Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response (1999)

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11
Conclusions and Recommendations

The preceding pages have addressed a wide range of issues related to effective medical response to acts of chemical or biological terrorism. Each chapter draws some conclusions about a single aspect of that response and makes some recommendations for desirable research and development. There are, nevertheless, some general conclusions, some stated, some implicit, which pervade the report as a whole. The most basic of these is that terrorist incidents involving biological agents, especially infectious agents, are likely to be very different from those involving chemical agents, and thus demand very different preparation and response. Figures 11-1 and 11-2 illustrate these differences in flow diagrams of actions involved in coping with what the committee views as the most likely chemical (Figure 11-1) and biological (Figure 11-2) terrorism scenarios. The diagrams are descriptive, not prescriptive, and certainly do not represent the only possible sequences of action. We believe they are representative, however, and illustrate the contrast between the relatively linear sequence of actions in the chemical event and the more diffuse, parallel, and recursive activities in the biological event. The myriad of ''chemical/biological" response teams being developed at federal, state, and local levels are, despite their names, almost entirely focused on detection, decontamination, and expedient treatment of chemical casualties. For both types of incidents, however, there is an existing response framework within which modifications and enhancements can be incorporated. An attack with chemical agents is similar to the hazardous materials incidents that metropolitan public safety personnel contend with regularly. A

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FIGURE 11-1 Flow chart of probable actions in a chemical agent incident.

major mission of public health departments is prompt identification and suppression of infectious disease outbreaks, and poison control centers deal with poisonings from both chemical and biological sources on a daily basis. It would be a serious tactical and strategic mistake to ignore (and possibly undermine) these mechanisms in efforts to improve the response of the medical community to additional, albeit very dangerous, toxic

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FIGURE 11-2 Flow chart of probable actions in a biological agent incident.

materials. Strengthening existing mechanisms for dealing with unintentional releases of hazardous chemicals, for monitoring food safety, and for detecting and responding to infectious disease outbreaks, is preferable to building a new system focused solely on potentially devastating but low-probability terrorist events. Indeed, a major reason for the committee's decision to focus the report on response to aerosol attacks with the short list of agents thought to be a threat by U.S. military forces was that these agents are unfamiliar to the U.S. civilian medical system. Regardless of relative probability of use or relative lethality, there are mechanisms in place for dealing with a wide variety of other agents and routes. Our concern was not to foster construction of yet another mechanism, but to encourage the incorporation of these unfamiliar agents and routes into existing mechanisms.

A second general conclusion relates to a question which underlays the whole study: whether military approaches to chemical and biological defense are applicable to domestic civilian situations involving these agents. The report points out several aspects of military standard operating

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procedure that, as the sponsors feared, will be difficult or impossible to implement in a very heterogeneous and independent civilian population. More importantly, the committee was impressed with the extent to which differences in prior knowledge about the identity of the enemy and the time and place of attack lead to important differences in the needs of military and civilian medical communities. Vaccination, for example, is an obvious preventive measure for a military force poised for combat against an enemy known or suspected to have a stockpile of certain biological weapons. The same holds true for deployment of chemical or biological detection systems, the use of highly specific antidotes and therapeutic and pretreatment drugs: with reasonable intelligence about the enemy's capabilities and proclivities, these tools can be put into action rapidly and confidently. The value of all of these actions diminishes considerably in the most probable civilian terrorism situations, in which the enemy, the agent, the time, and the place of attack are unknown. This difference, even more than differences in the physiology of civilian and military targets, influenced the committee to emphasize treatment over prevention, broad-spectrum drugs, detection with familiar or multiagent equipment, clinical diagnosis based on commercial technology, decontamination without agent-specific equipment or solutions, modification of familiar or multipurpose protective clothing and equipment, and even the advisability of prehospital treatment. Chapter 3 argues for including the medical community in the distribution of pre-incident intelligence to maximize medical response in dealing with chemical or biological incidents, but, important as that is, the time scale envisioned in those arguments is much too short for truly preventive measures like vaccination or the introduction of unfamiliar specialized equipment.

A third conclusion which shaped the committee's recommendations concerned problems of scale. In many of the areas surveyed in the previous section, we noted that some capability, often quite good capability, existed for incidents involving a small number of victims. Regardless of preparation, there will be some unpreventable casualties in all but the most incompetent attacks, but without planning, education, supplies, equipment, and training, the casualty count will mount rapidly when the number of persons exposed escalates, particularly as the event is likely to be unprecedented in a community. Local governments and hospitals are reluctant to spend large amounts of money and time preparing for what they judge as low-probability events. Therefore, although the need for integrated planning cannot be overstated, federal organizations can be very important. Because of the rapidity with which chemical agents act, federal help may actually be of less use in a chemical attack, for which they are much better prepared, than in a biological attack, where onset of signs or symptoms is delayed, variable, and potentially continuing, and

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victims are widely dispersed. The National Disaster Medical System (NDMS), for example, would be a critical component of response to any large-scale biological attack. The NDMS might also serve a useful role in a large-scale chemical attack, though the rapid onset of effects from these agents puts a premium on actions within the first few hours following exposure. For that reason, the Metropolitan Medical Strike Teams being organized and equipped by the Public Health Service may be the most useful federal help in managing the medical consequences of a chemical attack. Similar help from deployable military teams will be optimal only if intelligence allows for predeployment or the attack occurs near the team's home base.

Detection and identification of agents, either in the environment or in victims' bodies, is currently a piecemeal operation that, in the absence of other information, is as much art as science. In both chemical and biological agent incidents, initial treatment of victims is likely to remain symptom-based for some time. In part this is due to diagnosis problems (knowing what detector to deploy in the environment or what medical test to request), limited detection capability at low but potentially harmful concentrations, and lack of specific treatments for some agents. These difficulties are clearly amenable to technological solutions, and the committee is optimistic about the prospects for faster, easier, more specific patient diagnostics. The committee's recommendations on detection and identification of agents in the environment, however, were shaped very strongly by assumptions about terrorism scenarios: that vapor or aerosol delivery will mean that agents may be difficult to locate 10, 20, or 30 minutes after a chemical agent release, when the first detectors arrive at the scene, and that the release site and time of a biological attack will not be known for days or weeks after the release, if at all.

Finally, it is apparent that requirements of federal regulatory agencies (OSHA, FDA) not primarily concerned with emergency response to low-frequency events like chemical or biological terrorism nevertheless have a substantial influence on response capabilities. The characteristics and rules for use of personal protective equipment, for example, fall under the jurisdiction of the Occupational Safety and Health Administration. The investigational (IND) status of some very specific treatments, present and future, will hamper their use in mass-casualty situations. Furthermore, in the case of many treatments, collection of the data on efficacy necessary for full FDA approval will not be possible for ethical reasons or economically attractive to a potential manufacturer because of limited market potential.

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Recommendations for Research and Development

As expected, the committee's review of current capabilities pointed to a number of areas in which innovative R&D is clearly needed. Detailed, specific lists of R&D needs are offered at the end of each chapter (61 in all), and they are summarized below in the form of 8 overarching recommendations. As the text and the inventory in Appendix B reflect, there is a great deal of relevant R&D under way in both the public and private sectors that may meet some of the needs we point out, and the following list of recommendations should not be construed as commentary on the quality of that research or the utility of its intended products for military applications. The order within the list is not by priority, but follows the roughly chronological order of the chapters of this report.

Recommendation 1. There needs to be a system in every state and major metropolitan area to ensure that medical facilities, including the state epidemiology office, receive information on actual, suspected, and potential terrorist activity.

Specific R&D Needs:

Recommendation 2. The committee endorses continued testing of civilian commercial products for suitability in incidents involving chemical warfare agents, but research is still needed addressing the bulk, weight, and heat stress imposed by current protective suits, developing a powered air respirator with greatly increased protection, and providing detailed guidance for hospitals on dermal and respiratory protection.

Specific R&D Needs:

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Recommendation 3. The civilian medical community must find ways to adapt the many new and emerging detection technologies to the spectrum of chemical and biological warfare agents. Public safety and rescue personnel, emergency medical personnel, and medical laboratories all need faster, simpler, cheaper, more accurate instrumentation for detecting and identifying a wide spectrum of toxic substances, including, but not limited to military agents, in both the environment and in clinical samples from patients. The committee therefore recommends adopting military products in the short run and supporting basic research necessary to adapt civilian commercial products wherever possible in the long run.

Specific R&D Needs:

Recommendation 4. Improvements in CDC, state, and local surveillance and epidemiology infrastructure must be undertaken immediately and supported on a long-term basis.

Specific R&D Needs:

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Recommendation 5. R&D in decontamination and triage should concentrate on operations research to identify methods and procedures for triage and rapid, effective, and inexpensive decontamination of large groups of people, equipment, and environments.

Specific R&D Needs:

Recommendation 6. Optimize the utilization of currently available antidotes for nerve agents and cyanide though operations research on stockpiling and distribution, and give high priority to research on an effective treatment for vesicant injuries, investigation of new anticonvulsants, and antibody therapy for nerve agents, development of improved vaccines against both anthrax and smallpox, development of a new antismallpox drug, and research on broad spectrum antiviral and novel antibacterial drugs.

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Specific R&D Needs:

Recommendation 7. Educational materials on chemical and biological agents are badly needed by both the general public and mental health professionals.

Specific R&D Needs:

Recommendation 8. The committee recommends support for computer software R&D in three areas: event reconstruction from medical data, dispersion prediction and hazard assessment, and decontamination and reoccupation decisions.

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Specific R&D Needs: