingencies is not practical, so a risk management approach should be used. This would include a threat assessment to determine which chemical or biological agents are of most concern. The federal government has a variety of programs to prepare for and respond to chemical and biological terrorism, including response teams, support laboratories, training and equipment programs, and research efforts. Evaluations of chemical and biological preparedness have identified a number of problems and their solutions. Some of these solutions to improve the response to chemical and biological terrorism have broad applicability across a variety of contingencies while other response requirements are applicable to only a specific type of attack. For example, efforts to improve public health surveillance would be useful in any disease outbreak, whereas efforts to provide vaccines for smallpox would be useful only if terrorists used smallpox in a biological attack. The Congress faces competing demands for spending as it seeks to invest resources to better prepare our nation for chemical and biological terrorism. Funding to combat terrorism, which was originally budgeted to be less than $13 billion, may exceed $50 billion for fiscal year 2002, including supplemental emergency contingency funding. Given the uncertainty of the chemical and biological threat, the
Congress may want to initially invest resources in efforts with broad applicability over those that are only applicable under a specific type of chemical or biological attack. As threat information becomes more certain, it may be more appropriate to invest in efforts only applicable to specific chemical or biological agents.
Bioterrorism Federal Research And Preparedness Activities
A variety of federal research and preparedness activities related to the public health and medical consequences of a bioterrorist attack are under way. Research activities focus on various biological agents that could be used as weapons of terrorism; detection of such agents; development of new or improved vaccines, antibiotics, and antivirals; and performance standards for emergency response equipment. Preparedness activities include increasing state and local response capabilities, improving federal response capacity, developing response teams, increasing the availability of medical treatments, participating in and sponsoring exercises, aiding victims, and providing support at special events, such as presidential inaugurations and Olympic games. Activities in many departments and agencies have a dual use, being not only relevant for bioterrorism but also for other types of terrorism, emergencies, and infectious disease surveillance. For example, the Federal Emergency Management Agency
(FEMA) has a broad emergency and terrorist response system, which includes a bioterrorist response system. HHS has programs on emerging infectious diseases that benefit its activities on bioterrorism as well as research endeavors such as research on diagnoses, vaccines, and new therapies.
Federal departments and agencies use a variety of methods to coordinate their activities to combat terrorism. Departments and agencies are developing interagency response plans, participating in a variety of interagency work groups, and entering into formal agreements with other agencies to share resources and capabilities in order to improve coordination. However, coordination of federal terrorism research, preparedness, and response programs is fragmented, as we have discussed in a previous report.12 As we noted, several different agencies are responsible for various coordination functions, which limits accountability and hinders unity of effort. For bioterrorism, different agencies have developed separate threat lists of biological agents, several agencies have not been included in bioterrorism-related policy and response planning, and agencies have developed programs to provide assistance to state and local governments that are similar and potentially duplicative. However, the Office of Management and Budget and the National Security Council have created a process to reduce overlap and improve coordination as part of the annual budget cycle. In addition, the Vice President was asked by the President in May 2001 to lead an interagency effort to improve coordination. Also, on September 20, 2001, the President announced the creation of the Office of Homeland Security to lead, oversee, and coordinate a comprehensive national strategy to safeguard the country against terrorism.
The reports that we reviewed identified concerns about the preparedness of states and local areas to respond to a bioterrorist attack. These concerns include insufficient state and local planning for response to terrorist events and a lack of hospital participation in training on terrorism and emergency response planning. Some federal programs have begun to provide funding to state and local governments to improve preparedness.