Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities (1998)

The bombing 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, but the 1995 nerve gas attack on the Tokyo subway by an apocalyptic religious cult added a new dimension to plans for coping with terrorism. Traditional military approaches to battlefield detection of chemical and biological weapons and the protection and treatment of young healthy soldiers are not necessarily suitable or easily adapted for use by civilian health providers dealing with a heterogeneous population of casualties in an urban environment.

For these reasons, the Institute of Medicine (IOM), aided by the Commission on Life Sciences (CLS), has been asked by the U.S. Department of Health and Human Services' Office of Emergency Preparedness (OEP) to:

1. collect and assess existing research, development, and technology information on detecting potential chemical and biological agents and protecting and treating both the targets of attack and health care providers, and

2. provide specific recommendations for priority research and development.

This interim report focuses on current civilian capabilities rather than ongoing and planned research and development (R&D) programs, which will be addressed in the committee's final report. The interim report thus provides a baseline against which to evaluate the utility of technology and R&D programs. It identifies some general areas in which innovative R&D is clearly needed, and in some cases is already underway. Assessment of this work and its applicability to coping with domestic terrorism will constitute the second half of this study and be the focus of the final report.

It would be a grave mistake to assume that terrorists will not be able and willing to take advantage of biotechnology to develop new chemical or biological threats. 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. As a practical matter, the committee has taken as its reference point the relatively short list of chemical and biological agents that have constituted the core of military weapons programs: nerve agents, cyanide, phosgene, vesicants such as mustard; 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; the plant-derived toxin ricin, and fungal metabolite T-2 mycotoxin. Appendix C and Appendix D provide longer lists of chemical and biological agents respectively.

The committee also recognizes that for nearly any specific locale, a terrorist attack of any sort is a very low-probability event, and for that reason expensive or time-consuming actions in preparation for such events are 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 attack ever occurs. A second tier of recommendations focus on specific actions that would be valuable in a few more likely scenarios. A third level of suggestions, which are likely to be more prominent in the final report than here, involves more generic, long-term research and development.

This interim report describes current preparedness at each of four levels of medical intervention—local first responders, initial treatment facilities, state departments of emergency services and public health, and a variety of federal agencies. The specific capabilities assessed are preincident intelligence; detection of agents in the environment; personal protective equipment; safe and effective patient extraction; recognition of signs and symptoms in patients; detection of agent exposure in clinical samples; detection of covert exposures of a population; mass-casualty triage procedures; decontamination of exposed individuals; availability, safety, and efficacy of drugs and other therapeutics; and prevention and treatment of psychological effects. This executive summary discusses these capabilities under three broad headings (1) detection, (2) protection, and (3) treatment.

Hazardous materials or “Hazmat” teams are routinely equipped with a variety of chemical detectors and monitoring kits, primarily employing chemical-specific tests indicating only the presence or absence of a suspected chemical or class of chemical. The most common detectors test for pesticides, chlorine, and cyanide, but not specifically for phosgene, vesicants, or nerve agents. Although chemical tests, detectors, and monitors used by the military (Appendix G) are commercially available for civilian use, for various reasons they have not been acquired by civilian organizations in appreciable numbers.

Real-time detection and measurement of biological agents in the environment is more daunting, even for the military, because of the number of potential agents to be distinguished, the complex nature of the agents themselves, and the myriad similar microorganisms that are always present in the environment. Few if any civilian organizations currently have, or can easily obtain, even a rudimentary capability in this area.

Laboratory assays indicating exposure to nerve agents and cyanide are known and available at many hospitals, but there is no current clinical test for mustard agents or other vesicants. However, for all of these agents except mustard, individuals receiving significant doses usually develop signs and symptoms within a matter of minutes after exposure. Therefore initial diagnosis and treatment are likely to be based on observations of signs and symptoms by the paramedic or other health care professional on the scene.

Some serological, immunological, and nucleic acid assays are available for identifying all of the biological agents being considered in this report, and many hospitals and commercial laboratories have the necessary equipment and expertise to perform these and similar assays. However, these diseases are extremely rare in the United States, and for that reason these laboratories do not perform these assays regularly. It therefore seems unlikely that many labs will be immediately prepared to conduct the specific analytical test needed to identify the agent, even when the attending physician is astute enough to ask for the test.

In the case of biological agents, however, because the time lag between exposure to a pathogen and the onset of symptoms may be days or weeks, effective response to a covert terrorist action will be critically dependent upon (a) the ability of individual clinicians, perhaps widely scattered around a large metropolitan area, to identify and accurately diagnose an uncommon disease and (b) a surveillance system for collecting reports of such cases that is actively monitored to catch disease outbreaks as they arise.

The Centers for Disease Control and Prevention (CDC) operates a large number of infectious disease surveillance systems based on voluntary collaboration with state and local health departments, surveys, vital records, or registries. The best known of these systems, the National Notifiable Disease Surveillance System, currently includes only three of the diseases considered likely to be used in bioterrorism. In addition, no federal funds are provided to state and local health departments to support this system, and states' ability or willingness to support infectious disease surveillance has declined in recent years. CDC's Emerging Infectious Disease Initiative (EIDI) is attempting to reverse this trend by making grants to state and local health departments for improving epidemiological and laboratory capability. CDC has also signed agreements with seven state health departments, in collaboration with local academic, governmental, and private sector organizations, to create Emerging Infections Epidemiology and Prevention Centers. Priority activities of these centers include active population-based

surveillance on selected diseases. Few of the diseases resulting from the biological agents addressed in this report are among those currently being monitored in these centers, but expanding the activities of these centers would be an excellent way to raise awareness of bioterrorism.

In most of the chemical terrorism scenarios imaginable, the rapid onset of toxic effects would lead to highly localized collections of victims within minutes or hours, so the need for active surveillance is less pressing. A network of regional poison control centers is well established, however, and, if its personnel were educated about military chemical weapons, would be well suited for surveillance. Poison control centers are also obvious candidates to serve as regional data and resource coordinating centers in incidents involving multiple sites or large numbers of patients.

Personal protective equipment (PPE) refers to clothing and respiratory gear designed to shield an individual from chemical, biological, and physical hazards. The amount and type of protection required varies with the nature and concentration of the hazard and the duration of exposure anticipated. A basic rule in selecting PPE is that the equipment be matched to the hazard, but the testing and certification demanded by the Occupational Safety and Health Administration (OSHA) does not involve military nerve agents or vesicants and military PPE that has been tested for protection against those agents generally does not have the testing and certification that would allow its use by civilian workers. Thus it is difficult to say with confidence which, if any, civilian workers have suitable PPE, although some of the most protective ensembles, “Level A,” would almost certainly provide adequate protection for a short time.

Firefighters' normal PPE is designed to protect against heat, fire and smoke, not chemicals, but they often have sufficient respiratory protection available to allow for a brief reconnaissance and initial decontamination of victims if there is no threat of exposure by contact with skin. Hazmat teams have a small number of Level A suits, but emergency medical personnel most often have PPE suited only for treatment of previously decontaminated patients.

Hospitals receive not only field-decontaminated patients but also “walk-ins” who may have bypassed field decontamination. Despite Joint Commission on Accreditation of Healthcare Organizations standards calling for hospitals to have Hazmat plans and conduct Hazmat training, two recent reviews have suggested that most hospitals in the United States are ill prepared to treat chemically contaminated patients.

Emergency medical personnel, both at the scene of hazardous materials incidents and in hospital emergency departments have a wide selection of reference materials to call upon for guidance in patient management. However, few if any of these sources provide information on the purely military agents (e.g., nerve and mustard), and these resources are almost always

organized by chemical rather than by signs and symptoms. A similar situation exists for biological agents. The diseases and toxic responses they cause are rare in the United States, and because their signs and symptoms are not unique, doctors are not likely to suspect a disease or toxin associated with biological weapons.

The removal of chemical agent from exposed individuals is the first step in preventing severe injury or death. Civilian Hazmat teams generally have basic decontamination plans in place, though proficiency may vary widely. Very few teams are manned, equipped, or trained for mass-decontamination. Hospitals need to be prepared to decontaminate patients, despite plans that call for field decontamination of all patients before transport to hospitals. However, few hospitals have decontamination facilities; even fewer have outdoor facilities or an easy way of expanding their decontamination operations in an event involving mass casualties.

With a few exceptions, treatment of a very small number of individuals exposed to any chemical or biological agent is not beyond current medical capabilities. However, large numbers of casualties will quickly overtax those capabilities. Vaccines, drugs, antitoxins, and supportive medical equipment are generally available in small quantities. Moreover, many of the vaccines and antitoxins are not FDA approved and are only available as Investigational New Drugs (IND). This means not only that the product is only available in limited amounts, but that it can be used only in a research setting with the informed consent of the recipient. Thus, IND status effectively precludes use in a mass-casualty situation.

Incidents of chemical and biological terrorism may involve large numbers of victims. Risks to victims and rescue and health care workers in such incidents include not only physical injury but psychological trauma. Research on posttraumatic stress disorder (PTSD) has expanded far beyond studies of Vietnam veterans in the last 20 years, and includes a few studies of large-scale industrial accidents, among them, chemical spills. The latter studies have most often been epidemiological in nature, focusing on sequelae rather than treatment methods and their efficacy. One technique, Critical Incident Stress Debriefing (CISD), has gained wide acceptance among field emergency workers and is increasingly used by hospital-based emergency personnel, the military, public safety personnel, volunteers, victims, unwilling witnesses, and even schoolmates of victims. It can reasonably be expected that many local police, fire, and emergency medical units will be familiar with the process, have access to trained debriefers, and plans for their utilization, but, despite CISD's popularity, the few controlled studies have not yielded clear evidence of its efficacy.

At the federal level, the National Disaster Medical Service (NDMS) includes special Disaster Medical Assistance Teams specializing in mental health, and the Federal Emergency Management Agency (FEMA) funds the Crisis Counseling Assistance and Training Program (CCP). The focus of both the NDMS teams and the CCP is on short-term interventions that help people with normal reactions to abnormal experiences, rather than long-term therapy for pathological conditions.

Among the conclusions that have emerged from the committee's study to date, two are particularly important. The first is that terrorist incidents involving biological agents, especially

infectious diseases, are likely to be very different from those involving chemical agents and demand very different preparation and response. The second is that in both cases (i.e., biological and chemical) there are existing response frameworks 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.

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. No prioritization is intended by the order of appearance on the list.

• There needs to be a system in every state and major metropolitan area to insure that medical facilities 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 detection of these toxic 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.

• 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 and decontamination procedures.

• 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 items 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 Tokyo subway sarin release, 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 infection.

• 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.

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.

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), and 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 into the manuals, SOPs, textbooks, and reference libraries of first responders, emergency departments, and poison control centers. User-friendly online or CD-ROM databases are especially important. 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 (MMST) in high-risk cities throughout the country. Although MMSTs are designed to cope with chemical and biological terrorism, because they use local personnel and resources, they increase the community's general ability to cope with industrial accidents and other mass-casualty events.