3.Coordination among Institutions involved in Bio terrorism Preparedness, planning and implementation (Fig 4).

Institutional Coordination is an important aspect of response planning. The lack of a precise role and responsibilities among federal and state agencies involved in bio terrorist response is generally due to the lack of resources to dedicate to planning interagency collaboration and co-ordination. It is important to develop comprehensive statewide plans embracing all relevant parties- hospitals, emergency services, governmental health agencies as well as non-governmental agencies. Due to the threat to the national security, it is also critical for the co-ordination between the health departments and the law enforcement authorities for criminal investigation (33)

Text Box: Fig 4:  Responsibilities and Coordination Relationship between Federal Agencies, USA
The Federal Bureau of Investigation ( FBI): Lead responsibility for crisis management, immediate implementation of measures and criminal investigation
The Federal Emergency Management Agency (FEMA): Consequence management- coordination of subsequent assistance
The Health and Human Services (HHS) and Office of Emergency Preparedness (OEP): Coordination of all health and medical assistance
The Department of Defense ( DOD): Develop, and implement a domestic preparedness program to improve the ability of local, state and federal agencies to cope with terrorist attacks











B. Early Warning Epidemiological Surveillance and Response System-

1. Integrated Networks linking State, National and Global Reporting Systems for rapid investigation and response.

1.1 Global Systems:

            A. Global Outbreak Alert and Response Network: Biological agents that are most likely to be used in a deliberate outbreak are any infectious agents or its toxins that could be engineered for deliberate use as a weapon. Among such agents are small pox, anthrax, botulism and plague are the pathogens most likely to be used and are believed by many experts to be potential biological weapons. The Global Outbreak Alert and Response Network continuously monitor reports of rumors of diseases and outbreaks of infectious diseases worldwide. This network links more than 70 separate information and diagnostic networks around the world. The Formal Sources (information of the 191 WHO member countries, together with WHO regional and country offices), and informal sources information  are combined ( NGO’s, other partners and the Global Public Health Intelligence Network (GPHIN)) to create an internet based system that is the best and most up to date information on disease outbreaks around the world. Each report is thoroughly checked and verified by specialists at WHO headquarters and an appropriate response is then planned and launched with the national and international partners.

It is essential for the co-operation of national and international institutions in order to strengthen the public health infrastructure. These include specialist laboratories and epidemiologists.

            B. ProMED-Mail: ProMed- mail was established in 1994 to provide an early global warning of emerging diseases in human, animals and plants as well as diseases that may attributable to bio terrorist activities. One hundred and sixty countries comprising over 18,000 members from developing and developed world electronically linked to stimulate sharing of emerging and reemerging infectious diseases worldwide.


1.2. National Systems:

            A. The National Center for Infectious Diseases (NCID/CDC) have set up surveillance systems to track particular disease problems including emerging infectious diseases. Some of the surveillance systems that are operated by NCID/CDC are; National Notifiable Diseases Surveillance System (NNDSS), 121 Cities Mortality Reporting System, Border Infectious Disease Surveillance Project (BIDS), EMERGEncy ID NET , Global Emerging Infections Sentinel Network (GeoSentinel) and Internet-based Reporting Systems comprising of Unexplained Deaths and Critical Illnesses Surveillance System.

            B. The Rapid Syndrome Validation Project (RSVP) is an early warning syndrome based system that links individual health care providers and public health in the State of New Mexico. It provides early warning and response to emerging biological threats, as well as emerging epidemics and diseases (35).

          C. The Early Warning and Response Network System (EWARN) in Sudan: In collaboration with several agencies, EWARN was launched in July 1999 with WHO as the lead agency. The United Nations Fund for International Partnership (UNFIP) comprising the Rockefeller Foundation, the UN Foundation and the Gates Foundation. Currently, there are more than 40 health agencies (including non governmental organizations (NGOs), the International Committee of the Red Cross, UNICEF and WHO) participating in EWARN activities, as well as communities through church groups, community leaders and local counterparts.



C. Health Services Plan: Building human, technological and financial resources for provision of rapid health care services at local and State departments.

1.1 Training:


            Training activities are intended to prepare the health and medical community for contingencies such as bioterrorism and other terrorism events. An identified hospital that is equipped to provide support for training activities can be used to train doctors, nurses, paramedics and emergency medical technicians, to recognize and treat patients with chemical and biological exposures and other public health emergencies. However, each hospital should have a continuous education program on management and control of biological and chemical agents, for health care professionals. Several methodologies such as classroom training, distance learning, and hands-on training activities could be implemented based on resources. The key partners in these training programs are the Infectious Disease Society, Schools of Public Health and Center for Civilian Bio -defense. The scope of FEMA's Integrated Emergency Management Course (IEMC) could serve as a vehicle to integrate the emergency management and health community response efforts.

1.2. Community Level: Bioterrorism preparedness is clearly a goal for the health care at the community level. This could be accomplished by working in collaboration with both the city, county, state, and the federal public health and emergency authorities and with law enforcement at the local and federal levels. Effective, open communication between all groups involved in the prevention and control of bio terrorism related illnesses is the key component of a preparedness plan at the community level (36).

1.3. Home Care

            The home care and hospice organizations should be prepared to manage bioterrorism related events and conditions. A bioterrorism response plan for the special population should be developed and a systematic training on response and control programs for the staff, needs to be implemented. (37)

 1.4 The Public: Public is a key partner in the medical and public-health response for an effective management of an epidemic. Non participation increases the likelihood of social disruption. An integrated response plan, implemented in the response to an epidemic caused by a bioterrorist attack, includes the public and the civic bodies, as capable collaborators (38).

 1.5 Mobilization of Financial Resources : CDC has proposed a $ 348 million investment in anti-bioterrorism in the 2002 budget which is estimated to be an 18 percent increase over fiscal year 2001 funding. The majority of efforts will be focused on coordination, surveillance, rapid response and prevention. A special response to a bioterrorism event includes detecting the biological agent, investigating the outbreak, and providing stockpiled drugs and supplies. The U.S. Department of Health and Human Services (HHS) budgeted $4.3 billion for homeland security and public health which includes grants totaling $865 million to improve public health emergency preparedness and counter-bioterrorism in local and state departments.


Clinical Diagnosis, Control and Prevention strategies: Isolation Precautions, therapeutic guidelines, immuno-prophylaxis and vaccination strategies:

            All hospital emergency departments should have administrative plans, infrastructure, training and medical inventory for biological or chemical weapons incidents. The minimum recommended physical and therapeutic resources for hypothetical bioterrorist incidents such as Sarin and anthrax should be available. Health-care providers, clinical laboratory personnel, infection control professionals, and health departments play critical and complementary roles in recognizing and responding to illnesses caused by intentional release of biologic agents.

Health Care providers may use some of the indicators of intentional release of a biological agent such as 1) an unusual temporal or geographic clustering of illness (e.g., persons who attended the same public event or gathering) or patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak (e.g., >2 patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise healthy persons); 2) an unusual age distribution for common diseases (e.g., an increase in what appears to be a chickenpox-like illness among adult patients, but which might be smallpox); and 3) a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin. Agents of highest concern are Bacillus anthracis (anthrax), Yersinia pestis (plague), variola major (smallpox), Clostridium botulinum toxin (botulism), Francisella tularensis (tularemia), filoviruses (Ebola hemorrhagic fever, Marburg hemorrhagic fever); and arenaviruses (Lassa [Lassa fever], Junin [Argentine hemorrhagic fever], and related viruses)

The clinical manifestations and syndromes of bioterrorism related infections in children may be atypical. Some of the common syndromes reported were acute respiratory distress syndrome with fever, influenza like illness, acute rash with fever, neurological syndromes and blistering syndromes. It is critical that the diagnosis be established expeditiously and pediatricians obtain information on specific treatment for the management of bioterrorism related infections. The guidelines for pediatric management of bioterrorism related infections should be followed (39). Clinical features and management of anthrax, plague and small pox have been published by CDC and others (40). These guidelines also include chemoprophylaxis and vaccination strategies (41-47).

Clinical laboratories should be prepared to respond rapidly by providing diagnostic tests for the detection, identification of specific agents and provision of rapid results for prompt initiation of treatment and prophylaxis. As first-line responders, clinical laboratory personnel should become familiar with the bio weapons. A standard operating procedure manual describing techniques used in their identification and pre and analytical issues such as specimen handling and personal protective equipment and quality control should be prepared. Accurate assessment of resources in clinical laboratories is important because it will provide local authorities with an alternative resource for immediate diagnostic analysis (48, 49).


Infection Control: Infection control practitioners (ICPs) are important partners in enhancing public health infrastructure in the USA and worldwide. A lack of awareness about the potential threat of bioterrorism and a deficiency in knowledge about the potential consequences of an attack may impact on resource allocation for infection control and training program in heath care institutions (50). The Association of Practioners of Infection Control (APIC) Bioterrorism Task Force and CDC Hospital Infection Control Program Bioterrorism Working Group prepared a document entitled “Bioterrorism Rediness Plan- A Template for Health Care Facilities”. This document provided the framework for infection control activities such as isolation precautions, patient placement in case of small events, patient transport, cleaning, disinfection, sterilization of equipment and environment etc. The report also provides an outline of laboratory policy and public enquiry (51). 


Vaccines are an effective, safe, and relatively inexpensive means of preventing infection; thus, they are important tools for fighting biological terrorism. Vaccines for the two diseases, anthrax and smallpox are not available. However, three other vaccines -tetanus toxoid, influenza vaccine, and hepatitis B vaccine--generally recommended for adults, may be in short supply as a result of recent acts of terrorism (52).155 million doses of smallpox vaccine will be produced by the end of 2002 reaching the required 286 million doses by the end of 2002. The estimated cost per dose of vaccine is about $2.76. The National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health have been studying the possibility of diluting the vaccine by a ratio of 1 to 5 as a potential means of extending the supply. Early results indicate that the diluted vaccine retains the same level of effectiveness as the fully concentrated vaccine. Researchers are also studying whether a 1 to 10 dilution retains the same level of effectiveness, as well. The CDC plan does not call for mass vaccination of the U.S. population in advance of a smallpox outbreak. Based on what we know today, the risk of an outbreak of smallpox is substantially lower than the risk of serious complications from the vaccine. According to the plan, rings of personal contacts, such as family members and co-workers, would be identified and then be vaccinated and monitored. This strategy, known as ring vaccination, is credited with helping to wipe out smallpox in the late 1970s and is still the most efficient approach today.


Development , Enactment and implementation of regulations, legislations, and Policies in collaboration and co-ordination with the World Health Organization and the United Nations (53,54)


Geneva Protocol 1: This first attempt to limit the use of biological agents in warfare was the “1925 Geneva Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or other Gases and Bacteriological Methods of Warfare”. Many countries ratified the protocol but reserved the right for retaliation. This protocol was not ratified by the USA in 1925.


In 1969, a proposal was submitted to the United Nations Committee on Disarmament which included “The Prohibition of the Development, Production, and Stockpiling of Bacteriological and Toxin Weapons and Their Destruction (BWC)”. This proposal was ratified by member nations including the USA and the Soviet Union. However, there were few notable violations.


Key Regulations laws that were enacted to restrict biological weapons in the USA (53,54).

Presidential Declaration on biological weapons, 1969: Mr. Richard Nixon, the President of USA has declared the end of US involvement of production and use of biological weapons.

Biological Weapons Act, 1989: This act defines that the development, manufacture, transfer or possession of any biological agent, toxin or delivery system for use as a weapon is a federal crime. The act also broadly defines the biological agents.

Chemical and Biological Weapons Control Act, 1991: This act specifically deals with the economic sanctions and export controls to cut the proliferation of biological arms. This act also prohibited from exporting to certain countries any goods or technologies that might be used to develop biological weapons.

Anti-terrorism and Effective Death Penalty Act, 1996: This act has broadened penalties for development of biological weapons and illegitimate uses of microorganisms to spread disease. This act expanded the regulatory responsibilities of CDC for transport of dangerous biological agents. American Society for Microbiology has recommended the extension of the 1996 Act to include strict measures to prohibit possession of selected

biological agents and toxins and registration of institution that have viable agents with the CDC. The CDC regulatory framework governing hazardous biological agents was adopted in 1997.

            Several other bills were introduced and were passed in 2001. Among them were; Deadly Biological Control Act of 2001, Bioweapons Control and Tracking Act of 2001, Bioterrorism Enforcement Act of 2001 ( Amendment of Antiterrorism and Effective Death Penalty Act of 1996), Antiterrorism Legislation –Public Law, Public Health Security and Bioterrorism Response Act of 2001- Regulation of certain Biological Agents and Toxins, and Bioterrorism Preparedness Act of 2001.



Bioterrorism Response System: (During an incident) 


The bioterrorism attack itself would be either overt (announced, eg: letter threatening anthrax to an individual or agency) or covert. The covert attacks are the most disturbing and might be unnoticed for long time. In these attacks, many victims develop a common illness related to the agent with or without high mortality. It is important to systematically determine the nature and possible impact of the threat by assessment, identification and threat communication as well as simultaneously providing a rapid public health response to individuals and communities 



Threat Agent Assessment:

Fig 5 shows the process of Threat Assessment  in cases of overt or covert attack.








Terrorists or criminals can carry out three types of biological attacks. First, the pathogen or toxin may be injected. This method is best used when the terrorist or criminal wishes to assassinate an individual. Second, a quantity of pathogens or toxins may be used to contaminate or poison foods, beverages, or medicines. This method could cause hundreds of casualties. Third, pathogens or toxins may be suspended in a wet or dry formulation and dispersed over a target area as aerosolized particles. This type of attack could produce thousands of casualties, if the following conditions were met:

(1) The formulation was well designed for aerosol dispersal;

(2) The aerosol particles produced by the dispersal mechanism were of optimal size and could withstand environmental stresses; and

(3) Weather and wind conditions were just right for blanketing the target area with aerosol particles.

It is highly probable that food borne and waterborne pathogens or toxic chemicals may be utilized as biological attacks by terrorists or criminals. The probability that terrorists or criminals will carry out airborne attacks with pathogens is low. The reasons are that it is technically difficult to formulate pathogens and toxins for airborne dispersal, to operate dispersal mechanisms successfully, and to ensure proper meteorological conditions for effective aerosol dispersal. Pathogens or toxins are likely to loose their virulence or toxicity after a relatively short time (days to weeks). In addition, dissemination equipment may not effectively spray solutions containing pathogens or toxins due to the clumping of the stabilizing factor and the pathogens. The environmental stresses, such as UV light and desiccation, may kill or inactivate the aerosolized pathogens or toxins. There are possible applications of advanced molecular biology techniques to develop recombinant bacterial or viral pathogens such as smallpox and Ebola viruses (13) for bioterrorist attacks (56). The spectrum and behaviors of terrorists would also provide the necessary clues for the nature of threat and possible impact on society.


Threat Agent Investigation:  Following the threat assessment, the identification of the nature of the threat, credible or not credible, is conducted by the Federal Bureau of Investigation. The criteria applied for threat agent investigation are;

1.      Spectrum of Terrorists known based on previous data (lone offenders, identified groups, non-aligned terrorists, doomsday/cult-type groups)

2.      Behavior profile and intentions of terrorists

3.      Operational and technical characteristics of threat agent.

Based on the credibility of the threat and its agent, the appropriate response system is implemented.

Threat Communication:

Risk communication is a science approach for communicating effectively in high concern situations and it provides a set of principles and tools for meeting those challenges. It also addresses the problems of effective communication by the exchange of information about the nature, magnitude, significance, control and management of risks. The strengths and weakness of the channel through which information is communicated, such as press releases, public media, small discussions etc, are also addressed by the scientific literature. Stakeholders, government officials and industry representatives and scientists often state that non-experts and lay people irrationally respond to risk information and inaccurately perceive and evaluate risk information. However, the representatives of the citizen groups, worker groups and individual citizens question the legitimacy of the risk assessment and management process. These conflicts result in complex, confusing, inconsistent or incomplete risk messages, lack of trust in information sources and selective and biased reporting by the media that affects how risk information is processed.

            Effective risk communication is based on the sound knowledge, planning, preparation, skill and practices. It is an interactive tool that ensures the respect of different values and treats the public as a full partner. However, personnel involved from many agencies and organizations, lack the knowledge, sensitivity, and skills need for effective risk communication. Such organizations initiate risk communication efforts with inadequate resources and unclear objectives.

            Four risk communication theoretical models; Risk perception model, Mental Noise model, Negative Dominance model and Trust Determination model have been developed to describe how risk information is processed, how risk perceptions are formed and how risk decisions are made for a particular event. These models are very important to provide a foundation for thinking about a coordinated effective communication in a high concern situation such as bioterrorism attacks. There are several factors that could accumulate during a bioterrorist event. These include, an element of surprise, use of unpredicted lethal biological agents, the presence of an unknown perpetrator, the likelihood of wide spread attacks and the delayed detection by Public health agencies.

One of the models that combat the rise in emotions at the time of a biological threat is mental noise risk communication model. Such an event would trigger many risk perception factors that would amplify the perceived magnitudes of risk to high levels. Such perception factors that would most likely to be amplified include involuntariness, uncontrollability, unfamiliarity, ethical and moral violations and distrust in institutions.

            In order to modify the public’s risk perception response to a possible biological threat, a number of actions could be taken. Trust of the public in the emergency response should be established in advance for the effectiveness of any post event response. Also the public needs to be evaluated by introducing the potential for bio terrorist attack in a measured, progressive and interactive manner such as selected school programs, student take home assignments and public education.  Public participation in preparation process and by providing a voice in the decisions that affect them enables the public for a legitimate sense of control under threat. To address the intensity of the emotions evolved by a threat, all emergency response organizations must be committed to producing communication from preparatory stage to final resolution.

Rapid  Public Health Response and Management of Bioterrorist Attack.

Many documented attacks are covert in nature and the normal outcome would be an epidemic. Many of these cases come to the attention of physicians gradually and doctors may become aware of deaths among previously healthy individuals. The correct diagnosis of the type of biological or toxic agent responsible for such the disease depends on the speed and accuracy of physicians and laboratories.

In the case of an outbreak, vaccination of the peoples already exposed to the pathogen defeats the purpose of vaccination, hence containment of the infection is extremely important as is the checking of all contacts an infected person has had with others.

Presently the national governments of the various countries should have contingency plans to cope with any naturally occurring or deliberate outbreak of infectious disease. The international guidelines published by WHO should be used in response to the outbreak. The public health response to the situation should be instantaneous, by investigating the stocks of both drugs and vaccines to ensure that adequate supplies are available to deal with any natural or deliberate outbreak.

A National Health Alert Network (HAN), developed by the Centers for Disease Control and Prevention to act as a communications infrastructure for response to bioterrorist events and other emergencies is being implemented at the State and local health departments (57)

Conclusions: Bioterrorism is a complex and multidimensional issue that require local, national and international collaboration and co-operation for mitigating the effects an attack. While the risk of bioterrorism is small, the possibility of occurrence is real in every community and every country. In this review, an attempt was made to systematically address processes that have been developed and coordinated by both governmental and non-governmental agencies in the USA. The epidemiological concepts to address risk assessment and public health management during preparedness and at the time an attack is conceptualized around the critical role of people in the community. Bioterrorism attacks disrupts the entire social, political and economic fabric of a society and no one solution or solutions solve the problem until the root cause is known. International coalition against bioterrorism with sound national and international polices to improve the health and remove inequity and inequality between underdeveloped and developed world to achieve global socio-economic order may be one of the solutions but until that time, national interventions should focus on protection of health of the population.


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Other Websites:

The Centers for Disease Control (CDC) http://www.bt.cdc.gov

 The U.S. Army Medical Research Institute of Infectious Diseases   http://www.usamriid.army.mil/education/bluebook.html

The Federal Bureau of Investigation (FBI). http://www.fbi.gov

The National Medical Disaster System: http://ndms.dhhs.gov/NDMS/ndms.html

Federation of American Scientists: Working Group on Biological and Toxin Weapons

The Association for Infection Control Practitioners. http://www.apic.org

The Johns Hopkins Center for Civilian Biodefense.  http://www.hopkins-biodefense.org.

WHO: Health Aspects of  Biological and Chemical weapons. deliberate@who.int

PAHO/WHO: Pan American Health Organisation. http://www.paho.org