The recent Commission on the Prevention of WMD Proliferation and Terrorism “believes that unless the world community acts decisively and with great urgency, it is more likely than not that a weapon of mass destruction will be used in a terrorist attack somewhere in the world by the end of 2013.” The commission further “believes that terrorists are more likely to be able to obtain and use a biological weapon than a nuclear weapon.”
Opportunities exist before, during, and after a biological attack for governments, the public, and individuals to take prudent measures that ultimately will save lives and contribute to a more rapid recovery. Difficult decisions about which diseases to vaccinate against, what treatments to stock in the strategic national stockpile, how to communicate with the public, and when to quarantine will need to be considered carefully. Making the right decisions in a timely manner and having those decisions executed appropriately will be key to how our preparedness and response ultimately will be judged.
Variations on a Terrorism Theme
In planning for a biological attack, the terrorist is confronted with two distinct types of pathogens—non-contagious and contagious. This initial selection will greatly affect the type of attack and even the degree to which the attack presents a global or localized threat. A non-contagious pathogen such as anthrax, which does not allow for human-to-human transmission, would have a localized effect, with the dispersion based on the method by which it was released, the particle size, and the manner in which it was “weaponized.” An aerosol cloud may travel long distances, but the affected area would emanate from a single point or line-source along a predictable dispersal pattern. While this is a scary scenario with the potential for high death, disease, and disruption, it is not the most “stressful” scenario one could postulate.
In fact, the most stressful scenario would be an attack using a contagious pathogen that is essentially self-propagating. The initial release or releases would infect those within an immediate area, but then those infected would become human disseminators, continuing to spread the disease.
One such scenario, provided in the 2001 bio-terrorism attack simulation “Dark Winter,” was based on hypothetical smallpox attacks at six locations around the world, with five occurring at major transportation hubs. Such an attack likely would go unnoticed initially. Unlike a nuclear attack with its immediate effects, a biological attack would entail an incubation, or prodromal, period during which the pathogen would begin to grow or replicate inside the host. The length of time from exposure to the first symptoms would be highly dependent on several factors: the initial exposure dose, type of pathogen, method of deployment, time/weather/wind conditions of deployment, and the general health of the infected individuals.
Deadly Cargo
Smallpox has received much attention precisely because of its infectious properties. It is a highly contagious disease with a low dosage requirement for infection and high mortality. Since its eradication in the late 1970s, vaccines against the disease are generally not given except to military personnel and scientists working with the pathogen. Additionally, toward the end of the prodromal period and before the telltale symptoms are visible, the disease is transmissible from human to human.
A prodromal period is both a window of opportunity and a significant cause for concern. On one hand, it can allow for rapid treatment in the form of vaccines, antibiotics, or antivirals. If the attack is discovered, the pathogen can be rapidly identified, and a viable treatment exists. On the other hand, this period, which may vary from hours to weeks, can allow for the spread of disease as infected individuals go about their daily lives unaware of the deadly cargo they are carrying. With a highly infectious pathogen such as smallpox, and given today’s global travel patterns, the disease likely would spread rapidly around the world within a matter of days and weeks from the initial point or points of attack.
The most effective dissemination technique would be in an aerosol form: The individual virons of the smallpox virus would be inhaled and lodged deeply in the alveoli of the lungs where the deadly progression of the disease would ensue. The virus would begin to replicate and migrate to the regional lymph nodes, the spleen, and the bone marrow. Once in the lymphatic system, the virus travels and replicates throughout the victim. The first outward sign of infection would be fever. By this point, toxins would begin to flow through the victim, and the immune system would make a desperate attempt to respond. The overwhelming toxemia, in combination with circulating immune complexes, leads to death in over 30 percent of the cases.
The virus is spread through normal respiration, as respiratory particles teeming with highly infectious Variola major virions are exhaled from the viruses’ victims. The infectious chain would continue until broken by a combination of quarantine and ring vaccinations (which contain an outbreak by treating every susceptible individual with whom the victim has had contact), as were used to eradicate the naturally occurring smallpox disease.
The Mathematics of Infection
With contagious biological weapons, basic math contributes to the fearfulness of the disease and complicates efforts to control the spread: An initial victim may infect three or four others who each in turn may infect another generation. So if 5,000 individuals are infected at five different sites, that equates to 25,000 initially infected people who will then infect three or four more apiece. With these numbers it is not difficult to see how hundreds of thousands or even millions can become infected in a very short period of time. Only through isolation can the chain of infection be broken and the spread of the disease be controlled.
The first cases likely would occur ten days to two weeks following initial exposure. Victims would report to their local health-care providers hoping for relief from their smallpox symptoms. Of course, though they would have a rash and influenza-like symptoms, they would not necessarily realize that they had been infected with the deadly variola virus. The very act of seeking relief would actually accelerate the spread of the disease, as the increased contact would lead to more opportunities for transmission of the deadly virus.
These initial cases most likely would be under-diagnosed, as most health-care workers today have not seen smallpox firsthand. The centrifugal pattern on the skin would provide a clue as to the causative agent, but just as with the 2001 anthrax attacks, where the distinctive “black escher” failed to alert several doctors to the nature of the disease, it is likely that many of the first wave of smallpox cases would be misdiagnosed.
Once the official diagnosis of smallpox was made, health organizations around the globe would be on full alert. A series of discussions and meetings would occur to finalize the details of isolation, containment, and the global eradication effort. National decisions would have to made on such critical issues as whether to release part of our vaccine stockpile to other nations. A rapid decision also would be required concerning both national and international travel. The effect on commerce would be immediate and likely last for several months, if not longer.
Health-care providers would be largely powerless to provide any relief for the victims, as the primary treatment for smallpox for those having the full-blown disease is simply supportive care; while the historic mortality rate is approximately 30 percent, the fatality rate is 100 percent for those whose disease progresses to the hemorrhagic variant. Eventually, the isolation of victims and vaccination of those potentially exposed would defeat the attack, but not until the casualties had mounted and the economic damage had been done.
So what steps can be taken? Following are six areas where progress must be made to better prepare for the possibility of a biological attack. By design, we have focused our attention on managing such an attack rather than attempting to prevent the event.
Be Aware, Be Prepared
We must develop expertise in our first responders, public-health, and medical professionals for recognition, treatment, and recovery from a bio-attack.
If a series of attacks using a highly contagious and deadly pathogen are perpetrated in several locations across the United States, we know that our public health infrastructure would be overwhelmed. The fact is that our U.S. medical system is very fragile and simply not prepared to handle wide variations in patient flow. In the case of a bio-attack, that is exactly what would occur. A lessons-learned document published jointly by the Trust for America’s Health, the University of Pittsburgh’s Center for Biosecurity, and the Robert Wood Johnson Foundation concluded that “public health departments did not have enough resources to carry out plans.”
First responders, public-health, and medical professionals have a significant role to play in recovery. Early identification and treatment limit additional exposures and thus the spread of disease. Correct actions taken immediately reduce individual pain and suffering and provide the best chances for effective treatment and return to health.
We must begin to think differently about the relationship between individual well-being and public health. A first-line defense against disease is a healthy population with the proper vaccinations. For example, many do not get seasonal influenza vaccinations because of inconvenience and expense. Vaccinations should made available as part of the basic public health maintenance of our citizens.
Across-the-Board Biosurveillance
We must have a viable biosurveillance system. It must have national and international components and allow for real-time data exchanges. It must also have state and local components. Systems that require lengthy periods for collection, transport, and analysis of samples will be of limited utility. Response times from detect-to-treat that today are measured in days and weeks ideally must be measured in minutes and seconds. A national system of biosurveillance that relies on input from hospitals, clinics, doctors’ offices, and pharmacies must be established. To date, a number of disparate and discrete biosurveillance systems are in place around the United States. No single system for the entire nation has been established. This is not a question of capability, but rather of having deferred to state and local authorities to develop their own biosurveillance capabilities. This is inefficient and promotes seams in the overall biosurveillance architecture. A truly national system would have the capability to collect information, correlate data, and rapidly disseminate it to all levels of the public-health community.
International cooperation is a must for monitoring both natural and man-made diseases. The recent H1N1 influenza (formerly called swine flu) outbreak demonstrates how rapidly disease can spread in a globalized, interconnected world. Without the type of close informational cooperation that allows nations to track the transgenic shift of a disease, we are essentially attempting to develop vaccines and treatments with only part of the evidence. What happens in far-off lands really can and does affect our daily lives.
The biosurveillance system of the future must allow for timely vectoring of capabilities including vaccines, prophylaxis, and treatments to the localities where they are needed. This distribution must be rapid and targeted to ensure that capabilities get to the right place at the right time. The role of biosurveillance must be expanded beyond information-providing to include research-and-development and logistics.
Individual to International Integration
We must have the capacity for dealing with a biological-warfare crisis at all levels, providing integrated capabilities, immediacy in action, and whole-of-society solutions.
We need to develop solutions that cut across the public and private sectors, from the individual to the local, state, national, and international levels. The term “whole of society” is intended to indicate the magnitude of requirements for preparedness. It is more than reliance on governments and public-health authorities. In fact, our planning must begin with the individual, who has a responsibility to be prepared. In the event of a significant biological attack, public guidance may call for a prolonged period of remaining sheltered. Have individuals and families made adequate preparations in terms of food, water, medicines, and shelter to allow for such a possibility? Have state and local authorities practiced for supporting populations that may become infected through a biological attack? Have they prepared for the massive influx of the “worried well,” who will come streaming unnecessarily into emergency rooms and clinics across the country as panic spreads?
Have key government officials and those responsible for running critical infrastructure been appropriately vaccinated, and is prophylaxis readily on-hand to be provided to them in the event of such an attack?
The seams between federal authorities and the international community also must be addressed. Cooperative efforts in the face of such naturally occurring diseases as Severe Acute Respiratory Syndrome (SARS), H5N1 avian influenza, and H1N1 indicate that we have made progress in this regard, but more can and must be done. The lack of unified biosurveillance that impedes effective communication within the United States is exacerbated internationally. A biological-warfare attack would steamroll already-inadequate public health systems in many countries.
Continued emphasis on training, education, and exercises at all levels (and between levels) must serve as foundational elements of our preparedness systems. We must ensure that our plans are science-driven and adaptable to changing circumstances and scenarios. Rote execution of plans that result in angst, incorrect direction, and overreaction will serve to undermine public trust and ultimately lead to complacency.
Now is the time to think through the difficult scenarios involving travel bans, international sharing of therapeutics, and quarantines. We need to ensure that these difficult issues have been considered in detail prior to the actual outbreak and without the emotion of the moment. Many of these factors will be matters of life and death, as well as national sovereignty.
Rapid, Accurate, Definitive
We must the refine the capability for rapid, accurate, and definitive diagnosis.
When an individual arrives at an emergency room during the cold and flu season, the natural reaction is to make a presumptive diagnosis of seasonal influenza and provide support care to manage the observed symptoms. Few receive a definitive diagnosis; treatment is based on averages and likelihood rather than knowledge.
Today, the available technology has allowed for quicker, more pinpointed testing, albeit at a cost that makes definitive diagnoses for all patients unaffordable. But the goal should be to reduce the reliance on presumptive testing in favor of definitive testing to the maximum extent possible. To do so, we must develop ever-more reliable, low-cost, and accurate tests. Such innovations will rely on emerging techniques such as nanotechnology, monoclonal antibodies, and DNA engineering. There is no doubt that the pace of biotechnological innovation will provide the capability for definitive testing that will become the rule and not the exception.
Stockpile, Stockpile, Stockpile
We must continue efforts with regard to stockpiling of critical prophylaxes and treatments.
Antibiotics and antivirals are the gold standard for treating most bacterial and viral diseases, respectively. Despite the existence of the strategic national stockpile, individual states are expected to make complementary investments in these treatments. Yet we know from the recent H1N1 experience that states do not currently have such stockpiles. What can state and local authorities expect from the federal government? How do their requests for support get managed? And are the state and local authorities prepared to provide the necessary information required at the federal level to allow for maintaining a common medical picture concerning the status of the disease? Are the current communications channels and methods for sharing information and providing guidance adequate?
The strategic national stockpile has been demonstrated to provide the necessary capacity for the United States, be we have also seen its limitations. Stocks need to be continuously rotated and there are inadequate supplies. What other capabilities should be maintained at the federal level for early dispatch in the event of a bio-attack (not to mention a natural outbreak)?
An Informed Public, an Engaged Public
We must have the practiced capability to talk with populations, give instructions, and prevent the further spread of disease.
When confronting a biological attack, communications of course will be a critical element—essentially the ultimate prophylaxis, vectoring people away from the hot zones. We must ensure messages are tailored and comprehensible, describing clearly how to react and what actions are appropriate. National and international systems designed to indicate disease levels and requisite actions must be based on scientific evidence, provide unambiguous direction, and instill confidence. Emotional responses, stop-and-start direction, and unclear guidelines will cause public spirit to erode. In the H1N1 situation, the World Health Organization’s pandemic-alert phase system did not contribute to maintaining a reasonable response and likely contributed to a more panicked reaction than was necessary. Learning the art of effective communication in the event of a biological-warfare attack is both an art and science that must be mastered.
We also should expect that the international response to a biological-warfare attack likely will look more like a series of national responses rather than a well-coordinated single plan; this is the nature of national sovereignty. We must recognize these likely differences and attempt to devise methods that seek to unify response-outcomes to the maximum extent while still accounting for individual national prerogatives. This is another reason why international exercises are imperative, both for understanding the likely differences and closing policy gaps wherever possible.
Certain Plans for an Uncertain Future
The United States has never experienced a large-scale biological attack. But as the anthrax attacks of 2001 demonstrated, even a small attack can have a major effect on policy, resource allocation, and our general sense of well-being. To date, we have spent almost $60 billion based on the crude dispersal of a relatively small amount of anthrax through the U.S mail system that sickened or killed fewer than 25 people.
Ultimately, U.S. preparedness is not solely the purview of any single entity; it is a shared national responsibility requiring the collaboration and coordination of governments at all levels, relief organizations, public partners, and private citizens, as well as international partners.
Dr. Gerstein is the Principal Director for Countering Weapons of Mass Destruction within the Office of the Under Secretary of Defense (Policy).