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Chemical and biological terrorism: planning for the worst. (Health Policy Update).

KEY CONCEPTS

* Bioterrorism

* Surveillance

* Weapons of Mass Destruction (WMD)

* Bioweapons

* Chemical Agent

* Biological Agent

The Federal Bureau of Investigation defines terrorism as "the unlawful use of force against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in the furtherance of political or social objectives." Chemical or biological terrorism is the use of pathogenic microbes or toxins derived from plants, animals, microbes, or chemical agents to achieve terror. Both foreign and domestic groups or individuals have been implicated in this form of threat, They select these types of weapons because they are cheap, are easy to make and hide, have a high potential to cause illness or death, and are scary to the public.

Historical perspective

The use of biological agents against a population is not a new idea. In 600 B.C. the Athenians contaminated rivers with skunk cabbage to give their enemies violent diarrhea. During World War I the Germans used xylyl bromide gas against the French who retaliated with gas grenades. More modern examples include the release of Sarin gas in a Tokyo subway in 1995 by the religious cult Aum Shinrikyo or the contamination of several salad bars In The Dalles, Oregon with Salmonella by a religious cult in 1984. Most recently, several U.S. cities have undergone significant threats from individuals claiming to have exposed others to Anthrax; to date all have been hoaxes.

These historical events raise the specter of more serious concerns because of recent increases in:

* Rogue nations with biological and chemical warfare programs

* Rising anti-government sentiment in some parts of the world

* The availability of unemployed scientists with ties to former bioweapons producing countries

* The reduction in technical barriers that allow easier production of these weapons of mass destruction

Biological and chemical agents

Chemical and biological weapons, like nuclear weapons, are categorized as weapons of mass destruction (WMD) because of the high number of potential victims that can result from their use. (12) Releasing a WMD would have serious impact on the health care system. A recent mock scenario done by the U.S. Army demonstrates the significant problems with even a modest size exposure. (3)

While any chemical can be weaponized, the chemical agents traditionally of concern fall into four categories:

1. Nerve agents like Sarin, Soman, or VX, which create an anticholenergic-like syndrome

2. Vesicants like Mustard gas or Lewisite that cause a blistering or burn-like syndrome

3. Cyanide, which interrupts aerobic metabolism

4. Riot control agents, such as mace and teargas, which generally cause incapacitation

Biological toxins act like chemical agents but have a slower onset of action. Agents of concern include Ricin, which is made from the castor bean, Botulism toxin, Staphylococcal Enterotoxin B, and Fungal T-2 Mycotoxin. This kind of event would appear much like a disease outbreak, but with a shorter onset and with disease activity contained to a defined group or geographic area with little secondary spread.

The ideal bioweapon is hard to detect from the usual microbial flora, has person-to-person spread, and is easy to aerosolize. There are two groups of organisms of public health concern: Those that cause a high morbidity or a high mortality. Examples of high morbidity organisms include Salmonella, Cholera, or E. Coil. These organisms generally will make people sick and are not as virulent, except to the extremely young, old, or debilitated populations. The number of highly toxic organisms is fortunately quite low and includes Anthrax, Small Pox, and the viruses that cause hemorrhagic fevers, plague, brucellosis, and tularemia. Biological events are generally covert unless the perpetrator gives early warning and may not be suspected for some time.

Clues that biological terrorist events have occurred include an unexplained increase in respiratory cases or deaths, or dead and dying animals. Epidemiological clues include diseases with the wrong mode of transmission, which occur in an inappropriate geographic distribution or infect a new or novel population. The presence of a new or unusual bacterial agent into a community should also raise people's index of suspicion.

Health system impact

The response of the health care system is different for chemical events than for biological ones. Most chemical events present as acute at the onset and respond well to the traditional lights and siren emergency medical response from police, fire, or EMS. Adequate planning for this type of event involves well-trained first responders, effective decontamination procedures, and a well-practiced disaster plan. Emergency medical and fire department personnel frequently respond to this type of emergency with a hazardous material approach. There may also be injured first responders if they unsuspectingly enter an unknown scene. Preventing this type of injury requires intense training and a high index of suspicion.

Biological events are covert in nature. In this situation, the first responder will be an alert clinician or public health professional who recognizes an increasing or unusual pattern of illness in a community. An appropriate public health response includes active disease surveillance and case finding. The prospect of secondary spread must be considered with many biological agents and should be planned for.

Policy issues: planning for disaster

Taking an inventory of the community's health care delivery and public health system assets is the first step to crafting a comprehensive plan (please see Figure 1). In most cases, it is best to build on the existing infrastructure and processes since people will do best what they do every day.

Training is essential in planning for this kind of disaster. A wide range of providers including epidemiologists, laboratorians, senior public health professionals, physicians, nurses, pre-hospital care providers, and medical examiners must be trained to address this issue. Areas of importance include the epidemiology of high-risk diseases, identifying the covert release of a WMD, diagnosing and treating these diseases, and working in a unified command.

Linkages need to be established outside the traditional health care arena with law enforcement (especially the FBI), local emergency preparedness staff, and veterinarians. Effective disease control strategies such as case finding, decontamination, prophylaxis and vaccination, and quarantine must be defined.

Discussions with managed care and other integrated health care delivery systems must also occur to answer such questions as:

* When is pre-authorization needed?

* Who pays for drug prophylaxis and vaccination?

* How do we ensure appropriate medical record confidentiality in a mass casualty criminal investigation?

* How can managed care help with disease surveillance activities?

Plans need to be developed for both active and passive surveillance systems with rapid electronic communication links. Specimen transport issues must be addressed, as well as forensic issues such as evidence and specimen collection and chain of custody. New technologies such as rapid biologic screens and genetic fingerprinting of microbes need to be used for sample identification Many public health laboratories around the country are developing this capacity.

Conclusion

The use of biological or chemical weapons would have a devastating effect on any community and would severely tax the health care system. The role of physician executives is to ensure that adequate contingency planning has taken place, to rapidly detect, respond, and mitigate the health effects on a large population. This type of response requires a highly functional public health infrastructure and solid health system planning. Physician executives play a major role in this process. (1)

FIGURE 1 COMPONENTS OF A BIOLOGICAL/CHEMICAL TERRORISM DISASTER PLAN

Plan how to identify the threat

Develop an effective public health disease surveillance system

Link the public health system and the traditional medical care delivery system

Develop command and control systems

Determine hospital bed availability

Plan to obtain needed vaccines and pharmaceuticals

Define disease containment isolation, and quarantine procedures

Plan how to obtain extra life support equipment such as respirators

Plan how to train clinical staff to identify high-risk unusual diseases

Ensure non-clinical staff are trained on the management of suspicious packages and mail

Identify experts

Maintain a chain of custody in a disaster

Plan sample handling and transport

Plan how to communicate high risk information

Manage medical examiner cases

Maintain a crime scene

--Adopted from Maryland Department of Health & Mental Hygiene Weapons of Mass Destruction planning document

Note

The stated views are those of the author and do not represent those of the State of Maryland or the Department of Health and Mental Hygiene.

References

(1.) Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response, National Research Council: Institute of Medicine, National Academy Press, 1999.

(2.) Terrorism with Chemical and Biological Weapons: Calibrating Risks and Response, Roberts, B. (Editor), The Chemical and Biological Arms Control Institute, 1997.

(3.) Presentation to Institute of Medicine, COL Edward M. Eitzen, Jr, MD, MPH, U.S. Army Medical Research Institute of Infectious Diseases, July 23, 1997.

Additional Planning Resources

The Federal Emergency Management Agency at www.fema.gov

The U.S. Centers for Disease Contorl Bioterrorism Division at www.ed.gov/neidod.diseases/biotech.htm.

The Maryland Health Department website (lots of links but some are not accessible and are for reference purposes only) at www.dhmh.state.md.us/eis6501/biot- 1 /biotbiot.htm

RELATED ARTICLE: SHOPPING MALL SCENARIO.

Anthrax aerosolized into shopping mall ventilation system: 10,000 people are present and 9,000 are exposed; terrorist announces attack at 24 hours.

90 percent of exposed started on antibiotics by end at the second day 10 pecent cannot be found initially.

Total number hospitalized estimated at 4,950 total requiring ICU care 2,925, total deaths 855, total ventilators required 2,601, total ICU beds 300 (only 150 available).

Dven a small scalle bioterrorism event completely overwhelms city's medical care resources.

The 13,000 military beds deployed for the Persian Gulf War would still not provide enough ICU beds (only about 1300).

Presentation to Institute of Medicine, COL Edward M. Eitzen, Jr., MD,

MPH, U.S.Army Medical Research Institute of

Infectious Diseases, July 23, 1997

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Maryland, Baltimore. He can be reached by calling 410/767-6505 or via email at BENJAMING@dhamh.state.md. us.
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Author:Benjamin, Georges C.
Publication:Physician Executive
Geographic Code:1USA
Date:Jan 1, 2000
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