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11
Conclusions and Recommendations

The preceding pages have addressed a wide range of issues related to effective medical response to acts of chemical or biological terrorism. Each chapter draws some conclusions about a single aspect of that response and makes some recommendations for desirable research and development. There are, nevertheless, some general conclusions, some stated, some implicit, which pervade the report as a whole. The most basic of these is that terrorist incidents involving biological agents, especially infectious agents, are likely to be very different from those involving chemical agents, and thus demand very different preparation and response. Figures 11-1 and 11-2 illustrate these differences in flow diagrams of actions involved in coping with what the committee views as the most likely chemical (Figure 11-1) and biological (Figure 11-2) terrorism scenarios. The diagrams are descriptive, not prescriptive, and certainly do not represent the only possible sequences of action. We believe they are representative, however, and illustrate the contrast between the relatively linear sequence of actions in the chemical event and the more diffuse, parallel, and recursive activities in the biological event. The myriad of ''chemical/biological" response teams being developed at federal, state, and local levels are, despite their names, almost entirely focused on detection, decontamination, and expedient treatment of chemical casualties. For both types of incidents, however, there is an existing response framework within which modifications and enhancements can be incorporated. An attack with chemical agents is similar to the hazardous materials incidents that metropolitan public safety personnel contend with regularly. A



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Page 184 11 Conclusions and Recommendations The preceding pages have addressed a wide range of issues related to effective medical response to acts of chemical or biological terrorism. Each chapter draws some conclusions about a single aspect of that response and makes some recommendations for desirable research and development. There are, nevertheless, some general conclusions, some stated, some implicit, which pervade the report as a whole. The most basic of these is that terrorist incidents involving biological agents, especially infectious agents, are likely to be very different from those involving chemical agents, and thus demand very different preparation and response. Figures 11-1 and 11-2 illustrate these differences in flow diagrams of actions involved in coping with what the committee views as the most likely chemical (Figure 11-1) and biological (Figure 11-2) terrorism scenarios. The diagrams are descriptive, not prescriptive, and certainly do not represent the only possible sequences of action. We believe they are representative, however, and illustrate the contrast between the relatively linear sequence of actions in the chemical event and the more diffuse, parallel, and recursive activities in the biological event. The myriad of ''chemical/biological" response teams being developed at federal, state, and local levels are, despite their names, almost entirely focused on detection, decontamination, and expedient treatment of chemical casualties. For both types of incidents, however, there is an existing response framework within which modifications and enhancements can be incorporated. An attack with chemical agents is similar to the hazardous materials incidents that metropolitan public safety personnel contend with regularly. A

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Page 185 FIGURE 11-1 Flow chart of probable actions in a chemical agent incident. 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 mechanisms in efforts to improve the response of the medical community to additional, albeit very dangerous, toxic

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Page 186 FIGURE 11-2 Flow chart of probable actions in a biological agent incident. materials. Strengthening existing mechanisms for dealing with unintentional releases of hazardous chemicals, for monitoring food safety, and for detecting and responding to infectious disease outbreaks, is preferable to building a new system focused solely on potentially devastating but low-probability terrorist events. Indeed, a major reason for the committee's decision to focus the report on response to aerosol attacks with the short list of agents thought to be a threat by U.S. military forces was that these agents are unfamiliar to the U.S. civilian medical system. Regardless of relative probability of use or relative lethality, there are mechanisms in place for dealing with a wide variety of other agents and routes. Our concern was not to foster construction of yet another mechanism, but to encourage the incorporation of these unfamiliar agents and routes into existing mechanisms. A second general conclusion relates to a question which underlays the whole study: whether military approaches to chemical and biological defense are applicable to domestic civilian situations involving these agents. The report points out several aspects of military standard operating

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Page 187 procedure that, as the sponsors feared, will be difficult or impossible to implement in a very heterogeneous and independent civilian population. More importantly, the committee was impressed with the extent to which differences in prior knowledge about the identity of the enemy and the time and place of attack lead to important differences in the needs of military and civilian medical communities. Vaccination, for example, is an obvious preventive measure for a military force poised for combat against an enemy known or suspected to have a stockpile of certain biological weapons. The same holds true for deployment of chemical or biological detection systems, the use of highly specific antidotes and therapeutic and pretreatment drugs: with reasonable intelligence about the enemy's capabilities and proclivities, these tools can be put into action rapidly and confidently. The value of all of these actions diminishes considerably in the most probable civilian terrorism situations, in which the enemy, the agent, the time, and the place of attack are unknown. This difference, even more than differences in the physiology of civilian and military targets, influenced the committee to emphasize treatment over prevention, broad-spectrum drugs, detection with familiar or multiagent equipment, clinical diagnosis based on commercial technology, decontamination without agent-specific equipment or solutions, modification of familiar or multipurpose protective clothing and equipment, and even the advisability of prehospital treatment. Chapter 3 argues for including the medical community in the distribution of pre-incident intelligence to maximize medical response in dealing with chemical or biological incidents, but, important as that is, the time scale envisioned in those arguments is much too short for truly preventive measures like vaccination or the introduction of unfamiliar specialized equipment. A third conclusion which shaped the committee's recommendations concerned problems of scale. In many of the areas surveyed in the previous section, we noted that some capability, often quite good capability, existed 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. Local governments and hospitals are reluctant to spend large amounts of money and time preparing for what they judge as low-probability events. Therefore, although the need for integrated planning cannot be overstated, federal organizations can be very important. Because of the rapidity with which chemical agents act, federal help may actually be of less use in a chemical attack, for which they are much better prepared, than in a biological attack, where onset of signs or symptoms is delayed, variable, and potentially continuing, and

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Page 188 victims are 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, the Metropolitan Medical Strike Teams being organized and equipped by the Public Health Service 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. Detection and identification of agents, either in the environment or in victims' bodies, is currently a piecemeal operation that, in the absence of other information, is as much art as science. In both chemical and biological agent incidents, initial treatment of victims is likely to remain symptom-based for some time. In part this is due to diagnosis problems (knowing what detector to deploy in the environment or what medical test to request), limited detection capability at low but potentially harmful concentrations, and lack of specific treatments for some agents. These difficulties are clearly amenable to technological solutions, and the committee is optimistic about the prospects for faster, easier, more specific patient diagnostics. The committee's recommendations on detection and identification of agents in the environment, however, were shaped very strongly by assumptions about terrorism scenarios: that vapor or aerosol delivery will mean that agents may be difficult to locate 10, 20, or 30 minutes after a chemical agent release, when the first detectors arrive at the scene, and that the release site and time of a biological attack will not be known for days or weeks after the release, if at all. Finally, it is apparent that requirements of federal regulatory agencies (OSHA, FDA) not primarily concerned with emergency response to low-frequency events like chemical or biological terrorism nevertheless have a substantial influence on response capabilities. The characteristics and rules for use of personal protective equipment, for example, fall under the jurisdiction of the Occupational Safety and Health Administration. The investigational (IND) status of some very specific treatments, present and future, will hamper 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.

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Page 189 Recommendations for Research and Development As expected, the committee's review of current capabilities pointed to a number of areas in which innovative R&D is clearly needed. Detailed, specific lists of R&D needs are offered at the end of each chapter (61 in all), and they are summarized below in the form of 8 overarching recommendations. As the text and the inventory in Appendix B reflect, there is a great deal of relevant R&D under way in both the public and private sectors that may meet some of the needs we point out, and the following list of recommendations should not be construed as commentary on the quality of that research or the utility of its intended products for military applications. The order within the list is not by priority, but follows the roughly chronological order of the chapters of this report. Recommendation 1. There needs to be a system in every state and major metropolitan area to ensure that medical facilities, including the state epidemiology office, receive information on actual, suspected, and potential terrorist activity. Specific R&D Needs: • A formal communication network between the intelligence community and the medical community. • A national mechanism for the distribution of clinical data to the intelligence and medical communities after an actual event or exercise. Recommendation 2. The committee endorses continued testing of civilian commercial products for suitability in incidents involving chemical warfare agents, but research is still needed addressing the bulk, weight, and heat stress imposed by current protective suits, developing a powered air respirator with greatly increased protection, and providing detailed guidance for hospitals on dermal and respiratory protection. Specific R&D Needs: • Increased protection factors for respirators. • Protective suits with less bulk, less weight, and less heat stress. • Evaluation of the impact of occupational regulations governing use of personal protective equipment. • Uniform testing standards for protective suits for use in chemical agent incidents. • Guidelines for the selection and use of personal protective equipment in hospitals. • Alternatives to respirators for use by the general public.

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Page 190 Recommendation 3. The civilian medical community must find ways to adapt the many new and emerging detection technologies to the spectrum of chemical and biological warfare agents. Public safety and rescue personnel, emergency medical personnel, and medical laboratories all need faster, simpler, cheaper, more accurate instrumentation for detecting and identifying a wide spectrum of toxic substances, including, but not limited to military agents, in both the environment and in clinical samples from patients. The committee therefore recommends adopting military products in the short run and supporting basic research necessary to adapt civilian commercial products wherever possible in the long run. Specific R&D Needs: • Evaluation of current Hazmat and EMS chemical detection equipment for ability to detect chemical warfare agents. • Miniaturized and less expensive gas chromatography / mass spectrometry technology for monitoring the environment within fixed medical facilities and patient transport vehicles. • Standard Operating Procedures for communicating chemical detection information from first responders to Hazmat teams, EMS teams, and hospitals. • Simple, rapid, and inexpensive methods of determining exposure to chemical agents from clinical samples. • Faster, cheaper, easier patient diagnostics that include rare potential bioterrorism agents. • Inexpensive or multipurpose biodetectors for environmental testing and monitoring. • Basic research on pathogenesis and microbial metabolism. • Scenario-specific testing of assay and detector performance. Recommendation 4. Improvements in CDC, state, and local surveillance and epidemiology infrastructure must be undertaken immediately and supported on a long-term basis. Specific R&D Needs: • Improvements in CDC, state, and local epidemiology and laboratory capability. • Educational/training needs of state and local health departments regarding all aspects of a biological or chemical terrorist incident. • Faster and more complete methods to facilitate access to experts

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Page 191   and electronic disease reporting, from the health care provider level to global surveillance. • Expanded pathogen "fingerprinting" of microbes likely to be used by terrorists and dissemination of the resulting library to cooperating regional laboratories. • Symptom-based, automated decision aids that would assist clinicians in the early identification of unusual diseases related to biological and chemical terrorism. Recommendation 5. R&D in decontamination and triage should concentrate on operations research to identify methods and procedures for triage and rapid, effective, and inexpensive decontamination of large groups of people, equipment, and environments. Specific R&D Needs: • The physical layout, equipment, and supply requirements for performing mass decon for ambulatory and nonambulatory patients of all ages and health in the field and in the hospital; • A standardized patient assessment and triage process for evaluating contaminated patients of all ages; • Optimal solution(s) for performing patient decon, including decon of mucous membranes and open wounds; • The benefit vs. the risk of removing patient clothing; • Effectiveness of removing agent from clothing by showering; • Showering time necessary to remove chemical agents; • Whether high-pressure/low-volume or low-pressure/high-volume spray is more effective for patient decontamination; • The best methodology to employ in determining if a patient is "clean"; and • The psychological impact of undergoing decontamination on all age groups. Recommendation 6. Optimize the utilization of currently available antidotes for nerve agents and cyanide though operations research on stockpiling and distribution, and give high priority to research on an effective treatment for vesicant injuries, investigation of new anticonvulsants, and antibody therapy for nerve agents, development of improved vaccines against both anthrax and smallpox, development of a new antismallpox drug, and research on broad spectrum antiviral and novel antibacterial drugs.

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Page 192 Box 11-1 R&D Needs in Availability, Safety, and Efficacy of Drugs and Other Therapies HIGH PRIORITY   Nerve Agent • Antidote stockpiling and distribution system • Scavenger molecules for pretreatments and immediate post-exposure therapies Vesicants • An aggressive screening program focused on repairing or limiting injuries, especially airway injuries Anthrax • Vigorous national effort to develop, manufacture, and stockpile an improved vaccine Smallpox • Vigorous national effort to develop, manufacture, and stockpile an improved vaccine • Major program to develop new antismallpox drugs for therapy and/or prophylaxis Botulinum Toxins • Recombinant vaccines, monoclonal antibodies, and antibody fragments Non-specific Defenses Against Biological Agents • New specific and broad-spectrum anti-bacterial and anti-viral compounds   MODERATE PRIORITY   Nerve Agents • Intravenous or aerosol delivery of antidotes vs intramuscular injection • Development of new, more effective anticonvulsants for autoinjector applications Cyanide • Dicobalt ethylene diamine tetraacetic acid, 4-dimethylaminophenol, and various aminophenones • Antidote stockpiling and distribution system • Risks and benefits of methemoglobin forming agents, hydroxocobalamin, and stroma-free methemoglobin Phosgene • N-acetylcysteine and systemic antioxidant effects Viral Encephalitides and Viral Hemorrhagic Fevers • Antiviral drugs Botulinum Toxins • Botulinum immune globulin

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Page 193 LOW PRIORITY Brucellosis • Vaccine Pneumonic Plague • Second generation vaccine Q Fever • Genes and gene products involved in pathogenesis Staphylococcal Enterotoxin B (SEB) • Characterization of mechanism of action for vaccine development Ricin • Antiricin antibodies and formalin treated toxoid immunization Mycotoxin • Screening antivesicant treatments in animal models Specific R&D Needs: • See Box 11-1 for a complete listing by agent and priority. Recommendation 7. Educational materials on chemical and biological agents are badly needed by both the general public and mental health professionals. Specific R&D Needs: • Identify resource material on chemical/biological agents and enlist the help of mental health professional societies in developing a training program for mental health professionals • Psychological screening methods for differentiating adjustment reactions after chemical/biological attacks from more serious psychological illness. • Evaluation of techniques for preventing or ameliorating adverse psychological effects in emergency workers, victims, and near-victims. • Agent-specific information on risk assessment/threat perception by individuals and groups and on risk communication by public officials. Recommendation 8. The committee recommends support for computer software R&D in three areas: event reconstruction from medical data, dispersion prediction and hazard assessment, and decontamination and reoccupation decisions.

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Page 194 Specific R&D Needs: • Computer software for rapid reporting of unusual medical symptomology to public-health authorities and linking that data to both toxicological information and models of agent dispersion. • Examination and field-testing of current and proposed atmospheric-dispersion models to determine which would be most suitable for the emergency management community. • Models of other possible vectors of dispersion (e.g., water, food, and transportation). • Customizable simulation software to provide interactive training for all personnel involved in management of chemical or biological terrorism incidents. • Information on the chemical, physical, and toxicological properties of the chemical and biological agents, in order to improve modeling of their environmental transport and fate and to better support recommendations on decontamination and reoccupation of affected property.