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Introduction

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 overseas. Shocking as those attacks were to most Americans, the 1995 attack on the Tokyo subway with nerve gas by an apocalyptic religious cult, Aum Shinrikyo, was even more of a watershed event. The attack, which killed 12 people and sent over 5,000 others to local hospitals, was the first large-scale terrorist use of a chemical 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 used by the Rajneesh cult in Oregon in 1984 to keep 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 large supply of ricin and castor beans and a collection of neo-Nazi 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. The Aum Shinrikyo is reported to have experimented with anthrax and botulinum toxin before settling on the nerve gas sarin (GB) and may even have attempted to obtain a quantity of Ebola virus at the height of the outbreak in Zaire (Fainberg, 1997).



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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 1 Introduction 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 overseas. Shocking as those attacks were to most Americans, the 1995 attack on the Tokyo subway with nerve gas by an apocalyptic religious cult, Aum Shinrikyo, was even more of a watershed event. The attack, which killed 12 people and sent over 5,000 others to local hospitals, was the first large-scale terrorist use of a chemical 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 used by the Rajneesh cult in Oregon in 1984 to keep 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 large supply of ricin and castor beans and a collection of neo-Nazi 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. The Aum Shinrikyo is reported to have experimented with anthrax and botulinum toxin before settling on the nerve gas sarin (GB) and may even have attempted to obtain a quantity of Ebola virus at the height of the outbreak in Zaire (Fainberg, 1997).

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 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. Even more 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. Very 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 well-justified suspicion that Japanese police were about to launch a preemptive strike, employed a very crude delivery system; otherwise, the number of casualties might have been far higher. LEGISLATIVE BACKGROUND The United States government, while continuing to pursue the goal of preventing other countries from acquiring chemical and biological weapons, has 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, effective 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). 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

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities actions, which are predominantly of a law enforcement nature, to the federal government, namely the Federal Bureau of Investigation (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 Federal Emergency Management Agency (FEMA), relying on procedures of the Federal Response Plan originally developed by 27 federal departments and agencies for responding to natural disasters (Federal Emergency Management Agency, 1997) 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 FEMA, the FBI, the Department of Health and Human Services (HHS), 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. This initiative is being supported by $5 million in FY 1997. CHARGE TO THE COMMITTEE The Federal Response Plan designates the Secretary of HHS, 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. HHS'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 an urban environment. The importance to terrorists of psychological impact, which may be significant even when the number of casualties is very 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

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 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), has been asked by OEP to conduct an 18-month study that will (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 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 immediate 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. An annotated roster of committee members is provided in Appendix A, and the agenda from that meeting can be found in Appendix B . ASSUMPTIONS AND PARAMETERS OF THIS REPORT This interim report focuses on current civilian capabilities and makes recommendations for action without evaluation of ongoing and planned research and development, which will be addressed by the committee in the coming months and included in the final report. This focus was selected not only to provide a baseline against which to evaluate the utility of technology and R&D programs, but also because the committee recognizes that research and development programs are only one of a number of methods of improving civilian medical response. It would be irresponsible to focus solely on R&D while ignoring potentially simpler, faster, or less expensive mechanisms, such as organization, manpower, training, and procurement. 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 infinitely long. In practice, the few chemical and biological terrorist incidents that have

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities 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. Preincident intelligence about the specific agent suspected will always be important, for it is not feasible, and perhaps not possible, to be prepared for all possible agents in all possible circumstances. For practical purposes however, the committee has taken as its starting point and as a framework within which to discuss current capabilities, a limited number of “most likely” agents: the relatively short list of chemical and biological agents that have constituted the core of military weapons programs, namely, nerve agents, mustard and related vesicants, cyanide, and phosgene; the infectious microorganisms causing anthrax, brucellosis, plague, Q-fever, tularemia, smallpox, viral encephalitis, and hemorrhagic fever; the bacteria-produced poisons botulinum toxin and staphylococcal enterotoxin B (SEB); the plant-derived toxin ricin, and the fungal metabolite T-2 mycotoxin (Sidell et al., 1997). More comprehensive lists, including these chemical agents and the CDC list of restricted biological agents, are provided as Appendice C and Appendice D. The committee also recognizes that terrorist incidents could take a wide variety of forms. Evaluation of civilian medical and public health capabilities and shortfalls will be very much scenario-dependent. Important variables would 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. At one extreme is an attack with a single recognized chemical agent—a nerve agent, for example—at a site and time that intelligence or simple deduction suggests would be occasion for a terrorist attack—the Capitol Building during the President's annual State of the Union address for example —using a delivery device that yields a distinct “event” and a few dozen to a few hundred victims. Near the other extreme is a covert or surprise attack with a biological agent dispersed in aerosol form over an entire city from a moving automobile or small plane. The World Health Organization (WHO) has estimated that such an attack using 50 kg of anthrax spores might infect as many as 90,000 people in a city of a million inhabitants (WHO Group of Consultants, 1970). Consequence management in these two scenarios is obviously quite different, qualitatively and quantitatively. Our analyses focus on what is possible and what would be desirable in a world of unlimited resources. But the committee also recognizes that for nearly any specific locale (with the possible exception of a few obvious areas like Washington, DC) a terrorist attack of any sort is a very low-probability event, regardless of the magnitude of the consequences, and that effecting expensive or time-consuming actions in preparation for such events is extremely difficult for local governments to justify. As a result, the committee has given special attention to actions that will be valuable even if no terrorist attack ever occurs. A second tier of recommendations focuses on very specific actions that would be valuable in one or a few relatively more likely terrorist scenarios. A third group of suggestions, likely to be more prominent in the final report than here, involves more generic, long-term research and development programs.

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