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Our society is too complex a'~d intetconnectec! to defenc! against a/! possible threats. As some threats are diminished, others may arise; terrorists may change their goals anc! tactics.... For that reason, strengtI,e'~ing the nation- al effort in long-se' m research that can create new solutions should be a cornerstone ofthe strategyfor countering te'A`orisn~. Making the Nation Safely: TI?e Role of Science and Technology ill Countering Terrorism, 2002 Tire September 11, 2001 terrorist attacks on tire United States, along with the subsequent deliberate spread of potent forms of anthrax bacteria through tire U.S. mail, leave mol~itizecl diverse `,O O ,, O>h'l'7~ng sc'`~' merit local and national responses to prevent, detect, and defenc! against acts of terrorists. Since the ~~' 3~6 0~'n00~ `~3 founding of the National Academy of Sciences in 1863, tire importance of mobilizing science, r ~ - ~ C' dlelFense~ of Rhea nation hats ~ been OL centt~31 purposed of medicine, and engineering in defense of tile tIie con~po'ie'it scientific nation has been a central purpose of tile compo- eie`~nts now colie`ct'vely Relet scientific elements I low collectively known as the National Academies. Indeed, tire National Academies' ability to create, maintain, and draw from a reservoir of scientific, medical, and tecl~nological knowledge has underpinned many of Else nation's security strategies. known as The National Academies z ~ 0 UJ ~ 6 I

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iI~~.~6r 7~ i.~-~E Al Jim Or BALM Cot~vtt~c Tom Tire Institute of Medicine leas concluctect or participated in a number of studies focuses! on better understancling tire threats of terrorism and iclen- tifying ways to prevent terrorist attacks or Educe timid consequences. In 1998, the IOM ~ eleasec! C/~en7ical I'm/ Bio/ogicc~/ Terrorism: Research anc! Development to l~nprove Civilian Meclica/ Response, a r epo~-t treat assesses! the state of tire alit for detecting potential cl~emical and biological agents and for protecting both else targets of attack Alice tire l~ealtl~ care providers who will be vital ill respo~cli~g to sucks attacIcs. Tl~e report identified 61 specif- ic Research & Development (R&D) needs ilk tire following areas: pre-inci- clent intelligence; detections ant] identification of clinical and biological agents ilk else environment and ire clinical samples from victims; personal protective equipment; recognizing covert exposures of a population; mass- casualty decontamination acid triage procedures; availability, safety, and efficacy of drugs, vaccines, and Artier therapeutics; prevention and treat- ment of psycl~ological effects, and computer related tools for training and operations. Following tire events of September 11, tire National Academies initiat- ec} a project drawing on the experience of more than 100 dist~nguisI~eci experts Fisons a variety of felcis to help tire federal government street the complex new challenges posed by terrorism. Making the Nation Safer: The Role of Science and TecI~no/ogy in Countering Terrorism (2002) outlines a national strategy by which the strengths of U.S. science, medicine, and e~gineeri'~g cart be enlister] on a continuing basis to assist tire nations in anticipating, preventing, ant! responding to ter- MaL`~g tI7e Nation Sa Crab Prism. Issued by the Natiol al ResearcI, Council, The Role of Sc'ente ai7~' IeChnOlogy In Cling I; Aim cribe`s opportunities for reducing current: and future risks lthr`~' Ilium re`~3~:Lrch and ~levelopment aCtivities. tire report identifies numerous I OCR for page 101
~~l,J\,i/~.,\ Sp~i: '[~3~>r ,,q,~r~-' B~`,'~ Groups That Can Help Respond to a Terrorist Attack Using a Chemical Agent Many (if not most) cities and many industries have IJAZMAT teams trained and equipped to clear with accidental spiffs and releases of toxic industrial chemicals. They have not been trained or equippecl to clear with terrorist inci- dents, but chemical weapons of the types that would most plausibly be used by terrorists are not fundamentally different frown the chemicals that these teams already address. Among the first responders to chemical terrorism, fire departments can be a major resource. Ail fire departments have personnel who are trained and equipped to work with respirators ant] protective gear (as hazardous vapors are always a part of fires), and they are of course trained to deal with emergencies. The police are not routinely equipped to respond to chemical incidents per se (although they play an essential role in maintaining order). Equipping police units with protective gear is, however, a practical way of ext~ancling the number of individuals who can actively participate in the response to a chem- ical inciclent. Weapons of Mass Destruction Civil Support Teams from the Department of Defense are cJep~oyecl around the country. These groups have a ~imitecl but possibly useful capability to coordinate communications among responders and to carry out chemical and biological analyses. Another substantial capability in place is the military, including active-cluty, reserve, and National Guarc] personnel. The military has trained anc] equipped for chemical warfare flaring tire past 50 years. It maintains large supplies of rel- eva'~t eq~ipment-protective suits, prophylactics, and meclica~ countermeasures against nerve ant] blister agents. These assets are geared, however, to wars on foreign battlefields. An important issue is to understand how to use this capa- bi~ity in time of need inside the continental Uniter] States. As of April 2002, 27 teams hac] been depioyecij with five more authorized and in the planning stage. SOURCE: Making the Nation Safer: The Role of Science and Technology in Countering Terrorism, 2002, page 128.

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IPA;~/~(r 'lI-~E i4(f7~.~ 6~1716~Al i.~S IN BALM expancled research efforts to procluce new vaccines ant! other therapeutics treat target bioterrorist agents and new tools for surveillance of infectious agents in the environment for identification of pathogens and for rapid acid accurate diagnoses of diseases linked to bioterrorist agents. The nation s public health system weakener! by years of unclerinvestment must be revitalized and g Ives surge capacity to massage the masses of people who may be exposer! to pathogens or other haza~^clous substances during a terrorist attack. Tl~e anthrax attacks of 2001 moved bioterroris~n From I~ypotI~etical to teal. Bioterroris~n is flow a priority for policy-makers r esearcI~ers public heat officials and members of private industry altI~ougl~ tI~ese commu- nities continue to struggle witty finding affordable and effective protective measures. Biological Threats a`?c! Terrorism: Assessing the Science acid Response Capabilities: A Workshop stimn?ary (2002) reviews current knowledge about potential bioterrorist agents inclucling anthrax and smallpox and presents a discussion of the steps needed to strengthen response capacity. Issued for tire lOMs Forum on Emerging Infections tire workshop summary presents participants arguments treat bioterrorism is an urgent national security issue for which policy-makers ant] the public must clevelop acid ~naintai~ a coorclinat- ecl set of response initiatives. Specific priorities fall into tiered areas: developing vaccines ant! therapeutics treat act against bioterrorist agents; implementing a r esearch agenda that reflects current and emerging unclerstand- ing of bioterrorism threats; anti strengthening tile pub- lic-l~ealti~ infiastructure in order to ensure effective response to an attack. Changes in the public loyalty system sI~oulc] inclucle improving com~unica- tio~ and information programs; expanding laboratory capacity at local state ant! fecleral levels; entrancing surveillance systems for detecting sus- picious outbreaks of disease; and strengtI~eing local agencies titan likely will serve as else first line of defense against bioterrorist attack. To strengthen response capabilities most efficiently many workshop partici- pants caller! for expanding partnerships within ant! among government industry acaclemia tire healths care system ant] tire intelligence community. Tire Uniter] States also scow enlist tire air! of artier countries ant! international organizations in improving bioterrorism response preparedness globally.

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If. \~' ~l-~ir A. Bl~rl~~3~M Since 1997, as part of tire fecleral government's efforts to combat ter- rorism, tire Office of Emergency Preparedness (OEP) leas proviclect funds to the nation's most heavily populated cities to help them clevelol~ plans for coping witty else health acid medical consequences of a catastrophic terror- ist attack with chemical, biological, or racliological agents. More than 120 cities leave now r received funneling tl~rougI~ tile Metropolitans Medical Response System (MMRS) program. For assistance in jucI~,-inb- the program's effectiveness, the OEP turned to the Institute of Medicine. Preparing for Terrorisn?: Tools for Eva/~'ati'~g the Metropo/itn'~ Meclica/ Response Systemic Program (2002) provides a detailed guicle for assessing both tire level of preparedness of cities tight leave participated its tile program anal flow well its officials leave managed tile program. Among its proposed tools, tile r eport lists 23 essential capabilities that any community must leave its orcler to be able to respond effectively to the wicle variety of terrorism attacIcs float it may suffer; How well each city leas clevelopec! those capabilities can be measured tl~rougI~ a tI~ree-part process Bleat includes a site visit by a team of expert peers, observation of exercises and drills within the co~n- munity, and periodic review of documents and records. Since the threats of terrorism are continually clanging, the evaluation of preparedness also must be a continual process rather than a one-time event or even a series of events s,oacec! at Doing time intervals. Timid tr't~ ]~tit3~) OCR for page 101
I; ]~ p(~3~ CRI11~AL [.~S IN ~EAl711 PREPARING FOR 810~L AND CH EMICAl TERRORISM .~4~\ Vact:~e Anthrax is an attractive biological weapon, and its deadly capability has prompted the U.S. Department of Defense to launch a mandatory vac- cination program for military personnel. But concerns leave been raised about the vaccine's efficacy ant! safety. The A'~t/~rax Vaccine: Is It Safe? Does It Work? (2002) co~clucies treat AVA is indeed boric effective amuck safe. It, I~ow- eve~; cloes have certain drawbacks, inclucling a six-`iose vaccination scI~ed- ule over 18 nones titan u'~cierscores the need for a better vaccine. Altl~ougI~ tire current vaccine can still be used tire Movement shoulc! vig- orously support r esearcl~ to improve aci'~inistration of else current vaccine and to develop a better alternative. TO Centers for Disease Control and Prevention requested an IOM review of its anthrax vaccine research pro- gram. An Assessment of the CDC A'~t/?rax Vaccine Safety and Efficacy Research Program (2002) found that CDC bead provided a generally complete ant! appropriate response to tire charge frosts Congress but Protect treat acicli- tional research needs had become evident following tire bioterrorist events of 2001 and made recommendations about else leadership of tire overall program. Sn1~Ipox Vaccine Public and scientific concern about smallpox as a bioweapon also emerged after September 11. How best to respond] continues to be a mat- te'- of national clebate. Following tire Presidents decision to immunize 500000 first responders bite CDC was cl~argec! witty implementation of the program. The small- pox vaccine (vaccinia virus) is highly effective in preventing the disease but its use is not without risIc. Recognizing the usefulness of independent scientific advice CDC requester! lOM assistance in evaluating issues that Bigly arise as the vaccina- tion program unfoiclect. A standing committee was established to provide continuing assessment and advice. TI,ree letter reports Review of the Centers for Disease Control and Preve/7tior?'s Smallpox Vaccination Program Implementation: Letter Report #1 (2003) Letter Report #2 (2003) and Letter Report #3 (2003) have been isst~ecI. The second report offers updated rec- ommendations that reflect changes made by the government to the pro- gram ant] the thirc! report reaffirms the neec! for a pause in the smallpox vaccination program. Tire program originally called for phased-in vaccina- The~ smatipt3x vaccine (~ci'3~a virus) is highly effective in preventing it 0~;~' t)~t its ~0 i~ not without risk.

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I1{J,N,L,J,,\ SECT ~~r A,'\rI-) I3~O'I'rk17~;~sf~ tion, beginning Title I~ealtl~ workers who would! form volunteer teams ciur- in', a bioterrorist attack. A second wave of vaccinations was to include other health workers and traditional "first responders," sucks as police anct firefighters. Uncler the revised plan, states could begins vaccinating all healths worI OCR for page 101
INEt)~/~.~(r 'l~E I<(J'l-~ GAL [~.S IN GARY Strategies for Preparing for and Responding to the Psychological Consequences of Terrorism Summary of Recommendations Preventive Measures : Recon~men~at~or~ 2-1: HHS, inclucJi~g NIH, SAM HSA, and CDC, should devel- op evidence-based techniques, training, and education in psychological first aid. e Recommendation 2-~: HHS, including NIH, SAM HSA, and CDC, should devel- op public health surveillance for pre-event, event, and post-event factors related to the psychological consequences of terrorism. Education and Training for Providers Recommendation 3-1: Academic healthcare centers, professional associations and societies for mental health professionals, and state boards of educations, in col- laboratio`~ with HHS, including SAM HSA, NIH, and CDC, should ensure the educa- tion and training of mental health care providers on responding to the psychological consequences ot terrorism. Recommendation 3-2: Academic centers and professional associations and soci- eties, in collaboration with HHS, including SAM HSA, NIH, and CDC, should ensure the education and training of relevant professionals in health fields in the psycholog ical consequences of terrorism. Recommendation 3-3: SAM HSA, in collaboration with academic centers and state and local health care agencies, should ensure the provision of education and training in the psychological consequences of terrorism for a range of relevant com- munity leaders and ancillary providers. Workplace Preparedness ~ Recommendation 3-4: NIOSH, the Department of Labor, and the Department of Education should erasure appropriate g~ideli'~es to protect people in a variety of work environments including response sectors, food production and distribution, and schools Research Needs Recommendation 3-5: Federal agencies should coordinate research agendas, cooperate in funding, and award timely and sufficient funding. Ensuring Preparedness Through a Comprehensive Public Health Strategy ~ Recommendation 4-1: DHHS and the Department of Homeland Security should analyze terrorism preparedness to ensure that the public health infrastructure is pre- pared to respond to the psychological consequences of terrorism. Recommendation 4-?: Federal, state, and local disaster planners should address Psychological consequences in their planning and preparedness for terrorist attacks. SOURCE: Preparing tor the Psychological Consequences of Terrorism: A Public Health Strategy, 2003, page 18.

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H{J,~A.~\ 5~'rR3~7 y ANI) 8~;~M Ui0~9gica' Warfare '4gt't~ts Currently, the United States leas a limited repertoire of licensee] med- ical countermeasures that tire Department of Defense can use to protect itemizers of the are forces against more tea a clozen bacteria, viruses, ant! toxins identifier! as possible biological warfare agents. As part of its Chemical acid Biological Defense Program, DoD is engaged its research anc! development efforts aimed at malting available a be odder ravage of ~neclical cou~tern~easures. In tire National Defense Authorization Act for Fiscal Year 2002, Congress directed flee Secretary of Defense to contract witty tire Institute of Medicine and flee National Research Couch for a study of tire review acid approval process for new medical countermeasures in order to identify flew approaches to accelerate titan process and to identify metI~- ods for assuring that new countermeasures will be safe ant! effective. The Institute of Medicine/National Research Council Committee on Accelerating tire Research, Development, and Acquisition of Medical Countermeasures against Biological Warfare Agents has releaser! an inter- im report that provicles information on study progress, but cloes not con- tain findings and recommendations. The committee will issue a final report by the enc! of 2003. ~:~L ~~S (A lERR(~SM Tire Oklahoma City bombing, intentional crashing of airliners on Septembe' 11, 2001, anthrax attacI OCR for page 101
IN~.~.~(r 1~E I OCR for page 101
I, s~'ipi7~r Aims 8~3r~~M Defense in 1997 to contribute to the integrates] international surveillance ant] response effort through tire establishment of the Global Emerging Infections Surveillance ant] Response System. At the request of tire system's managers, Else IOM leas evaluated the system's structure and progress. Perspectives oil the Department of Defe'?se Globe! Emerging l'~fectio`~s Surveillance and Response System (2001 ~ co'~- clucles that it is well organized and comprises an app'-o- p~-iate response to tire thereat posed to national security by emerging infectious diseases. The ~ eport recommend- ed solve refinements to the system and called for Else government to increase fi~a'~cial support to Whelp ensure its long-term success.

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Selected Recommendations for Military and Veterans The Role of Vaccine Acquisition and Availability in the Military: The Department of Defense: (DoD) should combine all vaccine acquisition responsibilities under a single DoD authority and consolidate infrastructure, funding, ar1d~perso~nel for acquisition programs for biodefense and naturally occurring infectious disease vac- cines. DoD should also work toward arrangements with manufacturers that ensure consistent vaccine availability by acJdressing long term commitment, predictable vol- umes and prices, indemnification, and intellectual property issues; and should also seek a new approach to the regulation of certain special-use vaccines that remain in Investigational New Drug status at FDA (Protecting Our Forces: Improving Vaccine Acquisition anc! Availabi/ity in the U.S. Military, 2002) Focus on Gulf War Veterans: TI1e Department of Veterans Affairs (VA) should pro- vicle specific training to health care providers calling for Gulf War veterans to ensure that they are skilled in patient-centered care, and the VA should further ensure that such providers are allowed sufficient time with each patient in order to provide patient-centered care. In conducting treatment research, the VA should use a hierarchy of evidence struc- ture that includes effectiveness studies as well as efficacy studies for any future treat- ment guidelines it develops for symptoms or illnesses of Gulf War veterans. Current VA and Department of Defense Gulf War registries should be used as one way to identify patient samples and serve as a sampling frame for future treatment effec- tiveness studies. (Gulf War Veterans: Treating Symptoms and Sync/rom es, 2001 ~