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Responding to the Consequences of Chemical and Biological

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					                    Responding to the Consequences of
                     Chemical and Biological Terrorism

                                 07/11/95


                              "Introduction"
                      RADM Frank Young, Director OEP

Differences between manmade and natural catastrophic disasters

*    Public panic due to unfamiliar agent

*    Rapid assessment and technical consultation essential and time
     sensitive

*    Close coordination with crisis management essential

*    Law enforcement concerns are significant

*    Demand for health and safety information by public and health
     professionals. Requires prepared messages.

*    Rapid response required to save lives from toxic chemicals and
     biologicals

*    Most first responders have limited knowledge and experience
     with N/B/C/agents

*    Integrated response is required

*    Decontamination of patients and bodies is essential with
     nuclear and chemical agents

*    Mixed agent "cocktail" must be routinely checked for.

*    Worker safety depends on the use of specialized equipment

*    National security concerns are important



                      "A Threat to National Security"
                  Richard Clark, asst. to the President:

Presidential Decision Directive 39: "classified"
"FEMA with appropriate support from other agencies shall review
the FRP to deal with Nuclear/Biological/Chemical incident",
stockpiles and training deficits shall be identified and
resolved. (mentioned NDMS specifically)
                          "Combatting Terrorism"
                     Coordinator for Counter-Terrorism
                              Dept. of State
                        Ambassador Philip P. Wilcox

-    Terrorism: "the use of violence against non-combatants as a
     political threat"

New phenomenon:

Pattern toward mass casualties produced by terrorist acts.
Religious based terrorism, exploit religion or emotion to justify
acts of terrorism.
     -    More difficult to deter

-    Desperate & mentally ill terrorists who live on the fringe of
     society.

Use of materials for mass destruction: somewhat scientifically
based.

Copy-cat phenomenon: once the barrier has been breached, what was
once unthinkable becomes reality.

Seven countries that harbor or support terrorism:
Iran           Libya          Iraq
Syria          Sudan          Cuba
North Korea

Better Intelligence is the key to combating terrorism.

Legislative action to decrease funding of terrorism.
     - Counter Terrorism Legislation
     - Strengthen international support of the same

President has issued a directive with a work agenda for the Federal
Govt.: deals with the issues of consequence management

When asked to define the threat and resources planned:
Threat of terrorism internationally has declined, however
terrorists are increasing in their knowledge and sophistication,
their access to weapons is increasing. They have proved that they
can carry out terrorist acts.




                      "Making a big problem smaller"
                              Richard Danzig
                        Under secretary of the Navy

Share and pool knowledge.
Biological threats are more complicated and more challenging
than chemical or other modes of terrorism.

Biological terrorism difficulties:
     -    A weapon of mass destruction
     -    Potent
          -    1 g of anthrax can kill at lethality rates measured
               in millions
     -    Access to biological weapons are better than other modes
     -    Lends itself to attractiveness due to similarity between
          biological weapons and other clandestine activities: ie:
          drug labs
     -    cheap lethality rates (more damage per pound)
     -    Delivery methods
          -    Chemical is easier than other methods
          -    Biological is one of the easiest:
               -    crop duster, fogger, delivered by wind via
                    aerosol dispersion
     -    Ambiguity
          -    Easily disguised as symptoms don't show up
               immediately
          -    Allows perpetrators time to cover their tracks
          -    Enables uncertainty as to who "started it"
     -    Troops, mass gatherings, etc. occur quickly due to our
          ability to mobilize quickly. This allows opposition to
          deliver biological agents and inflict damage on a large
          number of the responders.

     -    Biological warfare has occurred throughout history
          -    Catapulting plague infected cadavers over walls of
               cities under siege in medieval times
          -    British infecting blankets with smallpox and giving
               them to the indians
          -    Japanese testing biological agents in manchuria
               prior to WWII
          -    Iraq developing biological weapons program

     -    Biological detection is the key, the technology is there
          but $ have not yet been spent on bio-tech weapon
          detection

     -    Increased human intelligence, increased knowledge of
          biological threat through inter-personal contacts

     -    Example of contact with one chemical agent: Ricin
          -    Potent
          -    Produced by common household chemicals and easy to
               produce
          -    Found by a highway patrolman and eventually
               analyzed and discovered: was going to be used by a
               drug gang toward a rival gang
          -    In minnesota: ricin was developed and brought into
               a local police dept in a coffee can.
What's being done:

     -    Military developing a Marine unit (2000 persons)
          specially prepared to deal with biological threats.
          Focused for 6 month deployments abroad (mediterranean).
          Although not geared toward domestic response, lessons
          learned will help domestic response units.

     -    Every agency needs to develop a crisis response unit that
          has a deeper knowledge of the biological / chemical agent
          threat, analysis and response

     -    Antibiotic "cocktails" and immunizations can provide a
          measure of protection against some agents if the threat
          is imminent or expected.

     -    Detectors: investment in this technology is sparse

     -    Education in personal protective equipment (PPE) use




                         "FBI Terrorism Briefing"
                                John O'Neil
                       FBI Counter-Terrorism Section

-    There is no law that makes terrorism illegal: ie:
     -    no law against transfer of biological hazards other than
          laws such as mail fraud, etc.

-    FBI's role in Terrorism Arena
     -    Designated by Pres. Reagan to be lead agency in US
          against Terrorism:
     -    FBI can under the auspices of Dept. of State can protect
          citizens overseas
     -    Lead crisis agency for the Feds

-    Terrorism categorized as:
     Domestic Terrorism
     -    Those individuals indigenous to US and not controlled by
          foreign power
     International Terrorism
     -    Persons controlled or supported by foreign powers

-    FBI Mission:
     -    Prevent acts of terrorism prior to occurrence
          -    Intelligence & surveillance
          -    Strengthen the targets of terrorism against
               terrorist acts
     -    Swift and robust action against terrorist act after the
          event
          -    Seek out and prosecute terrorists
         -   Continued tracking and evidence collection of past
             terrorists and terrorist acts

-   Terrorists are more interested in large scale terrorism with
    mass casualties:
    -    World Trade Center
    -    Oklahoma
    -    Japan (gas)

-   As a result of World Trade Center & Oklahoma bombing:
    -    need to put pressure on countries that support terrorism
    -    focus more attention on religious or other fanatics and
         trans-national movements
    -    became aware of organizations that seek funds and
         donations to support terrorism abroad (Israeli peace
         talks)
    -    Special interest groups and right-wing groups
         -    Anti-Abortion, Environmental, Animal Rights, and
              special interest groups who have political agendas
         -    Militias, white supremacists, etc.
              -    behavioral science section of FBI does
                   outreach to these groups

-   Events that fire the Radical Extremist movements:
    -    Shaw of Iran downfall
    -    Anwar Sadat killed
    -    Bosnia, Sudan, etc.
    -    Vatican re-opens diplomatic ties with Israel
    -    Anniversary dates of other events

-   Preparation for special events: Olympics, Pope visit, etc.
    -    "inside the center of olympic village is a working Nuc.
         Reactor"

-   Threat assessment component:
    -    grouping of behavioral sciences, PHS, FEMA, FBI Lab, etc.
    -    EG: video received by a public facility that indicated a
         threat to that facility during a mass event
         -    team assessed the threat and personnel were
              deployed to protect that facility
    -    Uses the joint command center

-   100 person hostage rescue team out of Quantico:
    -    Trained in personal protective equipment use and can
         execute their law enforcement role while protecting
         themselves against N/B/C threats

-   Various table-top and field exercises are being developed to
    train FBI and other agencies for N/B/C hazards

-   In the event an agent has been disbursed, the command of the
    response would shift from the senior FBI field officer to
    FEMA. The focus of the response would shift from law
    enforcement to consequence management. Law enforcement would
     still continue but would not hinder rescue or other responses
     to the consequence.



        "Concerns over chemical and biological dual-use technology"
                             Robert D. Walpol
              Deputy Director, Non-Proliferation Center, CIA:

Non-Proliferation: 4 aspects to US strategy
     -    Prevent acquisition of the technology
     -    Roll back program that generates that technology
     -    Deter use of the technology
     -    Adapt military and other existing resources for response
          to the use of the technology

-    Agent used for terrorist act depends on the terrorists intent:
     -    The intent of their act will determine what weapon they
          choose as each has a different effect

-    Chemical Weapons Convention:
     -    Libya & Iraq have refused to sign it, Iran signed it but
          does not comply
     -    Iran:
          -    Develops mustard and other choking agents
     -    Iraq:
          -    develops many chemical agents that can be delivered
               by numerous means
     -    Libya:
          -    Many agents and numerous facilities for Chemical
               Weapon production and delivery

-    Biological Weapon
     -    Cheap: so used by developing countries
     -    uses dual use equipment and supplies
     -    manufacturing of other legitimate agents can mask
          production of biological weapons (can be hidden from
          international inspectors).
     -    Shift from legitimate agent production to Bio-weapons can
          be done in a matter of days to weeks
     -    Delivered by off the shelf equipment (garden sprayers)
          rather than conventional weapons delivery systems
          (missiles)
     -    Iran:      end of development stages of Research &
                     Development of Bio-weapons
     -    Iraq:      maintains an aggressive Bio-Warfare program
     -    Libya:     lacks biological technology and sophistication
                     to make Bio-weapons



              "Medical Aspects of Biological Warfare Agents"
                      LTC Edward Eitzen, MD, US Army
Biological Warfare: the use of microorganisms or toxins derived
from living organisms to produce death or disease in humans,
animals or plants

Bacteria:
     -    unicellular organisms
     -    vary in size, shape
     -    under special conditions some can be transformed into
          spores: resistant to cold, heat, desiccation
     -    cause disease by invading the body tissues

Viruses:
     -     smaller than bacteria
     -     require a host cell in order to multiply

Toxins:
     -     products of living organisms that adversely effect other
           animals or plants
     -     not man-made

Bio-Weapon Characteristics:
     -    dispersed by aerosols and not visible
     -    silent, odorless, tasteless
     -    relatively inexpensive to produce
     -    may be unpredictable
     -    simple technology for delivery available
          (sprayer attached to any vehicle)
     -    user could tailor choice of arsenal to fit needs
     -    terrain and physical structures are usually spared
     -    may be easily used in combination
     -    used with other forms of warfare
     -    large area coverage capability (100's of miles)
     -    create fear, terror and panic

Lethal vs. Incapacitating Agents

Lethal         Incapacitation
Anthrax        Vee Virus
Botulism
Smallpox
Ricin Toxin


Hypothetical dissemination by airplane of 50kg Anthrax along a 2km
line upwind of 500,000 people

agent                 downwind    dead        incapacitated
-------------------   ---------   ---------   -----------------
rift valley fever     1           400         35000
typhus                5           9,500       35000
anthrax               >20         150         125000


Routes of exposure to Bio-Weapons
     -    Inhalation
          -    most significant route
          -    invisible clouds of small droplets (10 microns)
          -    Large droplets >10 microns are filtered or drop out
               of the air
          -    Smaller than 5 microns are delivered to alveoli and
               absorbed systemically
          -    same disease via lung as when ingested
     -    Oral
          -    Potentially significant route of delivery
          -    contamination of food or water supplies either
               purposefully or accidentally
          -    unlikely that an aerosol attack with toxins would
               significantly contaminate water supplies
          -    direct contamination of water supplies by pouring
               toxins into the water would require that it be done
               downstream from the processing plant
          -    Usually the body of water itself, dilutes agent
     -    Dermal
          -    Intact skin provides an excellent barrier for most
               toxins
          -    damaged skin (abrasion) makes it more likely to
               infect
          -    intradermal injection: ricin poisoning of bulgarian
               defector Georgi Markov by pellet from the end of an
               umbrella

General Preventive Measures
     -    Physical protection
          -    most important
          -    prevent exposure with full face respirator
               (respiratory tract and conjunctiva)
          -    surgical masks not effective
          -    need to decontaminate yourself prior to removal of
               protective equipment
     -    Decontamination
          -    dermal exposure should be treated with soap and
               water
          -    dilute chlorine or bleach for 10-15 minutes
     -    Vaccines
          -    civilian population are not routinely vaccinated
               foremost Biological Warfare agents
     -    other drugs:    prophylaxis
               -     secondary exposure protection

Post Exposure Management
     -    Anthrax
          -    Prototype Biological Agent
          -    Vaccinate immediately and antibiotics
          -    antibiotics for 12-16 weeks if not vaccinated
          -    primarily occurs in herbivores
          -    reservoir is in the soil
          -    person-to-person transmission does not occur
          -    Problem in: Pakistan, Iran, Sudan, Haiti
    -   Easy to make and cheap
    -   Short incubation period
    -   small number of spores to create infection
    -   spores are very hearty
    -   produces toxins that are responsible for most of
        anthrax's lethal effects
    -   Cutaneous form (95%)
        -    papule on skin that enlarges into ulcer
             surrounded by vesicles, swelling
        -    treatable with antibiotics
    -   Gastrointestinal
        -    ingestion of infected animal products
        -    high mortality rate >50%
    -   Pulmonary
        -    doesn't infect the lung but is absorbed by
             lung, picked up by lymph system and infects
             the mediastinal lymph glands, breaking down
             the mediastinal organs
        -    incubation for 2-5 days with sudden onset of
             cardiorespiratory symptoms: hemorrhagic
             mediastinitis, pulmonary effusion, etc.
        -    Chest Xray shows widened mediastinum as a
             clinical hallmark
    -   Anthrax vaccine available with very minor side
        effects: 3 doses over 4 weeks
    -   Dual treatment of antibiotics (Cipro) and vaccine

-   Botulism
    -    Affects the neuromuscular junction similar to the
         way a nerve agent would work, but in the opposite
         way.
    -    Food born most prominent due to improperly prepared
         food. Most common form affecting infants, fed
         milk, etc. Infant cant break down and combat the
         botulin toxin.
    -    Wound botulism is rare, infects open wounds and
         produces botulin toxins that have a systemic
         effect.
    -    Inhalation botulism occurs
    -    Onset of symptoms 24-36 hours to several days after
         exposure
    -    Descending paralysis: cranial nerves first
         (drooping eyelids), last symptoms being muscular
         paralysis and respiratory paralysis
    -    Senses are not effected, so although paralyzed,
         victim is aware of what is going on
    -    Can be confused with Myasthenia Gravis, Guillain-
         Barre, Organophosphate, nerve agents poisonings
         given too much atropine
    -    Vaccine available (investigational new drug)
         -    takes 12 weeks
    -    Management:
         -    ICU type care (ventilatory, etc)
         -    Anti-toxin is available but has secondary
                   risks due to it being a horse serum (allergic
                   rx): must be given prior to toxins being
                   absorbed into the nerve endings

    -    Ricin:
         -    Castor bean plant
         -    Used to kill Georgi Markov (Belgian defector)
         -    Cyto-toxic: severe necrotizing process to all cells
              it comes in contact with
              -    Lung, GI tract, etc.
         -    Causes Pulmonary necrosis, effusion, etc.
         -    Ingestion causes severe symptoms in 8-10 hours,
              abdominal cramps, hemorrhagic processes to mucus
              membranes and death within 2-3 days
         -    No specific medical therapy. Supportive management
              usually ICU required. Activated charcoal can be
              used for GI exposure if used within the first 1-2
              hours.
         -    Prophylaxis: physical protection
         -    Vaccine not yet available

    -    Staphylococcal Enterotoxin:
         -    Same as those that cause GI infection
         -    When inhaled cause severe problems and
              incapacitates for a couple of weeks: usually not
              lethal
         -    Complex interaction with immune system: super-
              antigens
         -    3-12 hour onset of symptoms
         -    High fever (103-106), SOB, N/V/D
         -    Diagnosis is epidemiologic
         -    Medical management is supportive
         -    No vaccine available

    -    Need to determine if a situation is an endemic infection
         or a Biological Attack
         -    Bio attack
              -    Increased number of victims than typical
              -    More respiratory exposure than normal
              -    Multiple or mixed attacks
              -    Exposure in a non-endemic area

    -    Impact on medical infrastructure
         -    overwhelming casualties and demands on ICU care
         -    barrier nursing (masks, gowns, etc)
         -    Agent dependent



                     "Potential Incident Scenarios"
                           William C. Patrick
                          BioThreats Assessment

-   Meteorology:
     -      Inversion layer that keeps smoke and dispersal on the
            ground
            -    most often occurs during early morning and at night

-    Munitions efficiency: number of infectious units rendered
     airborne in the 1-5 micron size

-    New york subway system: thrown from the back of trains
     -    Egland Air Force Base:
          -    Disseminated bacilli and infected base housing and
               planes
          -    Didn't need to get close to the security perimeter


Amount of Agent (kg) to produce 50% casualties on 1.5 KM^2 target:

     Anthrax    0.09
     SEB        78
     Botulism   512


Scenario:
14 story building attacked with 8g of bacilli
     -    introduced into ventilation system
     -    penetrated all floors of bldg in 15 minutes
     -    remained viable for 5 hours

Success of attack:
     -    Size of bldg in liters
     -    Man breathes 10L per minute
     -    number of doses of agent

World Trade Center scenario using various toxins:
     -    10 billion liters of air
     -    Grow botulona Toxin in garbage cans
     -    would need 264 gallons of toxin to spread through bldg.
     -    Botulana toxin requires more strength for pulmonary route
          and thus would not be feasible
     -    however, if you use dried botulana toxin, the volume
          required is only 1 kg of material to produce an effective
          dose in 1.2 hours
     -    Tulleremia would produce an infectious dose after 20
          minutes

Dedicated   Terrorist Group:
     -      Produce crude Biological Warfare agents with simple equip
     -      Gerry rig crude device from existing equipment
     -      Effect a large population in a very public place
     -      Produce bldg which people will not enter for weeks



                               "Chemical Agents"
                             Fred Sidell, US Army
              Medical Research Institute for Chemical Defense


Chemical agents are not new:
     -    13th century was the first. greeks used during the 14th
          century
     -    Cyanide shells used during WWI
     -    Chlorine shells used during Civil War
     -    WWI Germany used Chlorine gas, 1/3 of the casualties
          involved chemical agents
          -    CN tear gas, Chlorine, Phosgene, Cyanide, Mustard
     -    Since WWI: Nerve agents, CS tear gas

Physical Forms:     Gas, vapor, aerosol, liquid, solid

Chemical Hazard
     -    non-persistent (hours)
          -    vapor
          -    liquid: evaporation
     -    Persistent (1 day to years)

Agents of concern:
     -    Nerve Agents
     -    Vesicants
     -    Cyanide
     -    Phosgene and related
     -    Riot control
     -    Incapacitating agents (makes one unable to function
          normally for a period of time with a full recovery)
          (loss of vision, dizziness, GI upset)

Vesicants of Concern:
     -    Cause vesicles or blisters
     -    Mustard
          -    Chemical warfare Agent
          -    Synthesized in 1822
          -    Low lethality (<5%) causes lots of casualties
          -    100th of lethal amount will cause eye damage
          -    10mcg of liquid will cause a blister
          -    Skin, eyes and airways are affected, causes damage
               in bone marrow, CNS and GI tract
          -    Absorbed in minutes: action must be taken within
               minutes as effects are irreversible
          -    Clinical effects occur 2-48 hours later (4-8 hours
               commonly)
     -    Luicite
          -    similar effects to mustard
          -    Causes immediate pain
          -    very irritating to eyes and mucous membranes
     -    Cyanide
          -    effects within seconds
          -    burning plastics contain cyanide
          -    small amounts can be detoxified
          -    High amounts needed for lethality, no effects at
         lower doses
    -    Inhibits intracellular enzyme that helps cell use
         oxygen
    -    Ingestion:
         -    Vertigo, nausea, weakness, respiratory &
              cardiac depression
         -    Antidote very effective if given soon after
              exposure
    -    Inhalation
         -    death in 5-10 minutes
         -    Not effective outside due to dispersion
         -    Effective in confined space
    -    Antidote: amyl nitrite
-   Nerve Agents
    -    Inhibit cholinesterase allowing toxic buildup of
         acetylcholine
    -    Carbamate (insecticides)
    -    Organophosphate (malathion)
    -    Tabun(GA), Sarin(GB), Soman(GD)
    -    Colorless, odorless, tasteless
    -    Penetrate skin and clothing very well (not safe
         with just a gas mask)
    -    Volatile and evaporate readily (but less quickly
         than water)
    -    Vapor hazard
    -    Lethal dose is quite small (10mg for VX)
    -    Glands hypersecrete, muscle stops contracting,
         bronchial constriction and hypersecretion, vagal
         stimulation of heart, CNS effects from confusion to
         death which may linger weeks
    -    Atropine only effective on muscarinic effects
         (muscles, secretions)
    -    Initial effect depends on amount of exposure
    -    Skin exposure: small drop = localized sweating and
         fasciculation, larger drop = GI effects, Large drop
         = CNS effects and death within a few minutes
    -    Management:
         -    Decontamination
              -     Skin decontamination only worthwhile if
                    within minutes of exposure (skin
                    decontamination will help to protect
                    staff)
              -     Most victims of nerve gas are exposed
                    only to vapor and no decontamination is
                    needed
         -    Ventilate: will have very high airway
              resistance
         -    Atropine: has side effects and doesn't correct
              nicotinic effects (skeletal muscle paralysis)
              -     2mg effective dose (self-administered)
                    with up to 20mg total dose for severe
                    exposure
         -    Remove agent
              -     Oximes: help with nicotinic effect
               "Chemical Incidents: Issues and Concerns"
                           James A Genovesse
                    US Army R&D Engineering Center

-   "$30 shop-vac is a good disseminator for chemical agents"
    -    good example of a simple piece of equipment that can be
         purchased anywhere and used for chemical dispersal

-   Chemical vapors:
    -    All get into the deep lung and can be absorbed
    -    Work well in closed environment

-   Focus: chemical incidents involving volatile chemical agents
    in close quarters

-   Comparing Terrorism to Military Operations:
    -    terrorism targets are non-combatants
    -    minimal civilian training and preparedness
    -    open field engagement vs. covert, close quartered
         deployment
    -    terrorism evokes psychological and physical response from
         its victims
    -    Infinite number of scenarios (targets) possible

-   Why chemical terrorism?     IT'S EASY TO DO !!

-   Easiest cloud to generate
    -    Almost independent of dispersion method
    -    Gaseous molecules - well behaved - high rate of diffusion
    -    Rates of droplet evaporation
         -    Particle size
         -    Number density
         -    Heat of vaporization
    -    Already in respirable range

    -    Easy to get
    -    Nerve Agents:
         Sodium Fluoride + Methyl Phosphonic Dichloride +
         Isopropyl Alcohol = Sarin
         -    Commercially available
         -    Methods to make agents available on the Internet,
              etc.
         -    Malathion / Parathion: readily available and about
              1/10th the toxicity of Sarin (GB)
         -    Industrial hazards commercially available:
              Chlorine, Phosgene, Methyl Isocyanate, Hydrogen
              Cyanide

    -    Environmental mixing - outside
         -    Winds
         -    Solar heating
    -      Large "atmospheric" mixing bowl
    -      hence:
           -    Concentration rapidly decreases
           -    Lethality low

-   Environmental mixing - inside
    -    Physical barriers (walls)
    -    Forced air currents
    -    No wind and no infinite source of air
    -    Comparatively little dilution
    -    hence:
         -    concentration remains lethal for longer
    -    Commercial buildings have air intakes, personal
         houses usually get their fresh air from diffusion

-   ie: Cruise ship
         -    where do you evacuate to ?
         -    closed system

-   Why explosive dissemination ? (what the terrorist knows):
    -    Old wives tail: Chemical / biological material is
         consumed in the fireball - Not true
    -    Chemical / Biological material rides the shock wave
         ahead of the fireball
    -    Instant gratification for the terrorist

-   Pyrogenic agent generation: ie: Cigar dipped in teflon
    -    Produces Phosgene, Hydrogen Fluoride, sub-micron
         polymeric fumes (.01 micron particles), not
         recognized by alveolar macrophage thus absorbed
         interstitially (Hold what's absorbed in them for
         weeks until they degregate and then release the
         chemical)
    -    As more building materials are polymeric, when
         burned they release more toxic agents

-   What   is needed to cover a chemical incident
    -      Early detection
    -      Respiratory protection
    -      Consequence management education
    -      Responsive medical treatment
    -      Hazard prediction & analysis

-   Summary
    -    Chemical incidents are easy to accomplish
    -    Effective, lethal alternative to conventional
         terrorism
    -    Training and education are mandatory
    -    Blower masks (made by Israel company) are excellent
         public protection devices



                      "Surveillance Systems"
                                  Panel
       Scott Waterhall, Director, CDC Surveillance & Epidemiology

-   Began as malaria control

-   Public health surveillance: Collection, analysis,
    interpretation, dissemination and link to public health system

-   Uses   of surveillance
    -      Detect epidemics
    -      Evaluate control measures
    -      Monitor changes in infectious agents

-   Systems of disease surveillance
    -    Reporting systems
         -    sometimes under reporting due to no enforcement
         -    Sub-acute diseases are not reported
         -    Inconsistency of case determinations
    -    Laboratory based
    -    Hospital based
    -    Population based
    -    Vital records (birth & death certificates)
    -    Disease registries

-   CDC's Epidemic Intelligence Service
    -    DVM's PHD's and MD's
    -    Establish existence of outbreak
    -    Verify diagnosis
    -    Define and identify cases
    -    Characterize by time/person/place
    -    Develop, evaluate and refine hypotheses and conduct lab
         studies
    -    implement control methods
    -    report findings



        Remle Grove, Chief, FDA Emergency & Epidemiology division

-   Public assumes that food, cosmetics, etc. are safe

-   Small quantities of a hazardous chemical can be added to a
    product that is mass produced and can affect hundreds

-   Information / report of contamination usually comes from
    consumer



               Ken Stroech, EPA Special preparedness Programs

-   ERAM:      Environmental Radiological Monitoring system
    -     Samples from 60 locations
    -     Could be used to monitor for other chemical agents
-   Environmental Response Team

-   Safe drinking water monitoring
    -    It is conceivable for terrorist water contamination to
         take place
    -    Existing purification methods limit the potential




     Robert Southhall, Inspection Services US Dept of Agriculture

-   Economic impact a agricultural disease would have

-   Active Surveillance in slaughter houses for major diseases

-   Passive reports from the farmer

-   Watch for certain warning signs: death, abortion, skin lesions

-   Emergency Response Teams, Task force, field surveyors: can
    respond rapidly when a situation occurs and have authority to
    quarantine




                   Responding to the Consequences of
                    Chemical and Biological Terrorism

                                  07/12/95

       "Special challenges in planning and reacting to terrorism"
        Allan Holmes, Asst. Secretary of Defence for Special Ops
-   "A nuclear/biological or chemical terrorist is no longer
    beyond the imagination"

-   15 Countries known to have offensive Chemical weapons programs
    "the poor mans atomic bomb"

-   Advantages to conventional weapons: widespread death &
    destruction, built in hostages, news media coverage, allow for
    covert acts (death hours after, mis-identification), Terrorist
    knows: probability of a response in kind is low (he controls
    the lethal action)

-   Some of our allies find it difficult to comply with threat of
    terrorism because they are afraid of becoming a target
    themselves.

-   Even when State sponsorship is suspected it is difficult to
    prove and thus difficult to retaliate.

-   Cooperation between Fed, State & Local authorities is the most
    critical:
    -    Cant use military domestically
    -    most assets to combat chemical/biological weapons are in
         the military

-   Crisis managers must rely on responders who can do mass care
    and cleanup:
    -    planning and actions of crisis managers can inadvertently
         affect rescue and cleanup efforts and thus must be
         closely coordinated
    -    Warning, detection, identification, rendering safe, final
         disposition

-   US has three courses of action
    -    Maintain status quo:
         -    assumes that terrorists wont use c/b weapons
    -    Increase diplomatic efforts
    -    Increase / build up consequence management techniques
         -    Build both offensive and defensive methods

-   "Final analysis: take whatever means necessary to insure the
    safety of the American Citizen, Failure is not an option"

-   National Security Directive 39: New emphasis is in Chem/bio
    defense and mitigation




             "Medical Research to Support Counter-Terrorism"
         Commander Russ Zajtchuk, US Army Med. Research Command

-   US Military Medical Research Capabilities:
     -    Ft. Dietrick, Biological Defense Lab
     -    Aberdeen proving ground, chemical defense
     -    World Inst. of Infectious Diseases
          -    Emerging diseases labs overseas in Thailand, Egypt,
               Peru, Kenya, etc.
     -    Exploring pre-treatment methods for some chem/bio items
     -    Offers courses and Chem/Bio training that are open to
          non-military agencies




                          "Poison Gas Incidents"
                 Dr. Nobuo Yanagisawa, Shinshu Univ. Hosp.

-    Have had incidents twice in 1 year (Matsumoto & Subway)

-    A report on Sarin Incident in Matsumoto
     1)   Outline of the incident
     2)   Medical reports
          1)   Medicated patients
          2)   Questionnaire to residents
          3)   Casualties in rescue teams
     3)   Causative agents

Toxic Gas Poisoning Incident in Matsumoto:
-    7 deaths
-    54 admitted
-    208 visited Out Patient clinics
-    277 had symptoms but did not consulate MD

-    1 admitted to vegetative stated

Condition of Dead subjects
-    Three found dead inside living rooms while watching TV
-    All showed miosis, one in decerebrate posture
-    One in bathtub
-    One in sparse respirations, no radial pulses

Summary of subjects
-    Headache, decrease in visual acuity, fatigue
-    Muscarinic effects & Nicotinic effects
     -    Meiosis occurred from both inhalation and contact w/ gas
-    CNS effects: Seizures, Comatose, Deep Tendon Reflexes absent
-    Examination:
     -    Increase in Serum CPK, Leukocytosis and decrease in
          potassium and Chloride
-    In one case, Seizure activity and arrhythmias lasted 40 days


Treatment of Severe Cases
-    IV and Ventilator
-    Atropine sulfate (50mg for first 24 hours)
-    Oxime (pralidoxime iodide) [only used on 1 patient as
     causative agent unknown]
-    Diazepam
-    Adequate IV fluids (vomiting, diarrhea and secretions)

Questions posed to residents:
1st questionnaire: 3 weeks after incident
-    471 had subjective symptoms
-    40 Admitted to hospitals
-    156 visited Out Patient clinics
-    277 did not consult MD

at 4 months
-    55 had symptoms

-    Analysis of questionnaire showed correlation between wind
     direction from release of Sarin to reports of symptoms from
     those who returned the questionnaire

-    Casualties of Rescue Teams
     -    18 teams, 52 persons from 5 departments
     -    8 persons complained of symptoms, 1 admitted to hospitals
          for one day
     -    Wore no protection for gas or toxins
     -    Staff who developed symptoms worked early in the incident
     -    Rare symptoms from personnel at hospital, meiosis was
          found

The agent identified as Sarin (GB)
-    Compared with Hydrogen Cyanide, Halogenated compounds
     (Hydrogen Fluoride, HCL), Organophosphate, Phosgene
-    Identification of sarin was not possible from medical exam, it
     was only Identified after chemical detection
-    Sarin, byproducts of manufacture, or degradation products of
     sarin were detected in all of the dead victims

-    Less than 20 liters was deployed
-    Deployed from a truck with a heater and fan
-    Perpetrators were poisoned and treated by the terrorists

Summary:
-    did not use many oximes for treatment
     (were used and were effective in subway gas attack)
-    Information exchange system
-    Registration system of casualties
-    20L or less was released
-    Casualties lived 400m downwind from release
-    Deaths lived 80m downwind
     -    All dead victims had window open due to weather
     -    None were on the first floor, all were 2nd or 3rd
          -    1st floor keep windows closed for safety
-    Symptoms observed were all typical of sarin
-    a large number of rescue team experienced symptoms who worked
     during the early part of the response
-    Not many people displayed psychological (psychogenic) symptoms
    -    The cause was unknown until later



                         "Japan Subway System"
                   "Japanese medical team briefing"
         Dr. Sadayoshi Obu, St. Luke's International Hospital

-   Subway station involved was at the juncture of 3 lines
-   5500 passengers and employees sickened, 11 deaths
-   Converted chapel to observation area (22 patients held
    overnight in the chapel for observation)
-   08:16 first call to Emergency      08:32 first critical victim
-   by 14 :00 all ambulatory patients were evaluated (650 victims)
-   5 patients in critical condition (3 in Cardiopulmonary arrest,
    one of which expired (meiosis remained even after death), 1
    had brain death and expired 28 days later, 1 who responded
    after 5 minutes of resuscitation)) 2 were admitted in drowsy
    condition, went into respirator arrest and then treated and
    responded. (both were discharged from ICU in 4-5 days)
-   PAM (oxime) was used in most of the critical patients
-   111 patients (45 males / 66 females (5 pregnant)) were
    admitted
-   80 were discharged the next day (within 24 hours)
-   Within 24 hours all hospitalized patients were given Atropine
    and PAM (after diagnosis of SARIN was received 3 hours after
    attack), all received IV rehydration.
-   Patients could have been managed without PAM, however Serum
    Cholinesterase levels returned to normal faster than typical
-   A small percentage of hospital staff had symptoms (meiosis and
    other visual problems)

-   Sarin used in this attack was dilute

-   Factors that made response to this attack successful?
    -    Preparedness for disaster: frequent drills and practice
    -    Faculty design: had non-medical area that was used for
         holding / waiting
    -    Time of day (just prior to busy working day) which
         minimized victims
    -    Demographics of victims (young and middle aged) no very
         young or elderly
    -    Isolated injury: no trauma or other injuries
    -    Police suspected the incident, the terrorist group
         preempted their planned strike. Government had
         stockpiled PAM and Atropine incase of an incident




         Dr. Tatsuo Yamaguchi, St. Luke's International Hospital
Ocular symptoms of Sarin Gas incidents in Tokyo:

-    Anatomy of eye:
     -    Anterior chamber:   controls eye pressure by secretion of
          vitreous humor

-    07:50 incident occurs
-    08:28 first patient arrives (hospital 5 minutes away)
-    08:50 first patient arrived in ophthalmology dept,
-    09:00 Ophthalmologist sent to ER
-    09:40 Acetonitrile was determined to be agent
-    11:00 Sarin was determined, cholinesterase level was examined
     on all patients
-    11:30 symptoms and treatment for SARIN faxed to St. Lukes from
     Tokyo Ophthalmology Assoc. (sent also to other area hospitals)
-    14:00 patients showing light reflex
-    17:00 all 112 outpatients with ophthalmologic problems were
     sent home with D/C instructions to return for problems
     (saw 112 victims of the attack along with regular appointments
     of 185 persons)
-    1 day later: 138
     2 days later: 139
     3 days later: 81
     4th day: 100
     total 480

-    Treatment for meiosis
     -    Mydrin-P: 4-5 hours   (preferred)
     -    1% Atropine: 5-7 days
     -    1% Cyclogyl: 6-24 hours
-    Meiosis lasted days
-    ciliary injection / conjunctival congestion / constricting
     visual field / changes in accommodation

-    Anterior Chamber showed edema
-    Electro-Retinal-Gram (ERG) showed decreasing of the A & B
     waves

-    3 months after incident: 41 patients reviewed (17 admitted, 24
     outpatients)
     -    15 still had eye complaints
     -    16 had systemic complaints
     -    1 had psychological complaints
     -    Meiosis in 28 patients
     -    None experienced new blindness
     -    2 had increase in corneal thickness
     -    13 had abnormality in ERG

-    Treatments used:
     -    Miosis
     -    Hyperemia
     -    Foreign body sensation

-    Long term follow-up is needed in these patients even though
    symptoms are not severe.



                        US Medical Team Briefing
         Fred Sidell, US Army Medical Research for Chem Defense

-   Cited example of victim who after the subway incident, hailed
    a taxi and traveled to hospital, kept clothing on and was not
    decontaminated: potentially could have contaminated the taxi
    and other areas as she came within 6 feet of the SARIN.

-   US Govt. Team of:
    Scott Lillibridge, Sanford Leffingwell, John Liddle, Frederick
    Sidell
    -    In Tokyo for two days, 1 afternoon at St. Lukes hospital
    -    5510 casualties: 12 deaths, 17 critical (required ICU),
         37 severe (had GI complaints), 984 moderate (has meiosis)
         -    ~1400 patients that went to hospital and had
              nothing wrong

    -    4073 patients seen on day one and not hospitalized,
         dozens came during the next 48 hours who thought they
         were exposed.
         -    80 % of the casualties reported had no chemical
              injury
         -    Incidents of those who are scared and uninjured may
              be quite high and hamper access to those who are
              actually injured.

    -    Should antidote be administered via auto-injector on site
    -    Those physically exposed to an agent must be
         decontaminated, those who are exposed only to vapor may
         not need to be.

    -    Treatment:     Atropine (0.5mg q 15 minutes) use pupil
                        size as indication
                        Pralidoxime (1g q 8 hours)

    -    Why few deaths?
         -    Single source
         -    Slowly evaporating
         -    No dissemination
         -    People left quickly
         -    Factors caused low dose in most

-   "The Japanese handled 5010 victims with only 11 deaths, would
    this have been as well handled if this happened in a US city
    and would we have had the resources to do as well"




             "Recent incidents and responder implications"
               Kyle Olsen, Chem & Bio arms control institute

"State of the art terrorism: lessons learned from the tokyo
subway attacks"

-    8am monday morning March 20, 1995:
-    Similar attack in Matsumoto: June 27th, 1994
     -    No political, military or symbolic significance
     -    Nobody claimed responsibility
     -    Released at night in a residential neighborhood
-    Kamakuishiki in July 1994
     -    HQ of Aum Shinrikyo sect with factories and dormitories
     -    Cult members seen ill and claimed they were targets of
          chemical weapon attacks
-    Other similar events of gas and suspicious items
     -    Noxious chemical around Tokyo released in a train
     -    Tokyo: 3 briefcases found with a fan, battery operated
          and was releasing a gas (unidentified)

-    All these events indicated that someone was experimenting and
     testing techniques for a terrorist act

-    Plan:
     -     Place sarin on five trains, all converging on the center
           of tokyo
     -     Plan was to involve a large number of deaths and injury
     -     One delivery man, one "puncture" man who activated the
           substance
     -     15 stations affected

-    Japanese authorities had planned a raid to attack the sect and
     raid their locations
     -    Training in PPE and hazardous chemicals for police
     -    Raids and arrests occurred very fast (2 days) after
          incident
     -    Found a number of chemical and biological substances in
          raided establishments

-    The cult has a number of branches in other countries:
     -    Sarin was tested in Australian site prior to incidents in
          Japan
     -    Successful in attracting Scientists
     -    Most leaders were college educated
     -    Did have business arrangement with the Japanese mob

Since March 20th, 1995
-    At least 5-6 subsequent attacks on train stations
-    3 incidents of Cyanide gas devices that were disabled prior to
     "going off" (some are very sophisticated)
-    Significant media attention in Japan
-    Continuing public fear
-    Public demands for changes in the system

-    Specifics about Tokyo Sarin
     -    Manufactured with the German Salt process
     -    not distilled: ~25 % pure
     -    Acetonitrile (solvent) used to activate
     -    Produced in swiss-built chemical synthesizer
          -    Purchased in Tokyo
          -    Used to prototype chemicals
          -    possibly used an american software package
     -    Produced two days prior to the attack
     -    Less than 24 liters of the chemical
     -    Other chemical agents were made: VX, TABUN, Mustard,
          Cyanide compounds
          -     two assassination attempts with VX by cult
     -    Delivery system was very crude
     -    Two Japanese transit workers died trying to move chemical
          package

-    Reasons for attack?
     -    Attempt to deter Police who the cult realized were close
          to raiding their establishments (warning)
     -    Fulfillment of a prophecy (doomsday)
     -    "kids with matches", novel curiosity about the deadly
          aspect of the gas attacks

-    Could have been worse?
     -    Satyam7 (cults dedicated sarin production plant)
          -    never successfully operated
          -    designed to manufacture thousands of kilo's of sarin
          -    Included a distillation column
          -    Possibly had problems with leaks (plastic on floor,
               bucket to catch drops) and could have contaminated
               the area during production
     -    Previous unsuccessful attempt to produce botulin toxin
          and aerosolize it
     -    Had a truck with large air compressor and hidden vents
          and two helicopters with spray apparatus that could have
          been used for dispersal
     -    Nuclear option
          -    Cult had a russian connection
          -    Obtained access w/ frequent travel to Russia
          -    Notebooks captured by police made reference to
               various nuclear devices
          -    Had attempted to obtain land where uranium could
               have been mined

     -    Still 8 cult leaders out on the street
     -    Followers are trying to salvage business holdings

What Tomorrow?:
     -    Others will learn the lessons of tokyo and use CW or BW
          and use them with greater effectiveness.
     -    The taboo has now been erased after the first event


                          "Ebola Virus Incidents"
                       "Reston Virginia (Dec 1989)"

                       Col. Gerald Jaax, DVM USARMC
                         Col. Nancy Jaax, USAMRIID

USAMRIID: -   Provide defence against Biological Warfare and
              military importance, and agents that require
              special containment
          -   23 labs with 10,000 BL-4, 50,000 BL-3
              -    BL-4 = Biological Level - 4 protection, the
                   highest level personal protective equipment
                   (PPE)
          -   16 bed clinical research ward
          -   4 bed BL-4 ward
          -   BL-4 Morgue
          -   Technical biomedical expertise & consultation
          -   Unknown sample ID & Rapid diagnosis
          -   Special vaccines (responders & Targets)
          -   Specialized transport of biological casualties
          -   Specialized medical care facility
          -   Utilized team approach


Ebola
-    Emerging virus
-    Filoviridae (similar to Marsburg virus)




"Case study in emerging disease management"

-    Pathological Diagnosis:
     -    Sample selection
          -    must have immunologic history of where it came from
          -    selected samples from various areas
          -    "grab bag"
     -    Preliminary diagnosis
          -    Cast a wide net
          -    Multiple agent screening
     -    Rapid preliminary diagnosis (hours)
          -    Antigen capture ELISA
          -    Serology
          -    PCR
          -    Immunohistochemistry (days)
     -    Classical verification & characterization (weeks to
          months)
          -    Isolation of agent
          -    Reinoculation, recovery and identification (Koch's
               postulate)

-    Ebola virus outbreak in Reston, VA
     -    Strain of Ebola that did not kill humans but was fatal to
          monkeys
-   450 monkeys potentially infected
-   Potential human exposures (quarantine facility personnel)
    -    6-7 days until it was realized that the infectious
         potential of the Ebola-Reston had not infected a
         human population
    -    Ultimate decontamination of the blood occurred Dec
         7th
-   "Away" teams needed
    -    Vets, technicians and animal care specialists who
         have some biohazard experience
-   the players: USDA/APHIS, USPHS/CDC, WHO, Virginia and MA
    health departments., USAMRIID, State Dept.
-   Principle objective of incident: "contain the virus in
    the facility"
    -    Plan and organize operation
         -    Safety #1
              -    Team approach to all activities
              -    Strict needle hygiene
              -    Restrict scalpel use
              -    Deep plane of anesthesia "mandatory"
              -    Restrict contact with conscious monkeys
              -    Enforce rest periods (1 hour periods)
              -    Buddy system (nothing done alone)
              -    Organized "tear inspections" of PPE
              -    Visualize and conversational evaluations
                   of teams
         -    Command and Control
         -    Coordination
         -    Team Approach
         -    Equipment & Supplies
              -    "Space Suits"
              -    RACAL Unit
                   -    + pressure air supply through HEPA
                        filters
         -    Transportation
    -    Establish emergency field BL-4 Containment
         -    Use Aeromedical Evacuation Team
              -    Specialized Procedures / Equipment /
                   Personnel
              -    Staging / Preparation area
              -    Gray zone
              -    Communications
              -    Decontamination
    -    Maximize scientific Information
         -    Clinical and epidemiological observations
              -    Correlate with spatial relationships
              -    serology & pathology
         -    Collect, ID and package biosamples safely
         -    Transport samples safely
         -    Coordinate with RIID scientific staff
    -    Depopulate quarantine facility
         -    Humane concerns
              -    Food, Water, Procedures
         -    Systematic approach
           -    Sample collection
           -    Efficient and safe disposal
           -    Anesthesia team
                -    clinical observations, anesthesia,
                     transport to work area
                     -    massive anesthesia overdose
    -      Squeeze cages (30-40%): false back cage that slides
           forward to bring monkey to front of cage
                -    Improvise
                -    Loose monkey
                -    Blow guns / capture guns
                -    nets
                -    Biosample teams
                     -    bleed heart and harvest tissues
                          - nasal swabs, blood, liver/spleen
                     -    euthanasia
                -    Support teams
    -      Decontaminate facility
           -    Personnel Decontamination
                -    Bleach drenched
                -    Clothing bagged and incinerated
                -    5 quarantined personnel from the facility
                     tested
                     -    4 persons sero-converted to Restin-
                          Eubola (WERE EXPOSED & INFECTED)
                     -    1 did not sero-convert
                -    42 staff in cleanup, no sero-conversions
                     -    Shows that protective methods helped
           -    Facility Decontamination
                -    Taped all openings and cooked
                     paraformaldehyde with 39 electric
                     skillets in facility to gas sterilize the
                     inside.
    -      Transport samples
           -    Paraffin impregnated hat boxes
           -    Kitty litter absorbent w/ bleach
           -    Everything immersed in bleach
           -    Placed in styrofoam chest
    -      Protect civilian population
           -    Commuter traffic
           -    Day care center (just down hill from facility)
           -    HVAC Malfunction (heat & exhaustion factor)

-   More   Questions than answers after the incident
    -      Why didn't it kill people
    -      Was it aerosol spread
    -      What was the natural host?

-   Conclusion:
    -    NHP quarantine system worked
    -    Its a "small world" and transport of the virus was
         easy
    -    Revealed a vulnerability
    -    Possible template for action and a heightened
               awareness

     -    Lessons learned
          -    Chain of command and who was in charge was
               extremely important
          -    Team building perspective helped divide
               responsibility, match expertise and help protect
               the workers
          -    Pre-positioned "off the shelf" supplies
          -    Contingency flexibility: "Emergency operations can
               be planned and executed in short notice"

-    Current Ebola Outbreak initiatives
     -    Established routs of infection
          -     Oral and conjunctival
     -    Evaluation of passive antibody therapy
          -    Equine / Igg
     -    ID of potential reservoir species
     -    Rapid diagnosis / validate assays

Terrorist Threat or Natural Disease Outbreak
-    Some of the best threat agents for terrorism are natural,
     endemic, zoonotic diseases



                              "Zaire (1995)"
                 Russel Coleman, Diagnostic Div. USAMRIID

USAMRIID Involvement in the 1995 Ebola Outbreak in Zaire

-    Still cases occurring, not over yet.   Operation will continue
     until Sept, 1995

-    Documented Ebola Outbreaks
     Zaire 1976     277 Cases 92% Mortality
     Sudan 1976     280       53%

-    Index cases may have occurred 1/9/95
     -    Charcoal worker living near edge of forest (11 of 13
          family members are now dead)
     -    in Kikwit General Hospital in 36 yo Lab Tech
     -    70% of the first 70 patients were health care workers
-    Epidemic curve is now in it's fourth generation (5 major waves
     of infection in the population)
-    Disease is smoldering. Quarantine is not stabilized
-    Convalescent blood is being used for therapy without
     laboratory testing for antibody! (Blood taken from survivors
     of the infection - may be still virus in the serum).
-    Current lethality 80%
     -    293 deaths

-    USAMRIID Involvement
     -    CDC Team
     -    CDC / USAMRIID history
     -    Expertise

-    Aeromedical Isolation Team Capabilities
     -    (2) 6-8 man teams
     -    Can transport up to two patients at BL-4
     -    6 hour standby alter
     -    Prepared to evacuate American Citizens who become ill
          while working in Zaire
     -    Air force will fly on C-17 Aircraft to German US Airbase
          Hospital and placed in BL-4 Treatment facility

-    Environmental Assessment of Kikwit Area by CDC/USAMRIID
     -    8 person teams

-    Preparation:
     -    Initial Notification
     -    Identify Mission
     -    Identify Priorities
     -    Putting it all Together

-    Deployment:
     -    Air movement / Baggage (40 medical chests)
     -    Coordination

-    Mission:
     -    Overview
     -    Technology
     -    Vehicles / Manpower



          "The Challenge of Emerging and Re-Emerging Infections"
               Joshua Lederberg, The Rockerfeller University

"Outbreak" Novel by Robert Tine

-    Deaths by cause: (global basis)
     -    Parasitic ~20 million
     -    Cardiovascular 13 million
     -    Cancer 5 million

-    Major factors contributing to the emergence of infectious
     diseases:
     -    Human demographics and behavior
     -    Technology and industry
     -    economic development and land use
     -    International travel and commerce
     -    Microbial adaptation and change
     -    Breakdown of public health measures

          -      Institute of Medicine Report 1992

-    The Race:
     HUMAN
     -     Evolution
     -     Ecological Circumstances
     -     Science: Intelligent art

     versus

     THE BUGS
     -    Evolution

Genetic Evolution:
Host-parasite co-evolution
Co-adaptation to mutualism or accentuation of virulence?? Jury is
still out. (May & Anderson) Many zoonotic convergence. Probably
divergent phenomena, with short term flair ups and pyrrhic
victories, atop long term trends to co-adaptation

Microbes (bac. fungi. protozoa, viruses)
Intraclonal:
     -    DNA Replication: may be error prone- in a sea of mutagens
          -    Sunlight, chemicals, natural products
     -    RNA Replication
     -    Haploid
     -    Amplification
     -    Site-directed inversions and transpositions: phase
          variation
     -    Other specifically evolved mechanisms
     -    Genome quadrant duplication silencing

Interclonal:
     -    Promiscuous recombination
     -    Conjugation
     -    Viral Transduction & Lysogenic integration: universal
     -    Plasmid interchange (by any of above) and integration
     -    RNA viral reassortment and recombination
     -    Transgressive - across all boundaries - interkingdom

Technology:
     -    Vaccines
          -    Gross under-investment
          -    Vaccination as service to the herd
          -    Eventually some insight into safety issues about
               criteria for human cells lines

     -    Anti-bacterial Chemotherapy
          -    Potentially unlimited capability; bacterial
               metabolism and genetic structure
     -    Anti-viral Chemotherapy
          -    Much more difficult problem inherently
          -    Gross under-investment
          -    New approaches: antisense, riboenzymes, targeted
               D/RNA cleavers

Influenza as a prototype:
     -    Has periodic outbreaks and accounts from 5-7 % of deaths
          -     mostly to elderly and young
     -    Genetic re-assortment is accountable for rapid shifts in
          antigen characteristics
     -    1918: a variety of influenza that was similar to Hanta-
          Virus and was probably the result of a particularly
          virulent strain (SWINE FLU)

-    Distinction between Terrorist usable substances and those
     implicated in natural outbreaks
     -    (who would unleash a threat that might come back and
          disable the terrorist themselves)
     -    Usually a cheaply producible, somewhat controllable
          substance

NIH has identified:
-    About 400 viruses that identified as hazardous and need
     extraordinary precautions
-    a couple dozen that require extreme precautions and have
     caused death or serious illness to a researcher
-    Fortunately it requires sufficient sophistication to isolate
     and culture these viruses so as to make most of these not
     usable for terrorists

In the year 1346, Caffa was again besieged by the Mongols. During
this same time, a vast epidemic of bubonic plague had rapidly
spread through the Mongol empire. In the words of Gabriel De
Mossie, a contemporary chronicler, "the Tartars, fatigued by such
a plague and pestiferous disease, stupefied and amazed, observing
themselves dying without hope of health, ordered cadavers placed on
their catapults and thrown into the city of Caffa, so that by means
of these intolerable messengers, the defenders died widely"




                    Responding to the Consequences of
                     Chemical and Biological Terrorism
                                 07/13/95


           "The Importance of Cooperation in Responding to the
            Consequences of Chemical and Biological Terrorism"

                                Philip Lee
                        Asst. Sec. of Health, DHHS

Dept of HHS commitment to C/B Terrorism:
-    House has not renewed funding for Emergency Preparedness
     -    Incomprehensible, no idea what the rational was for the
          action
     -    Would be funded out of Assistant Secretary of Health's
          office at the expense of other funding
-    New vision for 21st Century
     -    Respond to disasters and assist communities during
          recovery (one of six identified goals)
-    President has cited NDMS as a model
     -    DMAT / DMORT
     -    Directed DHHS lead effort in the Health Response
          -    Developing an Integrated Consequence management plan
-    FEMA has been revitalized and made much more capable under the
     direction of J.L. Witt




              "National Consequence Management Concepts and
               Plans for the Biological Incident Response"

                            "United Kingdom"
                                Lynn Hall
                    Timothy C. Marrs, Dept of Health
              David Morgan-Jones, Major Defense NBC Center


Casualty Levels and Consequence Management (1995/96)
-    Type of attack                Scenario
     -----------------             -----------------
     Open Air                      Town Center
     Confined Space                Airport Terminal
     Food Contamination            Point of sale
     Water Contamination           Service Reservoir



Key factors governing utility of a material
-    Toxicity
-      Acquisition
-      Dissemination
-      Handling

Consequence Management
-    Survey of the literature
-    Identification

Some   key areas:
-      Organization
-      System approach
-      Evacuation / Sheltering
-      Factors affecting medical response (pre & post exposure)

UK Concepts for Chemical / Biological Incidents:
-    AIM
     -    Strategic Overview
          -    Prevention
               -    Planning
               -    Intelligence Services
          -    Incident
               -    Device discovered intact
                    -     National plans exist
               -    Device released
               -
          -    Reaction
               -
     -    Chemical Response
          -    Mass casualty incident almost immediately
     -    Biological Response
          -    Time delayed, incident develops a little more
               slowly and lasts a little longer
-    Management of N & C
     -    Potentially large numbers
     -    Major Incident
     -    Each region has incident plan
     -    Handling of contaminated casualties
-    Summary
     -    Building blocks exist: need to enhance
     Require:
     -    Central Planning agency
     -    Better Communications between the building blocks
     -    Training

Integrated Emergency Planning:
a)   Prevention
     -    Hospital beds, ICU's, Drugs, Ambulances
b)   Preparedness
c)   Response
     -    Save life, Prevent escalation, relieve suffering, protect
          property, enable criminal and forensic investigations
     -    UK Health Services
          -    4 Territorial Administrations (England, Scotland,
               Wales, N. Ireland)
     -    Produces handbook on response to all responders
     -    Health Emergency Planning Officer (HEPO's)
          -    Each territorial administration has one
          -    Kept updated on threats, etc.
     -    Categorization
          -    Dead -         No treatment
          -    Serious-       ICU (limiting factor as not many)
          -    Less Serious- DGH
     Treatments:
          -    Organophosphate:    Atropine, Oxime, Valium,
                                   Toxogonin (used for Tabun)
          -    Cyanide   Dicobalt Edetate
          -    Oximes: held in special centers based on analysis
               of historical use
d)   Recovery



                                "Canada"
                 Paul Dubrule, Nat. Security Directorate
                Dave Peterson, Emerg. Preparedness Canada
                   Lorraine Davies, Emergency Services

-    Has had a lack of Terrorist incidents to deal with
     -    Complacency: lack of public perception of a problem
     -    Tokyo & Oklahoma has changed the view
-    Canada shares the longest boarder in the world
     -    Incident in one country can have implications on the
          other
-    Increase in the size of the Counter-Terrorism office
     -    Increase in planning for exercises
     -    Coordination of all counter-terrorism issues in Canada
     -    Revision of plan to take into account current issues
-    Canadian Emergency Management:
     -    The lowest level person to respond, does so
     -    When the response exceeds that person, the next higher-up
          response is initiated
     -    Take and All-Hazards approach to response and planning
     -    Building block approach: try not to alter the normal flow
          of decision making during a time of emergency
     -    Each minister responsible for Emergency Planning within
          their constituent area: One minister given the Federal
          level planning
-    Does have a BL-4 lab that has not yet opened due to
     environmentalists who have prevented it from becoming
     active




                             "United States"
                            Crisis Management
            Richard Cimusz, Domestic Terrorism Planning, FBI
            Stephen Veyera, Domestic Terrorism Planning, FBI
                 Barry Subelsky, Crisis Management, FBI

-   There is not currently a law against terrorism
    -    Mail Fraud Bubonic Plague (Cincinnati)
         -    First indication came from CDC
    -    Part of the protection of citizens is the ability to
         prevent occurrences by providing a legal deterrence

-   Types of Incidents:
    -    Threat only
         -    Each threat is identified, evaluated, recipient and
              sender are identified if possible
    -    Confirmed presence of weapon (no release)
    -    Significant release of agent (without warning)

-   Statutory Authority
    -    Biological Weapons Anti-terrorism Act, Title 18, USC
    -    Sabotage, Title 18, USC
    -    Extortion, Title 18, USC
    -    Environmental Crimes, Toxic Substance Control Act
    -    Tampering with consumer products Act

-   Law enforcement Strategy
    -    Prevention (intelligence & Education)
    -    Containment (minimization)
    -    Post Incident Response

-   Stages of Graduated Response
    -    Threat credibility Assessment
    -    Technical Advice Provided to incident commander
    -    Deployment of technical personnel and resources to the
         incident scene
    -    Marshalling of consequence management resources

-   FBI HQ Responsibilities
    -    Initiate threat credibility assessment
    -    Coordinate request for technical advice
    -    Deploy federal resources
    -    Coordinate media and congressional affairs activities
    -    Coordinate with applicable Federal Agencies

-   Advisory support
    -    EPA
         -    Chemical Emergency Preparedness & Prevention Office
         -    Office of Water
    -    PHS
         -    CDC
         -    Agency for Toxic Substances & Disease Registry
         -    FDA
    -    Department of Agriculture
    -    Department of Defence
         -    Armed Forced Medical Intelligence
         -    US Army foreign Science Technology Center
         -    US Army Medical Research Institute for Infectious
              Disease
          -   US Army Technical Escort Unit
          -   US Army Chemical Research Development Engineering
              Center

-    Threat Assessment
     -    within 2 hours of receiving a threat, teleconference
          convened
          -    Includes behavioral scientists, toxicologists,
               operational and technical specialists
          -    Evaluate threat for reality and feasibility

-    Technical Response Group
     -    FBI Lab
     -    USPHS
     -    EPA
     -    Medical Research Institute of Infectious Diseases
     -    Chemical Research Development Engineering Center
     -    Technical Escort Unit

-    Critical Response Group
     -    Field Office Responsibilities
          -    Assume primary jurisdiction
          -    Initiate appropriate investigative and Crisis
               Management actions
          -    Coordinate on scene efforts with technical support
               personnel
     -    Response capabilities
          -    Chem/Bio rapid deployment team
               -    provide rapid emergency on-scene support to
                    the special agent in charge anywhere in the US
               -    Augmented by DoD, PHS, EPA and others
               -    Technical support / advice / assessment
               -    Limited decontamination and tactical ability
               -    phased response
                    -    advanced party / ongoing specialists
                    -    Tactical team
                    -    Transition from law enforcement to
                         disaster management (FBI in supporting
                         role)




                         "Consequence Management"
                      Bill Clark, OEP Deputy Director


Significant Emergency Responses

California floods        1995
Northridge               1994
Hantavirus               1992
Hurricane Hugo              1989
Hurricane Andrew            1992
Hurricane Iniki             1992
Hurricane Emily             1993
Midwest Floods              1993
Southwest US floods         1994

Chemical / Biological Terrorism:


         /No threat      USE
-----<                 /           Hoax
         \No Use------<           /               Use
                        \Threat--<               /
                                  \Credible-----<
                                                 \No Use


Chemical / Biological Attack:
-    Potential mass killing
-    Concurrent crisis management and consequence management
     situation

The Public:
-    What do they know?
-    What is their expectation of the government?
-    What is their reaction?

Current Imperatives:
-    Develop interim consequence management plan
     -    Federal Response plan
          -    Chem / Bio annex for critical functions
          -    Other supporting functions through FRP / ESF's
               -     move within hours not days


In the occurrence of an event:
-    Threat Assessment
-    Emergency Consultation
-    Chem/Bio Rapid Deployment Team
     -    National level team
          -    25 people
          -    Rapid deployment and activation (minutes and hours)
          -    Supportive role
          -    "smart people": special knowledge and experience
-    Additional assets as needed

Critical Medical support:
-    Medical
-    Pharmaceutical
-    Supply
-    Communications
-    Transportation
-    Security
Critical Situations Environment:
-    Demanding
-    Unforgiving
-    Need the ability to make correct decisions under pressure
-    Success requires interoperability and partnership




                        "Critical Functions Panel"
                            RADM F. Young, OEP
                              Bill Clark, OEP
                         Ltc. Dave Franz, USAMRIID
                          Jim Geovese, USA/ERDEC
                    Bill Goforth, USA Tech Escort Unit
                  Sfc. Mike Holden, USA Tech Escort Unit
                             Ken Stroech, EPA
                           Joseph Lafornara, EPA
                              Gary Moore, OEP
                              Bob Elliot, VA
                              Ron Berger, CDC

-    Threat assessment
     -    USAMRIID
          -    Technological Information base of people who
               understand pathogenesis of chemical & biological
               hazards
     -    Tech Escort Unit
          -    Hazard prediction

-    Emergency consultation with affected jurisdictions
     -    USAMRIID
          -    Assist with technological assistance in barrier
               nursing, personal protection, etc
     -    Tech Escort Unit
          -    Transportation of Biological hazards and samples
               collected
          -    Packaging and escort of those samples (chain of
               custody) to lab

-    Public Affairs
     -    Need to have pre-screened, pre-approved public affairs
          announcements: need to say the same thing
          -    Pre-trained, well respected public authorities (ie:
               C. Everet Coop)
     -    Media leaders brought in at the highest level
     -    Communicate between Emergency Responders
          -    Scientifically, Environmentally and Medically
               capable spokespeople

-    C/B rapid deployment teams
     -    Washington, D.C. area
     -    Federal Agency key people
    -    24 people
         -    ER Docs
         -    Medical Ops people
         -    Diagnosticians
         -    Chemical scientists, technicians
         -    Staging within 4 hours of call
    -    Level-5 DMAT that could be responding within hours

-   Agent Identification
    -    EPA has assets that exist to deal with pollution
         -    Already emergency response capable
         -    Skills and equipment that could be utilized during
              Chem/Bio situation with only slight modifications
         -    175 On-scene Coordinators already being utilized
              frequently for chemical pollution responses (300-
              400 times per year)
    -    USAMRIID
         -    On-site analysis and sampling
              -    ELISA Reagent Sets that can be used with water
                   and H2O source to quickly assay for a
                   substance
                   -     Body fluids or samples from environment
         -    PCR technology being developed
         -    Reference Lab back at USAMRIID
    -    CDDCOM
         -    On-Site and home base assessment
         -    Function as confirmation and back-up identification
              unit

-   Epidemiological Identification

-   Expedient Hazard Detection

-   Expedient Hazard Reduction

-   Environmental Decontamination
    -    USAMRIID
    -    EPA
         -    Environmental decontamination capability

-   Clinical Medical support
    -    Health professionals
    -    Laboratory support
    -    Patient evaluation
    -    In-hospital care

-   Pharmaceutical support

-   Human Toxin Affects Registry

-   Supplies and Equipment

-   Victim identification and mortuary services
    -    Rapid mobilization of storage and mortuary capabilities
    -    Contaminated remains issue still being discussed
         -    Incineration of remains not compatible with current
              US policy
         -    Externally chemical contamination can be removed,
              biological contamination is much more difficult




                            "Closing Remarks"
        Michael Jakub, Dept of State office of Counter-terrorism
                             Bill Clark, OEP


-   Look at the history of recent events and it is obvious that
    there is a problem

-   Consequence managers must be responsive to plans for managing
    a chemical / biological incident as well as emerging diseases

-   The problem is now on the scope of the highest level policy
    makers in the country
    -    They will be coming to us for more information and help
         when the policies are going to be written

-   PDD 39: Response to weapons for mass destruction
    -    US will be prepared to respond
    -    US will work with other countries
    -    Policy making being pushed down to the agencies that are
         most involved

-   Enhancing the field of intelligence and information on Foreign
    chemical / biological weapons programs and networks to obtain
    pre-cursors and equipment for their manufacture

-   Training and educational programs are key all the way down to
    the "front line" level
    -    Tap into the US military training for improving domestic
         response capability
    -    Exercise at all levels (including the state and local
         levels)

-   Better communication & coordination between Federal, State and
    Local agencies

-   Equipment development (detection, warning, decontamination,
    etc) need to be further developed

-   More investments in Antibiotics, vaccines, other therapies and
    the stockpiling of such

				
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