Supplement-United States Unprepared for Bioterrorism Attack, Experts Warn

Better Education Urged for Health Care Providers

By Stephen Lewis

When the united states is attacked with a biological agent (and a growing number of experts believe "when" is much more appropriate than "if"), it will be clinicians, emergency room physicians, and nurses who will be on the front lines. However, those health care providers need education on spotting and responding to a bioterrorism (BT) attack.

BT is defined by the Atlanta-based Centers for Disease Control and Prevention (CDC) as "The intentional or threatened use of viruses, bacteria, fungi, toxins from living organisms, or other chemicals, to produce death or disease in humans, animals, or plants."

BT agents can be "deliberately released into the population, the food supply, released into the air, or through infected persons," noted Scott Lillibridge, MD, director of the CDC's Bioterrorism Preparedness and Response Program. "And the first responders will be health care providers."

Lillibridge made his remarks during the International Conference on Emerging Infectious Diseases 2000, held in Atlanta July 16-19. The conference was organized by the CDC, the Council of State and Territorial Epidemiologists, the American Society for Microbiology, the Association of Public Health Laboratories, and the National Foundation for CDC.

"Initial detection and initial response, will be local," added Ali S. Kahn, MD, MPH, who is also affiliated with the Bioterrorism Preparedness and Response Program. "Clinical diagnostics at the point of care will be critical; astute clinicians will be invaluable. We need physician education."

Emergency room visits will be a critical point of identification, Kahn noted, adding: "We will be very dependent on calls from individuals such as infection control nurses."

Other presenters at the conference agreed. "The first place BT victims will be treated will be in emergency rooms and clinics," said Stephen S. Morse, PhD, a program manager in the Defense Sciences Offices of DARPA, the Defense Advanced Research Project Agency of the Defense Department, based in Arlington, Va.

A Different Kind of Emergency

BT presents the prospect of a disaster with which most responders would be unfamiliar, noted Lillibridge. "Whole cities and regions could be in peril," he warned. "We could be looking at a major medical emergency—far different from those that FEMA [Federal Emergency Management Agency], for example, has been dealing with, and with which we are more familiar."

The most likely biological agents used in an attack would be anthrax, smallpox, plague, botulism, tularemia, or VHF. These have been identified by the CDC as "Critical Biologic Agents," said Kahn. This is not necessarily because a terrorist would more likely choose these over other agents, but because "if released, we would have a major public health issue."

The treatment and outcomes, noted Lillibridge, may not be that different from what would be seen with an emerging infectious disease. "But it's been a long time since we've had to respond to a situation like this; we've had little experience here with epidemics involving the population at large—a major federal outbreak."

Yet Lillibridge is convinced the threat is very real. He noted the accessibility of biotechnology information to terrorist groups such as Aum Shinrykyo, "which, in addition to releasing nerve gas in Tokyo's subway, experimented with botulism and anthrax," he said in a September 22, 1999, statement before the Subcommittee on National Security, Veterans Affairs and International Relations Committee on Government Reform, U.S. House of Representatives.

"An attack with an agent such as smallpox could pose threats to large populations because of the potential for person-to-person transmission, enabling spread to other cities and states . . . would quickly culminate in a nationwide emergency. International involvement would be sure to follow," he said in his statement.

Time is of the Essence

The ability to recognize and respond quickly to a BT outbreak was stressed time and again by speakers at the Atlanta conference.

"There could potentially be many casualties, and there is a short window for intervention," noted Kahn.

"If we delay, we could pay a terrible price," added Martin I. Meltzer, PhD, of the CDC, who gave a presentation on smallpox—which has only been identified as a potential weapon in the last 18-24 months.

Meltzer presented a frightening graphic, which showed that if 10 people were initially infected and untreated, and each of them in turn infected three more individuals per day, that 774 billion people would be infected in one year's time.

Meltzer went on to note that vaccine and quarantine have worked well in combination against smallpox, since history shows an average of 1.48 people infected by each initially infected person. Nevertheless, he added, rapid response is essential. "The difference between 25 days and 45 days is unbelievable," he said. "We have to be prepared."

The subsequent "Q&A" session demonstrated that even the experts are not clear on what it would take to win such a war. Meltzer suggested that 40 million doses of vaccine should be stockpiled to be adequately prepared for a BT attack of smallpox. But Meltzer said that individuals vaccinated more than 30 years ago still have sufficient immunity that the virus would not kill them.

"I believe 80% of the individuals are susceptible in this population," argued a questioner. "And 40 million doses is not enough." In either case, with the virus "eradicated" years ago, the current stockpile is negligible.

Complicating the issue is that in the early stages of infection, BT agents are difficult to identify. "Many of the early symptoms are flu-like," said Morse, noting that they can include headache, muscle aches, chills, and loss of appetite. "Biological warfare agents are often indistinguishable from flu and from each other."

Morse then added this chilling admission: "By the time the symptoms appear, it may be too late to save the patient; we need to determine who was exposed before the symptoms appear."

All of this makes the case for better education that much more compelling. Health care providers with an intimate knowledge of how these agents behave will be in a better position to determine whether one of them is behind a certain constellation of symptoms.

A Nationwide Effort

With the CDC at the helm, a growing group of federal public health and military agencies is working together to better identify and respond to possible BT outbreaks. For example, the National Notifiable Disease Surveillance System (NNDSS) reports weekly to the CDC. Armed with data on previous outbreaks of infectious diseases, they are alerted by infections that occur "outside normal areas, or with unusual or unexplained [population] distribution," explained the CDC's Man-huei Chang, MPH.

But, Chang reported, there is no single U.S. system for the baseline data that are needed, underscoring the fact that national preparedness efforts are also in a race against time.

"Since 1973, at least 30 new viral agents have been identified, and there are new threats all the time," noted Lillibridge, who cited HIV, resistant TB, and West Nile as some of the more recent threats. "The tools of bioscience are increasingly available. There exists the ability to alter pathogens or to create new ones, and we are not prepared."

Kahn noted that several medical groups, including the American Medical Association and the American College of Emergency Physicians, are taking the lead in working with the CDC to educate their members and to help prepare for an event that may be more likely than many would like to admit.

A high state of preparedness could help ensure the public safety on more than one level, said Lillibridge. "After all," he noted, "in a BT attack, the health care provider population could be decimated as well."

(Editor's Note: For more information about the CDC's Bioterrorism Preparedness and Response Program, visit their Web site at: Or, contact: Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333. Telephone: (404) 639-3311.)