Public Health Management of Bioterrorism
Prabhakar Parimi. MD
“Ingenuity, knowledge and organization alter but cannot cancel humanity’s vulnerability to invasion by parasitic forms of life. Infectious diseases which antedated the emergence of humankind will lost as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history”
William E. McNeill. Plagues and People, 1976(1)
Definition of Bioterrorism and Biological Weapons
Bioterrorism is defined as “the unlawful
use of a biological agent or toxin against persons and property, in order to
intimidate or coerce a government or civilian population in furtherance of
political or social objectives “
Bio-weapon is “a weapon
comprising of biological agent or toxin that is designed or intended to cause
death or serious injury through release and dissemination”
Historical Perspectives on Biological Weapons:
The use of biological agents or
its toxins as weapons is neither novel nor new to the 21st Century. The
sequence of events from as early as Herodotus (poisoned arrows of Scythians)
and Hannibal (use of poisoned snakes), to the use of biological and
psychological warfare, initiated during an epidemic of bubonic plague in Kaffa
in14th Century, and from the weaponization and dissemination of anthrax using
warhead by the British to the use of postal system in the USA, are the
testimony to mankind’s extraordinary abilities to use microbial agents as
biological weapons .The concept of bio-weapons antedates dates as far back as
600 BC by poisoning of wells with rye ergot and contamination of water supplies
with a purgative such as hellebore. Such acts were to inflict a heavy toll on
enemy troops. Herodotus and Thucydides, famous Greek historians, described
arrows as tipped with poison, obtained from the decomposed bodies that probably
contained tetanus and botulism toxins. These arrows were suggested to have been
used by the Scythians archers and also for the poisoning of wells resulting in
a massive outbreak that killed many Athenians during the Peloponnesian War (2).
In the 14th and 15th Centuries,
knowledge on germs and their role in the causation of diseases was unknown.
Many diseases were considered to be caused by miasma or bad air. The decomposed
bodies were used as ammunition to transmit diseases and inflict a heavy toll on
enemy troops. Between 1340- 1422, humans’ corpses, dead horses and other
animals were catapult during the siege of Kaffa, Hainault (Now Northern France)
and Bohemia (3). The use of dead corpses as bio-weapons was instrumental for the
attack on the city of Kaffa (presently Ukraine) by the Tartar army. This resulted
in the beginning of the Dark Age in the Europe due to transmission of bubonic
plague. The outbreak of bubonic plague among their own troops, due to abundance
of rats, assisted the Tartar army during the capture of Kaffa in 1346. Bodies of plague victims containing rat
fleas were catapulted over the walls of Kaffa to initiate an epidemic in the
enemy territory. Rats and fleas that were infected in merchant ships during the
war may have contributed to the spread of the disease from Italy to Spain,
France and other European countries by 1350. The introduction of the bubonic
plague had devastating social, psychological, economic and human fabric consequences
in Europe, hence the term Dark Ages. The signs and symptoms of bubonic plague
without knowledge of the causation of the disease is well characterized in the
17th century (4). However, the efficiency of this strategy was again tested
with success by the Russian Army by catapulting bodies of those who died of
plague in Estonia in 1710 (5).
Modern Era: (18th Century to Present time)
Although
the epidemic nature of small pox was recorded between 1350 and 430 BC by the
historians, the accurate medical description of transmission and immunity was
written in about 910 AD (6 ). Small Pox affected the western civilization and
spread to the new world by the Spanish and Portuguese conquerors. The nature of
spread and the magnitude of devastation of the native population in the new
world may have provided the first example of biological warfare. During the French and Indian war between
1763- and 1767 (7), the British army was the first to experiment on the use of
inanimate objects to transmit smallpox to the susceptible native population. This
was the first recorded “bio-weapon” in North America that used blankets and
hand kerchiefs under the disguise of gifts to deliberately reduce Native
American Indians tribes.
The remarkable scientific
inventions of Louis Pasteur (1822-1985) and Robert Koch (1843-1910) and their subsequent
work has lead to the understanding of germ theory of disease and advancement of
microbiology. This paved the way for the weaponization of microbes in this
century.
Modern bio-weapon program was
first initiated by Germany during World War 1. Biological agents such as Bacillus anthracis (Anthrax) and Bacillus mallei (Glanders) were used in
the covert operation by deliberately infecting and exporting farm animals
(sheep, horses and mules) (8). The most remarkable and the extensive biological
warfare research and deployment was initiated by Japan from 1932 until the end
of World War 11 ( 9). The Infamous Unit 731, under the direction of Dr.Shiro
Ishii experimented on biological agents such as Shigella (bacterial dysentery),
V.cholerae (cholera) and Yersina pestis (the bubonic plague) as a
part of the program on prisoners (10). Field trials and deliberate attacks with
biological agents such as cholera, anthrax, plague and salmonella were
conducted to either contaminate water and food supplies or to disseminate these
agents by spraying from aircrafts. The attack on China using cholera bacteria, resulting
in high deaths in Japanese troops in 1941, clearly demonstrate the double-edged
nature of bio-weapons. The German Offensive biological weapons program during
the World War II focused on the study of natural history of disease and vaccine
development in experimentally infected prisoners of Nazi concentration camps,
than the weaponization of bacterial agents (11). The weaponisation of anthrax
and its effectiveness in dissemination by a conventional warhead was the focus of British BW Program but an outbreak of anthrax in sheep and cattle
and difficulty in de-contamination of the experimental territory may have
affected continuation of the
program(12)
The biological warfare program
in the United States of America and Soviet Union germinated out of the Unit 731
during 1940’s. The United States began its offensive biological weapons program
in 1942. The main purpose of the
program was to develop research capacity and to test sites for investigation of
the number of possible biological agents. During this time, the Soviet Union
and Iraq independently developed their successful biological weapons program.
The Soviet Union developed extensive research development and production
capacity for bio-weapon under the name of Biopreparat in 1973-4. The nature and
extent of the Biopreparat was published by
Ken Alibek , the defected former Deputy Director of the Program in a
book entitled “ Biohazard: The Chilling True Story of the Larger Covert Biological Weapons Program told from the
Inside by the man who ran it (13).The United Nations Special Commission
believes that Iraq is continuing its
biological weapons program but the true scope is unknown. Bioterrorist attacks
have occurred in recent history and potential to occur both in the United
States and world wide.
Epidemiology of Bio terrorism:
“I keep six honest serving
men ( they taught me all I knew) their
names are what ,why, and when and how and where and who” – Rudyard Kipling (14)
Epidemiological Triad is the underpinning philosophy of understanding bioterrorism for assessing the risk and developing and implementing prevention and control strategies. The Epidemiological triad is the Agent, the Host and the Environment.
A. Agent: Bio weapons / Biological agents:
The biological agents that are
thought to be the likely cause of bioterrorist attacks are Bacillus
anthracis (anthrax), Francisella tularensis ( tularemia), Yersinia
pestis (plague) Variola virus (small-pox) toxins of Clostridium
botulinum (botulism). Other agents include Brucella spp ( brucellosis) and ricin/mycotoxins.
Haemorrhagic Viruses: Ebola
Virus, Hanta virus , Marburg, Dengue and other haemorrhagic fever viruses such
as VEE, AHF etc have all the characteristics required to be a biological weapon
such as the ease of infectivity, lack of available treatment and vaccine/s as
well as ready availability of
prophylaxis (antibiotics or immuno-globulins)
The characteristics of an ideal biological weapon are the
ease of procurement, simplicity of production in large quantities at minimal
expense, ease of dissemination with low technology, and the potential to
overwhelm the medical system with large numbers of casualties. Dissemination of
a biological agent would be silent, and the incubation period allows a
perpetrator to escape to great distances from the area of release before the
first ill persons seeks medical care
B. Host: Susceptibility, Immunity, Disease Spectrum
Children are more susceptible to
bio terrorism agent that is disseminated by release of aerosols as the
respiratory rate is high. The inhalation type of anthrax has a high mortality
rate. The small pox lesions in early stage could easily be confused with
chickenpox infection (15). There are no current vaccines available for most of
the above agents. Vaccination against small pox was stopped in late 1970’s when
the disease was eradicated worldwide. The Anthrax vaccine is not routinely
given to population. Susceptibility also depends on the incidence of
immunological related diseases in the population such as HIV/AIDS,
Lymphoma/Leukemia, and other immuno-deficiencies. The disease spectrum in these
population may be quiet different compared to immuno- competent population.
Risk: The actual
risk of these forms of terrorism remains small for the reasons explained
bellow. The reason for which the risk remains low is because of the inherent
limitations involved in acquiring, producing and turning biological agents into
viable weapons. Such limitations are as result of factors such as the
availability of the agents and their acquisition and transportation that
require complicated storage containers. Also there are extreme obstacles to
disseminating biological agents to specific targets since the agents must be
kept alive and potent and must be delivered in sufficient quantities to cause
the illness. To have an effective result large scale effects might be more
efficiently achieved if the agent was delivered in the form of water or an
aerosol cloud that would be inhaled by its victims.
C. Social/Environmental Factors:
Inequity and Inequality,
Political/ Religious/ Racial factors:
"Poverty in
all its forms is the greatest single threat to peace, security, democracy,
human rights and the environment," Michael Moore, head of the World Trade
Organization (WTO), (16). Poverty accelerates turmoil and conflict. It creates
an ideal environment for the recruitment of terrorists. The perception of
oppression may initiate and incite ethnic and religious hatred. It is very
obvious that it fuels the violent rejection of the social and economic order in
developing countries. World Health Organization (WHO)
is developing plans to step up its campaign for a huge increase in health
spending in developing nations.
Concerns of poverty are also a factor that is a possible pre-cause for
bio terrorism (17). The WHO commission on Macro-economics and Health
recommended for an increase of $66 billion in health sector spending in
developing countries by 2015 which is expected to boost the economic growth by
six fold (18).
Environmental factors such as
food shortage, rise in food supplies, unemployment and de-stabilization of
social political and economic fabric of a country, contribute to the source of
the epidemics of highly contagious agents in the agriculture and live stock
sector (19).
Bioterrorism and Public Health:
The New York Times (5 February,
2000) reported that at least 12 countries have acquired or are trying to
possess biological weapons. Some of the countries that have been identified to
possess biological warfare capability include Iraq, Iran, Libya and Syria – all
of them have close links with religious fundamental terrorist groups in the Middle
East. (20)
1. Trends of Hoaxes and Cases related to Bioterrorism: The Monterey Institute’s Center
for Nonproliferation Studies reported over 415 incidents involving the
acquisition or use of chemical or biological agents from 1900 to 1999. Of 151
terrorist events, 33 were due to biological agents. There were two peaks (1995 Aum
Shinrikyo and the copy cat attack in 1998 in Japan). The Hoaxes involving
biological agents such as anthrax were also noted to peak in 1998.(Larry Wayne
Harris; White Supremacist Group). Although there is no clear pattern that is
apparent in the types of groups involved in biological incidents, religious
fundamentalism have been shown to emerge with in the past few years (21)
2. Hoaxes and Cases related to Bioterrorism:
A. The Americas:
USA and Canada: Between 1998 and
1999, over 6000 persons were affected by a series of anthrax related threats (22)
B. Europe: In Europe, despite the growing number of criminal
hoaxes, no cases of anthrax linked to deliberate releases have been reported,
and the only contaminated letters were addressed to American embassies abroad.
(23.)
C. Latin America and the Caribbean: The first confirmed case of mail contamination with B. anthracis was reported by Chile. A pediatrician in Santiago, Chile received
a letter containing the anthrax spores. This raised the possibility of
worldwide bio-terrorism attack (24). Similarly, a letter sent from Miami to a
woman in Buenos Aires, Argentina was found to be positive for anthrax. (25). The Caribbean Epidemiology Center, Trinidad (CAREC) received eight
suspicious envelopes without powder, nine envelopes with powder and three
environmental swabs from Guyana and Trinidad, and all were found to be negative
for anthrax. (26)
D. Asia: In Pakistan, there were
conflicting reports of whether or not certain letters contained anthrax. Among
200 suspicious envelopes tested for anthrax in India, anthrax was found in one
of the envelopes. Although, anthrax is endemic in southern parts of India, the
reappearance of human anthrax cases in several southern states is a cause for
concern (27, 28).
2. Outbreaks:
Anthrax: During an outbreak of anthrax in the city of
Sverdlovsk (in former Soviet Union) occurred in 1979 nearly 70 people died
following alleged consumption of contaminated meat. Although, USA linked this
outbreak to a secret bio-weapons laboratory, the Soviet-Union publicly denied
the link between the laboratory and the number of cases of anthrax. (29).
Salmonella Typhimurium: Over 751 individuals developed gastroenteritis following
consumption of contaminated salads at several restaurants in Dallas, Oregon in
1984. Forty-five were hospitalized during this outbreak. This outbreak was
investigated by the Center for Disease Control (CDC) and the criminal intent of
the outbreak was not identified for more than a year (30).
Shigella dysenteriae: Intentional food contamination in Texas in 1996, harmed
approximately 15 persons including laboratory workers (31).
Sarin Gas:
Twelve (12) deaths and 5000 injuries were reported in 1995 following inhalation
of Sarin nerve gas that was intentionally disseminated in Tokyo Subway system
by the members of Aum Shinrikyo cult.
Anthrax in the USA (2001): Twenty two cases of anthrax identified in the USA, were
due to the intentional contamination of mail with anthrax spores. Of the 22
cases, 10 were confirmed cases of inhalation anthrax and 12 were cutaneous
cases (of which seven were confirmed and five suspected).Most of the cases
comprised of people who were exposed to contaminated mail either at workplace (mail
room) or media offices.
Psychosocial Effects:
Psychological, behavioral, and social responses to
biological terrorism are similar to other natural disasters and infectious
disease outbreaks. A wide range of psychological disorders are noted ranging
from mild stress to full-blown post-traumatic stress disorder (PTSD), major
depression, or acute stress disorder. Recent
Anthrax laden letters induced fear and
anxiety in individuals and communities. These bio terrorism attacks hope that
the fear of future attacks will become more crippling, thus maximizing the
impact of the direct damage. The most
important intervention for Psychiatric illness following a biological terrorism
is the availability of and the access to psychiatric care and treatment as a
component of a comprehensive health care service preparedness plan. Initial
psychosocial interventions also include effective and accurate risk
communication, management of somatic symptoms, and the creation of a recovery
environment that restores effective social roles and returns people to their
usual sources of social support. Local, state and national bioterrorism
preparedness and response plans should reflect realistic consideration of
psychological, behavioral, and societal reactions to agents of bio terrorism (32)
Bioterrorism Preparedness
Program:
A: Multi-sectoral Disaster and
Bioterrorism Response System- Local, State and National Plans.
The main components of the CDC’s Strategic plan for Bioterrorsim Preparedness and Response are shown the Fig 2
.
Upgrading local and State Public Health Capacity : The creation of the Bio
terrorism Preparedness and Response Office within the CDC is a step in the
right direction. The office is mandated to initiate bio terrorism related
programs such as development of national pharmaceutical and vaccine stockpiles,
the strengthening of CDC’s laboratory capacity, the augmentation of CDC’s
epidemiological capacity and the improvement in surveillance systems. The
essential component of CDC’s bioterrorism response plan includes building the
public health capacity in state health departments.
The essential component of CDC’s
bioterrorism response plan includes building the public health capacity in
state health departments such as:
Preparedness planning and readiness
assessment;
Epidemiology and surveillance;
Laboratory capacity for biological or
chemical agents;
The Health Alert Network (a nationwide,
integrated, electronic communications system).
CDC has launched
an effort to improve public health laboratories that would likely be called
upon to identify a biological or chemical attack. The Laboratory Response
Network (LRN), a partnership among the Association of Public Health
Laboratories (APHL), CDC, FBI, State Public Health Laboratories, Department of Defense
(DOD) and the Nation's clinical laboratories, will help ensure that the highest
level of containment and expertise in the identification of rare and lethal
biological agents is available in an emergency event. The LRN also includes the
Reference Laboratory using advanced technology at CDC, which has the sole
responsibility of providing rapid and accurate diagnosis and subsequent
analysis of biological agents suspected of being terrorist weapons.
2. Engaging the Medical
Community in Bio terrorism Response Planning: The Office of Emergency Preparedness (OEP)
within HHS works with medical missions in cases of natural disasters. HHS coordinates and provides health leadership to the
National Disaster Medical System (NDMS), which is a partnership that brings
together HHS, DOD, FEMA, and the Department of Veterans Affairs (VA). The NDMS
provides medical response, patient evacuation, and definitive medical care for
mass casualty events.
The NMDS is envisioned to
provide additional support to state and local medical resources in cases of
national disasters.
3.Coordination among Institutions involved in Bio terrorism Preparedness,
planning and implementation (Fig 4).
Institutional Coordination is an
important aspect of response planning. The lack of a precise role and
responsibilities among federal and state agencies involved in bio terrorist
response is generally due to the lack of resources to dedicate to planning
interagency collaboration and co-ordination. It is important to develop
comprehensive statewide plans embracing all relevant parties- hospitals,
emergency services, governmental health agencies as well as non-governmental
agencies. Due to the threat to the national security, it is also critical for
the co-ordination between the health departments and the law enforcement
authorities for criminal investigation (33)
B. Early Warning Epidemiological Surveillance and Response System-
1. Integrated Networks linking State, National and Global Reporting
Systems for rapid investigation and response.
1.1 Global Systems:
A. Global Outbreak Alert
and Response Network: Biological agents that are most likely to be used in a deliberate
outbreak are any infectious agents or its toxins that could be engineered for
deliberate use as a weapon. Among such agents are small pox, anthrax, botulism
and plague are the pathogens most likely to be used and are believed by many
experts to be potential biological weapons. The Global Outbreak Alert and
Response Network continuously monitor reports of rumors of diseases and
outbreaks of infectious diseases worldwide. This network links more than 70
separate information and diagnostic networks around the world. The Formal Sources
(information of the 191 WHO member countries, together with WHO regional and
country offices), and informal sources information are combined ( NGO’s, other partners and the Global Public Health
Intelligence Network (GPHIN)) to create an internet based system that is the
best and most up to date information on disease outbreaks around the world.
Each report is thoroughly checked and verified by specialists at WHO
headquarters and an appropriate response is then planned and launched with the
national and international partners.
It is essential for the
co-operation of national and international institutions in order to strengthen the
public health infrastructure. These include specialist laboratories and
epidemiologists.
B. ProMED-Mail:
ProMed- mail was established in 1994 to provide an early global warning
of emerging diseases in human, animals and plants as well as diseases that may
attributable to bio terrorist activities. One hundred and sixty countries
comprising over 18,000 members from developing and developed world
electronically linked to stimulate sharing of emerging and reemerging
infectious diseases worldwide.
(34)
1.2. National Systems:
A. The National Center for Infectious Diseases (NCID/CDC) have set up surveillance systems to track particular disease problems including emerging infectious diseases. Some of the surveillance systems that are operated by NCID/CDC are; National Notifiable Diseases Surveillance System (NNDSS), 121 Cities Mortality Reporting System, Border Infectious Disease Surveillance Project (BIDS), EMERGEncy ID NET , Global Emerging Infections Sentinel Network (GeoSentinel) and Internet-based Reporting Systems comprising of Unexplained Deaths and Critical Illnesses Surveillance System.
B. The Rapid
Syndrome Validation Project (RSVP) is an early warning syndrome based system that links individual
health care providers and public health in the State of New Mexico. It provides
early warning and response to emerging biological threats, as well as emerging
epidemics and diseases (35).
C. The Early Warning and Response Network
System (EWARN) in Sudan: In collaboration with
several agencies, EWARN was launched in July 1999 with WHO as the lead agency. The United Nations Fund for International Partnership
(UNFIP) comprising the Rockefeller Foundation, the UN Foundation and the Gates
Foundation. Currently, there are more than 40 health agencies (including non
governmental organizations (NGOs), the International Committee of the Red
Cross, UNICEF and WHO) participating in EWARN activities, as well as
communities through church groups, community leaders and local counterparts.
C. Health Services Plan: Building human, technological and financial
resources for provision of rapid health care services at local and State departments.
1.1 Training:
1.2.
Community Level: Bioterrorism
preparedness is clearly a goal for the health care at the community level. This
could be accomplished by working in collaboration with both the city, county,
state, and the federal public health and emergency authorities and with law
enforcement at the local and federal levels. Effective, open communication
between all groups involved in the prevention and control of bio terrorism
related illnesses is the key component of a preparedness plan at the community
level (36).
1.3. Home Care
The
home care and hospice organizations should be prepared to manage bioterrorism
related events and conditions. A bioterrorism response plan for the special
population should be developed and a systematic training on response and
control programs for the staff, needs to be implemented. (37)
1.4 The
Public: Public is a key partner in
the medical and public-health response for an effective management of an
epidemic. Non participation increases the likelihood of social disruption. An
integrated response plan, implemented in the response to an epidemic caused by
a bioterrorist attack, includes the public and the civic bodies, as capable
collaborators (38).
1.5 Mobilization of Financial Resources : CDC has proposed a $ 348 million investment in anti-bioterrorism
in the 2002 budget which is estimated to be an 18 percent increase over fiscal
year 2001 funding. The majority of efforts will be focused on coordination,
surveillance, rapid response and prevention. A special response to a bioterrorism
event includes detecting the biological agent, investigating the outbreak, and
providing stockpiled drugs and supplies. The U.S. Department of Health and
Human Services (HHS) budgeted $4.3 billion for homeland security and public
health which includes grants totaling $865 million to improve public health emergency
preparedness and counter-bioterrorism in local and state departments.
Clinical Diagnosis, Control and Prevention strategies:
Isolation Precautions, therapeutic guidelines, immuno-prophylaxis and
vaccination strategies:
All hospital emergency departments should have
administrative plans, infrastructure, training and medical inventory for
biological or chemical weapons incidents. The minimum recommended physical and therapeutic
resources for hypothetical bioterrorist incidents such as Sarin and anthrax
should be available. Health-care providers, clinical laboratory personnel,
infection control professionals, and health departments play critical and
complementary roles in recognizing and responding to illnesses caused by
intentional release of biologic agents.
Health Care providers may use some of the indicators of intentional release of a biological agent such as 1) an unusual temporal or geographic clustering of illness (e.g., persons who attended the same public event or gathering) or patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak (e.g., >2 patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise healthy persons); 2) an unusual age distribution for common diseases (e.g., an increase in what appears to be a chickenpox-like illness among adult patients, but which might be smallpox); and 3) a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin. Agents of highest concern are Bacillus anthracis (anthrax), Yersinia pestis (plague), variola major (smallpox), Clostridium botulinum toxin (botulism), Francisella tularensis (tularemia), filoviruses (Ebola hemorrhagic fever, Marburg hemorrhagic fever); and arenaviruses (Lassa [Lassa fever], Junin [Argentine hemorrhagic fever], and related viruses)
The clinical manifestations and syndromes of bioterrorism related infections in children may be atypical. Some of the common syndromes reported were acute respiratory distress syndrome with fever, influenza like illness, acute rash with fever, neurological syndromes and blistering syndromes. It is critical that the diagnosis be established expeditiously and pediatricians obtain information on specific treatment for the management of bioterrorism related infections. The guidelines for pediatric management of bioterrorism related infections should be followed (39). Clinical features and management of anthrax, plague and small pox have been published by CDC and others (40). These guidelines also include chemoprophylaxis and vaccination strategies (41-47).
Clinical laboratories should be prepared to respond
rapidly by providing diagnostic tests for the detection, identification of
specific agents and provision of rapid results for prompt initiation of
treatment and prophylaxis. As first-line responders, clinical laboratory
personnel should become familiar with the bio weapons. A standard operating
procedure manual describing techniques used in their identification and pre and
analytical issues such as specimen handling and personal protective equipment
and quality control should be prepared. Accurate assessment of resources in
clinical laboratories is important because it will provide local authorities
with an alternative resource for immediate diagnostic analysis (48, 49).
Infection Control: Infection control practitioners (ICPs) are important
partners in enhancing public health infrastructure in the USA and worldwide. A
lack of awareness about the potential threat of bioterrorism and a deficiency
in knowledge about the potential consequences of an attack may impact on
resource allocation for infection control and training program in heath care institutions
(50). The Association of Practioners of
Infection Control (APIC) Bioterrorism Task Force and CDC Hospital Infection Control
Program Bioterrorism Working Group prepared a document entitled “Bioterrorism
Rediness Plan- A Template for Health Care Facilities”. This document provided
the framework for infection control activities such as isolation precautions,
patient placement in case of small events, patient transport, cleaning, disinfection,
sterilization of equipment and environment etc. The report also provides an
outline of laboratory policy and public enquiry (51).
Vaccines:
Vaccines are an effective, safe, and relatively inexpensive means of preventing infection; thus, they are important tools for fighting biological terrorism. Vaccines for the two diseases, anthrax and smallpox are not available. However, three other vaccines -tetanus toxoid, influenza vaccine, and hepatitis B vaccine--generally recommended for adults, may be in short supply as a result of recent acts of terrorism (52).155 million doses of smallpox vaccine will be produced by the end of 2002 reaching the required 286 million doses by the end of 2002. The estimated cost per dose of vaccine is about $2.76. The National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health have been studying the possibility of diluting the vaccine by a ratio of 1 to 5 as a potential means of extending the supply. Early results indicate that the diluted vaccine retains the same level of effectiveness as the fully concentrated vaccine. Researchers are also studying whether a 1 to 10 dilution retains the same level of effectiveness, as well. The CDC plan does not call for mass vaccination of the U.S. population in advance of a smallpox outbreak. Based on what we know today, the risk of an outbreak of smallpox is substantially lower than the risk of serious complications from the vaccine. According to the plan, rings of personal contacts, such as family members and co-workers, would be identified and then be vaccinated and monitored. This strategy, known as ring vaccination, is credited with helping to wipe out smallpox in the late 1970s and is still the most efficient approach today.
Development , Enactment and implementation of regulations, legislations,
and Policies in collaboration and co-ordination with the World Health Organization
and the United Nations (53,54)
Geneva Protocol 1: This first
attempt to limit the use of biological agents in warfare was the “1925 Geneva
Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or
other Gases and Bacteriological Methods of Warfare”. Many countries ratified
the protocol but reserved the right for retaliation. This protocol was not
ratified by the USA in 1925.
In 1969, a proposal
was submitted to the United Nations Committee on Disarmament which included
“The Prohibition of the Development, Production, and Stockpiling of Bacteriological
and Toxin Weapons and Their Destruction (BWC)”. This proposal was ratified by
member nations including the USA and the Soviet Union. However, there were few
notable violations.
Key Regulations laws that were enacted to restrict biological weapons in
the USA (53,54).
Presidential Declaration on biological weapons, 1969: Mr. Richard Nixon, the
President of USA has declared the end of US involvement of production and use
of biological weapons.
Biological Weapons Act, 1989: This act defines that the development, manufacture,
transfer or possession of any biological agent, toxin or delivery system for
use as a weapon is a federal crime. The act also broadly defines the biological
agents.
Chemical and Biological Weapons Control Act, 1991: This act specifically deals
with the economic sanctions and export controls to cut the proliferation of
biological arms. This act also prohibited from exporting to certain countries
any goods or technologies that might be used to develop biological weapons.
Anti-terrorism and Effective Death Penalty Act, 1996: This act has broadened
penalties for development of biological weapons and illegitimate uses of
microorganisms to spread disease. This act expanded the regulatory
responsibilities of CDC for transport of dangerous biological agents. American
Society for Microbiology has recommended the extension of the 1996 Act to
include strict measures to prohibit possession of selected
biological agents and toxins and
registration of institution that have viable agents with the CDC. The CDC
regulatory framework governing hazardous biological agents was adopted in 1997.
Several
other bills were introduced and were passed in 2001. Among them were; Deadly
Biological Control Act of 2001, Bioweapons Control and Tracking Act of 2001,
Bioterrorism Enforcement Act of 2001 ( Amendment of Antiterrorism and Effective
Death Penalty Act of 1996), Antiterrorism Legislation –Public Law, Public
Health Security and Bioterrorism Response Act of 2001- Regulation of certain
Biological Agents and Toxins, and Bioterrorism Preparedness Act of 2001.
(55)
Bioterrorism Response System: (During an incident)
The bioterrorism attack itself
would be either overt (announced, eg: letter threatening anthrax to an
individual or agency) or covert. The covert attacks are the most disturbing and
might be unnoticed for long time. In these attacks, many victims develop a
common illness related to the agent with or without high mortality. It is
important to systematically determine the nature and possible impact of the
threat by assessment, identification and threat communication as well as simultaneously
providing a rapid public health response to individuals and communities
Threat Agent Assessment:
Fig 5 shows the process of
Threat Assessment in cases of overt or
covert attack.
Terrorists or criminals can carry out three types of biological attacks. First, the
pathogen or toxin may be injected. This method is best used when the terrorist
or criminal wishes to assassinate an individual. Second, a quantity of
pathogens or toxins may be used to contaminate or poison foods, beverages, or
medicines. This method could cause hundreds of casualties. Third, pathogens or
toxins may be suspended in a wet or dry formulation and dispersed over a target
area as aerosolized particles. This type of attack could produce thousands of
casualties, if the following conditions were met:
(1) The formulation was well designed for
aerosol dispersal;
(2) The aerosol particles produced by the
dispersal mechanism were of optimal size and could withstand environmental
stresses; and
(3) Weather and wind conditions were just
right for blanketing the target area with aerosol particles.
It is highly probable that food borne and waterborne
pathogens or toxic chemicals may be utilized as biological attacks by
terrorists or criminals. The probability that terrorists or criminals will
carry out airborne attacks with pathogens is low. The reasons are that it is
technically difficult to formulate pathogens and toxins for airborne dispersal,
to operate dispersal mechanisms successfully, and to ensure proper
meteorological conditions for
effective aerosol dispersal. Pathogens or toxins are likely to loose their
virulence or toxicity after a relatively short time (days to weeks). In addition,
dissemination equipment may not effectively spray solutions containing
pathogens or toxins due to the clumping of the stabilizing factor and the
pathogens. The environmental stresses, such as UV light and desiccation, may
kill or inactivate the aerosolized pathogens or toxins. There are possible
applications of advanced molecular biology techniques to develop recombinant
bacterial or viral pathogens such as smallpox and Ebola viruses (13) for bioterrorist attacks (56). The
spectrum and behaviors of terrorists would also provide the necessary clues for
the nature of threat and possible impact on society.
Threat Agent Investigation: Following the threat assessment, the identification of the
nature of the threat, credible or not credible, is conducted by the Federal
Bureau of Investigation. The criteria applied for threat agent investigation
are;
1.
Spectrum
of Terrorists known based on previous data (lone offenders, identified groups,
non-aligned terrorists, doomsday/cult-type groups)
2.
Behavior
profile and intentions of terrorists
3.
Operational
and technical characteristics of threat agent.
Based on the
credibility of the threat and its agent, the appropriate response system is
implemented.
Threat Communication:
Risk communication is a science
approach for communicating effectively in high concern situations and it
provides a set of principles and tools for meeting those challenges. It also
addresses the problems of effective communication by the exchange of
information about the nature, magnitude, significance, control and management
of risks. The strengths and weakness of the channel through which information
is communicated, such as press releases, public media, small discussions etc,
are also addressed by the scientific literature. Stakeholders, government officials
and industry representatives and scientists often state that non-experts and
lay people irrationally respond to risk information and inaccurately perceive
and evaluate risk information. However, the representatives of the citizen
groups, worker groups and individual citizens question the legitimacy of the
risk assessment and management process. These conflicts result in complex,
confusing, inconsistent or incomplete risk messages, lack of trust in
information sources and selective and biased reporting by the media that
affects how risk information is processed.
Effective
risk communication is based on the sound knowledge, planning, preparation,
skill and practices. It is an interactive tool that ensures the respect of
different values and treats the public as a full partner. However, personnel
involved from many agencies and organizations, lack the knowledge, sensitivity,
and skills need for effective risk communication. Such organizations initiate
risk communication efforts with inadequate resources and unclear objectives.
Four
risk communication theoretical models; Risk perception model, Mental Noise
model, Negative Dominance model and Trust Determination model have been
developed to describe how risk information is processed, how risk perceptions
are formed and how risk decisions are made for a particular event. These models
are very important to provide a foundation for thinking about a coordinated
effective communication in a high concern situation such as bioterrorism attacks.
There are several factors that could accumulate during a bioterrorist event.
These include, an element of surprise, use of unpredicted lethal biological
agents, the presence of an unknown perpetrator, the likelihood of wide spread
attacks and the delayed detection by Public health agencies.
One of the models that combat
the rise in emotions at the time of a biological threat is mental noise risk
communication model. Such an event would trigger many risk perception factors
that would amplify the perceived magnitudes of risk to high levels. Such
perception factors that would most likely to be amplified include involuntariness,
uncontrollability, unfamiliarity, ethical and moral violations and distrust in
institutions.
In
order to modify the public’s risk perception response to a possible biological
threat, a number of actions could be taken. Trust of the public in the
emergency response should be established in advance for the effectiveness of
any post event response. Also the public needs to be evaluated by introducing the
potential for bio terrorist attack in a measured, progressive and interactive
manner such as selected school programs, student take home assignments and
public education. Public participation
in preparation process and by providing a voice in the decisions that affect them
enables the public for a legitimate sense of control under threat. To address
the intensity of the emotions evolved by a threat, all emergency response
organizations must be committed to producing communication from preparatory
stage to final resolution.
Rapid Public
Health Response and Management of Bioterrorist Attack.
Many documented attacks are covert in
nature and the normal outcome would be an epidemic. Many of these cases come to
the attention of physicians gradually and doctors may become aware of deaths
among previously healthy individuals. The correct diagnosis of the type of
biological or toxic agent responsible for such the disease depends on the speed
and accuracy of physicians and laboratories.
In the case of an outbreak,
vaccination of the peoples already exposed to the pathogen defeats the purpose
of vaccination, hence containment of the infection is extremely important as is
the checking of all contacts an infected person has had with others.
Presently the national governments
of the various countries should have contingency plans to cope with any
naturally occurring or deliberate outbreak of infectious disease. The
international guidelines published by WHO should be used in response to the
outbreak. The public health response to the situation should be instantaneous,
by investigating the stocks of both drugs and vaccines to ensure that adequate
supplies are available to deal with any natural or deliberate outbreak.
A National Health Alert Network (HAN), developed by
the Centers for Disease Control and Prevention to act as a communications
infrastructure for response to bioterrorist events and other emergencies is
being implemented at the State and local health departments (57)
Conclusions:
Bioterrorism is a complex and multidimensional
issue that require local, national and international collaboration and co-operation
for mitigating the effects an attack. While the risk of bioterrorism is small, the
possibility of occurrence is real in every community and every country. In this review, an attempt was made
to systematically address processes that have been developed and coordinated by
both governmental and non-governmental agencies in the USA. The epidemiological
concepts to address risk assessment and public health management during
preparedness and at the time an attack is conceptualized around the critical
role of people in the community. Bioterrorism attacks disrupts the entire
social, political and economic fabric of a society and no one solution or
solutions solve the problem until the root cause is known. International
coalition against bioterrorism with sound national and international polices to
improve the health and remove inequity and inequality between underdeveloped
and developed world to achieve global socio-economic order may be one of the
solutions but until that time, national interventions should focus on
protection of health of the population.
References:
- William E. McNeill. Plagues and People,
1976
- Ramirez A. Was the Plague of Athens
Really Ebola? New York Times, Sunday, August 18th 1996
- Mayor A. Dirty Tricks in Ancient
Warfare. Mil Hits Quart. 1997; 10(1): 37
- Frobisher M, Fuerst R. Microbiology in
Health and Disease. 3rd Ed. Philadelphia: W.B. Saunders, 1973
- Dire DJ, Long DA, Williams LD.
Historical Aspects of Biological Warfare, Emedicine. http://www.emedicine.com/emerg/topic853.htm
- Barquet N and Domingo P. Smallpox: The
Triumph over the Most Terrible of the Ministers of Death. Ann Int Med
1997; 127: 635-642.
- Parkman F. The Conspiracy of Pontiac
and the Indian War after the Conquest of Canada. Boston; Little Brown&
Co.1901.
- Witcover J. Sabotage at Black Tam:
Imperial Germany’s Secret War in America, 1914-17. Chappel Hill: Algonquin
Book of Chapel Hill; 1989
- Williams P, Wallace D. Unit 731:
Japan’s Secret Biological Warfare in World War II. New York,NY: Free
Press; 1989
- Harris S. Japanese Biological Warfare
Research on Humans: a case study of microbiology and ethics. Annals of NY
Academy Sci.1992; 666: 21-52
- Johnson TJ. A history of Biological
Warfare from 300 B.C.E to Present. http://www.aarc.org/resources/biological/history.asp
- Harris R, Paxman JA. A Higher Form of
Killing New York, NY: Hill& Wang; 1982
13. Alibek K and S Handelman. Biohazard: The chilling true story of the largest covert biological weapon program in the
world. Random House, New York, NY. 1999.
14. Kipling R: Just-So Stories: The Elephant’s child
1902.Reprinted by Everyman’s Library
Children’s classics. New York, Alfred A Knopf, 1992 page 79.
15. Children more susceptible to effects of bio terrorism.
American Academy
of
Pediatrics. Highlights, October 22, 2001 http://exhibiotor.net/aap
16. Poverty fuelling terrorism. World Leaders Development Summit, Mexico 2002. http://www.news.bbc.co.uk/hi/
17. WHO Executive Board
addresses poverty and bioterrorism. The Lancet 2002; 359: 239
18. The Lancet 2001; 358:2133.
19. Mark Wheelis. Threat of Agricultural Biological Warfare
and bioterrorism, 2002: University
of California, Davis http://www.fas.org/bwc/agr/agwhole
20. Kemp C. Bioterrorism: introduction and major agents. J
Am Acad Nurs Practice. 2001; 13,
(11): 483-91
21. Tucker JB Historical Trends Related to Bioterrorism: An
Empiric Analysis. Emerging
Infectious Diseases 1999; 5 (4): 498-504
22. Stern J: Anthrax Incidents: Hoaxes
and Threats. National Symposium on medical and
public response to Bio terrorism Session on domestic terrorism, Washington DC Feb 16, 1999
23. Harling R, Twisselmann B, Asgari-Jirhandeh N,
Morgan D, Lightfoot N, Reacher M,
Nicoll A; The Deliberate Release biological agents .Initial lesson for
Europe from the events in the United States. Euro Surveillance.2001; 6 (11):
166-71
24. ProMED-mail. Pro/EDR> Anthrax; Letters- Chile, 24, Nov
2001
25. http://news.bbc.co.uk/hi/english/world/americas/newsid-1610000/161
Saturday,
20 October, 2001. South America on anthrax Alert
26. CAREC Alert .November 16th 2001. http://www.carec.paho.org
27. ProMED–mail.
Pro/AH/EDR>Anthrax-India-Jan31, 2001, AP2 Nov, 2001.
28. http://www.nytimes.com/aponline/international/ap-Anthrax-overseas
30. Torok TJ, Tauxe RV etal. A large community outbreak of
salmonellosis caused by
intentional contamination of restaurant salad Bars. JAMA 1997; 278:389-95
31.
Kolavic SA., Kimura A., Simons SL., Slutsker L., Barth S.and Haley CE. An outbreak of Shigella dysenteriae Type 2
among laboratory workers due to intentional
food contamination. JAMA 1997; 278: 396-398
32. Norwood AE, Holloway HC, Ursano RJ. Psychological effects of biological warfare.
Mil Med. 2001; 166 (12 suppl):27-8.
33. Tara O” Toole. Terrorism Preparedness: Medical
Response. Johns Hopkins Center for
Civilian Bio- defense Studies. Sept 1999. http://bioterrorism.slu.edu
34. Martin Hugh Jones. Global Awareness of Disease
outbreaks: The experience
of ProMED-mail. Public Health Report 2001;
116 (suppl 2): 27-30.
35. Zelicoff A, Brillman J, Forslund DW, George J, Zink S, Koenig S, Staab T,
Simpson G, Umland E, Bersell K. The
Rapid Syndrome Validation Project (RSVP). Proc AMIA
Symp 2001; 771-5
36. Miller JM. Agents of bioterrorism; Preparing for bioterrorism at the community
health care level. Infect Dis Clin North Am 2001; 15 (4):1127-56.
37. Citarella BB, Marble MJ, Mueller CJ. Home care & Hospice's role in
response to a bioterrorist event. Caring. 2002; 21(1):36-9
38. Glass TA, Schoch-Spana M. Bioterrorism
and the people: how to vaccinate a city
against panic. Clin Infect Dis.2002; 34
(2):217-23
39.Patt HA and Feign. Diagnosis and Management of bioterrorism- Pediatric Perspective.
Pediatrics 2002; 109, (4): 685-92
40. Recognition of
Illness Associated with the Intentional Release of a
Biologic
Agent. MMWR.2001; 50 (41):893-7
41 Investigation of
Anthrax Associated with Intentional Exposure and Interim Public Health Guidelines, October 2001,
MMWR 2001; 50 (41) 889-93
42 Arnon SS, Schechter R, Inglesby TV, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA 2001; 285:1059
43 Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon: medical and public health management. JAMA 2000; 283:2281-90.
44 Henderson DA, Inglesby TV, Bartlett JG, et al.
Smallpox as a biological weapon: medical and public health management. JAMA
1999; 281:2127-37.
45 Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax
as a biological weapon: medical and public health management. JAMA 1999;
281:1735-963.
46 Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia
as a biological weapon: medical and public health management. JAMA 2001; 285:2763--73.
47 Peters CJ. Marburg and Ebola virus hemorrhagic fevers.
In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious
diseases. 5th Ed. New York, New York: Churchill Livingstone 2000;2:1821—3
48 Klietmann W, Ruoff KL. Bioterrorism: Implications the
Clinical Microbiologist Clin Micro Review 2001; 14 :( 2) 364-381.
49 Jortani SA, Snyder JW,
Valdes R Jr. The role of the clinical laboratory in managing chemical or
biological terrorism. Clin Chem 2000;
46(12):1883-93.
50. Shadel BN, Clements B, Arndt B, Rebmann T,
Evans RG. What we need
to know about bioterrorism preparedness: results
from focus groups
conducted at APIC 2000. Am J Infect Control 2001 Dec; 29 (6):347-51.
51.
APIC Bioterrorism Task Force and CDC Hospital Infections
Program Bioterrorism Working Group.Bioterrorism readiness plan:
A
template for healthcare facilities.http://www.cdc.gov/ncidod/hip/Bio/bio.htm
52. Simberkoff MS. Vaccines for adults in an age
of terrorism. J Assoc Acad Minor Phys 2002; 13 (1):19-22.
53. Public health response
to biological and chemical weapons:WHO guidance. 2nd edition,
2001. deliberate@who.int
54. Atlas RM. Biological Weapons Pose
Challenge for
Microbiology Community. ASM News
1998; 64 (7): 1-7
55. Legislation.
http://www.asmusa.org/pcsrc/biolegislation.html
56. Raymond Zilinskas:
Assessing the threat of bioterrorism.http://cns.miis.edu
57.Doniger AS, Labowitz D, Mershon S, Gotham IJ. Design and implementation
of a local Health Alert Network.J
Public Health Manag Pract 2001; 7(5):64-74
Other Websites:
The Centers for Disease Control (CDC) http://www.bt.cdc.gov
The U.S. Army Medical Research Institute of Infectious Diseases http://www.usamriid.army.mil/education/bluebook.html
The Federal Bureau of Investigation (FBI). http://www.fbi.gov
The National Medical Disaster System: http://ndms.dhhs.gov/NDMS/ndms.html
Federation
of American Scientists: Working Group on Biological and Toxin Weapons
http://www.fas.org/bwc/
The Association for Infection Control Practitioners. http://www.apic.org
The Johns Hopkins Center for Civilian Biodefense. http://www.hopkins-biodefense.org.
WHO: Health Aspects of Biological and Chemical weapons. deliberate@who.int
PAHO/WHO: Pan American Health Organisation. http://www.paho.org