Investment in bioterror refueling public health

But preparation is a journey, not a destination 

The massive public health investment to prepare for bioterrorism is paying for itself in the widespread benefits of an improved public health infrastructure, said Julie Gerberding, MD, MPH, director of the Centers for Disease Control and Prevention.

"I do take some pride at times in boldly stating that of all the investments we are making in homeland security in our country, it is the public health investment that is absolutely guaranteed to pay off," she said. "And in fact, it already has paid off, and it will continue to pay off even if we never have another terrorist attack. The reason it’s paying off is because our public health infrastructure — at least our infrastructure’s capability to respond to emerging threats — is evolving in the context of the investments that are being made."

Delivering the keynote address recently in Washington, DC, at the 1st National Congress on Public Health Readiness, Gerberding said bioterrorism preparations have helped break down the barriers between public health and clinical settings. The conference was cosponsored by the CDC and the American Medical Association, and fittingly, the theme was the increasingly strong marriage between clinical and public health.

"We’ve got communication. We’ve got networking," Gerberding said. "We know how to identify clinicians. The system is much further evolved than it was three years ago. We have more to do, but we have made substantial progress."

But preparing for bioterrorism is more of a journey than a destination. "A lot of times people ask me Well, are we prepared?’ And the answer to the question is, It’s the wrong question,’ because preparedness is not a black and white event. It’s not yes or no, on or off. Preparedness is a process; and it is an ongoing process, and it will continue to be an ongoing process of improvement over time."

While much has been accomplished, "you can still always imagine a scenario that’s one step beyond where you are today," she said. The CDC and state and local health departments have made major strides in preparedness planning and readiness assessment, surveillance and epidemiological response, laboratory capacity, communications and information technology, risk communication, education, and training, she said. "The beauty of this investment is, of course, its multifactorial benefit."

A tsunami of federal bio money

The investment in bioterrorism preparedness includes Project Bioshield, a $5.6 billion program that President Bush signed into law on July 21, 2004. "BioShield is a federal project to purchase and develop countermeasures on an emergency basis to more rapidly develop and, hopefully in some cases, take these threats off the table," Gerberding said. (See related story, p. 45.)

The federal government also has formed Biowatch, a system of environmental detection in several cities around the country that samples air for a certain category of agents. The samples are sent to the laboratory response network for evaluation and ultimately for triage if there is a need for a public health response, she noted.

"But we can’t have Biowatch in isolation, or you’d have nothing but chaos in the system. So we have to support Biowatch with other means of threat assessment. And one of these is Biosense, which is our electronic capability to collect health information from existing resources and interpret trends in those data as additional points of information in the context of local health. Right now, we’re getting about 500,000 laboratory reports everyday from national sources," Gerberding said.

The surveillance system culls data on over-the-counter drug purchases, nursing hotlines, and other sources that may signal an unfolding bio-terrorism attack, she added. "Ultimately, this connectivity that CDC is building for detection and response is something that is very integrally tied to the medical community and hopefully will be a very useful tool for the entire health system."

Alert clinician still is the key 

In that regard, no matter how evolved the infrastructure, the alert clinician remains the key aspect of bioterrorism response. The lessons learned dealing with the 2001 anthrax attacks and emerging infections like monkeypox underscore the critical role of the clinician, Gerberding added.

"We know that the prepared clinician is the frontline of defense for recognizing many of the emerging threats and terrorism threats that we’re concerned about. It was the infectious disease doctor in Florida who had the foresight to recognize that those gram-positive rods in the spinal fluid were not contaminants and clearly represented most likely anthrax," she notes.

Similarly, an alert clinician recognized that West Nile virus was causing encephalopathy in organ transplant recipients. An Italian physician, who ultimately died of severe acute respiratory syndrome, was the first to report the emerging infection posed grave risk to health care workers, said Gerberding. "And it was an alert clinician who recognized the small lesion on the hand of a child represented a pox infection and connected that pox infection with the sick prairie dog that the child was handling. . . . And it is the clinician who ultimately will be the arbitrator of the countermeasure delivery — these are medical products, these are medical assets, and they, in large part, will be managed by medical personnel."

In addition, frontline clinicians will make the decisions about management of patients, separating those who need treatment from the worried well. "We learned head on in the middle of anthrax [about] the worried well and the confusion about who needed prophylaxis and who didn’t," she explained. "It’s the clinician who has to stand in front of the patient and make those decisions."