Preparation to Face Bioterrorism

India is among the most vulnerable countries that run the risk of facing threats of bioterrorism.   A lot of R&D and groundwork has to be planned and carried out speedily, for the vulnerable countries to offer even a semblance of fight against bioterrorism.   In the current absence of awareness and preparedness, we need to examine what the developed world has been doing to face bioterrorism.

A number of recommendations, based on a very comprehensive survey, to deal with chemical and biological terrorism and to increase civilian medical response, appeared in the publication “Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities (1998)”. This report was prepared by the Committee on R & D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents, Division of Health Science Policy, Institute of Medicine, Board on Environmental Studies and Toxicology, National Research Council, in the US.   While we cannot directly import the western models, which are aimed at improving an existing and reasonably effective preparedness, they will certainly help in planning our own strategies, basing on our ground realities. A summary of the 10 R&D needs and eight recommendations from this report is given here.   Developing countries do not have the organisational infrastructure basis comparable to that in North America or Europe (mentioned in here), although there are some governmental and non-governmental organisations, involved in R&D in public health, drug development and medical issues.   These efforts need to be upgraded to suit each country’s requirements to face bioterrorism and/or natural calamities.

The R&D needs and recommendations presented here may seem to be simple at the first glance, but they are loaded with prescription for extensive and expensive work, on several fronts simultaneously and each one of the 18 statements requires an elaborate explanation, to put it into action.   They would do a lot of good to gear up the potential of a country to manage disease in its day-to-day occurrence and prepare as never before to face natural calamities such as cyclones, floods and earthquakes, which epidemics follow in the wake.

Research and Development Needs

A system is needed to ensure 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 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. The watchwords are simplicity, speed, cost, sensitivity and specificity. The key to widespread purchase and uses lies with identifying a wide spectrum of toxic substances, including but not limited to military agents.
Work on symptom-based tools 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.
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, such as the young, the elderly and those in ill health. This information is necessary to develop guidelines (for example, susceptible 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 environment.
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 (for example, anticholinergics other than atropine), are to be identified.
Complete information is needed on possible interactions of antidotes and therapeutic drugs with anti-hypertensives, 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 (recent threat of anthrax in the US), and unintentional releases of toxic chemicals (the Bhopal gas tragedy) would be especially valuable.
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 of pollutants and toxic waste, but there is little or no systematically collected data on fears and anxieties related to the possibility of purpose fully introduced disease.
Standardised 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

The Committee considered it irresponsible to focus solely on technology R&D that requires elaborate and meticulous planning and is both time consuming and expensive.   Hence, the Committee made eight recommendations involving potentially simpler, faster or less expensive mechanisms than R&D of new technology.     These are slightly modified here for the use of the Developing Countries, which should make a beginning with these recommendations and also take up the R&D measures, simultaneously.

1. Provide financial support for improvements in state and local surveillance
      infrastructure, such as poison control centres and communicable disease
      programmes.

2. Survey major metropolitan hospitals for 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.

3. Encourage the governmental and private agencies engaged in health and medical R&D to share      their information on diseases and drugs and on the location and owners of dangerous biological      materials.    State health departments in turn should be encouraged, by education or training, on      the effects of agents and medical responses required, to add infections by these materials to their      lists of reportable diseases.

4. Provide support to the Army’s efforts to test commercial personal protective
     equipment for protection against nerve and vesicants.

5. Convene discussions among the appropriate agencies on the use of investigational products in           mass-casualty situation and on acceptable proof of efficacy for products where clinical trials are not      ethical or are otherwise impossible.

6. Develop incentives for hospitals, both public and private, to be ambulance
     receiving hospitals, to stockpile nerve-agent antidotes and selected antitoxins
     and put them in the hands of first responders, by changing laws if needed, to
     purchase appropriate personal protective equipment and expandable
     decontamination facilities and train emergency department personnel in their
      use.

7. Provide for state and central training initiatives with a programme to incorporate existing information      on possible chemical and biological terror agents and their treatment into the manuals and      reference libraries of first responders, emergency departments and poison control centres.        Professional societies and journal publishers should be recruited to help in this effort.

8. Intensify Public Health Service efforts to organise and equip Urban Medical Strike Teams, in high-
     risk cities throughout the country.   Although these teams are to be primarily designed to cope up      with terrorism, using local personnel and resources, they also increase the community’s general      ability to cope with industrial accidents and other mass-casualty events.

Related titles:

1. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. 1999. Committee on R&D Needs for Improving Civilian Medical Response to Chemical and Biological Terrorism Incidents. Institute of Medicine, US, National Academy Press.

2. Firepower in the Lab: Automation in the fight against infections, diseases and bioterrorism. 2001. Solt, P Layne, J. Beugeldijk, and C Kumar N. Patel (Eds.). Joseph Henry Press.

Websites:

http://www4.nationalacademies.org/news.nsf/
http://www.medscape.com/Medscape/features/ResourceCenter/BioTerr/
http://books.nap.edu/books/N1000850/html/52/html
http://www.cdc.gov/