February 2006
Biological terrorism: Are you prepared?
by Susan Cantrell, ELS
It’s no longer a matter of if, but when, the United States will
be the victim of biological terrorism. It’s already happened;
we have reason to believe it will escalate. Is your facility
prepared?
A study by the Centers for Disease Control and Prevention
(CDC) examined 1,099 outbreaks from 1988 to 1999 with
bioterrorism potential; in 6 of the events, it was considered
there was intentional use of infectious agents, either
bioterrorism or intentional contamination; another 41 events
were considered suspect.1 Perhaps the most frightening,
indeed shocking, part of these findings is that "For 6
outbreaks in which bioterrorism or intentional contamination
was possible, reporting was delayed for up to 26 days." No
wonder the report concluded, "In the future, shortening the
time from detecting to reporting an outbreak to public health
authorities, including CDC, will be essential to an effective
response."1
In another report, the CDC tells us, "the consequences of
being unprepared could be devastating. . . . Terrorist
incidents in the United States and elsewhere involving
bacterial pathogens . . . have demonstrated that the United
States is vulnerable . . . Recipes for preparing ‘homemade’
agents are readily available, and reports of arsenals of
military bioweapons raise the possibility that terrorists might
have access to highly dangerous agents, which have been
engineered for mass dissemination as small-particle aerosols.
. . . Responding to large-scale outbreaks caused by these
agents will require the rapid mobilization of public health
workers, emergency responders, and private health-care
providers. Large-scale outbreaks will also require rapid
procurement and distribution of large quantities of drugs and
vaccines, which must be available quickly."2
The CDC maintains a national pharmaceutical stockpile to
ensure availability of drugs, devices, and equipment that
might be needed to respond to a bioterrorism attack.2 Quick
access to large quantities of drugs and medical equipment is
something that others are prepared to help with, too. Gina
Pugliese, RN, MS, vice president, Premier Safety Institute,
Oakbrook, IL, said, "At the time of a disaster, such as a
bioterrorism event or a hurricane, as a healthcare alliance
offering group-purchasing and supply-chain services, Premier
is able to assist our members with the location and
identification of key materials, supplies, medications, etc., to
supplement the needed inventories."
Novation, LLC, also a supply-chain service, can provide help
to their members, too. Larry Dooley, vice president, contract
and program services, told Heathcare Purchasing News:
"Novation has a disaster-operations team that can address all
types of natural and manmade disasters. This team helps
members meet their supply-chain needs during the time
leading up to, during, and after a disaster. Regarding
bioterrorism, the only thing you can do is work with members
on preparedness, so the disaster operations team is
formulating the list of necessary supplies to address the
bioterrorism threats that we know exist today and is
educating members on these topics. The good news is that
most of the members served by Novation are already dealing
with this and are prepared to deal with this type of tragedy,
based on their own community profiles."
What are goals, who should be involved?
"Hospitals should have a team that represents a crosssection of their operational and clinical departments," said
Dooley. "This team should lead planning and implementation
efforts, if necessary; so, the people serving on the team
should be senior-level executives who would command
respect during a crisis."
Pugliese told HPN that clinical staff, as well as key
supervisory staff who know "operations" thoroughly should
be involved in developing a bioterrorism preparedness plan,
but also involved should be "senior leadership responsible
for, or having oversight for, both safety and infection control
functions. Supervisors involved in supply chain are essential
for planning supplies of all types and backup sources,
including specific supplies needed for controlling potential
biological agents. In early planning, there need to be liaisons
with the local health agency and local emergency planning
committee."
Judene Bartley, MS, MPH, CIC, clincal/safety consultant with
Premier Safety Institute, commented on goals for being
prepared for bioterrorism: "The initial goal in preparation
should include completion of a Hazard Vulnerability
Assessment, considering specific needs of that organization
or community, specifically addressing potential vulnerability
to bioterrorism agents. This would also include feasibility to
respond to influx of patients that would need special handling
(for example, isolation) and overall surge-capacity issues.
The next step would be development of an "all-hazard plan,"
so that special needs involving biological agents would be
addressed effectively, along with other hazards such as
chemical. This includes patient, worker, and occupant
protection, as well as specific supply needs (for example,
masks, gloves). Also, presuming the plan is some variation of
HEICS (Hospital Emergency Incident Command System),
another key goal would be to test and retest the
organization’s readiness to ensure each member knows his or
her role and response. Given typical workplace turnover,
these plans have to be tested periodically for effectiveness,
not just to meet requirements of a regulatory or accrediting
agency like JCAHO."
Ashok Chetty, marketing manager, DuPont Personal
Protection, Emergency Response/Government Markets,
Richmond, VA, also emphasized the importance of conducting
drills: "In DuPont’s view, an effective preparedness plan has
to ensure that response personnel have adequate and
frequent training under a variety of simulated disaster
situations. It is important that these simulations incorporate
all the critical players and systems by including the hospital
personnel, the public health system, the response
equipment, and other related emergency management
agencies."
Dooley commented on the need for security to protect staff,
patients, and visitors from harm in such a volatile situation
and the need to support facility staff and their families: "Each
healthcare organization, based on their community, might
have slightly different goals, but all members should have
goals that ensure a quick and sufficient response to the crisis
at hand. This should include clinical as well as operationalresponse objectives, such as staffing for the event and
securing the perimeter of the hospital. Additionally, the
member’s goals should also include sufficient planning and
preparation to meet staff members’ personal needs. VHA and
Novation have been involved in helping member hospitals
recover from hurricanes for more than a decade, and the first
step we usually take, besides ensuring that supplies are
getting to the hospitals, is making sure that hospitals can
take care of their employees, so that the employees are not
distracted from their duties."
What are we preparing to face?
For what, exactly, does your facility need to prepare?
Bioterrorism is no nebulous boogeyman; it presents real
threats in the form of bacteria, viruses, and poisons. The
CDC explained: "Bioterrorism is the intentional use of
microorganisms or toxins derived from living organisms to
cause death or disease in humans, animals, or plants on
which we depend."1
The CDC developed three categories of organisms,
categorized A, B, and C, by priority in which they "pose a risk
to national security because they can be easily disseminated
or transmitted person-to-person; cause high mortality, with
potential for major public health impact; might cause public
panic and social disruption; and require special action for
public health preparedness."2 The A-list includes these
agents:
• variola major (smallpox)
• Bacillus anthracis (anthrax)
• Yersinia pestis (plague)
• Clostridium botulinum (botulism)
• Francisella tularensis (tularemia; also known as rabbit
fever)
• filoviruses: Ebola and Marburg hemorrhagic fevers
• arenaviruses: Lassa fever, Argentine hemorrhagic fever,
and related viruses.
Even one case of illness or death caused by any of these
organisms should alert healthcare workers to the possibility
of intentional exposure to unsuspecting victims or accidental
exposure to the perpetrator.1 The trick is in identifying these
infections, since they’re not something seen by healthcare
workers every day.
Logical Images Inc., has developed software in its VisualDx
program, for everyday use that could have added value in
the event of bioterrorism. "Conditions caused by agents of
bioterrorism are rare," observed Art Papier, MD, chief
scientific officer. "Many clinicians have not seen a case and
may not think to include it as a possibility. During the
anthrax attacks of 2001, the Wall Street Journal (November
27, 2001) reported that patients lived or died depending on
whether the doctor diagnosing them considered anthrax as a
possibility. Providing healthcare professionals with the
information tools to support diagnosis and management is
key. With a system like VisualDx, which doctors use every
day for more common diagnostic problems, the physician is
reminded to consider bioterrorism when it’s clinically
appropriate. In addition, they have rapid access to clinical
information and photographs (10,000 images covering 600
diseases) of all the look-alike conditions to help them quickly
and effectively rule bioterrorism in or out. A randomized,
controlled university study showed that, in comparison to
textbooks and medical atlases, VisualDx improved primary
care and emergency physicians’ diagnostic accuracy by
124%.3" More recently, the system included images from
Katrina victims with Vibrio Vulnificus, a gram negative rod
infection that had been diagnosed in Katrina flood water
exposed patients. The system provided diagnostic assistance
for the potentially lethal infection as well as the instructions
for immediate administering of antibiotic therapy.
Importance of early detection
While it’s possible that a bioterrorism event could be
announced publicly, the CDC’s strategic-plan document
points out that "attacks with biological agents are more likely
to be covert."2 This means that the attack may not have an
immediate impact because of the delay between exposure
and onset of illness, with the pathogens or toxins in the
meantime freely doing their dirty work in the dark, so to
speak. Persons initially infected in a mass attack could
unknowingly spread disease that could lead to a deadly
epidemic, with public panic following close at its heels.
Bioterrorists count on the ensuing psychological terror to
cause panic and to demoralize the public, perhaps sowing
seeds of distrust in efforts to respond to the situation, which
has the potential to hamper containment and control of the
disease.4,5 In the meantime, the biological agent has its
way. With airplanes and worldwide travel, there is the
potential for its tentacles to reach far and wide, undetected,
within hours.
The CDC noted: "Only a short window of opportunity will
exist between the time the first cases are identified and a
second wave of the population becomes ill. During that brief
period, public health officials will need to determine that an
attack has occurred, identify the organism, and prevent more
casualties through prevention strategies . . . As person-toperson contact continues, successive waves of transmission
could carry infection to other worldwide localities."2
Early detection of a biological terrorist attack is crucial, so
the need for those on the front line to be alert and discerning
cannot be overstated, because they are the ones in the best
position to detect and report suspicious illnesses. "The earlier
the accurate detection of a bioterrorism-agent release, the
more likely the extent of the attack can be minimized,"
observed Papier.
The CDC "confirmed that the most critical component for
bioterrorism outbreak detection and reporting is the frontline
healthcare profession and the local health departments.
Bioterrorism preparedness should emphasize education and
support of this frontline as well as methods to shorten the
time between outbreak and reporting." 1
An automated surveillance system in place at a healthcare
facility can be useful in early detection, which could shorten
the time between outbreak and reporting. "Automated
systems that help hospitals monitor and track hospitalacquired infections can also play a critical role in bioterrorism
preparedness," says Dan Peterson, MD, MPH, president and
CEO of Cereplex Inc, Germantown, MD. "Systems such as
those from Cereplex, which can track both inpatient and
outpatient data, including emergency department visits, and
monitor laboratory and pharmacy data, can detect patterns
that are significantly more specific than typically syndromic
surveillance measures. For instance, our hospitals can set up
an alert that captures and counts patients who show up at
the emergency department (indicator of acute onset); are
admitted to the ICU; have blood, urine, and sputum cultures
done; and are started on broad-spectrum antibiotics (as
indicators of clinical uncertainty of cause of illness). Such an
approach substantially reduces the noise otherwise
associated with syndromic surveillance. Most importantly,
because such automated surveillance systems run entirely
with data already gathered in hospital information systems,
no manual data entry is required." A veteran of 8 years at
CDC, Dr. Peterson concluded that "Using automated
surveillance systems for hospital infections to monitor for
bioterrorism events is a clear example of exactly the kind of
dual-use systems that CDC is advocating."
Where to start?
A good place to start preparing your facility for bioterrorism
is by educating yourself with advice and recommendations
developed by organizations such as the CDC; Association for
Professionals in Infection Control and Epidemiology, Inc
(APIC); American Hospital Association; Joint Commission on
Accreditation of Healthcare Organizations (JCAHO); U.S.
Department of Homeland Security; Agency for Healthcare
Research and Quality, Department of Health and Human
Services; Institute of Medicine; National Institute of Allergy
and Infectious Diseases; Society for Healthcare Epidemiology
of America; Infectious Diseases Society of America; the
Occupational Safety and Health Administration; and the
Federal Emergency Management Agency, among others. All
of these organizations have web sites chock full of good
advice on how healthcare facilities can prepare for
bioterrorism, and some offer tools to help achieve it. Some
schools such as University of North Carolina at Chapel Hill;
Johns Hopkins; Washington University at St. Louis, Missouri;
and Detroit Medical Center at Wayne State University also
have excellent resources.
APIC even has a template for healthcare facilities to "guide
the development of practical and realistic response plans for
their institutions in preparation for a real or suspected
bioterrorism attack."5 The document strongly urges that
response plans "should be prepared in partnership with local,
state, and regional resources including health departments,
emergency management, and first responders." Assessing
your facilities, according to the document, is the first step,
and a mass-casualty disaster-plan check list is included. The
document also contains helpful information including but not
limited to FBI Field Offices contact information, a telephone
directory of state and territorial public health directors, and a
list of web sites relevant to bioterrorism preparedness.
Aside from regulatory and advisory agencies, others are in a
position to help in preparing for bioterrorism. Education is the
answer, and the Premier alliance is one organization that is
supplying information and materials. Pugliese explained:
"Premier Safety Institute addresses that need by developing
materials that clarify risk and provide easy access to sample
protocols, tools, assessments, educational and training
programs, product lists, and suppliers from a variety of
sources that can be used for all stages of planning for a
bioterrorism event."
DuPont, which makes personal protective equipment for use
in emergencies such as a bioterrorism attack also offers help.
Chetty said: "DuPont has a network of technical support
personnel who can help healthcare providers with the proper
selection and use of protective apparel. In addition, we have
a variety of tools including technical information bulletins,
videos, and presentations that can be used to train personnel
on the use of protective apparel."
It’s frightening to realize that we have a genuine need for
protective apparel against a bioterrorism attack. We are
fortunate that those tangibles are readily available. Another
component necessary to the fight against bioterrorism is not
so tangible but perhaps even more important. Pugliese put it
well: "Communication, communication, communication! The
more the public or healthcare communities understand the
more realistic their preparations will be, versus a sense of
panic or helplessness." HPN
REFERENCES
1.Ashford DA, Kaiser RM, Bales ME, Shutt K, Patrawalla A,
McShan A, et al. Planning against biological terrorism:
lessons from outbreak investigations. Emerg Infect Dis [serial
online] 2003 May [December 19, 2005].
http://www.cdc.gov/
ncidod/EID/vol9no5/02-0388.htm
2.Centers for Disease Control and Prevention. Biological and
chemical terrorism: strategic plan for preparedness and
response. Recommendations of the CDC Strategic Planning
Workgroup. MMWR 2000;49(RR-4).
3.Papier A, Allen E, McDermott M. Software improves
diagnostic accuracy with minimal training. American Medical
Informatics Association Annual Meeting; Washington, DC;
November 2001. Poster presentation.
4.Strongin R. Biological terrorism: is the healthcare
community prepared? Issue brief no. 731. Washington, DC:
George Washington University; 1999.
5. APIC Bioterrorism Working Group. April 2002 interim
bioterrorism readiness planning suggestions.
http://www.apic.org/
Content/NavigationMenu/
PracticeGuidance/Topics/
Bioterrorism/
APIC_BTWG_BTRSugg.pdf.
Other recommended reading:
Ferguson NE, Steele L, Crawford CY, Huebner NL, Fonseka
JC, Bonander JC, et al. Bioterrorism web site resources for
infectious disease clinicians and epidemiologists. Clin Infect
Dis 2003;36:1458-1473.
Bradley CA, Rolka H, Walker D, Loonsk J. BioSense:
Implementation of a national early event detection and
situational awareness system. MMWR 2005;54(suppl):11-19.
http://www.cdc.gov/
mmwr/preview/
mmwrhtml/su5401a4.htm.
American Hospital Association. Readiness for potential attack
using chemical or biological agents.
http://www.hospitalconnect.com/
aha/key_issues/disaster_readiness/
readiness/MaDisasterB1003.html.
American Hospital Association. Disaster readiness.
http://www.hospitalconnect.com/
aha/key_issues/disaster_readiness/
readiness/MaDisasterB0921.html.
American Hospital Association. Hospital preparedness for
mass casualties. http://www.hospitalconnect.com
/ahapolicyforum/
resources/disaster.html.
American Hospital Association. Bioterrorism readiness plan: a
template for healthcare facilities.
http://www.aha.org/aha/
key_issues/disaster_readiness/
readiness/
MaBioterrorismReadinessB1017.html
Gostin LO, Sapsin JW, Teret SP, Burris S, Mair JS, Hodge JG,
et al. The Model State Emergency Health Powers Act:
planning for and response to bioterrorism and naturally
occurring infectious diseases. JAMA 2002;288:622-628