Bioterrorism Preparedness Are We Ready

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					                                  Bioterrorism Response in the U.S.: Are We Prepared? 1


                Bioterrorism Response in the U.S.: Are We Prepared?

                             CPT Michael S. Whiddon

                        US Health Care Systems: HCA 5301


                                   09 Sep 2008
                                           Bioterrorism Response in the U.S.: Are We Prepared? 2

                      Bioterrorism Response in the U.S.: Are we prepared?

       The threat of biological weapons has existed for centuries and it continues to grow.

Crude techniques, such as dumping dead animal or human remains in an enemy’s water supply,

provided the ancient Greeks and Romans a tactical advantage in defeating their enemies. This

research paper focuses on the historical aspect of the bioterrorism threat, the types of biological

agents that pose the greatest danger to our population, and the current state of bioterrorism

response preparedness from a public health prospective.

The Bioterrorism Threat

       As stated previously, the threat of bioterrorism has existed for centuries. A look at the

historical impact of using this approach to defeat one’s enemy is important in understanding the

devastating affects it can have on society. A popular and extremely effective technique of the

ancient Greeks and Romans was to contaminate their enemy’s water sources with dead remains.

As technology evolved, so did the delivery method of biological agents. The introduction of

catapults led to a strategic warfare advantage in medieval Europe. During the siege of Kaffa,

1346, the Tartar forces allegedly catapulted their dead soldier’s bodies into the city in order to

create a plague (Khardori and Kanchanapoom 2005). The strategy worked extremely well for

the Tartars, so well that their actions possibly resulted in the bubonic plague outbreak that

devastated Europe in the 14th century. Another well known historical example involves the

transmission of smallpox to the North American Indian tribes during the French and Indian War.

Lord Jeffery Amherst, Commanding General of North American British Forces, deliberately

influenced the provision of smallpox contaminated blankets to the Indians tribes in order to

reduce their population (Spencer and Lightfoot 2001).
                                          Bioterrorism Response in the U.S.: Are We Prepared? 3

         Modern wars have also led to the enhancement of biological threats. Germany began this

trend by introducing cholera, plague and anthrax as weapons during World War I. At this time

the delivery method continued to rely directly on human means of transmission. It wasn’t until

prior to World War II that the method of delivery advanced significantly. The Japanese were the

first to attempt weaponization of a biological threat. During the Sino-Japanese War, The

Japanese accomplished this by using bombs containing plague infected fleas to bomb China; the

bombings resulted in plague outbreaks and thousands of Chinese deaths (Khardori and

Kanchanapoom 2005). Germany continued to aggressively pursue biological weapons during

this time as well. In response to Germany’s growing threat, the Allies began focusing on a

measured response. Great Britain focused their efforts on developing an anthrax bomb; the N-

bomb was designed to deliver an aerosolized version to the weapon (Spencer and Lightfoot


         After World War II, the research and development of biological agents increased

significantly. As the two major superpowers began rebuilding their militaries, they also focused

much of their effort on this particular area. Both the former Soviet Union and the United States

created immense stockpiles of biological agents. The United States continued this trend until

President Nixon decided to abandon the program in light of the U.S. nuclear capability (Spencer

and Lightfoot 2001). Shortly after the U.S. denouncement of their biological weapons program,

a unanimous decision to implement the Biological Weapons and Toxins Convention (BWC)

treaty of 1972, was agreed upon by over 140 nations (Hamburg 2002).

         The Biological Weapons and Toxins Convention became an important initiative in

preventing the creation and storing of bio-weapons, but unfortunately it left the door open for

rogue nations to continue their research and development; this convention did not call for an
                                          Bioterrorism Response in the U.S.: Are We Prepared? 4

inspection program. Nations such as Iraq and the former Soviet Union serve as examples of

those who continued bio-weapons production. Iraq admitted to arming missiles with biological

weapons and using them during battle. The former Soviet Union’s weapons development

program is most concerning. They actually lost track of many of their stockpiles which possibly

remain a threat today. More recent attempts to outlaw the use of these devastating weapons

include the Export of Goods Control Order of 1994, the Dual Use and Related Goods Regulation

of 1996, the Anti-Terrorism Act of 1996, the Chemical Weapons Convention of 1997 (Spencer

and Lightfoot 2001) and the Public Health Security and Bioterrorism Response Act of 2002 (Shi

and Singh 2008).

Biological Agents of Concern

       The World Health Organization defines a biological agent “as an agent that produces its

effect through multiplication within a target host and is intended for use in war to cause disease

or death in human beings, animals, or plants” (Radosavljevic and Jakovljevic 2007).

Unfortunately biological agents are easily created under the proper conditions, easily transmitted

from person to person and produced at a fraction of the cost of other conventional weapons. For

this reason, the growing threat of their use by terrorist organizations is immense.

       The Center for Disease Control (CDC) identifies critical biological agents into three

separate categories. Category C is the lowest priority category of concern. It includes pathogens

such as the hantavirus and the nipah virus which may have the potential of weapons use.

Category B is the next highest priority of concern. This category includes pathogens which are

threats to the food or water supply as well as other pathogens like brucellosis, typhus fever and

ricin toxin. Category A is the final and highest priority category. “The four Category A agents
                                           Bioterrorism Response in the U.S.: Are We Prepared? 5

identified by officials as those of major concern for use in a potential bioterrorism attack include

smallpox, botulism, plague and anthrax” (Stillsmoking 2002).

Response Preparedness

       Unfortunately, our nation recently became familiar with the direct effects of bioterrorism.

One of the most infamous bioterrorism events occurred in 2001. Shortly after the terrorist

attacks of September 11, 2001, anthrax became our nations’ primary domestic threat focus.

Various government officials and media entities received letters through the postal system

containing a white powdery substance which tested positive as anthrax spores. Unfortunately the

incident resulted in fatalities; luckily the overall casualty numbers were minimal. It is estimated

that if employed in the most effective manner and in the proper conditions, 50kg of anthrax can

cause up to 125,000 casualties and 95,000 fatalities (Atlas 1999). Fortunately this attack

occurred on a much smaller scale and the results were less severe. The Federal Bureau of

Investigation (FBI) reports the following concerning the outcome of this attack, “Five Americans

were killed, 17 were sickened, and the nation became terrorized in what is known as the worst

biological attacks in U.S. history” (FBI 2008). The resulting investigation involved 17 special

agents and 10 U.S. postal inspectors. These individuals conducted more than 9,100 interviews,

executed more than 70 searches, and followed leads across six continents; this case remained

unsolved until earlier this year (FBI 2008). The anthrax attacks achieved their objective of

instilling fear in the mind of the public and consuming valuable local, state and federal resources.

       The events of 9/11 along with the anthrax attacks revealed shortfalls throughout the

disaster response system. The CDC’s 2003 study on bioterrorism and mass casualty

preparedness in U.S. hospitals reported that 84.8% out of a sample of 500 non-Federal general

and short-stay hospitals have plans for responding to biological disasters (Niska and Burt 2005).
                                           Bioterrorism Response in the U.S.: Are We Prepared? 6

Although this seems like an acceptable percentage, many of the hospitals simply had the plan on

record, but weren’t exercising it. Organizations also lacked memorandums of understanding

with external organizations. In fact the same CDC report states the following, “One interesting

anomaly in the results was the high percentage of hospitals that were unaware of whether they

were designated by National Defense Medical System (NDMS) to receive patients in a disaster”

(Niska and Burt 2005).

       The ever-present threat of domestic and international terrorism along with the ability of

rogue nations to obtain lethal doses of casualty producing biological agents raises the question,

how do we prepare? The answer to this question is complex, but it is essential in order to protect

the citizens and infrastructure of our nation. “The best way to combat biological warfare and

terrorism is to be prepared to respond to a biological weapons attack” (Simon 1997). Every

agency in the realm of responsibility remains important in the biological response effort. Ronald

M. Atlas made the following statement in a 1999 bioterrorism focused article, “By improving our

readiness to respond to biological weapons, many lives can be saved and terrorists denied their

goal of creating panic and crisis throughout the country” (Atlas 1999). Responding effectively to

the bioterrorism threat involves a coordinated effort at the local, state and federal emergency

management level. Along with the increased effort of these traditional agencies, a shift toward

the importance of strong public health response occurred.

       The only way to ensure an effective public health response is to ensure it is well

supported throughout the local, state and federal levels of emergency management. President

Bush, realizing this truth in light of the previously mentioned terrorist related incidents, enacted

the Public Health and Security Act of 2002 (Shi and Singh 2008). Additional efforts later

resulted in the Homeland Security act of 2002 (Shi and Singh 2008). Both of these Acts placed a
                                          Bioterrorism Response in the U.S.: Are We Prepared? 7

heightened emphasis on the importance of the CDC as well as the entire public health system.

The CDC is crucial in this system of response and serves as the overarching public health entity.

Its’ mission is to “promote health and quality of life by preventing and controlling disease,

injury, and disability” (CDC 2008). Under the direction of the CDC, the Coordination Office for

Terrorism Preparedness and Emergency Response (COTPER) is the lead agency in providing

direction, coordination and support for terrorism preparedness and emergency response; their

proposed “mission is to safeguard health and save lives by providing a flexible and robust

platform for public health emergency response” (CDC 2008).

       The Coordination Office for Terrorism Preparedness and Emergency Response is

organized into four major divisions which allow it flexibility in response. These four divisions

include the following: The Division of Emergency Operations (DEO), The Division of Select

Agents and Toxins (DSAT), The Division of State and Local Readiness (DSLR) and The

Division of Strategic National Stockpile (DSNS). Each of these sub-organizations works to

provide a crucially effective combined response.

       This combined response begins with the Division of Emergency Operations which serves

as the command center for the COTPER. It is operational at all times and serves to provide

situational based updates, assessments, coordination and direction during an actual biological

event. The DEO is accompanied by the Division of Select Agents and Toxins. The DSAT

focuses on the regulation of biological items and works to ensure the public health’s safety from

potential threats. Next, the Division of State and Local Readiness administers the Public Health

Emergency Preparedness (PHEP) Cooperative Agreement which “supports preparedness

nationwide at the state, local, tribal and territorial public health departments” (CDC 2008). The

cooperative agreement is primarily focused on improving the ability of local health departments
                                           Bioterrorism Response in the U.S.: Are We Prepared? 8

and their capacity to respond accordingly to disaster related events. Another important factor of

the DSLR is that it manages the Centers for Public Health Preparedness (CPHP) program. This

program focuses on the important aspect of training and education. As of 2007, “$5 billion was

spent on training and educating the public health workforce, healthcare providers, students, and

others based on community need” (CDC 2008). Finally, the DSNS serves to provide the

important medical logistics requirement. This includes managing the pre-positioned strategic

national stockpile of chemical, biological, and toxin prophylaxis as well as life support

medications, supplies and equipment. This stockpile is intended “to supplement state and local

resources during a large-scale public health emergency” (CDC 2008).


       The growing threat of bioterrorism is of great concern to our nation. Historical accounts

of employing biological substances for malicious effect proved devastating to society. Terrorist

are drawn to substances such as anthrax and botulism toxin because of their minimal cost and

ease of production. Due to unfortunate events, our government regained focus on the importance

of disaster response specifically in the area of public health. To date, billions have been spent on

response preparation to include an increased focus on training and educating health care workers,

students and communities concerning the nature and possible effects of this threat. Eliminating

the possibility of an attack is unlikely, however increased preparation efforts will help in

detecting the occurrence of an event and hopefully mitigate the outcome. A strong public health

response, integrated at the local, state and federal level is key to minimizing the probable effects

of a possible future attack.
                                         Bioterrorism Response in the U.S.: Are We Prepared? 9


Atlas, R. M. (1999). "Combating the Threat of Biowarfare and Bioterrorism." BioScience 49(6):

CDC. (2008). "The Coordinating Office for Terrorism Preparedness & Emergency Response
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CDC. (2008). "Vision, Mission, Core Values and Pledge." Retrieved September 7, 2008, from

FBI. (2008). "Amerithrax Investigation." Retrieved September 8, 2008, from

Hamburg, M. A. (2002). "Bioterrorism: Responding to an Emerging Threat." Trends in
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Khardori, N. and T. Kanchanapoom (2005). "Overview of Biological Terrorism: Potential
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Niska, R. W. and C. W. Burt (2005). Bioterrorism and mass casualty preparedness in hospitals:
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Radosavljevic, V. and B. Jakovljevic (2007). "Bioterrorism--Types of epidemics, new
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Shi, L. and D. A. Singh (2008). Delivering Health Care in America: A Systems Approach (4th
        ed.). Sudbury, MA, Jones and Bartlett.

Simon, J. (1997). "Biological Terrorism: Pre-paring to Meet the Threat." Journal of the
       American Medical Association(278): 428-430.

Spencer, R. C. and N. F. Lightfoot (2001). "Preparedness and Response to Bioterrorism." Journal
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Stillsmoking, K. (2002). "Bioterrorism--Are You Ready for the Silent Killer?" Association of
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