Chicago Hospitals International
The limitation and eventual elimination of chemical and biological weapons are two of the greatest challenges facing the international community in this century. Unfortunately, proliferation of capabilities to construct such weapons is continuing despite the best efforts to contain such technologies by many nations, including the United States.
Biological terrorism, in particular, is of great concern for several reasons:
Many potent agents are readily available. Theoretically, any microorganism or toxin capable of inflicting death or disease has the potential of being adapted for use as a biological weapon.
Naturally occurring infectious agents could be used to generate epidemics among susceptible populations, creating confusing disease situations. Naturally occurring or deliberately disseminated spore-forming microbes might continue to persist in the environment, and some aerosolization might occur; environmental detectors might not be able to differentiate between natural and artificially generated contamination.
Many classic agents of concern can be mass produced in a short time by using basic laboratory techniques. Large fermenters may not be necessary if a small amount of agent is all that is required.
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop Biological Terrorism: Regional Preparedness1 Russ Zajtchuk Chicago Hospitals International INTRODUCTION The limitation and eventual elimination of chemical and biological weapons are two of the greatest challenges facing the international community in this century. Unfortunately, proliferation of capabilities to construct such weapons is continuing despite the best efforts to contain such technologies by many nations, including the United States. Biological terrorism, in particular, is of great concern for several reasons: Many potent agents are readily available. Theoretically, any microorganism or toxin capable of inflicting death or disease has the potential of being adapted for use as a biological weapon. Naturally occurring infectious agents could be used to generate epidemics among susceptible populations, creating confusing disease situations. Naturally occurring or deliberately disseminated spore-forming microbes might continue to persist in the environment, and some aerosolization might occur; environmental detectors might not be able to differentiate between natural and artificially generated contamination. Many classic agents of concern can be mass produced in a short time by using basic laboratory techniques. Large fermenters may not be necessary if a small amount of agent is all that is required. 1 Editor’s Note: This paper was presented before the natural disasters in 2005 in the United States and thus does not incorporate the lessons learned from those events.
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop Theoretically, biological agents can be genetically altered to escape detection. Dangerous biological agents require no precursors for development, unlike chemical and nuclear agents, and a covert program is much more difficult to detect. Before 1990 little thought was given to the possibility of a biological terrorist attack on U.S. cities. Even as recently as 1997, the U.S. Department of Defense spent only $137 million on biodefense to protect the deployed force, while academia, industry, local governments, and the rest of the federal government were in some cases doubtful about the threat of biological terrorism. Since fiscal year 2000, the United States has committed billions of dollars to military biodefense and to domestic preparedness for biological attack. The federal government has formed the U.S. Department of Homeland Security, a number of university medical centers have received funding for developing research programs in biodefense, and state and local governments have become proactive in developing and implementing emergency preparedness and disaster response plans to counter terrorism. REGIONAL PREPAREDNESS At the request of the Illinois Department of Public Health, a proposal was developed primarily by the University of Illinois for a statewide bioterrorism plan. In 2002 a number of leading universities were designated as Regional Centers of Excellence for Biodefense and Emerging Infectious Diseases by the National Institute of Allergy and Infectious Diseases (NIAID), one of the National Institutes of Health,2 and charged to develop emergency preparedness and disaster response plans. The first year focused on needs assessments and planning activities. The centers of excellence coordinated the needs assessments for nongovernmental health care entities. Upon completion of assessments, the health care entities and the Illinois Department of Public Health received reports on their emergency and terrorism preparedness. With the assistance of centers of excellence and the Illinois Department of Public Health, all health care entities developed uniform clinical protocols for clinical interventions for biological, chemical, radiological, nuclear, and explosive acts of terrorism. They developed a syndromic round-the-clock surveillance system in Illinois for uniform reporting of diseases from hospital emergency departments to the Illinois Department of Public Health. Finally they integrated 2 For more information about the National Institute of Allergy and Infectious Diseases (NIAID) Regional Centers of Excellence for Biodefense and Emerging Infectious Diseases program, see http://www.rcebiodefense.org/ and http://www3.niaid.nih.gov/Biodefense/Research/rce.htm#map.
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop surveillance with a statewide laboratory network for testing and reporting of results. A General Accounting Office (GAO) report in August 20033 indicated that hospitals do not have surge capacity to support a large-scale terrorist event. Consequently steps have been taken to develop a plan to accommodate at least 1,700 patients in an emergency. Additionally an emergency system was developed to increase staffing levels in acute care hospitals during a major event and to develop a cadre of reserve health care personnel by reaching out to retired practitioners, nurses, and health care students and by providing education to the public to further emergency preparedness. Resources were allocated to obtain a self-contained, fully equipped mobile medical facility with a capacity for 100 beds, including 30 intensive care, 24 ambulatory, and 46 acute care beds. Staffed by personnel from 31 acute care hospitals and state governmental agencies, it has the potential to be used in any location across the state because of mobility and has the capability to provide isolation care for any type of infectious disease, including smallpox. This mobile hospital is being used to enhance emergency preparedness through training, drills, and exercises. Communication systems were assessed. A communitywide and statewide communication strategy and plan for round-the-clock availability, interoperability, and redundant capacity was developed. Additionally, each of the acute care hospitals installed MEDSAT satellite phones and developed protocols for their utilization. After coordinating with state and local public health and health care delivery entities on stockpiling equipment, supplies, vaccines, and pharmaceuticals, a uniform plan was developed for the distribution of stockpiles. Administrators in acute care hospitals received orientation and training on how to procure, track, and deliver strategic national stockpile supplies. The statewide laboratory system’s capabilities were assessed and communication capabilities between laboratories and health care providers were evaluated. Health care facilities have been asked to address the following: HVAC/high-efficiency particulate arrestance filtration water systems security/lockdown isolation rooms decontamination equipment personal protection equipment 3 U.S. General Accounting Office. 2003. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. Report to Congressional Committees GAO-03-924. Washington, D.C.: U.S. General Accounting Office. In July 2004 the General Accounting Office became the Government Accountability Office.
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop radiation detection equipment chemical detection equipment Additional information on statewide regional preparedness may be obtained from the Yale New Haven Center for Emergency Preparedness and Disaster Response, Yale School of Medicine.4 The center has an emergency management course on CD-ROM. INFORMATION ANALYSIS CENTER FOR HOMELAND SECURITY AND MEDICAL RESPONSE There is a wealth of information on homeland security and medical response with different areas of expertise ranging from clinical protocols to logistical solutions. However, this information is not systematized or easy to locate, access, evaluate, and implement. National defense organizations and other government and civilian groups are mandated to implement emergency preparedness and disaster response programs. To maximize their effectiveness, these groups need resources to help them identify the most accurate, comprehensive, and current information available on homeland security and medical response topics, whether from a military or civilian, public or private, or domestic or international source. Best practices already developed and successfully implemented for homeland security and medical response need to be assessed, adapted, and disseminated to a broader audience. Formation of an Information Analysis Center (IAC) for Homeland Security and Medical Response is to be that resource. The significance and power of the IAC will be derived from the partnership of diverse groups, each of which has resources and expertise that the others cannot now access in a coordinated way. The groups include military and civilian, public and private, and domestic and international organizations. Groups engaged in homeland security and medical response will benefit from having access to sources of information previously unavailable to them. Prime examples include making available to civilian groups’ information on biological and chemical threat agents and emergency response drills and exercises conducted by the military. The IAC will facilitate application of existing homeland security and medical response solutions with demonstrable capabilities, nonduplication of financial and other resources, and maximum return on investment for governmental and private funding sources, supporting uniform coordinated national preparedness and response. An IAC has been established for use by Rush-Presbyterian-St. Luke’s Medi- 4 For additional information, contact: Yale New Haven Center for Emergency Preparedness and Disaster Response, 1 Church Street, 5th Floor, New Haven, CT 06510, Telephone: (203) 688-3224, Fax: (203) 688-4618, E-mail: email@example.com; Web site: http://www.ynhhs.org/emergency/index.html.
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop cal Center in the field of telemedicine, and another IAC has been created for use by the U.S. Department of Defense. Both IACs may be accessed by the public through the institutions’ Web sites. In addition, plans are being developed to establish a regional IAC for the Chicago area. Areas of Focus In general, the IAC will leverage the considerable operational, clinical, and managerial expertise of its collaborators. It will seek out subject matter experts (SMEs) from around the world to augment that expertise, and it will disseminate uniform, consistent, and accurate homeland security and medical response information, educational material, and emergency response programs to a broader audience through the following areas of focus. Repository of Best Information The IAC will develop a secure electronic repository to house (1) current, relevant homeland security and medical response information and (2) policies, protocols, and programs identified by SMEs as representing best practices. The repository will include a reference database, a relational database, and a search engine component that will speed access to information within the repository and other approved databases. Information in the repository will be gleaned from an array of military, civilian, public, private, domestic, and international organizations and agencies invested in homeland security, and emergency preparedness efforts and will be evaluated by IAC staff or appropriate SMEs prior to inclusion in the repository. Secured access to current research in areas such as response to chemical, biological, radiological, nuclear, and explosive threats will provide high-quality information that will be used by IAC staff and subscribers to develop and enhance best practice policies, protocols, and programs available through the repository. The sharing of uniform and coordinated information and best practices among military, civilian, public, private, domestic, and international homeland security partners will build national and international response capacity to address terrorist threats and other disaster events. For example, civilian response can be enhanced and federal homeland security funding can be leveraged through adaptation and incorporation of an extensive menu of emergency medical response solutions developed by the military in the areas of surge capacity, mass casualty response and recovery, education and training, and drills and exercises. Analytical Services The IAC will utilize expertise from the collaborators and recruited SMEs to provide information analysis services that will enhance the value of the reposi-
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop tory and make it more accessible and usable to a broad audience. Services will include development and dissemination of a search engine available to subscribers to facilitate independent research into the repository and other approved Web content and created using specific taxonomy developed for homeland security and medical response topics bibliographies on selected topics focused technical reports, specialized white papers, handbooks, and data books that address general or specific homeland security and medical response issues retrospective analyses of information related to homeland security and medical responses to improve future emergency response to disaster events reports on existing military and civilian, public and private, domestic and international projects to minimize duplication of efforts and maximize existing investments identification of homeland security and medical response program gaps and engagement of groups with proven expertise to create programs to fill those gaps meta-analysis of repository material requested by IAC staff or by clients IAC Technical Requirements System Description The IAC technical infrastructure will (1) enable staff and authorized users to initiate a secure Web connection to view and download files with a standard Web browser, (2) maintain a reference database application tied to a search engine that functions as a database of databases, and (3) maintain a relational database of documents relevant to homeland security and medical response. System components include a public Web portal, a virtual private network (VPN), a reference database, and the IAC relational database in a secured environment. System Design Where possible, the configuration of hardware and software will utilize existing systems and commercial off-the-shelf components. Several key components are as follows: Web portal and scalability: The system will utilize the single-point-of-entry concept that has been demonstrated by existing IACs; it will be designed to accommodate increasing numbers of users as utilization increases and will also facilitate redirection to existing and future database components as the system evolves.
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Countering Urban Terrorism in Russia and the United States: Proceedings of a Workshop Security: The system will utilize a VPN with Secure Sockets Layer pages for login and access, and a dedicated firewall attached directly to the incoming Internet connection will provide additional security; while users will include both civilian and military partners, user access will be categorized according to each user’s need to know and their ability to conform to all government regulations and procedures for information security. Reference database: This component will store keywords and search algorithms created by subject matter, information technology, and bibliographic experts to speed acquisition and analysis of the relational database. Relational database: The IAC will maintain numerous relational databases, such as Microsoft SQL Server and Oracle, and requirements for the relational databases will be designed to facilitate migration to and from other existing databases. CONCLUSION The thought of an outbreak of disease caused by the intentional release of a pathogen or toxin in a U.S. city was alien just 10 years ago. Many people believed that biological warfare was only in the military’s imagination, perhaps to be faced by soldiers on a faraway battlefield, if at all. The anthrax letters of 2001 and the resulting deaths from inhalation anthrax have changed that perception. The national, state, and local governments in the United States are preparing for what is now called not if, but when and how extensive biological terrorism. In contrast to the acute onset and first responder focus with a chemical attack, in a bioterrorist attack, the physician and the hospital will be at the center of the fray. Whether the attack is a hoax, a small foodborne outbreak, a lethal aerosol cloud moving silently through a city at night, or the introduction of a contagious disease, the physician who understands threat agent characteristics and diagnostic and treatment options and who thinks like an epidemiologist will have the greatest success in limiting the impact of the attack. As individual health care providers, we must add the exotic agents to our diagnostic differentials. Hospital administrators must consider augmenting diagnostic capabilities and surveillance programs and even making infrastructure modifications in preparation for the treatment of victims of bioterrorism. Above all, we must educate ourselves. If we respond correctly, preparation for a biological attack will be as dual use as the facility that produced the weapon. A sound public health infrastructure, which includes all of us and our resources, will serve this nation well for control of the disease, no matter what the cause of the disease.