Chemical and Biological Terrorism
Research and Development to Improve Civilian Medical Response
NATIONAL ACADEMY PRESS
Washington, D.C. 1999
NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, NW • Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
Support for this project was provided by the Office of Emergency Preparedness, Department of Health and Human Services (Contract No. 282-97-0017). This support does not constitute an endorsement of the views expressed in the report.
Library of Congress Cataloging-in-Publication Data
Chemical and biological terrorism: research and development to improve civilian medical response / Committee on R&D Needs for Improving
Civilian Medical Response to Chemical and Biological Terrorism Incidents, Health Science Policy Program, Institute of Medicine, and Board on
Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council.
Includes bibliographical references and index.
ISBN 0-309-06195-4 (hardcover)
1. Chemical warfareHealth aspects. 2. Biological
warfareHealth aspects. 3. Civil defenseUnited States. 4.
TerrorismGovernment policyUnited States. 5. Disaster
medicineUnited States. I. Institute of Medicine (U.S.). Committee
on R & D Needs for Improving Civilian Medical Response to Chemical
and Biological Terrorism Incidents. II. National Research Council
(U.S.). Board on Environmental Studies and Toxicology.
RA648 .C525 1999
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Committee on R&D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents
PETER ROSEN (Chair), Director, Emergency Medicine Residency Program, School of Medicine, University of California, San Diego
LEO G. ABOOD, Professor of Pharmacology, Department of Pharmacology and Physiology, University of Rochester Medical Center*
GEORGES C. BENJAMIN, Deputy Secretary, Public Health Services, Department of Health and Mental Hygiene, Baltimore, Maryland
ROSEMARIE BOWLER, Assistant Professor and Fieldwork Coordinator, Department of Psychology, San Francisco State University
JEFFREY I. DANIELS, Leader, Risk Sciences Group, Health and Ecological Assessment Division, Earth and Environmental Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California
CRAIG A. DeATLEY, Associate Professor, Department of Emergency Medicine and Health Care Sciences Program, The George Washington University, Washington, D.C.
LEWIS R. GOLDFRANK, Director, Emergency Medicine, New York University School of Medicine and Bellevue Hospital Center, New York
JEROME M. HAUER, Director, Office of Emergency Management, City of New York
KAREN I. LARSON, Toxicologist, Office of Toxic Substances, Washington Department of Health, Olympia
MATTHEW S. MESELSON, Thomas Dudley Cabot Professor of the Natural Sciences, Department of Molecular and Cellular Biology, Harvard University, Cambridge, Massachusetts
DAVID H. MOORE, Director, Medical Toxicology Programs, Battelle Edgewood Operations, Bel Air, Maryland
DENNIS M. PERROTTA, Chief, Bureau of Epidemiology, Texas Department of Health, Austin
LINDA S. POWERS, Professor of Electrical and Biological Engineering, and Director, National Center for the Design of Molecular Function, Utah State University, Logan
PHILIP K. RUSSELL, Professor of International Health, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland
JEROME S. SCHULTZ, Director, Center for Biotechnology and Bioengineering, University of Pittsburgh
ROBERT E. SHOPE, Professor of Pathology, University of Texas Medical Branch, Galveston
ROBERT S. THARRATT, Associate Professor of Medicine and Chief, Section of Clinical Pharmacology and Medical Toxicology, Division of Pulmonary and Critical Care Medicine, University of California, Davis Medical Center, Sacramento
*Deceased, January 1998.
JUDITH H. LAROSA, Professor and Chair, Department of Community Health Services, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, and Liaison to the Board on Health Science Policy
WARREN MUIR, President, Hampshire Research Institute, Alexandria, Virginia, and Liaison to the Board on Environmental Studies and Toxicology
FREDERICK J. MANNING, Project Director
CAROL MACZKA, Senior Program Officer
C. ELAINE LAWSON, Program Officer
JENNIFER K. HOLLIDAY, Project Assistant (May 1997 through May 1998)
THOMAS J. WETTERHAN, Project Assistant (June 1998 through November 1998)
Institute of Medicine Staff
CHARLES H. EVANS, JR., Head, Health Sciences Section
ANDREW POPE, Director, Health Sciences Policy Program
LINDA DEPUGH, Section Administrative Assistant
JAMAINE TINKER, Financial Associate
National Research Council Staff
JAMES REISA, Director, Board on Environmental Studies and Toxicology
Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report:
JOHN D. BALDESCHWIELER, Professor of Chemistry, California Institute of Technology, Pasadena
DONALD A. HENDERSON, University Distinguished Professor, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland
DAVID L. HUXSOLL, Dean, School of Veterinary Medicine, Louisiana State University, Baton Rouge
JOSHUA LEDERBERG, Sackler Foundation Scholar, Rockefeller University, New York
H. RICHARD NESSON, Senior Consultant, Partners Health Care System, Inc., Boston
MICHAEL OSTERHOLM, Chief, Acute Disease Epidemiology Section, Minnesota Department of Health, Minneapolis
ANNETTA P. WATSON, Research Staff, Health and Safety Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee
MELVIN H. WORTH, Clinical Professor, State University of New York-Brooklyn and Uniformed Services University of Health Sciences, and Institute of Medicine Scholar-in-Residence
The committee would also like to thank the following individuals for their technical reviews of single chapters of the draft report:
ROBERT E. BOYLE, Formerly Technical Advisor, Chemical Warfare and NBC Defense Division, Office of the Deputy Chief of Staff for Operations, Plans, and Policy, Department of the Army, Washington, D.C.
GREGORY G. NOLL, Hildebrand and Noll Associates, Inc., Lancaster, Pennsylvania
ROBERT S. PYNOOS, Professor and Director, Trauma Psychiatry Service, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
JOSEPH J. VERVIER, Senior Staff Scientist, ENSCO, Inc., Melbourne, Florida, and formerly Technical Director, Edgewood Research, Development and Engineering Center, Aberdeen Proving Ground, Maryland
Although the individuals listed above have provided many constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests solely with the authoring committee and the institution.
American military forces have been struggling with the issue of chemical and biological warfare for decadesa 1917 National Research Council Committee laid the groundwork for the Army Chemical Warfare Servicebut it was the attack of the Tokyo subway with the nerve gas sarin in March 1995 that suddenly put the spotlight on the danger to civilians from chemical and biological attacks. The Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services' Office of Emergency Preparedness (OEP), which is responsible for medical services, have an admirable record of helping state and local governments cope with floods, storms, and other disasters, including terrorism, but, fortunately, no direct experience with the consequences of chemical or biological terrorism. In May 1997, the Institute of Medicine was asked to help OEP prepare for the possibility of chemical or biological terrorism, and, with help from the National Research Council's Board on Environmental Studies and Toxicology, formed this committee to provide recommendations for priority research and development (R&D).
In the ensuing year and a half, the committee met four times, heard presentations on existing technology and ongoing R&D, attempted to absorb a virtual mountain of information, and formulated their recommendations. In the process, a number of things became clear to me. I suspect the rest of the committee would agree, but I will exercise the chair's prerogative at this point, and share the view from my perspective.
First, there is no way to prepare in an optimal fashion for a terror incident. There is too low an incidence to justify the enormous financial
outlay it would take to optimally prepare every community for every possible incident. Furthermore, there are not enough incidents for any community to acquire enough experience to make a significant impact on response to the next episode.
Second, although there is a sophisticated technology, described within the body of the report, for in-line detection of an opposing forces chemical agent, it will not be possible to select the sites to protect in a civilian setting with such technology, even if the expense could be borne. At best, it might be possible to selectively protect a public arena where the President was to give an address.
Third, there is no guarantee that the terrorist will announce the attack. Without such an announcement, there will be no recognition that a biological attack is occurring until enough cases, including a number of fatalities, are observed and reported to allow recognition of an epidemic of an unusual disease. Since exposed victims will almost certainly not seek medical care in the same facility, the problem becomes compounded even more greatly. *
Fourth, virtually all the militarily important biologic agents present with early clinical symptoms that resemble viral flu syndromes. Since these are the most common form of acute illness, and since they are usually mild and nonserious, it is probable that the early victims of the attack will be unrecognized, and sent home from a physician's office or Emergency Department as a mild viral syndrome. Therefore, in any response planning, it has to be acknowledged that it will be impossible to prevent ALL mortality, no matter how good a technology can be developed, and no matter how much money we are willing to spend to enhance our response.
Fifth, there is a huge gap between detection technology and therapy. There are many biologic agents, and certainly many chemical agents for which there are no known treatments. We should not expect that terrorists will choose the agents for which we are prepared, and for which we have effective treatment, even if they are the easiest to create and disperse, such as anthrax or sarin.
Sixth, the approach that the committee found most useful to consider in making its recommendations was considering how to superimpose a response
* For example, in Wyoming this year (Summer 1998), there has been an epidemic of E. coli diarrhea from a contaminated spring that fed the water supply of the small town of Alpine. There were well over a hundred cases that involved 12 states since the tourists who acquired the disease were from many different locations. It took at least two months to find the source of the contamination, and the only reason that the epidemic was recognized as early as it was, is that there were only a small number of medical facilities available to the victims.
to a terror attack upon the systems that are already in place to deal with nonterror events. For example, an earthquake, or a chemical spill, or a flu epidemic will all stress and often overload existing medical facilities. There must be systems in place to deal with these problems, not only on a local basis, but when help must be brought in from outside the afflicted area. These are the systems that will be most appropriate to build on for an effective response to an incident of chemical or biological terrorism.
Seventh, communication between the medical community and agencies that gather and analyze intelligence about potential terrorists and attacks is critical. As alluded to above, it will not only shorten the identification issues and lead to more effective responses, but will clearly lower mortality.
There are a number of areas that will not be covered in this report. For example, it was not possible for the committee to discuss every conceivable biological and chemical weapon that might be used in an attack. It is probable that to prepare only for the list of known weapons and most likely agents will take a commitment and a financial expenditure that will exceed the resources of virtually all communities.
The committee's charge did not include making recommendations on organization and training of individuals and groups faced with managing the consequences of a chemical or biological incident, nor on how to equip such persons or groups, nor on what therapeutic options they should choose. Nevertheless, as noted in our interim report, the committee believes that it would be irresponsible to focus solely on R&D while ignoring potentially simpler, faster, or less expensive mechanisms, such as organization, staff, training, and procurement. Examples from our interim report include:
Even though the tasks of being prepared and responding adequately appear at times to contain insurmountable obstacles, the committee does believe that by utilizing the resources that are present, along with improvements in communications, monitoring capabilities, detection, and therapeutics, it will be possible to minimize the damage that a terror attack will cause. It is not our intent to leave the readers of this report with feelings of hopelessness. Even if preparation for certain attacks only forces the attackers to choose a weapon that we have not prepared for, we will have developed a system with which we can improvise. The goal, as always in medicine, is to reduce morbidity and mortality and minimize suffering.
In closing I would like to offer my sincere thanks to the staff of the Institute of Medicine, who made our meetings as comfortable and efficient as possible and pulled our sometimes splintered efforts into a coherent whole, and to the members of the committee, busy professionals who volunteered precious time and energy in a highly collegial manner. It was a privilege to work with this outstanding group.
PETER ROSEN, M.D.
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