The threat of chemical and biological terrorism, coupled with current world events, has caused the many disciplines responsible for the health and welfare of the public to evaluate their ability to respond adequately to an intentional use of a weapon of mass destruction. The national medical communityincluding public health agencies, emergency medical services, hospitals, and health care providerswould bear the brunt of the results of a chemical or biological attack. An attack of a chemical or biological agent could result in civilian mortality and morbidity that have not been seen in natural disasters or infectious outbreaks in the United States since the influenza epidemic of 1918–1919.
As noted in the preceding chapter, the medical community must prepare for three general types of incidents. The first is an overt release resulting in a chemical or biological exposure to a population with its subsequent morbidity or mortality. In most cases illness exposure or risk is known from the moment the exposure is identified, and efforts to mitigate its effects as well as treat victims can begin immediately. The second type of terrorist incident is a covert release involving an agent with a delayed onset of illness and delayed identification that a population is at risk. In this situation, exposure, illness, or injury may be widespread before mitigation or treatment can begin. Finally, there is the threat of a release by a terrorist group that has identified itself or is discovered through normal intelligence operations. In this case, medical authorities can serve as a surveillance system for law enforcement by looking for medical indicators suggestive of terrorist activity. Such indicators might
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Page 29 2 Pre-Incident Communication and Intelligence: Linking the Intelligence and Medical Communities The threat of chemical and biological terrorism, coupled with current world events, has caused the many disciplines responsible for the health and welfare of the public to evaluate their ability to respond adequately to an intentional use of a weapon of mass destruction. The national medical communityincluding public health agencies, emergency medical services, hospitals, and health care providerswould bear the brunt of the results of a chemical or biological attack. An attack of a chemical or biological agent could result in civilian mortality and morbidity that have not been seen in natural disasters or infectious outbreaks in the United States since the influenza epidemic of 1918–1919. As noted in the preceding chapter, the medical community must prepare for three general types of incidents. The first is an overt release resulting in a chemical or biological exposure to a population with its subsequent morbidity or mortality. In most cases illness exposure or risk is known from the moment the exposure is identified, and efforts to mitigate its effects as well as treat victims can begin immediately. The second type of terrorist incident is a covert release involving an agent with a delayed onset of illness and delayed identification that a population is at risk. In this situation, exposure, illness, or injury may be widespread before mitigation or treatment can begin. Finally, there is the threat of a release by a terrorist group that has identified itself or is discovered through normal intelligence operations. In this case, medical authorities can serve as a surveillance system for law enforcement by looking for medical indicators suggestive of terrorist activity. Such indicators might
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Page 30 include unusual illness or injury in a community. Although medical organizations have historically not been recipients of pre-incident intelligence, this practice needs to change in light of recent concerns about chemical and biological terrorism. The CDC now maintains a database of individuals and organizations possessing any of 36 biological agents (listed in Appendix D) with potential to cause a severe threat to public safety and health. The legislation does not require CDC to share this information with state or local health departments, however, and sharing has not been done in any systematic way. Although facilities willing to report to CDC that they are working with these agents are unlikely to be terrorist threats themselves, they may be targets of terrorists, victims of theft by rogue employees, or the source of an unintended release. All of these events will be handled better if the local medical community is aware of the possibility. Of far more importance is the need for an institutionalized linkage between the law enforcement and medical communities. The response of even the most well prepared medical facilities will be markedly improved by advance notice from the law enforcement community. The latter understandably fear compromising ongoing investigations, but may not fully appreciate the substantial impact even very general information about possible incidents can have in facilitating a rapid and effective response by the medical community. Receipt of information concerning a possible mass-casualty event need not involve more than a few key individuals who can review the organization's seldom-used plan and begin to think about treatment options, where and how to obtain needed antidotes and drugs, make hospital beds and resources available on short notice, and ensure adequate staffing levels. Inclusion of these key medical personnel in anti-terrorist intelligence activity would no doubt be facilitated by their willingness to undergo training on the needs of the law enforcement community, especially procedures for proper preservation of evidence. After-action reports on the Tokyo subway incident (Obu, 1996; Olson, 1996; Yanagisawa, 1996) provide an example of the value of communication between the law enforcement and medical communities as well as an example of a missed opportunity for communication within the medical community that might have made the medical response even more effective than it was. Japanese police had apparently been planning a raid on Aum Shinrikyo facilities throughout Japan, and for that reason the government had ordered medical supplies, including nerve agent antidotes, not normally stocked in quantity by hospitals (anonymous comments in Obu, 1996). One of the reasons for the raids was the suspected involvement of the Aum Shinrikyo in a previous toxic gas incident in the city of Matsumoto almost a year before the Tokyo attack (Morita et al., 1995). The release in that city in 1994 of what was subsequently identified as
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Page 31 sarin resulted in seven deaths and the treatment of an additional 250 people. A group of Matsumoto physicians, recognizing that data from humans exposed to sarin were very rare, collected a great deal of information on these patients, which they sent to Tokyo hospitals and the Ministry of Health and Welfare as soon as they heard of the subway attack. Although the information reportedly was helpful, it seems obvious that a more formal mechanism by which the Matsumoto group could have more rapidly and systematically alerted other cities and hospitals to such an unusual event might have been even more valuable. In this country, the District of Columbia's Emergency Management Office and Public Health Agency were provided an extensive, although generic, briefing on the terrorism threat just before the start of the Gulf War. Similar briefings have no doubt taken place on occasions such as the 1996 Atlanta Olympic Games, and personal relationships may provide good communication between the law enforcement and medical communities in some cities. However, few have the sort of structural links that the MMSTs are attempting to build into their operationsa law enforcement section, headed by a local law enforcement officer, one of whose major duties is to establish relationships with the local FBI office and other law enforcement agencies sufficient to ensure that the team has the maximum prior warning of potential nuclear, chemical, or biological incidents. It is necessary to have an accurate ongoing assessment and prioritization of the chemical and biological agents that pose the greatest threat as well as identification of the agents that pose the most credible threat (using some of the 36 agents on the CDC list of restricted agents). In order for the medical community to efficiently prepare and respond to chemical and biological terrorism, it must be equipped with the latest and most accurate information on current risks. This is essential to ensure adequate preparatory measures, such as stocking and maintaining appropriate and sufficient amounts of vaccines, antibiotics, and other pharmaceutical agents and to ensure maximum effort in providing for the safety of health care providers, paraprofessionals, and support personnel. These events often involve the use of medications or vaccines that are often not available in large enough supply locally and, even if maintained in regional stockpiles, still require time to obtain or produce adequate stores to effect meaningful treatment or prophylaxis. Emergency medical workers would benefit from preincident warnings by entertaining a broader range of hypotheses when entering an illness or injury site where the risks are unclear. These added considerations could be the difference between the loss or incapacitation of the rescue team or the secondary spread of potentially contaminated/infected patients to other health care sites.
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Page 32 Identification of the agents used in chemical and biological terrorism may involve sophisticated tests that take several hours to days for results. Initial signs and symptoms in victims of biological terrorist events may present as common disease processes. Not thinking about the possibility of these more lethal or infectious diseases runs the risk of secondary spread and additional cases of epidemic proportions. Early warning of potential threats will stimulate an earlier screen of potentially exposed individuals for intoxication or infection and a more rapid public health response. This is even more important if multiple infectious agents or a combination of chemical and infectious agents are suspected. Traditional medical teaching is to try to explain a clinical condition by a single disease process. Containing the disease outbreak or the chemical contamination is the most important public health responsibility of consequence management of a biological or chemical terrorist event. Timely and accurate pre-incident intelligence is essential to achieve this goal. Health officials are often the first medical personnel to be contacted by the press whenever an epidemic or other public health threat occurs. Early knowledge of the threat of a chemical or biological event would allow public health officials to develop plans for effective risk communication and ensure appropriate coordination with law enforcement authorities. Accurate and timely information from public health officials is essential to prevent public panic. Benefits of effective communication include: reducing the inappropriate use of scarce health care resources by low-risk individuals and ensuring that individuals at highest risk present for treatment. Although further research is needed into the best ways to improve communication, the many advantages of providing the medical community information obtained by agencies monitoring and gathering intelligence on terrorist activity and threats is vital. In summary, the medical community has the diversity to respond to a wide array of biological and chemical health emergencies, including those which are intentional. Although the intelligence community has a legitimate need to protect its sources and the law enforcement community its operations, current and accurate information must be made available to the medical community in the pre-incident phase as well as the response phase of an event. This includes any information regarding credible threats to a community and potential agents that might be used. Information on successful interdictions, including agents and plans for their dissemination, would even be valuable after the fact for planning and training. The bilateral sharing of information, intelligence, and clinical data will ensure that victims receive the most efficient care possible, based on fact and experience rather than on assumptions and conjecture.
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Page 33 R&D Needs The committee is encouraged by the recent provisions of Presidential Decision Directive 63 that call for establishing a national center to warn owners and operators of critical economic and governmental infrastructures of terrorist threats. We hope that as the details of this center are developed, the medical community will not be overlooked. To enhance communication to and within the national medical community, the following R&D needs have been identified: 2-1 Development of a formal communication network between the intelligence community and the medical community that incorporates local emergency management agencies as an important element and thereby creates a mechanism for public health and emergency management officials to gain access to intelligence information. This might best be accomplished by incorporating public health and other health professionals into the intelligence community to monitor and assess biological agents and terrorist threats from the perspective of a health emergency (health intelligence liaisons). Operations research should be done to identify what triggers should initiate the transfer of intelligence information and what medical and intelligence agencies should be involved. 2-2 Development of a national mechanism for the distribution of clinical data, including treatment modalities, patient outcomes, efficacy of pharmaceutical agents, best practices, and other medical interventions, to the intelligence and medical communities after an actual event or exercise.