Bioterrorism: The New Threat of Infectious Diseases
By Dorothy Wright
Nearly three years after it was the first target in a series of anthrax attacks launched through the mail, the former Boca Raton, Fla. headquarters of a tabloid newspaper was declared clear of viable Bacillus anthracis spores, according to a July 13 Associated Press (AP) report. The unsolved bioterrorist attacks, which also targeted sites in New York City and Washington, D.C., in October 2001, killed five persons and made 17 others ill. Since that time, progress has been made in the effort to improve the nation’s preparedness for bioterrorism, yet significant gaps remain, according to experts Marguerite A. Neill ’73, Monica Schoch-Spana ’86, and Joel Selanikio ’88, who discussed this issue for part two of S&T’s look at the threat of new and re-emerging infectious diseases. Part one (S&T, May 2004) examined the issue of naturally occurring infectious disease.
Building a Network
“Many clinicians feel that bioterrorism and emerging pathogens are really part of the same cloth,” says Marguerite Neill, associate professor of medicine at Brown Medical School and chair of the Bioterrorism Work Group of the Infectious Diseases Society of America. “The way to enhance bioterrorism preparedness is by building a strong and competent clinical and public health network that is working to identify anything that is unusual.”
Marguerite A. Neill '73
Toward that end, Neill says the Centers for Disease Control (CDC) has invested heavily in laboratory capabilities and in their public and intra-agency communications infrastructures. “If they are sent a laboratory specimen, it can be examined in a phenomenally short time for various agents of bioterrorism,” she says. “The CDC has also strengthened its connectivity to health departments and clinicians through list-serves, Web sites and other communications infrastructures.”
Laboratory capacity also has been upgraded in the state health departments. “Last summer, a number of the states that were hardest hit by West Nile virus said that they never would have been able to handle this naturally occurring infectious disease had their laboratory infrastructure not been upgraded to handle bioterrorism,” Neill says.
For several years, Neill says, state health departments also have been sending laboratory personnel to CDC headquarters in Atlanta for additional training to perform sophisticated tests for agents of bioterrorism.
The U.S. Department of Health and Human Services (HHS) has invested money in upgrading metropolitan-area hospitals’ capital infrastructure to respond to bioterrorism. “One of the best examples of this was the renovation of the emergency department at Washington Hospital Center in Washington, D.C.,” Neill says. “They put several million dollars into renovations to handle chemical, radiation, biological and nuclear attacks.”
The U.S. Department of Homeland Security (DHS) is trying to develop an appropriate interface with HHS for designing our national civilian response to bioterrorism. “This has mainly been through establishing liaisons with particular clinical personnel within HHS,” Neill says.
Since 2003, the DHS BioWatch initiative, which is designed to detect trace amounts of biological agents in the air, has been operating in a number of the country’s urban centers.
Neill says a number of public and private entities are also conducting trials of real-time computer tracking of emergency department visits, patient billing records, 911 and poison center calls, over-the-counter drug purchases, etc., in an effort to turn up clues to possible bioterrorist activity, such as a localized spike in complaints of cough or diarrhea.
In the event of a bioterrorist attack, the National Pharmaceutical Stockpile is prepared to dispatch “push packages” of drugs, vaccines and medical supplies from strategically located secure warehouse within 12 hours of a federal decision to deploy these resources to a designated receiving site. Jointly managed by HHS and DHS, the stockpile is designed to supplement and re-supply state and local public health agencies in the event of a national emergency within the United States or its territories.
In July, President Bush signed the BioShield Act of 2004, which authorizes $5.6 billion over 10 years for the government to purchase and stockpile vaccines and drugs against potential bioterrororism agents, gives the government new authority to expedite bioterrorism R&D, and permits the Food and Drug Administration to speed distribution of new drugs and antidotes. Neill summarizes, “It says, ‘If you build it, we will buy it.’”
Meanwhile, some large-scale and local exercises have been conducted, and others are planned, to test responsiveness to simulated bioterrorist attacks. For example, in June 2001, the Johns Hopkins Center for Civilian Biodefense Strategies, in collaboration with three other institutions, conducted the first senior-level exercise of its kind, a two-day simulation of a smallpox attack, involving a dozen participants and about 60 observers. Neill says some public health departments, including New York City’s, have conducted pill distribution exercises using placebos, and this fall at least one exercise is planned that will test the ability to rapidly immunize persons by using real influenza vaccination stations as surrogates.
In spite of these gains, significant gaps remain in the nation’s bioterrorism readiness. For starters, the medical community is still struggling with an operational definition of preparedness. In July, a joint CDC-American Medical Association conference on public health readiness included a roundtable on how to define, benchmark and measure preparedness. “For example,” Neill says, “if 84 percent of hospital workers in Manhattan were to pass a quiz on bioterrorism, is that a benchmark for readiness? Nobody knows. People are saying, ‘We are better off than we were, but how will we know that we are where we need to be?’”
Neill says the answers to these questions will be different for each sector of the medical community. Compared with public health labs, which have a structured mechanism to require training, specific training sites, definable content, and discrete performance measures, she says, “The training issues for doctors, nurses, respiratory therapists and pharmacists are more diffuse. When you look through programs of their professional meetings over the past few years, you’ll see sessions on bioterrorism. But right now there is no clear identification of the knowledge these people should have and how to require them to obtain it.”
Moreover, Neill notes “an ominous statistic”: fewer than 40 percent of hospitals have conducted any kind of bioterrorism response drill.
Joel Selanikio '88
Joel Selanikio, a consultant on terrorism and disaster preparedness and response planning, argues that the threat of bioterrorism has been underestimated, both by health professionals and the public. He points to the CDC’s effort to vaccinate first responders and other health providers against smallpox, which stalled soon after it began in 2003. (At the time, Selanikio was an adviser in HHS.) “There was so much resistance from the people who would have been vaccinated,” he recalls. “I don’t think the government did a very good job in selling the risk, not just for smallpox, which is substantial, but for other events.”
At the root of the problem is the risk equation. “I think it is difficult for people to deal with low-probability, high-consequence risks,” Selanikio observes. “I would say that the probability of a smallpox attack is low, but not nonexistent. At the same time, the consequence would be catastrophic. Therefore, the risk, which is the sum of these two factors, is enormous.”
The National Pharmaceutical Stockpile is intended to help avert catastrophe, but logistical problems remain. Once a push package of drugs and supplies arrives at a designated site, state and local authorities are responsible for distributing them. However, Selanikio says, “Most states haven’t figured out how to set up clinics or deliver vaccines and supplies to the people who are going to need them. New York City, Florida and Illinois are pretty far along in terms of their practice and plans. Many other cities and states are not at the point where they could receive the stockpile effectively in a drill, much less in a real situation.”
Only recently have states begun receiving antidotes against chemical weapons. Acknowledging “an uneven level of protection across the country,” the CDC started shipping these materials in March, and the effort is expected to take two years to complete, according to a July 15 AP report.
Selanikio believes an effective response to a bioterrorist attack will require a coordinated effort among public health responders, first responders and hospital providers, but funding has lopsidedly favored state health departments. “In a practical sense, if you want to find folks that will help you vaccinate large groups of people, you won’t necessarily find them at the CDC or a state health department,” he says. “You are going to find them among first responders and in the local hospitals. Response must be coordinated among public health providers, clinical health providers, logistics experts and hospital administrators. But most of the money has gone to the state health departments to upgrade their labs because that’s the pipeline from CDC to the states.”
Monica Schoch-Spana '86
Monica Schoch-Spana, a senior fellow at the Center for Biosecurity at University of Pittsburgh Medical Center and chair of the center’s Working Group on ‘Governance Dilemmas’ in Bioterrorism Reponse, suggests putting epidemiologists in every hospital and state health department to forge crucial connections. “Part of the problem is a major disconnect between our health care system and our public health system,” she explains. “If there were better exchanges of information about what is going on in the population as it relates to infectious disease, then we’d have both a better medical and a better public health response. That requires salaries and strategies for what we want these persons to do, but that’s not rocket science.”
However, many hospitals and health departments are operating in the red. “Governors facing budget shortfalls cut back state funds for public health based on the assumption that health departments were getting preparedness money from the feds,” Schoch-Spana says. “More often than not, there was no net gain in terms of funding.”
Moreover, HHS Secretary Tommy G. Thompson has informed Congress that he intends to take $55 million from state bioterrorism projects to pay for a new program called the “Cities Readiness Initiative.” The program would train U.S. postal workers to help deliver antibiotics or antidotes to 20 major cities and the District of Columbia, install disease surveillance equipment, purchase vaccines and build new quarantine stations at U.S. airports, according to a May 21 Washington Post article.
At the same time, Schoch-Spana says, “We have large amounts of money being poured into BioWatch, a technologically-based detection system. There is an unfortunate American proclivity to spend money on shiny, bright things. But we don’t have a major new training grant program for people to get master’s degrees in public health so they can infuse more expertise into the health departments. Pending federal legislation may change that.”
“It’s easier to say, ‘We’ve got a hundred gizmos here and they read 1,000 samples per minute,’” Schoch-Spana continues. “It’s the desire to quantify improvement. Work force training and skill sets are less tangible, so it’s harder to show one is doing good things with the money. Plus it’s harder to show progress on a short time scale, and people move in and out of public office. Some of these fixes we are talking about are decades long; who will get to take credit for those?”
That brings Schoch-Spana to the subject of leadership. She is corresponding author of the paper, “Leading During Bioattacks and Epidemics with the Public’s Trust and Help”, which reports the conclusions of the Center for Biosecurity’s 30-member w orking group. The paper aptly begins with a quote from former Senator Sam Nunn, who played the role of the U.S. president in Dark Winter, the June 2001 smallpox bioterrorism exercise: “The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300 million people to take steps they don't want to take.”
As Schoch-Spana explains, “Leadership in an epidemic, whether it is deliberate or not, is about consciously pursuing and institutionalizing a sense of shared responsibility for public health. It’s not about people asking, ‘What is government doing to take care of me?’ or ‘How do I take care of myself?’ It is really about the societal responsibility to take care of one another.”
The working group has concluded that government at every level must use a shared responsibility model rather than a top-down model of leadership. “You have to approach the public as a capable ally and not as a problem that needs managing,” Schoch-Spana says. “You have to keep government’s response to a health crisis transparent through open channels with the media and the community’s other trusted sources of information. You have to prioritize voluntary compliance of the many over coercion of the few.”
The public’s cooperation often hinges on whether or not people perceive that leaders respect their intelligence, autonomy and equality. “Failed public health campaigns turn on poorly instituted public health practice, where force is selectively used against particular groups and individuals, or mandates for people to behave in a particular way instead of giving compelling reasons for people to do it on their own,” Schoch-Spana says.
The question on many minds remains, “What if a bioattack were launched tomorrow? Would we be prepared?”
Observing the lessons learned from the anthrax letter attacks of 2001, Neill replies, “There were very few actual anthrax infections, but the volume of people seeking rapid information almost brought our medical system to its knees. If there were another attack on the same scale as that one, I believe we would be able to act much faster to handle the situation. It would still be stressful, but our reaction time would be shorter and we would know better what to do than we did in 2001. We’ve got a lot more on the ball.”
But in contrast to a small-scale attack, Neill says, “If the anthrax attack were launched by a crop duster, resulting in mass exposure and large numbers of illnesses and casualties, then our response plans are not as well developed. Without practice drills or exercises to test pragmatic considerations, our response capacity and capabilities will be in a more rudimentary form.”
Clearly, much has been accomplished, yet still more needs to be done to develop the infrastructure and leadership to address the global threat of infectious disease, whether it is natural or intentional.
About Our Sources
Marguerite A. Neill ’73 is an associate professor of medicine at Brown Medical School and a member of the Division of Infectious Disease at Memorial Hospital of Rhode Island. She is a nationally recognized expert on food-borne pathogens. Neill chairs the Bioterrorism Work Group of the Infectious Diseases Society of America, and has led the Society’s effort to develop their Web site on bioterrorism. She has served on the U.S. Department of Agriculture’s National Advisory Committee on Microbial Criteria for Food Safety, and has published extensively on national biodefense preparedness as well as infectious disease. Neill earned her M.D. at George Washington University School of Medicine, Washington, D.C.
Monica Schoch-Spana ’86 is a senior fellow at the Center for Biosecurity at University of Pittsburgh Medical Center. She is chair of the center’s Working Group on ‘Governance Dilemmas’ in Bioterrorism Reponse, which seeks to enhance government leaders’ ability to effectively manage the conflicts of interest, priority and purpose that emerge during public health crises. A medical anthropologist, Schoch-Spana has served as a technical adviser to the Ad Council’s national campaign on emergency preparedness in conjunction with the Department of Homeland Security and the Sloan Foundation. She earned her M.A. and Ph.D. at Johns Hopkins University, Baltimore.
Joel Selanikio ’88 (Postbaccalaureate Premedical Program) is co-founder and senior vice president for medical and public health programs for Red Cell Associates, consultants in terrorism and disaster preparedness and response planning. Since 1995 he has advised the Centers for Disease Control, the Public Health Service, and the Department of Health and Human Services on these and other issues. Selanikio earned his M.D. at Brown Medical School, Providence, R.I., and is currently on staff at Georgetown University Hospital.
Dorothy Wright contributes news and feature articles on science, technology, engineering and general interest topics to a variety of publications, including Civil Engineering and Engineering News Record.