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1
Introduction

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     The bombings of the World Trade Center in New York in 1993 and the Alfred P. Murrah Federal Building in Oklahoma City in 1995 have forced Americans to face the fact that terrorism is not simply something that happens only overseas. Shocking as those attacks were to most Americans, the 1995 nerve gas attack on the Tokyo subway by an apocalyptic religious cult, Aum Shinrikyo, and the subsequent revelation of its attempts to acquire and use biological weapons (Broad, 1998) have added a new dimension to plans for coping with terrorism. The Tokyo attack, which killed 12 people and sent over 5,000 others to local hospitals, and an apparent rehearsal in the city of Matsumoto some months beforehand, were the first large-scale terrorist uses of a chemical or biological agent (Fainberg, 1997).

     Scattered and smaller-scale incidents occurred previously (e.g., mercury poisoning of Israeli citrus in 1978, the Tylenol-cyanide poisoning of 1982 that led to current "tamper-proof" packaging, and the Salmonella poisonings by the Rajneesh cult in Oregon in 1984 intended to keep other voters from the polls), but a number of more recent incidents besides the Tokyo attack suggest that terrorists in the United States and abroad may be finding chemical and biological weapons increasingly attractive. In the United States, several members of a right-wing group called the Patriot's Council were convicted of acquiring the castor bean toxin ricin for use against local Minnesota officials in 1995. An Ohio man was arrested later that year and charged with fraudulently obtaining freeze-dried Yersinia pestis (plague) bacteria, and another individual was arrested in Arkansas in possession of a supply of ricin and castor beans and a collection of neoNazi books on making poisons. Overseas, German police confiscated a coded diskette containing directions for making mustard gas early in 1996, and political extremists in Tajikistan killed seven people and sickened a number of others with cyanide in 1995 (Oehler, 1996). The Aum Shinrikyo is reported to have experimented with anthrax and botulinum toxin before using the nerve gas sarin (GB) in the subway attack and may even have attempted to obtain a quantity of Ebola virus during the outbreak in Zaire (Fainberg, 1997; Broad, 1998).

     The rapid breakup of the Soviet Union was accompanied by well publicized concern about the security of its nuclear arsenal. Other "weapons of mass destruction," namely, chemical and biological agents, drew less attention, but the extent of the Soviet chemical arsenal and the large Soviet biological weapons program are cause for concern about sales to or theft by terrorist groups and rogue states. Also disturbing is the fact that some chemical and biological agents and devices to deliver them efficiently can be inexpensively produced in simple laboratories or even legally purchased. Small quantities can cause massive numbers of casualties, covertly if the perpetrator so desires. The Tokyo attack, which may have been initiated prematurely because of justified suspicion that Japanese police were about to launch a preemptive strike, employed a very crude delivery system; otherwise, the number of deaths might have been far higher.

     The United States government, while continuing to pursue the goal of effective international prohibition of chemical and biological weapons through the Chemical Weapons Convention, the Biological Weapons Convention, and activities such as those of the Australian Group, has also recognized the need to address possible use of these agents by individuals or groups unlikely to be deterred by threats of economic sanctions or massive retaliation. In the past decade, Congress has passed three major laws aimed at preventing the acquisition and use of chemical or biological weapons by states, groups, or individuals. The Biological Weapons Act of 1989 makes it a federal crime knowingly to develop, manufacture, transfer, or possess any biological agent, toxin, or delivery system for use as a weapon. It calls for heavy criminal penalties on violators and allows the government to seize any such material for which no legitimate justification is apparent (P.L. 101-298). The Chemical and Biological Weapons Control Act of 1991 (CBWCA) established a system of economic and export controls designed to prevent export of goods or technologies used in the development of chemical and biological weapons to designated nations (P.L. 102-82).

     The Anti-Terrorism and Effective Death Penalty Act of 1996 expanded the government's powers under CBWCA to cover individuals or groups who attempt or even threaten to develop or use a biological weapon. It also broadens the definition of biological agent to include new or modified agents produced by biotechnology and charges the Centers for Disease Control and Prevention (CDC) with creating and maintaining a list of biological agents that potentially pose a severe threat to public health and safety (P.L. 104-32). CDC is also charged with establishing regulations for the use and transfer of such agents that will prevent access to them by terrorists. CDC's new regulations, which took effect April 15, 1997, identify 24 microorganisms and 12 toxins, possession of which now requires registration with CDC and transfer of which now involves filing of forms by both shipper and receiver (Centers for Disease Control and Prevention, 1997). Appendix D is a list of those agents.

     Another law, the Defense Against Weapons of Mass Destruction Act of 1996, directs the Secretary of Defense to take immediate actions to both enhance the capability of the federal government to respond to terrorist incidents and to support improvements in the capabilities of state and local emergency response agencies. In recognition of this requirement, an amendment (widely known as Nunn—Lugar II or Nunn—Lugar—Domenici after its congressional sponsors) to the Defense Authorization Act for Fiscal Year 1997 (P.L. 104-201) authorized $100 million to establish a military rapid response unit; to implement programs providing advice, training, and loan of equipment to state and local emergency response agencies; and to provide assistance to major cities in establishing "medical strike teams." The Department of Defense (DoD) has shared these funds with the Federal Emergency Management Agency (FEMA), the Federal Bureau of Investigation (FBI), the Department of Health and Human Services (DHHS), the Environmental Protection Agency (EPA), and the Department of Energy (DoE). Use of these funds for simple purchase of equipment for local users is, however, prohibited by the legislation.

     Also relevant is the Local Firefighter and Emergency Services Training Act of 1996, which authorizes the Department of Justice, in consultation with FEMA, to provide specialized training to state and local fire and emergency services personnel.

     In addition to congressional action, Presidential Decision Directive 39 (PDD-39), United States Policy on Counterterrorism, was issued in June, 1995. It specifies the responsibilities of federal agencies and their relationships to one another in the conduct of crisis management and consequence management. As defined in PDD-39, crisis management involves actions to anticipate and prevent acts of terrorism. United States law assigns primary authority for these actions, which are predominantly of a law enforcement nature, to the federal government, namely the FBI. Consequence management involves measures to protect public health and safety, restore essential government services, and provide emergency relief to governments, businesses, and individuals affected by acts of terrorism. United States law assigns primary authority in this sphere to the states; the federal government provides assistance as required. This assistance is coordinated by the FEMA, relying on procedures of the Federal Response Plan developed by 27 federal departments and agencies for responding to disasters of all kinds (Federal Emergency Management Agency, 1997).

     PDD 62, Combating Terrorism, and PDD 63, Critical Infrastructure Protection, issued in May 1998, establish a National Coordinator for Security, Infrastructure Protection, and Counter-Terrorism and authorize the FBI to set up a National Infrastructure Protection Center (NIPAC) to issue warnings to public and private operators of essential elements of our government and economy. An additional element of the two directives is a four-part initiative focused on biological weapons. 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.

     The Federal Response Plan designates the Secretary of DHHS, acting through the Assistant Secretary for Health, and the Office of Emergency Preparedness (OEP), to coordinate assistance in response to the public health, medical care, and health-related social service needs of victims of a major emergency and to provide resources when state and local resources are overwhelmed. DHHS's experience planning and preparing for possible terrorist actions aimed at the 1996 Atlanta Olympic Games and other events revealed that traditional military approaches to battlefield detection of chemical and biological weapons and the protection and treatment of young, healthy soldiers under relatively isolated and controlled circumstances are not necessarily suitable or easily adapted for use by civilian health providers dealing with a heterogeneous population of potential casualties in a civilian setting. The importance to terrorists of psychological impact, which may be significant even when the number of casualties is low, also suggests that a different approach from that of the military may be necessary. Advances in detection and personal protective equipment in the hazardous waste disposal and hazardous materials handling areas are also unlikely to be readily transferred to a mass-casualty situation requiring protection or extraction, decontamination, and treatment of large numbers of civilians of widely varying size, age, and health.

     For these reasons, the Institute of Medicine (IOM), aided by the Commission on Life Sciences (CLS), was asked by OEP to conduct an 18-month study to (1) collect and assess existing research, development, and technology information on detecting chemical and biological agents as well as methods for protecting and treating both the targets of attack and the responding health care providers, and (2) provide specific recommendations for priority research and development. Areas of concern include, but are not limited to (1) the safety and efficacy of known and potential vaccines, prophylactic drugs, antidotes, and therapeutics; (2) vaccine production and distribution capabilities, surveillance for disease caused by biological agents, and real-time detection of chemical agents and rapid assays of biological agents; (3) the need for acute and chronic toxicological studies of emerging-threat agents; (4) plans for short-term and long-term follow-up of personnel exposed to chemical or biological agents; (5) adequacy and availability of personal protective equipment suitable for medical care providers; and (6) integrated triage, decontamination, and treatment practices and systems. The study thus focuses on medical responses to chemical or biological incidents and extends neither to prevention of terrorism nor to long-term actions like site remediation.

     IOM and CLS assembled a committee of knowledgeable scientists and medical practitioners in accordance with established National Academy of Sciences procedures, including an examination of possible biases and conflicts of interest, and held an initial organizational and data-gathering meeting July 22—24, 1997. A roster with brief biographies of committee members is provided in Appendix A.

     A wide variety of sources were used in assembling the requested inventory, which is attached as Appendix B. The initial meeting of the committee in July of 1997 provided an overview of important organizations and R&D programs within the federal government (Army, Navy, Marine and Defense Department units and laboratories, including the Defense Advanced Research Projects Agency; the Department of Energy's Chemical and Biological Nonproliferation Program; the Centers for Disease Control and Prevention; and the DHHS Office of Emergency Preparedness). Follow-up with the briefers provided a more detailed list of projects and points of contact for technical information. The Office of Emergency Preparedness shared information on promising technology from its files, and, of course, the committee members themselves contributed both personal contacts and specific information from their own files and experience. The World Wide Web provided much information about both relevant commercial products and R&D activity, and the following databases were accessed and searched: National Technical Information Service, Defense Technical Information Center, Federal Research in Progress, Federal Conference Papers, Medline, MedStar, and HSRProj.

     Information on the products in the above inventory was distilled from a ProCite database of more than 450 records and entered into a series of databases, a description of which constitutes the gap and overlap analysis at the end of Appendix B. In the process, we eliminated most products or R&D that did not explicitly address military chemical or biological agents or appear to be sufficiently generic in nature to encompass those agents without a major change. Exceptions were made only in categories in which there were very few or no products or R&D explicitly directed at chemical and biological weapons. We also excluded technology represented in our database by only a single experiment, journal article, or Small Business Innovative Research contract (i.e., we focus on products and R&D programs).

     The committee's interim report (Institute of Medicine and National Research Council, 1998) focused on current civilian capabilities and made recommendations for action without evaluation of ongoing and planned research and development. That focus was selected primarily to provide a baseline against which to evaluate the utility of technology and R&D programs. The present report builds on that baseline by adding analyses of improvements in capability that might be possible through incorporation of technological innovations, either currently available or in some stage of research and development. However, the committee recognizes that technology is only one of a number of methods of improving civilian medical response and that it would be irresponsible to focus solely on technology, while ignoring potentially simpler, faster, or less expensive mechanisms, such as organization, manpower, training, and procurement. The committee's recommendations therefore include a number of suggestions for operational research in addition to calls for more traditional product development.

     Many of the actions required for effective consequence management are agent-specific (antidotes, for example). Some have argued that chemical and biological terrorism are especially vexing problems, because would-be terrorists have a much longer list of agents from which to choose than does a military force, which must be concerned with production in quantity, weaponization, storage, safety of their own personnel and civilian noncombatants, and contamination of desired physical and geographical objectives. Indeed, some have pointed out, correctly, that genetic engineering may eventually make the list of potential terror agents extremely long. In practice, the few chemical and biological terrorist incidents that have occurred to date have involved only a few different agents, and these agents are well known from military weapons programs. There is no guarantee that this will continue to be the case, indeed; it would be a grave mistake to assume that terrorists will not be able and willing to take advantage of biotechnology to produce new agents. Pre-incident intelligence about the specific agent suspected will always be important, for it is not possible to be prepared for all possible agents in all possible circumstances.

     As a practical matter, the committee has taken as its reference point and as a framework within which to discuss current capabilities a limited number of agents: the relatively short list of chemical and biological agents discussed in the U.S. Army's recent textbook on medical aspects of chemical and biological warfare (Sidell et al., 1997). These are nerve agents, cyanide, phosgene, and vesicants, such as sulfur mustard; the bacteria-produced poisons botulinum toxin and staphylococcal enterotoxin B (SEB); the plant-derived toxin ricin; the fungal metabolite T-2 mycotoxin; and the infectious microorganisms causing anthrax, brucellosis, plague, Q-fever, tularemia, smallpox, viral encephalitis, and hemorrhagic fever. More comprehensive lists, including these chemical agents and the CDC list of restricted biological agents, are provided as Appendixes C and D respectively, to illustrate the breadth of the problem facing planners.

     The committee also recognizes that terrorist incidents can take a wide variety of forms. Evaluation of civilian medical and public health capabilities and shortfalls will be scenario dependent. Like the number of possible agents, the number of possible scenarios is also very large. Important variables include the extent of prior intelligence or warning about the time, place, or nature of the attack; the degree to which time and place of the attack itself is obvious; and the number and location of individuals exposed.

     Again, as a practical measure, the committee chose to limit analyses of the possible utility of technology and R&D programs to three general scenarios. The first is an overt attack producing significant casualties at specific time and place--something similar to the Oklahoma City bombing, but involving chemical or biological agent rather than, or in addition to, high explosives. A second, quite different scenario is a covert attack with an agent producing disease in those exposed only after an incubation period of days or weeks, when the victims might be widely dispersed. The infectious agents listed in the previous section have incubation periods ranging from 2 days to 6 or 8 weeks, depending on the agent and the dose received (Franz et al., 1997). A third scenario involves attempts at preemption, such as full-time monitoring of likely targets (the White House, subways), deployment for specific events (Olympic Games or the State-of-the-Union address), or simply dealing with a suspicious package. Consequence management in these three general scenarios is obviously quite different, qualitatively and quantitatively: there will be no 911 call to which emergency personnel respond, indeed no site or identifiable event in the second scenario, so training and equipment for that scenario must be focused not on public safety personnel (fire and rescue, emergency medical services) but on hospitals, medical laboratories, and public health officials.

     For the above agents and scenarios, a particularly threatening means of delivery, on which both military offensive and protective programs and the committee's considerations have concentrated, is as vapors or aerosols designed to cause poisoning or infectious disease as a result of inhalation. Nevertheless, it would be a mistake to assume that terrorists will not be able to use other agents, even novel ones, or other means of delivery, including product tampering, attacks on crops, and contamination of food or water supplies. In fact, the IOM, in conjunction with the National Research Council Board on Agriculture, recently released a report assessing the current food safety system and providing recommendations on scientific and organizational changes needed to ensure an effective system for present and future generations (Committee to Ensure Safe Food from Production to Consumption, 1998). Although focused on naturally occurring contamination rather than deliberate acts, carrying out the report's recommendations is likely to be an important first step in guarding the country against chemical or biological attack by this route as well.

     The charge to the committee focuses on what is possible and desirable. It makes no reference to cost, financial or otherwise. The committee nevertheless recognizes that for nearly any specific locale (with the possible exception of a few obvious areas like Washington, D.C.) a terrorist attack of any sort is a very low-probability event, regardless of the magnitude of the consequences, and that taking expensive or time-consuming actions in preparation for such events is extremely difficult for state and local governments to justify. Moreover, many of the actions that could contribute to averting or mitigating casualties from terrorist chemical or biological attacks are urgently needed anyway to avert or mitigate severe hazards to health from toxic substances and prevailing or emerging infectious diseases of natural origin. As a result, the committee has given special attention to actions that will be valuable even if no terrorist attack ever occurs. A second type of recommendation focuses on very specific actions that would be valuable in a few more plausible terrorist scenarios. A third category of suggestions involves more generic, long-term research and development programs. Even here, much of what needs to be done to deal with possible terrorist incidents will be of benefit to the nation's health irrespective of actual attack.

     The committee's Interim Report (Committee on R&D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents, 1998) focused on current capabilities. Much of that analysis survives in the present document, albeit modified in a number of places due to new developments or simply receipt of additional information. Table 1-1 is a summary table adapted from a similar table in the interim report. The leftmost column of the table lists capabilities or actions likely to be required for an effective response to the medical consequences of a chemical or biological incident. The table entries represent the committee's best estimates of current capabilities, though there are few hard data to support them and the committee recognizes that capabilities vary widely at the state and local level. In effect, the table also provides an outline of the remainder of the report, which will describe current preparedness in each of these areas, along with possible improvements achievable through existing technology or research and development. Regardless of technology, of course, integrated planning and coordination among different levels of the medical community will be necessary for effective response.

     For purposes of this report, we differentiate four levels of medical intervention, primarily on the basis of proximity to the precipitating event or initial victims. Response to a distinct, immediately recognizable terrorist incident (as opposed to a covert release of an agent whose effects would not be apparent for hours or days) would, in most instances, be initiated by law enforcement or fire and rescue personnel, followed at some point by a hazardous materials (Hazmat) team and emergency medical technicians. This is the group referred to in Table 1-1 as "Local Responders." In the same table, "Initial Treatment Facilities" refers to the fixed-site medical facilities to which victims might initially be transported (or transport themselves) or that might initially be called upon for assistance by victims or personnel on the scene. Under "State" in the table, we refer primarily to state departments of emergency services and public health and to regional resources, such as poison control centers and public health laboratories. A state public health agency would probably initiate the systematic response to a covert release of an agent with delayed effects (e.g., anthrax).

     The "Federal" category in Table 1-1 refers to capabilities that are many and varied. Upon request from the governor, the Federal Emergency Management Agency (FEMA) may deploy an emergency response team, the health and medical services portion of which is the responsibility of the Department of Health and Human Services (DHHS), specifically the Office of Emergency Preparedness. The DHHS National Counterterrorism Plan includes initiatives both to create or improve local capabilities and to enhance the existing National Disaster Medical System (NDMS). One initiative involves organizing, equipping, and training groups of local fire and rescue personnel as Metropolitan Medical Strike Teams (MMST) in 25 or more of the nation's largest cities. The first of these teams, in Washington, D.C., became operational in early 1997, and contracts have been awarded to establish 10 more teams in 1998. The goal of these teams is to enhance local planning and response systems capability, tailored to each city, to care for victims of a terrorist incident involving a weapon of mass destruction (nuclear, chemical, or biological, although, in practice, the core of most of the teams is the Fire Department and its hazardous materials team, with a resulting emphasis on chemical attack). This is to be accomplished by providing special training to a subset of local emergency responders (120 to 300, depending on the size of the metropolitan area); specialized protective, detection, decontamination, communication, and medical equipment; special pharmaceuticals and other supplies; and enhanced emergency medical transport and emergency room capabilities. Other capabilities include threat assessment, public affairs, epidemiological investigation, expedient hazard reduction, mental health support, victim identification, and mortuary services. Twenty-five of these teams will obviously cover only a small proportion of the U.S. population, but they should also serve as effective test beds and models for Hazmat teams of the future.

     The National Disaster Medical System (NDMS) supplements state and local medical resources by delivering direct medical care to disaster victims. Disaster Medical Assistance Teams (DMAT) provide prehospital treatment. Sixty existing teams, some tailored to focus on pediatrics, burns, mental health, and other specialties, including mortuary services, are in place around the country. Like military reserve units, the teams are community-based and composed of local health providers who train on weekends. Twenty-one are fully deployable and can be on the scene in 12 to 24 hours with enough food, water, shelter, and medical supplies to remain self sufficient for 72 hours and treat about 250 patients per day. Three teams are being organized and trained specifically to respond to chemical or biological terrorism. NDMS hospitalization assistance is accomplished though a regional network of 72 Federal Coordinating Centers that are run by the Department of Veterans Affairs (VA) and the DoD. These centers have agreements with private sector hospitals to make ready a total of more than 100,000 in-patient hospital beds; the VA provides medicines and DoD provides patient transportation.

     The Centers for Disease Control and Prevention (CDC) is a widely recognized source of expertise in the diagnosis of infectious agents known to be pathogenic in humans, and their epidemiological and laboratory resources are often called upon to assist state health departments identify and manage outbreaks of severe unexplained illness. In cases of suspected biological or chemical terrorism CDC itself can consult with experts at academic institutions and research institutes and several DoD medical research units specializing in biological or chemical defense: the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), the U.S. Army Medical Research Institute of Chemical Defense (USAMRICD), the U.S. Navy Medical Research Institute (NMRI), and the U.S. Navy Environmental and Preventive Medicine Unit.

     Representatives of these units and additional DoD organizations with expertise in bomb disposal (the Army's 52nd Ordnance Group) and the detection and disposal of chemical and biological weapons (the Army's Technical Escort Unit and Chemical Treaty Laboratory and the Naval Research Laboratory) form the DoD Chemical/Biological Rapid Response Team (C/B-RRT). The C/B-RRT is a deployable source of advice and expertise that can coordinate more extensive and more specialized assistance as necessary. Under some circumstances, a U.S. Marine Corps unit called the Chemical Biological Incident Response Force (CBIRF) may provide assistance in evacuation, decontamination, and medical stabilization of victims. This 350-person force is based at Camp LeJeune, North Carolina and can have an advance party airborne four hours after notification. Other deployable units designated to assist local civilian responders include Specialty Response Teams at the Army's Regional Medical Centers, which can provide advice on casualty management and coordinate more extensive support. An Aeromedical Isolation Team of physicians, nurses, and technicians from USAMRIID specializes in the transport of patients with highly contagious diseases. One destination for those patients may be a small isolation ward at USAMRIID designed for the care of patients requiring the highest levels of containment.

     A newly established hotline to the U.S. Army Chemical Biological Defense Command provides 24-hour access to these DoD assets. Given the very rapid action of chemical weapons, telephonic advice will probably be the most valuable assistance that local authorities can count on. CBIRF and other "hands-on" units are likely to play a major role only when deployed in advance to a site where there is reason to suspect an attack (e.g., the 1996 Atlanta Olympics). The Secretary of Defense has announced plans to expand and decentralize assistance to local, state, and federal agencies responding to attacks with chemical or biological weapons by equipping and training elements of the National Guard units (under the control of state governors) and the Army and Air Force Reserves to provide decontamination, medical care, security, and transportation. Initial actions would establish rapid assessment and initial detection (RAID) teams in 10 areas designated by FEMA, to be followed by 55 reconnaissance elements and 127 decontamination teams throughout all 50 states. Expertise and equipment associated with these teams, like the CBIRF, will be heavily biased toward response to chemical attack, an event at which, also like CBIRF, barring predeployment, they will almost certainly arrive too late to provide significant help with the medical response.

     Capabilities at each level and promising leads for improvements are treated in detail in the following chapters, but several general conclusions that emerge serve to summarize the reasoning behind the ratings of Table 1-1.

     First, the committee believes that the incubation period associated with infectious biological agents makes responding to an attack with such agents very different from responding to a chemical attack. Thus, victims of biological attack may not be concentrated in time and space the way victims of most chemical attacks will be. Recent emphasis on preparing "local responders" for chemical and biological terrorism is therefore primarily preparation for chemical attacks.

     Second, in many of the areas surveyed in subsequent chapters, we note that some capability, often quite good, exists for incidents involving a small number of victims. Regardless of preparation, there will be some unpreventable casualties in all but the most incompetent attacks, but without planning, education, supplies, equipment, and training, the casualty count will mount rapidly when the number of persons exposed escalates, particularly as the event is likely to be unprecedented in a community. For both chemical and biological exposures however, there is an existing response framework within which modifications and enhancements specific to chemical and biological terrorism can be incorporated. An attack with chemical agents is similar to the hazardous materials incidents that metropolitan public safety personnel contend with regularly. A major mission of public health departments is prompt identification and suppression of infectious disease outbreaks, and poison control centers deal with poisonings from both chemical and biological sources on a daily basis. It would be a serious tactical and strategic mistake to ignore (and possibly undermine) these long-neglected mechanisms in efforts to improve the response of the medical community to additional, albeit very dangerous, toxic materials. It would be similarly ill advised to ignore the existing mechanisms for providing federal disaster assistance to local communities.

     Local governments and hospitals are reluctant to spend large amounts of money and time preparing for what they judge as unlikely events. Federal organizations can, therefore, be very important. This is particularly true in the case of biological agent incidents, where onset of signs or symptoms is delayed, variable, and potentially continuing, and victims may be widely dispersed. The National Disaster Medical System (NDMS), for example, would be a critical component of response to any large-scale biological attack. The NDMS might also serve a useful role in a large-scale chemical attack, though the rapid onset of effects from these agents puts a premium on actions within the first few hours following exposure. For that reason, properly trained and organized Metropolitan Medical Strike Teams organized by local communities with Public Health Service funding may be the most useful federal help in managing the medical consequences of a chemical attack. Similar help from deployable military teams will be optimal only if intelligence allows for predeployment or the attack occurs near the team's home base.

     Finally, it will be apparent that federal regulations intended to protect the public in very different circumstances may have, in fact, impeded efforts to prepare for chemical or biological terrorism. Regulations on worker safety apparel, for example, have made it difficult for civilian rescue workers to take advantage of military equipment specifically designed for protection from chemical warfare agents. Similarly, the difficulty of obtaining the human efficacy data currently required for FDA approval of specific treatments for chemical and biological warfare agents may limit their use in mass-casualty situations. Furthermore, in the case of many treatments, collection of the data on efficacy necessary for full FDA approval will not be possible for ethical reasons or economically attractive to a potential manufacturer because of limited market potential.