Biological Warfare 101

The use of microorganisms and toxins as weapons of destruction has a long history, with examples of biological terrorism dating back to before the 14^th century. Methods used have ranged from deliberately infecting water supplies with diseased cadavers to passing out smallpox-infected blankets to “extirpate” Native American tribes in 1763.³ Other examples include the use of fomites (objects that harbor and can transmit disease agents), as the Viet Cong did in the early 1960s when they smeared pungi sticks with excrement.⁴

Diseases resulting from biological agents, whether spread person-to-person or through other means, have incubation periods of days. This means, for example, that a person infected in a mass casualty attack could unwittingly continue to spread the disease, perhaps unleashing a deadly epidemic and most likely causing a wave of panic as the death toll mounted. Terrorists count on this added psychological dimension to erode trust in the target country’s government and further cripple efforts at containment and control.

Biological agents considered to be priority biological terrorism threats can be categorized into three groups: bacteria, viruses, and toxins. In a March 8, 1998, New York Times article, Tom Kuntz excerpted the following from Jane’s Chem-Bio Handbook, a “guide for military, police, and emergency personnel responding to suspected or real chemical or germ attacks.”

Anthrax. Anthrax is an acute bacterial infection of the skin, lungs, or gastrointestinal tract. The skin infection can be caused by direct contact with contaminated wool, hides or [livestock] tissues.… As a biological weapon, it is expected that anthrax spores would be released at a strategic location to be inhaled. Inhalation anthrax results from deposition of the bacterial spores in the lungs and causes fever, shock, and eventually death…. Iraqi and Soviet biological warfare programs worked to develop an anthrax weapon.

Ricin. Ricin is a toxin made from the mash left over after processing castor beans for oil. Castor bean processing is a worldwide activity; therefore, the raw materials for making ricin are easily available. Ricin is easy to produce and is stable. Ricin was used in 1978 by Bulgarian intelligence operatives in the “umbrella murder” of Gregori Markov, a Bulgarian dissident. A ricin-tipped bullet was discharged into the victim, and he died a day after the attack.

Ebola. Ebola virus is one of the most pathogenic viruses known to science, causing death in 50 to 90 percent of all clinically ill cases.… The Ebola virus is transmitted through direct contact with the blood, secretions, organs, or semen of infected persons. Transmission of the virus has also occurred by handling ill or infected chimpanzees. The virus has an incubation period of 2 to 21 days, and is characterized by sudden onset of fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, limited kidney and liver functions and both internal and external bleeding.… Ebola viruses must be considered to have a high priority as a candidate for biological warfare.… This virus was assigned high priority in the former offensive program of the Soviet Union.

Additional biologic agents potentially available to bioterrorists include smallpox, brucellosis, plague, Q fever, tularemia, viral encephalitides, viral hemmorrhagic fevers, botulinum, and staphylococcal enterotoxin B.

Detecting Biologic Agents: The Role of the CDC and State Health Departments

Detecting and isolating biologic agents requires not only the ability of clinicians to identify and accurately diagnose uncommon diseases but also a surveillance system for collecting reports of such cases. Fortunately, the Centers for Disease Control and Prevention (CDC) operate a large number of infectious disease surveillance systems based on voluntary collaboration with state and local health departments, surveys, vital records, or registries. Unfortunately, the IOM report noted:

The best known of these systems, the National Notifiable Disease Surveillance System, currently includes several, but not all, of the diseases considered likely to be used in bioterrorism, and, like all passive surveillance systems, suffers from omissions and long-delayed reports. All of the systems depend upon confirmed diagnosis and are thus no help to a puzzled physician trying to arrive at a diagnosis. No federal funds are provided to state and local health departments to support these systems, and states’ ability or willingness to support infectious disease surveillance has declined in recent years. CDC’s Emerging Infections Program (EIP) is attempting to reverse this trend by making grants to state and local health departments for improving epidemiological and laboratory capability. Expanding the activities of these centers would be an excellent way to raise both the awareness of bioterrorism and the ability to respond to it.

Crisis and Consequence: Managing Terrorist Attacks

According to the September 1997 GAO report Combating Terrorism: Federal Agencies’ Efforts to Implement National Policy and Strategy:

U.S. policy on combating terrorism has been evolving for about 25 years. In June 1995, the President issued Presidential Decision Directive 39 (PDD 39), “United States Policy on Counterterrorism,” the central blueprint for the U.S. counterterrorism strategy. PDD 39 restated standing U.S. policy and elaborated a strategy for combating terrorism and measures to implement it. The U.S. strategy consists of three main elements: (1) reduce vulnerabilities and prevent and deter terrorist acts before they occur; (2) respond to terrorist acts that do occur, including managing crises and apprehending and punishing terrorist perpetrators; and (3) manage the consequences of terrorist attacks.

More recently, in May 1998, PDD 62 (“Combating Terrorism”) and PDD 63 (“Critical Infrastructure Protection”) were both issued. These directives establish a national coordinator for security, infrastructure protection, and counterterrorism and authorize the Federal Bureau of Investigation (FBI) to set up a National Infrastructure Protection Center to issue warnings to public and private operators of essential elements of the U.S. government and economy. In addition, the directives include a four-part initiative focused on biological weapons. According to the IOM report,

It calls for a national surveillance system based on the public health system, provision of local authorities with necessary equipment and training, stockpiles of vaccines and specialized medicines, and a research and development program on pathogen gene mapping to guide development of new and better medicines and vaccines.

Preparing to meet the needs of civilian victims of a bioterrorist attack will require the coordination of the health care community as a whole, as well as of many other organizations, experts, and agencies at all levels of government. It has been estimated that more than 40 federal departments, agencies, and bureaus have some role in combating terrorism. Part of the challenge, not surprisingly, involves working through the complex maze of multiple bureaucracies to figure out who does what when and who reports to whom.

Generally, if an incident occurs without a warning, crisis and consequence management will be concurrent. The FBI would be in charge of crisis management (that is, controlling the crime scene and gathering evidence used to prosecute the terrorists). Primary responsibility for consequence management, however, rests with the states. The federal government supports state and local governments in domestic incidents through the Robert T. Stafford Disaster Relief and Emergency Assistance Act. The Federal Emergency Management Agency coordinates the federal response through a generic disaster contingency plan known as the Federal Response Plan, which categorizes types of federal assistance into specific emergency support functions. Support functions include, for example, health and medical services, urban search and rescue, and information and planning.

Paying for Preparedness

Increasing the level of preparedness is not cheap. In addition to funds appropriated more generally to counter-terrorism efforts, Congress appropriated funds for bioterrorism and related public health infrastructure activities within DHHS. Specifically, the Omnibus Consolidated and Emergency Supplemental Appropriations for FY99 allocated $216,922,000 to the Public Health and Social Services Emergency Fund. According to the conference report, “The fund addresses the Administration request for bioterrorism and related activities as well as for bolstering public health infrastructure, conducting studies regarding health and national security, and combating certain infections diseases.”

According to the conference report, the $216,922,000 is to be allocated as follows:

• $154,750,000 for the CDC for a variety of activities. These include: $1 million for the development of an overall preparedness plan, $1 million to enhance technical capabilities to identify certain biological agents, $51 million⁵ for the CDC to establish a pharmaceutical and vaccine stockpile for civilian populations,⁶ $1.75 million for conducting independent studies of health and bioterrorism threats specified in the Senate report, $2 million to assist states in developing emergency preparedness and response plans, $2 million to expand the CDC Epidemic Intelligence Service, $2 million for regional laboratories for measuring chemical exposures, $5 million to better identify potential biological and chemical terrorism agents, $5 million to develop new sources and methods for surveillance, $5 million to develop rapid toxic screening, $5 million for the environmental health laboratory, $7 million to strengthen state and local epidemiological and surveillance capacity, $11 million for regional laboratories for detecting and measuring biological and chemical agents, $28 million to establish a national health alert network, $20 million for polio eradication activities, and $8 million for measles eradication activities.
• $12,172,000 for the Office of the Secretary, allocated as follows: $2.5 million for the Office of Emergency Preparedness for a national disaster medical system, $1.5 million for developing national response capabilities, $3 million for metropolitan medical response systems, $1.85 million for a nuclear weapons radiation study, and $3 million in for the renovation and modernization of Fort McClellan’s Noble Army Hospital in Alabama for bioterrorism training activities. The conference agreement also included $322,000 to be provided to Calhoun County, Michigan, for reimbursement of certain expenses related to food-borne illnesses.
• The remaining approximately $50 million is to be used “to address the HIV/AIDS crisis facing the African American community and other racial and ethnic minority communities due to the changing demographics of the disease.”

The Forum Session

The Forum has invited a number of experts to help sort through how the health care community can better prepare for and contribute to the prevention of a biological terrorist attack. Margaret A. Hamburg, M.D., assistant secretary for planning and evaluation within DHHS and a past commissioner of health for the City of New York, will set the stage by addressing the following: What are we preparing for? How well prepared are we? And what do we need to do in the short-term and the long-term? Dr. Hamburg has a distinguished record of scientific accomplishments and outstanding public service. She has been elected to membership in the Institute of Medicine, the New York Academy of Medicine, and the Council on Foreign Relations and is a fellow of the American Association of the Advancement of Science.

Following Dr. Hamburg’s remarks panelists representing several areas of expertise will participate in a roundtable discussion focusing on the following questions:

• What are the medical and public health ramifications of a bioterrorist event?
• What are the most serious bioweapons facing the public health community today?
• How prepared or ill-prepared are various sectors of the health community to respond to a successful bioterrorist attack of any proportion?
• What kind of practical steps could be taken to reduce the risk? To minimize the consequences?
• How much would such steps cost? How should they be funded?
• What are the research needs? Who should be conducting the research?
• What are the commonalities and differences between chemical and biological terrorism? What elements need to be considered in preparedness planning and resource allocation? Should biological and chemical terrorism be linked or unlinked for planning purposes?

Scott R. Lillibridge, M.D., director of the CDC’s bioterrorism preparedness and response activities, was the lead public physician during the initial U.S. Public Health Service response to the Oklahoma City bombing and was team leader for the U.S. Medical Delegation to Tokyo following the Sarin release in 1995.

Davi M. D’Agostino, assistant director of GAO’s National Security and International Affairs Division, has been leading GAO’s work on crosscutting counterterrorism issues for the past three years. In 1995, Ms. D’Agostino was selected to attend the Industrial College of the Armed Forces. She received the GAO Meritorious Service Award in 1997.

Robert F. Knouss, M.D., director of the DHHS Office of Emergency Preparedness, also directed the Public Health Service’s refugee health activities during the Cuban-Haitian entrant and Southeast Asian refugee crisis and served as deputy director of the Pan American Health Organization.

Peter Rosen, M.D., director of the emergency medicine residency program at the University of California, San Diego and professor of clinical medicine and surgery there, also served as chair of the IOM’s January 1999 study, Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response.

Donald A. Henderson, M.D., M.P.H., director of the Johns Hopkins Center for Civilian Biodefense Studies, is also the Johns Hopkins University Distinguished Service Professor and has appointments in the Departments of Epidemiology and International Health in the School of Hygiene and Public Health. Dr. Henderson also served as dean of the faculty of the Johns Hopkins School of Public Health and directed the World Health Organization’s global smallpox eradication campaign.

Jerome M. Hauer, director, New York City’s Office of Emergency Management, served on the faculty of the Northeastern University Paramedic Program, joined the Biomedical Division of IBM as clinical research coordinator, and served as a volunteer firefighter and as a member of a HAZMAT team in Connecticut. Mr. Hauer is a member of the New York City Police Department’s Honor Legion.

Robert M. Blitzer, associate director of the Center for Counterterrorism, Technology, and Analysis at Science Applications International Corporation, recently retired from the Federal Bureau of Investigation, where he served as the chief of the bureau’s domestic terrorism section.