Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response
Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response
Abstract & commentary
Synopsis: The CDC has published a detailed plan for dealing with potential biological and chemical terrorism.
Source: Khan AS, et al. Biological and chemical terrorism: Strategic plan for preparedness and response. Recommendations of the CDC strategic planning workgroup. MMWR Morb Mortal Wkly Rep 2000;49(No. RR04):1-14.
By now many infectious disease and emergency physicians are sick and tired of hearing about the impending wave of bioterrorism. The CDC must be aware of some ennui on our parts as it starts its guidelines for strategic planning with the following quote from Sir Francis Bacon: ". . . and he that will not apply new remedies must expect new evils; for time is the greatest innovator. . ." Indeed, it seems that innovation derives from rage and craziness in our fellow humans who cohabit this planet with us and think bioterrorism represents the lowest expression of humanity.
Go on we must, it seems, to get ready for the inevitable. Thus, the publication of this 14 page set of rationales and recommendations should have an immediate effect on how public health facilities and institutions prepare for biological and chemical terrorism.
The guidelines begin with an Introduction giving a rationale that the public health infrastructure must be prepared for bioterrorism. This section hints at the advantages of "capitalizing on the advances in technology, information systems, and medical sciences."
The section on Vulnerability is straightforward, stating that incidents have already occurred and that the United States is poorly prepared to cope with the rapid responses that will be necessary to minimize injury to our citizens.
The next section emphasizes that covert attacks are more likely than overt terrorists attacks. The delay that would occur with covert attacks probably effects infectious disease physicians more than other aspects of bioterrorism. Consider the example of contagious variola that would not kill people until weeks after the first manifestation of disease. The monograph goes on to implore that public health officials would be the ones to uncover the attack, identify the microorganisms responsible, and prevent further disease.
| Table-Preparing Public Health Agencies for Biological Attacks |
| Steps in Preparing for Biological Attacks |
| • Enhance epidemiologic capacity to detect and respond to biological attacks. |
| • Supply diagnostic reagents to state and local public health agencies. |
| • Establish communication programs to ensure delivery of accurate information. |
| • Enhance bioterrorism-related education and training for health care professionals. |
| • Prepare educational materials that will inform and reassure the public during and after a biological attack. |
| • Stockpile appropriate vaccines and drugs. |
| • Establish molecular surveillance for microbial strains, including unusual or drug-resistant strains. |
| • Support the development of diagnostic tests. |
| • Encourage research on antiviral drugs and vaccines. |
| Source: Khan AS, et al. MMWR Morb Mortal Wkly Rep 2000;49:1-14. |
The next is the most important section for Infectious Disease physicians, entitled Focusing Preparedness Activities. Box 2 (see Table) outlines the steps in preparing for biological attacks and box 3 lists the critical biological agents. Of particular interest is Category C under critical agents since it includes agents like Nipah virus, yellow fever, and multidrug-resistant tuberculosis. Of course, terrorism is not necessarily needed to spread multidrug-resistant tuberculosis.
In the section Key Focus Areas, the CDC lists their five areas of focus: 1) Preparedness and prevention; 2) detection and surveillance; 3) diagnosis and characterization of biological and chemical agents; 4) response; and 5) communication. There are multiple important developments necessary to achieve the goals of these focus areas. The CDC will help state labs develop a coordinated preparedness plan and response protocols. Diagnostic preparedness will include a multilevel laboratory response network. It will be necessary for the CDC to transfer certain diagnostic technologies to state labs and, perhaps, additional labs. The CDC will house its own rapid-response and advanced technology (RRAT) lab, to respond at all times to the needs of any state or region. Analogous chemical laboratories will also be established.
In the area of response, the CDC is making a huge commitment. For a confirmed attack, the so called Presidential Decision Directive (PDD) 39 designates the FBI as the lead agency. For suspected attacks, the CDC will send out response teams to investigate the unconfirmed or suspicious illness.
The Communication System may be the most innovative of the directives. Indeed, by 2005 the CDC will implement a "state-of-the-art communication system to support surveillance," a "rapid notification and information exchange" of suspected bioterroristic outbreaks, rapid dissemination of diagnostic results, and finally an effective emergency response. Moreover, (and take note you hospital epidemiologists and front line ID physicians) the CDC will "provide terrorism-related training to epidemiologists. . .and other front line health care providers. . ." The piece of the proposal that seems most realistic is creation of a website to help with bioterrorism preparedness.
The next section, Partnerships and Implementation, lists all the groups who are involved in the grand scheme, and it is a daunting vision for sure. A set of priorities (Box 6) has been created for the years 2000-2002. The response priority includes establishment of a national pharmacy stockpile to offset biological and chemical agents.
COMMENT by Joseph F. John, MD
Well, this is as adventuresome an item as I have ever seen come out of the CDC. That is not to say it is not insightful, even needed, but the scope of these recommendations will take a level of national cooperation and commitment not seen since World War II. By their very nature, wars can command full commitment, but whether the spectre of bioterrorism can evoke the level of commitment, not to mention the financial support, necessary to pull off the grand scheme remains to be seen.
Financial and tactical support will certainly be welcomed at the regional and certain urban locations. We in New Jersey are already keenly aware of our strengths and weaknesses. Our State Department of Health already has a comprehensive plan that may be achievable in our small, though heavily populated, state. Still, it is hard enough to coordinate communication in any single state, including our state, so creating the type of "national electronic infrastsructure," that will prove effective to coordinate a national communication network poses a challenge on a much more complex level.
One of the most satisfying elements of the plan is the establishment of regional laboratories that will link to an around-the-clock suppot lab at the CDC that will "expedite molecular characterization of critical biological agents." Such a multilevel laboratory effort would certainly provide a net of protection that we currently lack. Such labs could also distinguish among emerging and reemerging pathogens that arise naturally from those that are purposely dispersed. I suspect that any highly multiresistant, emergent, nosocomial pathogen will be suspect and would have to be moved through the bioterrorism lab network.
Creation of new gene banks that include comprehensive databases of existing virulence genes and pathogenesis islands will help screen suspect microorganisms. A massive educational effort will be needed to coordinate regional labs and local labs with new gene banks. New personnel will need to be educated and the challenge of keeping the labs up to date will persist into the forseeable future.
My memory bank does not include a recollection of such an undertaking. My skeptical side chides about feasibility of certain recomendations, for example, like the scope implied by the wording of the last Recommendation: A cadre of well-trained health care and public health workers will be available in every state. I assume this means that the cadre is well trained and available to fight bioterrrorim. If that is the case, just how much is the government willing to spend on this project? From some cursory calculations, for a state like New Jersey, if we were to argue that at least one such person is needed for every million in population (I just pulled that ratio out of my hat), then that would require eight such individuals. The salary budget alone should approach $1 million for those individuals so that we start to approach real money when the entire nations falls under that type of extrapolation.
It is neither easy nor fun to write about bioterrorism. Have we really sunk so low as a species to have foisted this inevitability on ourselves? Doesn’t the earth have enough problems without dredging up pathogenic microbes for homicidal means? Apparently not. Assuming we have sunk this low, and assuming that this massive national initiative has become necessary, then hats off to the innovators of this CDC document. They have covered the bases!
Ironically, just months after the publication of these guidelines, the Morbidity and Mortality Weekly Report itself reported an incident suspicious as a bioterroristic ploy.1 Now, I must admit that I seldom think of a case of brucellosis as a potential terroristic event—but there you are. New Hampshire (the Live Free or Die state) was the site of the suspicious incident. In March 1999, a woman was admitted to a New Hampshire hospital with an acute disease and paired sera on day 4 and 22 showed a 16-fold rise in titer for Brucella. Cultures of the blood were negative. The patient’s family reported a possibility that the patient’s boyfriend may have exposed her to laboratory flasks. The authorities got involved (this makes good reading) and, ultimately, there was no implication that this was biological terrorism.
Regarding the new CDC recommendations, let’s see if the legislatures have the nerve to provide the support necessary. Hopefully we will never have to test our bioterrorism defenses, regardless of the state of their maturation. Yet, I suppose that the country will have to be convinced that our vulnerability is real before the upper levels of the CDC recommendations can be realized. In the interim, physicians, in particular our infectious disease and public health physicians, need to lead the preparedness effort and understand how the pathogens they have studied well may manifest in a biological attack.
Reference
1. Suspected brucellosis case prompts investigation of possible bioterrorism-related activity—New Hampshire and Massachusetts, 1999. MMWR Morb Mortal Wkly Rep 2000;49:509-512.
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