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Bioterrorism Resources
ID Center Bioterrorism
Table of Contents
Economic Impact
The
Economic Impact of a Bioterrorist Attack
Understanding and quantifying the impact of a bioterrorist attack are
essential in developing public health preparedness for such an attack.
We constructed a model that compares the impact of three classic agents
of biologic warfare (Bacillus anthracis, Brucella melitensis, and
Francisella tularensis) when released as aerosols in the suburb of a
major city. The model shows that the economic impact of a bioterrorist
attack can range from an estimated $477.7 million per 100,000 persons
exposed (brucellosis scenario) to $26.2 billion per 100,000 persons
exposed (anthrax scenario). Rapid implementation of a postattack
prophylaxis program is the single most important means of reducing these
losses. By using an insurance analogy, our model provides economic
justification for preparedness measures.
Epidemiology
Epidemiology of Bioterrorism
To effectively counter the potentially devastating effects of an attack,
we need to understand the basic epidemiologic principles of biological
agents used as weapons. A biological agent is commonly portrayed as a
genetically engineered organism resistant to all known vaccines and
drugs, highly contagious, and able to harm thousands of people. However,
alleged attacks by the Aum Shinrikyo did not result in a single illness
from a biological agent (2), and the successful 1984 contamination of
salad bars in The Dalles,
Oregon, by a religious cult involved
a common salmonella strain that was not lethal or contagious and was
susceptible to antibiotics (3).
Identification and
Diagnosis
Case
Definitions for Infectious Conditions Under Public Health
Surveillance
In the United
States, requirements for reporting
diseases are mandated by state laws or regulations. In October 1990, the
CDC published this report, which for the first time, provided uniform
criteria for reporting cases. This report provides updated uniform
criteria for state health department personnel to use when reporting the
nationally notifiable infectious diseases listed in Part 1 of this
report. The link included here provides access to the original 1990
report, the updated and revised 1997 report and new and revised case
definitions developed after the 1997 report was published.
Management and Treatment
Medical
Management of Biological Casualties Handbook
The purpose for this Department of Defense handbook is to serve as a
small and concise manual for medical personnel to carry as a guide to
medical prophylaxis and management of biological casualties. It is
designed as a quick reference and overview, and is not intended as a
definitive text on the medical management of biological casualties. U.S.
Army Medical Research Institute of Infectious Diseases. Fourth Edition,
Februrary 2001.
NATO
Handbook on the Medical Aspects of NBC Defensive
Operations
The purpose of this Department of Defense handbook is to provide a guide
for medical officers on the medical aspects of NBC operations. The
handbook is intended as a compilations of reference material and as a
source of information for training. In addition, it provides the basic
philosophy for the development of concepts of operations and in the
management, including evacuation and treatment, of NBC casualties as
well as conventional battle casualties in a NBC environment. Departments
of the Army, Navy and the Air Force. February 1996.
Meetings,
Symposiums, and Proceedings
National
Symposium on Medical and Public Health Response to
Bioterrorism
Real Audio files of the sessions from the National Symposium on Medical
and Public Health Response to Bioterrorism held in
Crystal
City,
Virginia in February
1999.
National
Symposium on Medical and Public Health Response to
Bioterrorism
By making these symposium presentations available, the symposium
organizers hope to raise awareness of the medical and public health
threats posed by biological weapons and to foster mutual understanding
and collaboration among the diverse groups addressing the threat of
bioterrorism. February 1999.
Readiness Planning
April 2002
APIC Bioterrorism Working Group Interim Bioterrorism Readiness Plan
Suggestions
APIC’s Bioterrorism Working Group (BTWG) has been working to
compile suggestions from our many APIC Advisors, the general membership,
and numerous agency liaisons as the original Bioterrorism Readiness
Plan: A Template for Healthcare Facilities is being reviewed/revised by
various individuals at the Centers for Disease Control and Prevention
(CDC). This compilation represents a summary containing comments from
the original Template as well as suggestions concerning additional
agents of bioterrorism including Tularemia, Viral Hemorrhagic Fevers,
and supplemental information on Smallpox and Anthrax. We value the many
comments and suggestions that have come from professionals across the
United States of
America, freely sharing them via this
document for your use in individual facility as well as regional
planning. PLEASE NOTE: The "Mass Casualty Disaster Plan
Checklist" is included in this document as Appendix 7,
beginning on page 46.
Federal
Response Plan, Emergency Support Function #8 Health and Medical Services
Annex
Health and Medical Services provides coordinated Federal assistance to
supplement State and local resources in response to public health and
medical care needs following a major disaster or emergency, or during a
developing potential medical situation. Assistance provided under ESF #8
is directed by the Department of Health and Human Services (HHS) through
its executive agent, the Assistant Secretary for Health (ASH). Resources
will be furnished when State and local resources are overwhelmed and
public health and/or medical assistance is requested from the Federal
Government. June 1996.
Biological
and Chemical Terrorism: Strategic Plan
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.
Domestic
Preparedness for Events Involving Weapons of Mass
Destruction
Until recently, chemical and biological weapons have not been the focus
of domestic planning, unlike our long-standing preparedness for a
nuclear attack. Today, however, these weapons of mass destruction (WMDs)
are readily available to many countries, including so-called rogue
states. Even more alarming, WMDs are a viable alternative to
conventional weapons for terrorist groups and disgruntled individuals.
This availability, coupled with terrorists' willingness to use these
deadly agents, has created a credible and serious threat to the nation's
security. The probability of a WMD incident is greater than ever and
threatens the United
States and other countries with
potentially devastating consequences, including widespread death and
disease and destruction of societal infrastructure and possibly society
itself.
Bioterrorism as a Public Health
Threat
The threat of bioterrorism, long ignored and denied, has heightened over
the past few years. Recent events in
Iraq,
Japan,
and
Russia
cast an ominous shadow. Two candidate agents are of special concern:
smallpox and anthrax. The magnitude of the problems and the gravity of
the scenarios associated with release of these organisms have been
vividly portrayed by two epidemics of smallpox in Europe during the
1970s and by an accidental release of aerosolized anthrax from a Russian
bioweapons facility in 1979. Efforts in the
United
States to deal with possible incidents
involving bioweapons in the civilian sector have only recently begun and
have made only limited progress. Only with substantial additional
resources at the federal, state, and local levels can a credible and
meaningful response be mounted. For longer-term solutions, the medical
community must educate both the public and policy makers about
bioterrorism and build a global consensus condemning its use.
California
Hospital Bioterrorism Response Planning
Guide
The California Hospital Bioterrorism Response Planning Guide draft
contains guidelines for managing patients with diseases such as smallpox
and end-stage viral hemorrhagic fevers. Each section has a brief
overview of the disease, a one page quick reference, FAQs, screening
form and homecare instructions.
JCAHO
Perspectives
This issue of the Joint Commission on Accreditation of Health Care
Organizations (JCAHO) newsletter Perspectives,
provides guidance to health care organizations in preparing for
terrorists attacks that may involve nuclear, biological, and/or chemical
incidents. It also offers lessons learned from hospitals located near
the World
Trade
Center and the Pentagon. As
part of this effort, JCAHO is paying particular attention to emergency
management planning during its ongoing, onsite evaluations of hospitals
and other health care organizations.
Resources and Reference
Information About Anthrax and Bioterrorism
from MMWR
You will find plenty of useful information on Anthrax and bioterrorism
in the Morbidity and Mortality Weekly
Report from the Centers for Disease Control and Prevention
(CDC).
Defense
Against Toxin Weapons
The purpose of this Department of Defense manual is to provide basic
information on biological toxins to military leaders and healthcare
providers at all levels to help them make informed decisions on
protecting their troops from toxins. Much of the information contained
herein will also be of interest to individuals charged with countering
domestic and international terrorism.
Quick
Reference for Potential Biological Weapons
Provided by the Greater Prince William Chem-Bio Terrorism Preparedness
Committee, this quick reference guide developed by Raymond S. Weinstein,
MD, will help provide information on symptoms and treatment options for
multiple bioterrorism agents.
Bioterrorism Agent Wall
Chart
The North Carolina Statewide Program for Infection Control and
Epidemiology (SPICE), based in the
School of
Medicine at the
University of
North Carolina in
Chapel Hill, has developed a wall chart on
bioterrorist agents. It is available in a printer-friendly format and
can be freely printed and used for educational purposes. The wall chart
developed by SPICE provides the following information for the more
likely biological weapons: common presenting signs/symptoms,
communicability, decontamination methods, recommended isolation
precautions, prophylaxis for exposed persons, and therapy. Diseases
included are the following: smallpox, anthrax, plague, and botulism.
ResourceNurse.com Offers Course for
Nurses
ResourceNurse.com has a free online CE course for nurses entitled
Responding to Terrorism - What you Must Know. This program offers an
up-to-the-minute look at what nurses can do to identify when an attack
has occurred, and how to efficiently and expertly manage the care that
terror victims will need. Another program, Anthrax: Critical Information
for Nurses will give you the information you need to confidently care
for patients who may have been infected with Anthrax and addresses
prophylaxis, management, and disaster management issues to help care for
them. CE credit available for a nominal fee.
Medical
Library Association
This Medical Library Association Web page will assist physicians,
parents, teachers, and others learn more about anthrax, smallpox,
botulinum toxin, plague, and other bioterrors and the extent to which
government agencies and medical organizations are ready to cope with
outbreaks. This page also offers readings and citations to help adults
talk about bioterrorism threats to young people.
Scenarios
Aftermath
of a Hypothetical Smallpox Disaster
The second day of the symposium featured a discussion of a scenario in
which a medium-sized American city is attacked with smallpox. Four
panels represented various time milestones after the attack, from a few
weeks to several months. Panelists discussed what they and their
colleagues might be doing at each of these milestones. The goal of the
responses was to communicate the complexity of the issues and to explore
the diverse problems that might arise beyond the care and treatment of
patients.
Anthrax: A
Possible Case History
Federal Bureau of Investigation (FBI) offices in five
U.S.
cities have received warnings of an imminent bioterrorist attack. Each
threat indicated that a "shower of anthrax would rain on
U.S.
cities," unless certain demands were met immediately. One of these calls
was in Northeast, a large city on the Eastern Seaboard with a
metropolitan population of 2 million. The threats were credible, but no
information was relayed to city officials in Northeast or elsewhere.
Applying
Lessons from Anthrax Case History to Other
Scenarios
Northeast, the city described in the anthrax scenario (Inglesby, this
issue, pp. 556-60) is actually
Baltimore, a metropolitan
area of 2 million population, with a football stadium that holds 74,000.
Route 95 would be where the anthrax dispersion took place. My test case
started on February 13 at 6
a.m. when I went to the emergency room at
Johns
Hopkins
University
Hospital and asked to see the
physician in charge. I described the typical case and asked what the
procedure would be if a patient came down with these symptoms. The
physician in charge had actually taken the specialized 8-hour training
course on bioterrorism (one of five physicians in
Maryland to have completed
this course entitled "Train the Trainer"). Nevertheless, she confessed
that the typical early case of inhalation anthrax would have a presumed
diagnosis of flu, and the patient would probably be sent home. Despite
the emphasis on emergency room physicians as the "early response team,"
the actual diagnosis would be made after hospitalization. Many seriously
ill patients arriving at the same time might arouse suspicion, but the
initial cases would likely be isolated events or would be dispersed in
multiple emergency rooms.
Addressing
Bioterrorist Threats
A fundamental step toward addressing the threat of bioterrorism is
comprehensive planning that focuses first and foremost on local
preparedness and response capacity—integrating the role of state,
regional, and federal governments, as well as state, regional, and
national assets. To plan effectively, we have to think through the
different types of scenarios that may confront us, including the
announced release of a biological agent, the silent release of a
biological agent, or some kind of hybrid event, such as having a bomb go
off, that is followed by the release of a biological or chemical agent.
In addition, we have to think about the scenarios where person-to-person
transmission can occur or those with noncommunicable infectious
diseases. Bioterrorism covers a very broad spectrum of concerns, from
catastrophic terrorism with mass casualties, to microevents using low
technology but producing civil unrest, disruption, disease,
disabilities, and death. All these scenarios must be considered. We need
to identify the assets and capabilities at all different levels and
identify the gaps, critical players, policymakers, and stakeholders, and
we must forge working relationships within the public health and
health-care community as well as with outside partners. We need to
develop shared understandings and mechanisms of communication. All of
these efforts are best undertaken before an emergency or crisis.
Bioterrorism Special
Report
The March 5, 1999
issue of New Scientist revived a Bioterrorism special report by Robert
Taylor entitled "All fall down." This article, originally published
May 11, 1996 (New
Scientist, Volume 150, Issue 2029) includes a picture depicting the
theoretical impact of dissemination of anthrax spores over the
Washington
DC metropolitan area. This article
also contains links to several other bioterrorism articles published in
New Scientist.
Threat of Bioterrorism
Biologic
Terrorism: Responding to the Threat
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.
Bioterrorism: How Prepared Are
We?
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.
The
Emerging Threat of Bioterrorism
The threat of bioterrorism focuses attention on overall preparedness to
address the challenges posed by new and reemerging infectious diseases.
Bioterrorism scenarios illustrate the diversity of disciplines and
perspectives required to confront these threats, whether naturally
occurring or purposely caused. The need to strengthen existing and
develop new partnerships is clear.
Congressional Efforts to Address
Bioterrorism
In government—and particularly in the federal
government—ideas normally come from the bottom up. When finally
approved, proposals are reasonably well thought out in terms of what we
are going to do and why we are going to do it. Sometimes knowledge of
"what" we are going to do far exceeds the ability to explain why we are
going to do it. However, for bioterrorism we are better able to talk
about the "why" than the "what." When Congress received a request from
the administration to address bioterrorism, we had only the vaguest idea
what they wanted to do. As a result, the availability of funds was
delayed until an operating plan was in place. We are still fleshing out
exactly how to approach this problem, what the roles of the various
agencies are, and what the legal issues are.
Finding
the Right Balance Against Bioterrorism
For the first time the Department of Health and Human Services is
part of the national security apparatus of the
United
States. That reflects a change in our
views on chemical and biological defense programs. Almost 5 years ago at
the bidding of the president we began to look at what has come to be
known as "asymmetrical threats," ways in which opponents (be they
nations or terrorist groups) could attack us without directly engaging
our military forces. At the same time we were faced with two events that
drew our attention to chemical and biological threats.
Iraq
used chemical weapons on
Iran and
on its own citizens and appeared to be concealing a biological weapons
program. Also, the hitherto unknown Japanese cult Aum Shinrikyo used
sarin nerve agent in the
Tokyo subway; the cult
failed in an attempt to use biological weapons against Americans in
Japan.
Historical
Trends Related to Bioterrorism: An Empirical
Analysis
The vulnerability of civilian populations to chemical, biological,
radiologic, or nuclear terrorism has been widely discussed, but
information on historical cases is anecdotal and often inaccurate.
Without a realistic threat assessment based on solid empirical data,
government policymakers lack the knowledge they need to design prudent
and cost-effective programs for preventing or mitigating future
incidents.
The Threat
of Biological Attack: Why Concern Now
For a biological attack to occur, three elements must be in place: a
vulnerable target, a person or group with the capability to attack, and
the intent (by the perpetrator) to carry out such an attack. Much of
what can be done to limit the capability and the intent of potential
attackers is already on its way to being accomplished. The most work,
and the highest return on investment, involve reducing the vulnerability
of the United
States to both intentional and
unintentional pathogen releases.
Biological
Weapons Programs of the Former Soviet Union and
Iraq
The demise of the biological weapons capability of the United States in
1969 and the advent of the Biological and Toxin Weapons Convention in
1972 caused governments in the West to go to sleep to the possibility of
biological weapons development throughout the rest of the world, as
technically knowledgeable workers were transferred and retired,
intelligence desks were closed down, and budgets were cut. By 1979,
despite the Sverdlovsk
anthrax release, a senior British government policy official described
any biological weapons threat as nebulous. President Nixon's biological
weapons disarmament declaration in 1969 had conveyed the impression that
biological weapons were uncontrollable and that the
U.S.
program had not been successful in producing usable weapons (when in
fact the opposite was true). Add to this the rise of truly
intercontinental ballistic missile delivery of nuclear weapons, and the
stage was set for what I have termed "nuclear blindness" and defined as
"the tunnel vision suffered by successive governments, brought on by the
mistaken belief that it is only the size of the bang that matters."
Throughout this period, both the former Soviet
Union and
Iraq
conceived, albeit in different ways, their new biological weapons
programs. It took until 1989-1991 for government technical experts in
the West to persuade the world and their own governments that these
programs were real and of enormous potential importance to the security
of the West, if not the whole world.
Aum
Shinrikyo: Once and Future Threat?
On March 20, 1995,
members of the Aum Shinrikyo cult entered the
Tokyo subway system and
released sarin, a deadly nerve agent. The subway attack was the most
deadly assault in an ongoing campaign of terror waged by this mysterious
cult. Four years later, with Aum Shinrikyo attempting to rebuild itself,
many in
Japan
and around the world are asking whether the "Supreme Truth Sect" poses a
current or future threat. Answering this question may further our
understanding, not only of the Aum but also of other extremist and
terrorist groups.
The
Prospect of Domestic Bioterrorism
Candidates for successful use of biological weapons represent the
intersection of three sets: groups that want to use these weapons
despite formidable political risks; groups that can acquire the agent
and a dissemination device (however crude); and groups whose
organizational structure enables them to deliver or disseminate the
agent covertly. The intersection of these sets is small but growing,
especially for low-technology attacks such as contaminating food or
disseminating biological agents in an enclosed space. Major attacks are
also becoming more likely. In the sections that follow, we consider
eroding motivational, technical, and organizational constraints.
Vaccination
Vaccines
in Civilian Defense Against Bioterrorism
In the United
States, over the past half century, we
have lived under the protective umbrella of vaccination programs that
shield our population from a dozen serious and sometimes fatal naturally
transmitted illnesses. Vaccination has been the single most
cost-effective public health intervention. However, the value of
vaccines in protecting the population against the deliberate release of
infectious organisms is not so clear-cut.
Vaccines,
Pharmaceutical Products, and Bioterrorism
In regards to bioterrorism, the goal of the U.S. Food and Drug
Administration (FDA) is to foster the development of vaccines, drugs and
diagnostic products, safeguards of the food supply, and other measures
needed to respond to bioterrorist threats. Many products (vaccines,
therapeutic drug and biological products, food, devices, and
diagnostics) regulated by FDA could be affected by bioterrorism.
Pathogens or pathogen products adapted for biological warfare include
smallpox (variola), anthrax (Bacillus anthracis), plague (Yersinia
pestis), tularemia (Francisella tularensis), brucellosis (Brucella
abortus, B. melitensis, B. suis, B. canis), Q fever (Coxiella
burnettii), botulinum toxin (produced by Clostridium botulinum) and
staphylococcal enterotoxin B. New products are needed to diagnose,
prevent, and treat these public health threats.
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