Scott R. Lillibridge

Public Health Assessment of Potential Biological Terrorism Agents

As part of a Congressional initiative begun in 1999 to upgrade national public health capabilities for response to acts of biological terrorism, the Centers for Disease Control and Prevention (CDC) was designated the lead agency for overall public health planning. A Bioterrorism Preparedness and Response Office has been formed to help target several areas for initial preparedness activities, including planning, improved surveillance and epidemiologic capabilities, rapid laboratory diagnostics, enhanced communications, and medical therapeutics stockpiling (1). To focus these preparedness efforts, however, the biological agents towards which the efforts should be targeted had to first be formally identified and placed in priority order. Many biological agents can cause illness in humans, but not all are capable of affecting public health and medical infrastructures on a large scale. The military has formally assessed multiple agents for their strategic usefulness on the battlefield (2). In addition, the Working Group on Civilian Biodefense, using an expert panel consensus-based process, has identified several biological agents as potential high-impact agents against civilian populations (3–7). To guide national public health bioterrorism preparedness and response efforts, a method was sought for assessing potential biological threat agents that would provide a reviewable, reproducible means for standardized evaluations of these threats. In June 1999, a meeting of national experts was convened to 1) review potential general criteria for selecting the biological agents that pose the greatest threats to civilians and 2) review lists of previously identified biological threat agents and apply these criteria to identify which should be evaluated further and prioritized for public health preparedness efforts. This report outlines the overall selection and prioritization process used to determine the biological agents for public health preparedness activities. Identifying these priority agents will help facilitate coordinated planning efforts among federal agencies, state and local emergency response and public health agencies, and the medical community.

Emergency Department Impact of the Oklahoma City Terrorist Bombing

STUDY OBJECTIVE To collect descriptive epidemiologic injury data on patients who suffered acute injuries after the April 19, 1995, Oklahoma City bombing and to describe the effect on metropolitan emergency departments. METHODS A retrospective review of the medical records of victims seen for injury or illness related to the bombing at 1 of the 13 study hospitals from 9:02 AM to midnight April 19, 1995. Rescue workers and nontransported fatalities were excluded. RESULTS Three hundred eighty-eight patients met inclusion criteria; 72 (18.6%) were admitted, 312 (80.4%) were treated and released, 3 (.7%) were dead on arrival, and 1 had undocumented disposition. Patients requiring admission took longer to arrive to EDs than patients treated and released (P =.0065). The EDs geographically closest to the blast site (1.5 radial miles) received significantly more victims than more distant EDs (P <.0001). Among the 90 patients with documented prehospital care, the most common interventions were spinal immobilization (964/90, 71.1%), field dressings (40/90, 44.4%), and intravenous fluids (32/90, 35.5%). No patients requiring prehospital CPR survived. Patients transported by EMS had higher admission rates than those arriving by any other mode (P <.0001). The most common procedures performed were wound care and intravenous infusion lines. The most common diagnoses were lacerations/contusion, fractures, strains, head injury, abrasions, and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and analgesics were the most common pharmaceutical agents used. Plain radiology, computed tomographic radiology, and the hospital laboratory were the most significantly utilized ancillary services. CONCLUSION EMS providers tended to transport the more seriously injured patients, who tended to arrive in a second wave at EDs. The closest hospitals received the greatest number of victims by all transport methods. The effects on pharmaceutical use and ancillary service were consistent with the care of penetrating and blunt trauma. The diagnoses in the ED support previous reports of the complex but often nonlethal nature of bombing injuries.

Public-health preparedness for biological terrorism in the USA

and public concerns due to accounts in the popular press of killer germs. 7 The initial activities were aimed at regulation of biological agent transfers and training emergency responders in 120 cities—commonly referred to as the Nunn-Lugar-Domenici preparedness programme—and was aimed at overt chemical terrorism. 8,9 This focus has expanded to acknowledge and address the key role that public health will have in detection and management of a covert biological terrorist incident. Similar efforts to coordinate national contingency arrangements and successfully conclude negotiations over the protocol for verification of the Biological Weapons Convention are underway in the UK. 9

Chemical Warfare Agents: Emergency Medical and Emergency Public Health Issues

The threat of exposure to chemical warfare agents has traditionally been considered a military issue. Several recent events have demonstrated that civilians may also be exposed to these agents. The intentional or unintentional release of a chemical warfare agent in a civilian community has the potential to create thousands of casualties, thereby overwhelming local health and medical resources. The resources of US communities to respond to chemical incidents have been designed primarily for industrial agents, but must be expanded and developed regarding incident management, agent detection, protection of emergency personnel, and clinical care. We present an overview of the risk that chemical warfare agents presently pose to civilian populations and a discussion of the emergency medical and emergency public health issues related to preparedness and response.

Medical Preparedness for a Terrorist Incident Involving Chemical and Biological Agents During the 1996 Atlanta Olympic Games

During the 1996 Centennial Olympic Games in Atlanta, Georgia, unprecedented preparations were undertaken to cope with the health consequences of a terrorist incident involving chemical or biological agents. Local, state, federal, and military resources joined to establish a specialized incident assessment team and science and technology center. Critical antimicrobials and antidotes were strategically stockpiled. First-responders received specialized training, and local acute care capabilities were supplemented. Surveillance systems were augmented and strengthened. However, this extensive undertaking revealed a number of critical issues that must be resolved if our nation is to successfully cope with an attack of this nature. Emergency preparedness in this complex arena must be based on carefully conceived priorities. Improved capabilities must be developed to rapidly recognize an incident and characterize the agents involved, as well as to provide emergency decontamination and medical care. Finally, capabilities must be developed to rapidly implement emergency public health interventions and adequately protect emergency responders.

Disaster assessment: The emergency health evaluation of a population affected by a disaster

In the past decade, interest in the operational and epidemiologic aspects of disaster medicine has grown dramatically. State, local, and federal organizations have created vast emergency response networks capable of responding to disasters, while hospitals have developed extensive disaster plans to address mass casualty situations. Increasingly, the US armed forces have used both their ability to mobilize quickly and their medical expertise to provide humanitarian assistance rapidly during natural and man-made disasters. However, the critical component of any disaster response is the early conduct of a proper assessment to identify urgent needs and to determine relief priorities for an affected population. Unfortunately, because this component of disaster management has not kept pace with other developments in emergency response and technology, relief efforts often are inappropriate, delayed, or ineffective, thus contributing to increased morbidity and mortality. Therefore, improvements in disaster assessment remain the most pressing need in the field of disaster medicine.

Complex, Humanitarian Emergencies: III. Measures of Effectiveness

Complex humanitarian emergencies lack a mechanism to coordinate, communicate, assess, and evaluate response and outcome for the major participants (United Nations, International Committee of the Red Cross, non-governmental organizations and military forces). Success in these emergencies will depend on the ability to accomplish agreed upon measures of effectiveness (MOEs). A recent civil-military humanitarian exercise demonstrated the ability of participants to develop consensus-driven MOEs. These MOEs combined security measures utilized by the military with humanitarian indicators recognized by relief organizations. Measures of effectiveness have the potential to be a unifying disaster management tool and a partial solution to the communication and coordination problems inherent in these complex emergencies.

Disaster Medicine: Challenges for Today

Abstract [Waeckerle JF, Lillibridge SR, Noji EK: Burkle FM, Disaster medicine: Challenges for today. Ann Emerg Med April 1994;23:715-718.]

Centers for disease control and prevention bioterrorism preparedness and response

As the United States’ disease control and prevention agency, the Centers for Disease Control and Prevention (CDC) has been designated by the US Department of Health and Human Services to coordinate and lead the overall planning effort to upgrade national public health capabilities at the local, state, and federal levels to respond to bioterrorism—the deliberate use of biological agents to harm civilian populations. CDC’s overall program has concern for chemical terrorism as well as biological terrorism and has taken steps to include chemical laboratory and appropriate medical stockpile enhancements as part of its planning. The initial detection of a covert bioterrorist attack is likely to be made by public health workers. Complicating the problem of dealing with such a crisis, a bioterrorist attack may involve many different types of biological agents. Biological agents may range from rare viruses to commonly available bacteria. Chemical agents may range from noxious gases to airborne chemicals. Preparing the United States to address these dangers is a major challenge. The public health and health care systems in the United States must be capable of responding to threatened, suspected, or actual uses of all types of biological and chemical agents that may harm the population. We must be ready to detect, investigate, identify, and manage any bioterrorist threats. CDC INITIATIVES TO ENHANCE PUBLIC HEALTH CAPABILITIES TO RESPOND TO BIOTERRORISM

The rapid implementation of a statewide emergency health information system during the 1993 Iowa flood.

In the face of disastrous flooding, the Iowa Department of Public Health established the statewide Emergency Computer Communications Network to establish rapid electronic reporting of disaster-related health data, provide e-mail communications among all county health departments, monitor the long-range public health effects of the disaster, and institute a general purpose public health information system in Iowa. Based on software (CDC WONDER/PC) provided by the Centers for Disease Control and Prevention and using standard personal computers and modems, this system has resulted in a 10- to 20-fold increase in surveillance efficiency at the health department, not including time saved by county network participants. It provides a critical disaster assessment capability to the health department but also facilitates the general practice of public health.