BIOTERRORISM, PROTECTIVE MEASURES

In the aftermath of the September 11, 2001 terrorist attacks on the United States and the subsequent anthrax attacks on U.S. government officials, media representatives, and citizens, the development of measures to protect against biological terrorism became an urgent and contentious issue of public debate. Although the desire to increase readiness and response capabilities to possible nuclear, chemical, and biological attacks is widespread, consensus on which preventative measures to undertake remains elusive.

The evolution of political realities in the last half of the twentieth century and events of 2001 suggest that, within the first half of the twenty-first century, biological weapons will surpass nuclear and chemical weapons as a threat to the citizens of the United States.

Although a range of protective options exists—from the stockpiling of antibiotics to the full-scale resumption of biological weapons programs—no single solution provides comprehensive protection to the complex array of potential biological agents that might be used as terrorist weapons. Many scientists argue, therefore, that focusing on one specific set of protective measures (e.g., broadly inoculating the public against the virus causing smallpox) might actually lower overall preparedness and that a key protective measure entails upgrading fundamental research capabilities.

The array of protective measures against bioterrorism are divided into strategic, tactical, and personal measures.

Late in 2001, the United States and its NATO (North Atlantic Treaty Organization) allies reaffirmed treaty commitments that stipulate the use of any weapon of mass destruction (i.e., biological, chemical, or nuclear weapons) against any member state would be interpreted as an attack against all treaty partners. As of June 2002, this increased strategic deterrence was directed at Iraq and other states that might seek to develop or use biological weapons—or to harbor or aid terrorists seeking to develop weapons of mass destruction. At the tactical level, the United States possesses a vast arsenal of weapons designed to detect and eliminate potential biological weapons. Among the tactical non-nuclear options is the use of precision-guided conventional thermal fuel-air bombs capable of destroying both biological research facilities and biologic agents.

Because terrorist operations are elusive, these largescale military responses offer protection against only the largest, identifiable, and targetable enemies. They are largely ineffective against small, isolated, and dispersed "cells" of hostile forces, which operate domestically or within the borders of other nations. When laboratories capable of producing low-grade weaponizable anthrax-causing spores can be established in the basement of a typical house for less than $10,000, the limitations of full-scale military operations become apparent.

Many scientists and physicians argue that the most extreme of potential military responses, the formal resumption of biological weapons programs—even with a limited goal of enhancing understanding of potential biological agents and weapons delivery mechanisms—is unneeded and possibly detrimental to the development of effective protective measures. Not only would such a resumption be a violation of the Biological Weapons Convention to which the United States is a signatory and which prohibits such research, opponents of such a resumption argue any such renewal of research on biological weapons will divert critical resources, obscure needed research, and spark a new global biological arms race.

Most scientific bodies, including the National Institutes of Health, Centers for Disease Control and Prevention, advocate a balanced scientific and medical response to the need to develop protective measures against biological attack. Such plans allow for the maximum flexibility in terms of effective response to a number of disease causing pathogens.

In addition to increased research, preparedness programs are designed to allow a rapid response to the terrorist use of biological weapons. One such program, the National Pharmaceutical Stockpile Program (NPS) provides for a ready supply of antibiotics, vaccines, and other medical treatment countermeasures. The NPS stockpile is designed to be rapidly deployable to target areas. For example, in response to potential exposures to the Bacillus anthracis (the bacteria that causes anthrax) during the 2001 terrorist attacks, the United States government and some state agencies supplied Cipro, the antibiotic treatment of choice, to those potentially exposed to the bacterium. In addition to increasing funding for the NPS, additional funds have already been authorized to increase funding to train medical personnel in the early identification and treatment of disease caused by the most likely pathogens.

Despite this increased commitment to preparedness, medical exerts express near unanimity in doubting whether any series of programs or protocols can adequately provide comprehensive and effective protection to biological terrorism. Nonethless, advocates of increased research capabilities argue that laboratory and hospital facilities must be expanded and improved to provide maximum scientific flexibility in the identification and response to biogenic threats. For example, the Centers for Disease Control and Prevention (CDC), based in Atlanta, Georgia, has established a bioterrorism response program that includes increased testing and treatment capacity. The CDC plan also calls for an increased emphasis on epidemiological detection and surveillance, along with the development of a public heath infrastructure capable of providing accurate information and treatment guidance to both medical professionals and the general public.

Because an informed and watchful public is key element in early detection of biological pathogens, the CDC openly identifies potential biological threats and publishes a list of those biological agents most likely to be used on its web pages. As of July 2002, the CDC identified approximately 36 microbes including Ebola virus variants and plague bacterium, that might be potentially used in a bioterrorist attack

Other protective and emergency response measures include the development of the CDC Rapid Response and Advanced Technology Laboratory, a Health Alert Network (HAN), National Electronic Data Surveillance System (NEDSS), and Epidemic Information Exchange (Epi-X) designed to coordinate information exchange in efforts to enhance early detection and identification of biological weapons.

Following the September 11, 2001 terrorist attacks on the United States, additional funds were quickly allocated to enhance the United States Department of Health and Human Services 1999 Bioterrorism Initiative. One of the key elements of the Bioterrorism Preparedness and Response Program (BPRP) increases the number and capacity of laboratory test facilities designed to identify pathogens and find effective countermeasures. In response to a call from the Bush administration, in December 2001, Congress more than doubled the previous funding for bioterrorism research.

Advances in effective therapeutic treatments are fundamentally dependent upon advances in the basic biology and pathological mechanisms of microorganisms. In response to terrorist attacks, in February 2002, the US National Institute of Allergy and Infectious Diseases (NIAID) established a group of experts to evaluate changes in research in order to effectively anticipate and counter potential terrorist threats. As a result, research into smallpox, anthrax, botulism, plague, tularemia, and viral hemorrhagic fevers is now given greater emphasis.

In addition to medical protective measures, a terrorist biological weapon attack could overburden medical infrastructure (e.g., cause an acute shortage of medical personnel and supplies) and cause economic havoc. It is also possible that an effective biological weapon could have no immediate effect upon humans, but could induce famine in livestock or ruin agricultural production. A number of former agreements between federal and state governments involving response planning will be subsumed by those of the Department of Homeland Security.

On a local level, cities and communities are encouraged to develop specific response procedures in the event of bioterrorism. Most hospitals are now required to have response plans in place as part of their accreditation requirements.

In addition to airborne and surface exposure, biologic agents may be disseminated in water supplies. Many communities have placed extra security on water supply and treatment facilities. The U.S. Environmental Protection Agency (EPA) has increased monitoring and working with local water suppliers to develop emergency response plans.

Although it is beyond the scope of this article to discuss specific personal protective measures—nor given the complexities and ever-changing threat would it be prudent to offer such specific medical advice—there are a number of general issues and measures that can be discussed. For example, the public has been specifically discouraged from buying often antiquated military surplus gas masks, because they can provide a false sense of protection. In addition to issues of potency decay, the hoarding of antibiotics has is also discouraged because inappropriate use can lead to the development of bacterial resistance and a consequential lowering of antibiotic effectiveness.

Generally, the public is urged to make provisions for a few days of food and water and to establish a safe room in homes and offices that can be temporarily sealed with duct tape to reduce outside air infiltration.

More specific response plans and protective measures are often based upon existing assessments of the danger posed by specific diseases and the organisms that produce the disease. For example, anthrax (Bacillus anthracis), botulism (Clostridium botulinum toxin), plague (Yersinia pestis), smallpox (Variola major), tularemia (Francisella tularensis), and viral hemorrhagic fevers (e.g., Ebola, Marburg), and arenaviruses (e.g., Lassa) are considered high-risk and high-priority. Although these biogenic agents share the common attributes of being easily disseminated or transmitted and all can result in high mortality rates, the disease and their underlying microorganisms are fundamentally different and require different response procedures.

Two specific protective measures, smallpox and anthrax vaccines, remain highly controversial. CDC has adopted a position that, in the absence of a confirmed case of smallpox, the risks of resuming general smallpox vaccination far outweigh the potential benefits. In addition, vaccine is still maintained and could be used in the event of a bioterrorist emergency. CDC has also accelerated production of a smallpox vaccine. Moreover, vaccines delivered and injected during the incubation period for smallpox (approximately 12 days) convey at least some protection from the ravages of the disease.

Also controversial remains the safety and effectiveness of an anthrax vaccine used primarily by military personnel.