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3

Conclusions and Recommendations

Several general conclusions may be drawn from this brief survey of existing capabilities. Perhaps most obvious is that terrorist incidents involving biological agents, especially infectious agents, are likely to be very different from those involving chemical agents and demand very different preparation and response. 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 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 materials. It would be similarly ill advised to ignore the existing mechanisms for providing federal disaster assistance to local communities. Actions such as decontamination and antidote administration may be needed on an unprecedented scale, however, and the need for integrated planning cannot be overstated.

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. 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 are widely dispersed. The National Disaster Medical System (NDMS), for example, would be a critical component of response to any large-



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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 3 Conclusions and Recommendations Several general conclusions may be drawn from this brief survey of existing capabilities. Perhaps most obvious is that terrorist incidents involving biological agents, especially infectious agents, are likely to be very different from those involving chemical agents and demand very different preparation and response. 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 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 materials. It would be similarly ill advised to ignore the existing mechanisms for providing federal disaster assistance to local communities. Actions such as decontamination and antidote administration may be needed on an unprecedented scale, however, and the need for integrated planning cannot be overstated. 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. 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 are widely dispersed. The National Disaster Medical System (NDMS), for example, would be a critical component of response to any large-

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 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. Rapid 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 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. Finally, it is apparent that the 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. RESEARCH AND DEVELOPMENT NEEDS As expected, the committee's review of current capabilities pointed to a number of areas in which innovative R&D is clearly needed. The committee realizes that there is considerable R&D underway in both the public and private sectors that may meet some of these needs, and the following list of needs should not be construed as commentary on the quality of that research or the utility of its intended products. Rather, it should be seen as an empirically grounded starting place for the committee's subsequent assessment of potentially useful technology and R&D. The order within the list is not by priority, but follows the roughly chronological sections of this report. 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. Research may be necessary to determine what should be communicated, to whom it should be communicated, and even whether the system should vary by state and city, but it must include links to the law enforcement community. 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. First responders, emergency medical personnel, and public safety officials all need improved instrumentation for detecting and identifying chemical and biological agents in both the environment and in clinical samples from patients. Areas for improvement are simplicity, speed, cost, sensitivity, and specificity, but the key to widespread purchase and use lies with identifying a wide spectrum of toxic substances, including but not limited to military agents.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Further work on a symptom-based tool for identifying unknown toxic agents, including but not limited to, military chemical weapons, is an area where benefits may extend well beyond response to terrorist acts. More complete information is needed on the toxicity and adverse health effects that could result from acute exposure to low levels of agents, especially in sensitive populations (e.g., the young, the elderly, and those in ill health). This information is necessary to develop guidelines (e.g., acceptable human exposure levels) for safe and effective evacuation, decontamination, and other protective action. Methods are needed for rapid, effective, and inexpensive decontamination of large groups of personnel, equipment, and environments. New approaches to treatment are needed that have utility beyond terrorism or chemical and biological warfare: vaccines or drugs aimed at families of pathogens or toxins, substances to bind toxic molecules before they reach their site of action, and perhaps even existing drugs and other chemicals that can serve as expedient treatment (e.g., anticholinergics other than atropine). More complete information is needed on possible interactions of antidotes and therapeutic drugs with antihypertensives, psychotherapeutics, anti-inflammatory compounds, immunosuppressants, and other medications in widespread public use. There is a need for evaluation of interventions for preventing or ameliorating adverse psychological effects in emergency workers, victims and near-victims. Examination of the Japanese experience following the release of sarin on the Tokyo subway, other acts of terrorism, and unintentional releases of toxic chemicals would be especially valuable. Additional information is needed on risk assessment/threat perception by individuals and groups, and on risk communication by public officials, especially the roles of both the mass media and the internet in the transmission of anxiety (or confidence). Some information is available in EPA studies of pollutants and toxic waste, but there is little or no systematically collected data on fears and anxieties related to the possibility of purposefully introduced disease. Standardized protocols for follow-up of first responders, healthcare providers, and victims are required, for improving care of those individuals, for improving medical response to future incidents, and for improving risk assessments. INTERIM RECOMMENDATIONS As noted in the Introduction, the committee believes that it would be irresponsible to focus solely on technology R&D. The report therefore concludes with the following eight recommendations involving potentially simpler, faster, or less expensive mechanisms than research and development of new technology: Recommendation 1: Provide federal financial support for improvements in state and local surveillance infrastructure—namely poison control centers and communicable disease programs, including expansion of the CDC Emerging Infections Initiatives.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Recommendation 2: Survey major metropolitan hospitals on supplies of antidotes, drugs, ventilators, personal protective equipment, decontamination capacity, mass-casualty planning and training, isolation rooms for infectious disease, and familiarity of staff with the effects and treatment of chemical and biological weapons. Recommendation 3: Encourage the CDC to share with the states its database on the location and owners of dangerous biological materials. State health departments in turn should be encouraged, perhaps by education or training on the effects of the agents and medical responses required, to add infections by these materials to their lists of reportable diseases. Recommendation 4: Provide additional support for the Army's efforts to test commercial (i.e., OSHA/NIOSH/NFPA-approved) personal protective equipment for protection against nerve agents and vesicants. Recommendation 5: Convene discussions with FDA on the use of investigational products in mass-casualty situations and on acceptable proof of efficacy for products where clinical trials are not ethical or are otherwise impossible. Recommendation 6: Develop incentives for hospitals to be ambulance-receiving hospitals, to stockpile nerve-agent antidotes and selected antitoxins and put them in the hands of first responders (this may require changes to existing laws or regulations in some states), to purchase appropriate personal protective equipment and expandable decontamination facilities and train emergency department personnel in their use. Recommendation 7: Supplement existing state and federal training initiatives with a program to incorporate existing information on possible chemical or biological terror agents and their treatment into the manuals, SOPs, and reference libraries of first responders, emergency departments, and poison control centers. Professional societies and journal publishers should be recruited to help in this effort. Recommendation 8: Intensify Public Health Service efforts to organize and equip Metropolitan Medical Strike Teams in high-risk cities throughout the country. Although MMSTs are designed to cope with terrorism, because they use local personnel and resources, they also increase the community 's general ability to cope with industrial accidents and other mass-casualty events.