Bioterrorism - a perspective for the community hospital

Clinical Microbiology Newsletter Vol. 23, No. 23

December 1,200l

Bioterrorism

- A Perspective for the Community Hospital

J. Michael Miller, Ph.D., (D)ABMM ChieJ Epidemiology and Laboratory Branch Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Atlanta, GA 30333

Could a community in America ever be the victim of a bioterrorist attack?’ Consider the following incidents. In 1984, the Rajneeshee cult in The Dalles, Oregon, contaminated salad bars with Salmonella and 7 15 people developed gastroenteritis. In 199 1, a ricin toxin threat was reported in Minnesota. In 1994, a highly publicized event occurred when Sarin gas was released in the subways of Tokyo, Japan, illustrating the vulnerability of large populations. In 1995, an individual carrying deadly ricin toxin was arrested crossing the Canadian border. In that same year, Iraq confirmed production and deployment of weapons containing BaciNus unthrucis and botulinum toxin. In 1996, an unhappy laboratorian in Dallas, Texas, provided pastry coated with Shigella to her coworkers. In 1998, the Centers for Disease Control and Prevention was notified of more than 50 threatened incidents, six of which were deliberate anthrax hoaxes in Kentucky, Tennessee, and California. From 1999 to 2000, more “hoaxes” were announced as threats to individuals and corporations. The bombings at the World Trade Center in New York and at the Alfred P. Murrah Federal Building in Oklahoma City shattered the myth that the United States is somehow invulnerable to terrorism.

‘Thisarticle

was submitted for publication to CMN prior to the events of September 11,200

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2323.2001

1,

Terrorists are criminals subject to prosecution under existing criminal statutes. The criminal statutes include 18 USC 175-178, passed in 1990, making it illegal to knowingly develop, produce, stockpile, transfer, acquire, retain, or possess a biological agent, toxin, or delivery system. The use of weapons of mass destruction was addressed in 18 USC 1223A, which criminalizes the use of destructive devices such as bombs, grenades, or rockets; the use of chemical and biological weapons; and the release of life-threatening levels of radioactive material. In many cases, to accomplish their mission, terrorists need not kill. By imposing a very real . or perceived threat to the health of a community, a person or group can create terror and panic that can destroy all sense of calm and rational thinking. To destroy the health care inI?astructure would impose an even greater threat. It is important to remember that biocrimes may also include a bioteirorist action against agricultural animals and plants, but this issue will not be addressed here. In a potential bioterrorist event, many investigative and emergency response components will be mobilized, but the President of the United States has directed that the Federal Bureau of Investigation (FBI) be in charge of all formal operations regarding the event. By Presidential Decision Directive (PDD) 39 and PDD 62, the FBI is designated as the lead agency for operational response to a bioterrorist incident. This may impose federal chainof-custody responsibility on the laboratory should specimens that were associated with the crime arrive for analysis. 0 2001 Elsevier Science Inc.

The threat of bioterrorism or biocrimes is real. Having a community health care infrastructure that is unprepared for these events may be an even greater threat to community security than an actual b&rime. We must prepare for any health care emergency, including bioterrorism, by becoming informed and being aware that the health care community is an important sentinel of any unusual or unexpected illnesses, not just those anticipated to occur as bioteirorist events. Members of the health care community must work as a team to become sentinels of these events and, coupled with a welldesigned communication and response plan, should provide stability and integrity (1). An overt biocrime is an event in which an announcement either precedes or accompanies the crime. In this case, because of the warning, the disease may be recognized early in exposed individuals, triggering early therapy and an

In This Issue Bioterrorism - A Perspective for the Community Hospital . . . .179 A template for readiness in preparing our health care infrastructure for response to possible incidents of biocrimes.

Public Health Responses to Terrorism . . . . . . . . . . . . . . . . . . . 185 Recommendations for a plan of action from the American Public Health Association.

01964399/00

(see frontmatter)

179

emergency response from first responders. such as emergency medical services and public safety departments. A covert event occurs without announcement, and those responsible may be days away when symptoms begin to appear within a population. In this case, recognition of the disease and the agent may take longer, thereby delaying appropriate therapy and’ leading to more severe consequences. The first responders in covert events are likely to be health care workers in clinics, private practices. and emergency rooms because public safety and emergency medical technicians may not yet have been engaged. Clinically, syndrome-based recognition of disease caused by each of the microbial agents considered potential bioterrorism agents is the challenge to physicians and practitioners because timely initiation of an appropriate and measured response is critical. Of course, natural illnesses also occur that are the result of new or re-emerging pathogens, not because they are a part of a bioterrorist incident. The tirst goal of the health care team is to distinguish between the two. Epidemiologically, clinicians and infection control professionals must work together to (i) recognize an increased incidence of a particular organism or disease in a community or institution, (ii) document a sharp rise and fall in the epidemic curve of an agent, (iii) evaluate any unusual increase in upper respiratory or gastrointestinal illness during a prescribed period, and (iv) note a large number of fatal cases or large clusters of disease from a single locale. Also of note might be the lack of indoor exposures with these victims. These epidemiologic clues, coupled with the characteristic syndromes, would also trigger rapid responses to determine if the outbreak is natural or nefarious, but only if the health care facility and the staff are prepared.

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Because some of the listed bioterrorism agents are rare, most clinical microbiology laboratorians have seldom, if ever, cultured or studied those most likely to be used in biocrimes (i.e., Bacillus anthracis, Brucella spp., and Francisella tularensis). In addition, clinicians in many parts of the country have not seen patients with the diseases caused by these organisms. Laboratorians west of the Rocky Mountains are far more likely to have worked with Yersiniapestis than laboratorians working east of the Rockies. Virtually none will have seen cases caused by the smallpox or viral hemorrhagic fever viruses. Some agents, such as Brucella spp. and I;: tularensis, are extremely dangerous to work with in the laboratory, and laboratorians should be aware of special characteristics that will direct them to forward the isolate to a reference laboratory rather than continue to work with it. Microbiologists should be prepared to provide information on specimen selection, collection, transport, and storage, as well as the optimum processing criteria for each agent. Virtually all community hospitals should go no further in the identification process than to understand how to rule out these agents. Any suspicious specimens or isolates should be forwarded to a state or county public health laboratory that is properly equipped to confirm and perform susceptibility testing on bioterrorism agents and has the capacity for safely manipulating the organisms. On a national scale, the CDC has been designated by the Department of Health and Human Services to lead the

The local community hospital or clinic and the practicing clinician will likely be the first to recognize a potential biocrime and initiate a response. Therefore, the local health care professionals and facilities must be ready for such an event. Preparation is a major challenge because of the scale on which a bioterrorism event may take place and the severity of the illness such an attack may cause. Some health care personnel may not feel that the effort required to prepare is cost-efficient for such a lowprobability event; however, early preparation for a bioterrorism event will strengthen the infrastructure by reducing the fear and anxiety of health care workers and will facilitate a rapid, effective, and measured response while keeping the medical community and facility a sturdy and confident ally dur. ing crisis. A preparedness document developed by the CDC can be of assistance in developing responses at the local level (3). The existing emergency response program of a health care facility may provide the basis or template for developing a bioterrorism response plan, but the administrator should appoint a leader or facilitator to work with all involved to develop a response agenda specifically for bioterrorism. The leader of this effort might be the infection control professional, an infectious disease clinician, or any effective physicianleader committed to a preparedness

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agenda. Templates for response plans are already available for access by infection control personnel through the web site of the Association for Professionals in Infection Control at www.apic.org or at the bioterrorism information site of the CDC at www.bt.cdc.gov.

The clues to a potential biocrime (2) include (i) outbreak of a rare or novel disease, (ii) outbreak of disease in a non-endemic area, (iii) seasonal disease during an off-season time, (iv) known pathogen with unusual resistance protile or unusual epidemiologic features, (v) unusual clinical presentation or age distribution, and (vi) genetically identical pathogens emerging rapidly in different geographical areas.

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overall effort to upgrade national public health capabilities to recognize and respond to biological and chemical terrorism (3). In 1999, more than $121 million was allocated to the CDC for developing a laboratory response plan, building a surveillance and epidemiology network for bioterrorism response, stockpiling vaccines and therapeutics, developing a Health Alert Network to enable nationwide communication, and facilitating a national plan for coordinating these efforts. As a result, the CDC established the Bioterrorism Preparedness and Response Program, developed and began to implement a CDC strategic plan for bioterrorism preparedness, facilitated a state-level bioterrorism preparedness planning process, created a National Health Alert Network, and helped finance state and local public health efforts for preparedness planning. Future funding will assist states in completing their readiness plans. The National Laboratory Response Network (LRN) was a part of the CDC strategic plan. The CDC has worked with state public health laboratories, the FBI, the United States Army Medical Research Institute of Infectious Diseases (USAMRIID), and other partners to enable each state to establish its own laboratory readiness plan. Four levels of laboratory capacity are described within the LRN.

Level A laboratories Level A laboratories are the local community hospital laboratories whose role is to recognize the phenotypic clues for identifying a suspicious agent and to package the agent for transfer to a Level B or higher level laboratory. The Level A laboratory will rule out agents and would likely be the initial critical link in the chain of recognition. One does not “join” a Level A group in a particular state, nor are there special privileges or official recognition of Level A laboratories within the network system. The state public health laboratory should be contacted regarding the LRN within a state.

Level B laboratories Level B laboratories often include the state and county public health laboratories that have more capacity for working with biosafety level (BSL) 3 agents. The Level B laboratory has

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the core capacity for agent isolation, presumptive level testing of suspect specimens and identification of isolates, and antimicrobial susceptibility testing. These laboratories are agent specific in the LRN. For example, one may be a Level B laboratory for B. anthracis but only Level A for E tularensis.

Level C laboratories Level C laboratories have the technical ability of the Level B laboratory in addition to the ability to perform advanced tests for rapid identification using molecular methods. They can help with surge capacity, i.e., unusually large numbers of isolates or specimens arriving at one time. In addition, these laboratories have greater BSL-3 working and storage capacity or certified animal facilities.

only at the set-up station but for storage of all associated items related to a suspicious culture until it can be safely packaged and shipped to the next-level laboratory. Laboratory management should reemphasize and support the aggressive use of aseptic technique by laboratorians and suggest that the ageold practice of sniffing plates for characteristic odors should be discontinued, since some of the agents of bioterrorism are infectious at very low levels of inoculum (i.e., 1 to 10 organisms).

Education Laboratorians should know how the agents of bioterrorism can be handled safely. With the proper precautions, the risk of infection from working with any of the agents is small, as illustrated in Table 1.

Level D laboratories

Communication

Level D laboratories have the highest level of containment (BSL-4) and expertise in diagnosis of rare or highly dangerous agents. The CDC and USAMRIID maintain Level D laboratories. Specimens, such as smallpox virus, would be sent directly to the CDC bypassing other laboratories after consultation with the CDC, the state epidemiologist, and the state public health laboratory. Throughout the LRN, work is progressing toward establishing and instituting standardized testing algorithms for rapid confvmatory testing. Some Level laboratories may have the capacity to provide more definitive laboratory results than others. The state public health laboratory should be contacted to discuss available testing protocols if further tests are requested at any of the levels. Protecting patients, protecting health care personnel, and promoting health care quality must be the overriding theme of all activities involving bioterrorism preparedness at the community hospital level. At least four areas described next must be carefully considered in the preparation stages.

Laboratorians should participate in the development of and know the bioterrorism readiness plan for the institution and understand their role in each part of the plan. Whether commrmicating microbiology information regarding pathogenic agents to other health care workers or knowing who is responsible for making public statements regarding a suspected event, laboratorians should have clear roles and processes for communicating accurate information.

Biosafety A risk analysis of the microbiology laboratory would help determine the areas most likely to be a problem should one of the listed critical agents be encountered. This analysis offers an opportunity to reinforce the need to use Class II biological safety cabinets not

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Recognizing the limitations of the laboratory The local hospital laboratory will serve as a sentinel for the health care community but it should not attempt to do a complete workup on any suspected critical agent. Every laboratorian should know how far to go with specimen workup and when and how to submit an isolate or a specimen to the next-higher level laboratory. In order to optimize the capacity of microbiology laboratories to recognize and respond to any unusual isolate, access to a board-certified clinical microbiologist of the American Board of Medical Microbiology or equivalent is recommended for all clinical laboratories. Because many of these critical agents are rarely isolated and the diseases they cause are infrequent or do not occur in most communities, it is imperative that laboratorians and clinicians be aware of the salient features of each illness and the etiologic agents. Some of these features are summarized

01964399100

(see frontmatter)

181

Blood, urine, respiratory and throat secretions, semen, and tissue

4

4

Viral hemorrhagic fever viru$

has been more commonly

‘Ingestion

‘Respiratory

exposure to infectious

parenteral inoculation,

aerosols, mucous membrane exposure to infectious

droplets,

are the primary

or tissues are the primary

and accidental parenteral inoculation

fluids

Direct skin/mucous

hazards to labomtorians. hazards to labomtorians.

pare&ml

by 0. I M sodium hydroxide. inoculation,

ingestion,

C. borrrlinum

is and aerosol exposure have

for a total contact time of 40 min.

tract. The toxin can be neutralized treated with bleach and sodium hydroxide membrane contact with cultures,

the spill must be sequentially

BSW: Activities with high potential for aerosol or droplet production

BSW: All activities involving manipulations of cultures

BSL3: Activities with high potential for aerosol or droplet production

BSL3: All activities involving manipulations of cultures

BSL3: Activities with high potential for aerosol or droplet production

sprays into eyes, nose. and mouth; and direct contact with clinical specimens. the respiratory

inoculations: including

accidental parentera

than with clinical materials/animals.

and droplet or aerosol exposure of mucous membranes or broken skin to infectious

associated with cultures

transport,

BSLZ: Activities involving clinical material collection and diagnostic quantities of infectious cultures

can occur with direct contact with skin, eyes. or mucous membranes,

of household bleach. Contact time is 20 min. If material contains both toxin and organisms.

hdaremia infection

dilution

laboratory hazard. since absorption

‘Special care should be taken to avoid the generation of aerosols.

resulted in infection.

‘Labomtory-acquired

I :I0

to toxin is the primary

inactivated by a

hExposu~

‘Labomtory-acquired

mouth pipetting;

BSL4: Specimen collection/transport

Lesion fluid or crusts, respiratory secretions, or tissue

4

4

Smallnox’

aerosols generated by cenhifugation;

BSL4: Specimen collection/transport

Bubo fluid, blood, sputum, CSF, feces, and urine

2

2

Yersinia pestisd

cultorcs:

BSL2: Activities limited to collection, and plating of clinical material

Skin lesion exudates, respiratory secretions, CSF, blood, and urine. Tissues from infected animals and fluids from infected arthropods

3

2

Francisella tularensis’

has occurred by sniffing

BSLZ: Activities with materials known to contain or potentially containing toxin must be handled in a biological safety cabinet (Class II) with a lab coat, disposable surgical gloves, and a face shield (as needed)

Toxin may be present in food specimens, clinical material (serum, gastric fluids and feces), and environmental samples (soil, surface water). TOXIN IS EXTREMELY DANGEROUS!

2

2

Clostridium botulinum”

bmcellosis

BSL2: Activities limited to collection, transport and plating of clinical material

Blood, bone marrow, CSF, tissue, semen and occasionally urine

3

2

spp.”

Brucella

BSL2: Activities involving clinical material collection and diagnostic quantities of infectious cultures

Blood, skin lesion exudates, cerebrospinal fluid (CSF), pleural fluid, sputum, and rarely urine and feces

for Level A laboratories

2

orecautions

2

Recommended

Bacillus anthracis

Specimen exposure risk

Culture handline

Aeent

Specimen handling

Biosafety level

Table 1. Biosafety with critical agents (H.T. Holmes and J.M. Miller)

LPSh PMN survival

Neurotoxin

Intracellular survival

VandW antigens’ LPS endotoxin Fl antigen’

Inhalation anthrax

Brucellosis

Botulism

Tularemia

Pneumonic plague

7-17 days

4-21 days

I-IO particles

2-3 days

1-21 days

6 h-IO days

S-60 days

l-6 days

10-100 particles

cl00 organisms

lo-50 organisms

0.001 @kg (type A)

I 0- 100 organisms

8,000-50,000 spores

7-16 days

-4 weeks

l-6 days

-2 weeks

24-72 h

Weeks to months

3-5 days

Duration of illness

514%

100%

53-88%

Variola minor:
unless treated

<4%

< I %d

-99%

Treated

33%

Subsequent cases, 4% Overall, S-IO%

1Stpatient, 25%

Outbreak:

-+X4

-100%

Untreated

Mortality

Yes (moderate)

Yes (high)

Yes (high)

No

No

No

No

Personto-person transmission’

AirbomeD and contact4

Airborne4

Droplef

Standard

Standard

Standard

Standard

Isolation precautions hospitalized patients’

Unstable

Very stable

Soil, >I yr

Moist soil, -months

Food/water, -weeks

Water/soil, -10 wks

Soil, -40 yrs

Persistence of organism

exotoxin(s) consists of three components: the edema factor and lethal factor exelt their effects within cells by interacting with a common transport protein designated protective antigen (so named because, when modified, it contributes to vaccine efficacy). Expression of toxic factors is mediated by one plasmid, and the capsule (o-glutamic acid polypeptide) by a second plasmid Strains repeatedly subcultured at 42°C become avirulent as a result of losing virulencedetermining‘plasmids, which is thought to be the basis for Pasteur’s attenuated anthrax vaccine used at Pouilly-le-Fort in 1881. *The major virulence factor for bmcellosis appears to bc an endotoxic lipopolysaccharide (LPS) among smooth strains. ’ The V and W antigens and the Fl capsular antigens arc expressed only at 37°C and not at the lower body tempemture of the flea (20-25’C). d Endocarditis accounts for the majority of bmcellosis-related deaths. ’ Period of communicability: inhalation anthrax, brucdlosis. botulism, or tularemia, none (no evidence of person to person transmission); pneumonic plague, 48 h following initiation of appropriate antimicrobial therapy or until sputum culture is negative; smallpox: approximately 3 weeks (usually corresponds with the initial appearance of skin lesions to their final disappearance, most infectious during the first week of rash via inhalation of virus released fmm ompharyngeal-lesion secretions of the index case); VHF, varies with virus, but at minimum. all for the duration of illness. and for EbolaMarbmg transmission, through semen may occur up to 7 weeks after clinical recovery. ’ Guideline for isolation precautions in hospitals. Infect. Control Hosp. Epidemiol. 1996:17:53-80. www.ulc.gov/ncidodn,ip/~olat/isofat.l, s In addition to standard precautions, which apply to all patients.

nB.anthracis

VHF

Smallpox

Exotoxin’ capsule

Disease

Incubation period

(H.T. Holmes and J.M. Miller)

Infective dose

agent summary

Virulence factor(s)

Table 2. Bioterrorism:

in Table 2. The disease- and organismspecific information discussed below (4) and links to other valuable sites can be accessed at http://www. bt.cdc. go~~/links.asp.

Recognizing

infectious

agents

The microbial agents used in a biocrime have the potential to produce mass casualties that could overwhelm the health care system of one or more communities. While most any pathogenic agent can potentially be used in a biocrime, the agents that are most likely to be used will be ones that are virulent, capable of producing high morbidity and mortality, and transmissible from person to person. The biological agents of current concern to the health care community include, but are not limited to, variola major virus (smallpox), B. anthracis (anthrax), I: pestis (plague), F: tularensis (tularemia), botulinum toxin (botulism), filoviruses and arenaviruses (viral hemorrhagic fevers), and Brucella spp. (brucellosis) (3). All suspected or confirmed illness due to these agents must be reported to health authorities immediately. If there is ever a question as to whom such a clinical or laboratory report should go to, contact the state public health department. At the Level A laboratory, only limited tests need be performed to conclude whether an isolate is suspicious or not. For the viruses of smallpox and viral hemorrhagic fever, laboratory work need not be requested or performed at any level other than the Level D facility. In this case, the CDC would be telephoned, the caller would be given specific instructions on how to package specimens, and must be given the authority to ship the specimen to the laboratory. These illnesses are diagnosed clinically, not from local laboratory data. The microscopic observation of tiny, faintly staining, gram-negative coccobacilli should raise the suspicion of either Bruce/la spp. or E tularensis, and any further manipulations of isolates with this description should be done under the biological safety cabinet after the supervisor has been notified. Visible growth for either isolate may take 48 to 72 h, and the resulting colonies on blood agar are small, convex, glistening, non-hemolytic, and non-pigmented. If the organism is both oxidase- and catalase-positive, a positive test for urea hydrolysis would suggest a Brucella

184

0196-4399:oO (see frontmatter)

spp. and the isolate should be sent to the nearest Level B or C laboratory. A negative urea hydrolysis test would rule out Brucella sp. in most instances, and work could resume. If the isolate is not oxidase- and catalase-positive, then E tularensis must be considered. If the isolate is oxidase-negative, catalase-positive (perhaps weakly positive), and negative in a satellite test (if Haemophilus sp. had been suspected) then Francisella spp. cannot be ruled out and the isolate should be sent to the nearest level B or C laboratory. I;: tularensis cells on a Gram-stained smear may be smaller than Brucella spp. cells. If other results are noted in these tests, one can rule out Francisella spp. and routine identification procedures may continue. Yersinia spp. may be a little easier to rule out because they will appear as plump, gram-negative rods on Gram stain and may demonstrate bipolar staining when seen in peripheral blood smears stained with Wright-Giemsa stain. Colonies on sheep blood agar appear within 48 h and are non-lactose fermenters on MacConkey and eosinmethylene blue agar. Yersinia spp. may be identified accurately to the genus level in automated or rapid identification systems, and unless Y pestis can be ruled out, the isolate should be forwarded for confirmation. Isolates will classically be oxidase-negative, catalase-positive, indole-negative, and ureanegative. If the identification method provides identifications other than Yersinia spp., I: pseudotuberculosis, or I: pestis, one may assume that I: pestis has been ruled out. Bacillus spp. are large, gram-positive, broad rods that form spores once the organisms are grown in air. If the isolate is hemolytic on blood agar, one may assume B. anthracis is ruled out and no further work need be done (keeping in mind that there are conditions under which other Bacillus spp. are clinically significant). Motility should be observed by wet mount (prepared while wearing gloves). If the cells are motile, B. anthracis is ruled out. If the isolate is non-motile (and nonhemolytic), it should be forwarded to the nearest Level B or C laboratory for identification. A report should be submitted to the physician to indicate that B. anthracis could not be ruled out

0 2001 Elsevier Science Inc.

and the specimen was forwarded for confirmation. Clearly, competent laboratorians can do more tests on these isolates, and many may feel compelled to do so. However, because of the virulence of the organisms or the potentially suspicious circumstances under which they were found, the laboratory and the patients will be better served if standard procedures for confirming these organisms are followed. Rapid confirmation at the Level B and C laboratories is a critical component of laboratory response from these sites. Indeed, if the FBI were investigating a potential bioterrorist event, they would require that accepted protocols be followed. Opening the channels of communication among all groups involved, obtaining the necessary resources, and maintaining an understanding of the potential agents and the diseases they cause will foster a smooth transition to a rational program directed at protecting patients, protecting health care workers, and promoting health care quality. References Miller, J.M. Agents of bioterrorism: preparing for bioterrorism at the community healthcare level. Infect. Dis. Clin. N. Am., in press. Kadlec, R.P., A.P. Zelicoff, and A.M. Vrtis. 1997. Biological weapons control. Prospects and implications for the firture. JAMA 278:351-356. Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response recommendations of the CDC Strategic Planning Workgroup 2000. Morb. Mortal. Wkly. Rep. 49(RR-4): l-14. Centers for Disease Control and Prevention. 2000. Agents of bioterrorism: level B training manual. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Atlanta, GA.

Additional Reading: Chin, J. (ed). 2000. Control of communicable diseases manual, 17th ed. American Public Health Association, Washington D.C. Cieslak, T.J. et al. 2000. Immunization against potential biological warfare agents. Clin. Infect. Dis. 30:843-850. Dunn, M.V. 1999. The threat of bioterrorism to U.S. agriculture. Ann. N.Y. Acad. Sci. 894: 184- 188. English, J.F. 1999. Overview of a bioterrorism readiness plan: a template for health care

Clinical Microbiology

Newsletter 23:23,2001

facilities. Am. J. Infect. Control 27:468-469.

Civilian Biodefense.

Fidler, D.P. 1999. Facing the global challenges posed by biological weapons. Microbes Infect. I : 1059- 1066.

JAMA281:2127-2137.

biological weapon:medical and public health management.WorkingGroup on Civilian Biodefense. JAMA 283:2281-2290. Inglesby, T.V. et al. 2000. Plague as a

Gilchrist, M.J. 2000. A national laboratory network for bioterrorism: evolution from a prototype network of laboratories performing routine surveillance. Mil. Med. 165(Suppl. 2):28-31.

The United States Army Medical Research Institute of Infectious Diseases. 2000. Behind the scenes at USAMRIID. Maryland Med. I : 18-22.

Henderson, D.A. et al. 1999. Smallpox as a biological weapon: medical and public health management. Working Group on

Health Alert Network:

Websites of Interest:

www.phppo.cdc.gov/han/ Bioterrorism Preparedness www.bt.cdc.gov

and Response:

Biosafety in the microbiolo& www.cdc.gov/od/ohs/

laboratory:

Guidelines for Isolation Procedures: wwwcdc.gov/ncidod/hip/ Public Health Image Library: phil.cdc.gov/ WHO: zoonotic diseases: m who. int/emc/

Editorial

Public Health Responses to Terrorism A call to action for public health leadership’ Emergency response and public health preparedness has gained a heightened awareness because of the

tragic events of Sept. 11,200l. Because of these events and of the increasing number of natural disasters that have struck across the United States, there are concerns that the public health infrastructure is not sufficient to meet the need from the threat of bioterrorism or weapons of mass destruction. The tragic events of September 11 dramatically altered the landscape of American life, suddenly introducing us to the terrorist violence that has unfortunately become commonplace in many parts of the globe. We will never be the same, nor will our approach to public health. This disaster has created an urgent obligation for leaders in our field to respond to perhaps the greatest public health challenge in our lifetime. We must work together to ensure our ability to address the dangers confronting our nation now and in the titure. The American Public Health Association (APHA) urges all public health leaders from this time forward, in your daily professional and personal lives, to reflect and act upon the following five positions deeply rooted in APHA policy. We also urge you to share your

‘This editorial was excerpted from the web site of the American Public Health Association (www.apha.org) and is published with their permission. Clinical Microbiology Newsletter23:23,2001

opinions on these positions with your legislators and the media.

1. War is The Enemy of Public Health As has been sadly demonstrated on countless occasions, nothing can be more detrimental to public health than the inevitable devastation of its i&-astructure that occurs in times of armed conflict. Yet at no time is having an intact and functioning public health system more vital than in wartime. President Jimmy Carter wrote in his foreword to War and Public Health, “War and militarism have catastrophic effects on human health and well-being. These effects include casualties during war, long-lasting physical and psychological effects on noncombatant adults and children, the reduction of human and financial resources available to meet social needs, and the creation of a climate in which violence is a primary mode of dealing with conflict.” Though few doubt the need to respond decisively and effectively to the recent attacks on our country, America’s public health leaders must be a voice for tempering the response to avoid destroying public health infrastructure and death of innocent civilians. Such acts are not justified under the ever-expanding definition of “collateral damage.”

2. Diversity is Our Strength Whenever deplorable actions are associated with an identifiable racial, 0 2001 Elsevier Science Inc.

ethnic, or religious group, we witness an increase in racial profiling and its consequences, including violence. Unfortunately, the last 2 weeks have evidenced a resurgence of this practice. Public health leaders must stand firm in our vocal opposition to profiling and for fair treatment of all people. And we must lead in promoting diversity as a positive national asset.

3. Funding for Public Health Must be Bolstered Now that the economy is facing its most severe threats in decades, public health leaders must strive not merely to maintain but to increase funds allocated in federal, state, and local budgets for public health in%structure and programs. Our challenge: legislators tend to view terrorism as a law enforcement issue, not a public health emergency. Though public health departments, in conjunction with fire and rescue services, can respond to conventional emergencies, disasters on the scale of September 11 stretch the capabilities of even the best departments. In the event of a bioterrorism attack, there is unanimous agreement that no current combination of available local services would provide an adequate response. We must rise to this challenge immediately. Now is the time in the budget cycle to make our voices heard in demanding long-overdue tinding to bolster public health. APHA cannot overemphasize the importance of your support in this area. 0196-4399/00

(see frontmatter)

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