Washington—Last May, nearly 1000 people "died" in Denver after a terrorist sprayed airborne plague bacteria at a concert. As reports of hundreds of people seeking relief from fever and coughs trickled up from hospitals to the state health department to the Centers for Disease Control and Prevention, a hastily convened expert panel struggled to contain the outbreak, allocate limited antibiotics, and keep the public peace. Through it all, confusion reigned.
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Yersinia pestis, the plague bacterium, is one of the biological agents that concern bioterrorism experts. (Photo credit: Centers for Disease Control and Prevention)
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Fortunately, it was all a simulation, run by the Department of Justice at the behest of Congress, designed to test the United States' ability to respond to bioterrorism. Officials called the 3-day, $3-million exercise a success. But the chaos the exercise engendered revealed that "the systems and resources now in place would be hard-pressed to successfully manage a bioweapons attack," according to a publication (Biodefense Q. 2000;2:1-10) of the Johns Hopkins Center for Civilian Biodefense Studies.
With that lesson in mind, the Hopkins Center, the Department of Health and Human Services (DHHS), the Infectious Diseases Society of America, and a host of cosponsors convened the second conference on public responses to bioterrorism, held here in late November. The 1999 conference had established bioweapons as a serious threat, elevating bioterrorism from science fiction to scientific credibility. This year's gathering of 800 public health and military professionals focused on the challenges of dealing with that possibility. Chief among them: lack of training among "front-line responders"—physicians and nurses—and inadequate planning at the local, state, and federal levels.
DIAGNOSING THE PROBLEM
Unlike an explosion or chemical attack, the release of an airborne or waterborne pathogen may go undetected. But within a few days, people with strange symptoms would begin to appear at local clinics and hospitals. If physicians failed to recognize the problem at hand—and most surely would fail, according to several speakers—delays in diagnosis and treatment could send the casualty rate soaring.
The 1999 outbreak of West Nile virus in New York City provides a crucial example of the importance of reporting unusual cases, whether or not they occur naturally, said Marcelle Layton, MD, MPH, director of the Office of Communicable Diseases at the New York City Department of Health. Layton said her office launched an investigation of the previously unrecognized local outbreak only after a physician in Queens called about two patients with unexplained muscle weakness. She later discovered that other early cases went unreported. "Physicians need to be open-minded about the unexpected," she said. "A report from a single physician can make a difference."
Part of the problem is the low probability of a bioterrorist attack occurring in any one place. "Physicians in this country have never seen a single case of bioterrorism," said Ken Bloem, former chief executive officer of Georgetown University Medical Center and a senior fellow at the Hopkins Center, referring to what experts consider the top three threats: smallpox, anthrax, and plague. Subsequently, most view bioterrorism as an "issue for somebody else," said John G. Bartlett, MD, chief of infectious diseases at Johns Hopkins Hospital. "A limited number [of health care workers] think that it's an issue for them, and almost none know about local plans or have participated in local planning," he said. Physicians are not trained, paid, or required to know about bioterrorism, he said, meaning they need motivation to learn about the threat.
Hospitals are generally unwilling to spend money for an event that may never occur, said James D. Bentley, PhD, senior vice president at the American Hospital Association. "No one pays for planning and preparation," he said, referring to health insurance reimbursements. But there are other motivators. Bartlett recommends adding a bioterrorism section to board tests, an idea that, he says, met with a cool reception from Harry Kimball, MD, president of the American Board of Internal Medicine. Incorporating training into medical and nursing school curriculums would increase knowledge and awareness among the next generation of health care professionals.
But for today's practitioners, another solution is needed, argued Bartlett. He proposed putting detailed criteria for responding to possible bioweapons attacks in physicians' palms—on handheld computers. He predicted that these "point-of-care decision tools" would be in general use within a year. "What could we put on it that would say, ‘Think bioterrorism, call this number'?" Bartlett answered his own question with a short list of suspicious symptoms and circumstances, including a young or healthy person dying from pneumonia, a case of "summer flu," and viral hemorrhagic fever. Positive laboratory tests for anthrax, smallpox, or glanders, which "never happen in this country," should also raise alarms, he said, as should "unusual or unexplained clusters" of illness.
OVERWHELMED CAPACITY
If the front lines answer the first challenge and recognize a possible bioterrorist attack, what next? According to conference speakers, they'll be facing a surge of unprecedented proportions: emergency departments bursting with sick patients, shortages of antibiotics and other medicines, unclear lines of authority, even panic in the streets. And unlike airplane crashes or other disasters with large numbers of casualties, the situation would worsen for days before improving. The Denver plague scenario "made it clear that the local hospital system would be overwhelmed, paralyzing their ability to help out," said Robert Knouss, MD, director of the Office of Emergency Preparedness at DHHS. Knouss' office estimates that a large amount of anthrax in the water supply of Washington, DC, could produce 250 000 cases of illness within a week—in a city with 3000 hospital beds.
The solution, expounded by every speaker, is better planning to pool local, state, and national resources. The federal strategy for dealing with any disaster includes the National Disaster Medical System (NDMS), administered by Knouss' office, designed to "ensure resources are available to provide medical services following a disaster that overwhelms the local health care resources." But Bloem said the plan was fundamentally flawed because it makes two big assumptions: that localities have their own disaster plans and that enough health care workers will be available. "Many of my colleagues in hospital leadership are unconvinced the federal plan will work," said Bloem.
Knouss was undeterred, saying that the strategy is both simple enough and thorough enough to be effective. When asked if DHHS had any strategies to increase medical capacity to deal with an epidemic, Knouss said that the current system asks localities to meet "extraordinary demands." That means bioterrorism or disaster planning at the local level, something California has repeatedly grappled with because of natural events. In 1992, largely in response to the 1989 San Francisco earthquake, the state began encouraging hospitals to adopt a disaster preparedness strategy called the Hospital Emergency Incident Command System (HEIC). It provides common terminology across health care and law enforcement agencies and flexible staffing routines to deal with crises.
Jeffrey Rubin, who administers the plan at the California Emergency Medical Services Authority, said that hospitals that adopted HEIC fared better during the 1993 Northridge earthquake than those that did not. But he added that planning has not completely avoided problems. Last December, Los Angeles experienced a worse than usual flu season, that—although mild compared with a bioweapons attack—strained the city's health care system to the breaking point. Rubin said that some overbooked hospitals broke with protocol by rerouting ambulances and calling in the National Guard. And in the face of severe flooding in northern California in 1997, hospitals did not follow directions from the state and refused to evacuate. "Obviously, we have a long way to go," said Rubin.
The California situation points to a major problem during any epidemic: confusion over authority. Biodefense Quarterly quotes several participants in the Denver plague scenario as saying that the state health department was in charge while others pointed to the Federal Bureau of Investigation and still others had no idea who was running the show. Major decisions were made during marathon conference calls with 50 to 100 people, where the "roles, authorities, and even identities of those participating in the calls . . . were unclear."
During the West Nile virus outbreak in New York, 18 agencies jockeyed for authority. "It was unclear who was in charge," said Leyton, adding that several groups maintained separate databases of cases, duplicating the efforts of her time-crunched staff. Daily group e-mails and conference calls helped sort out the confusion, but she said she wished there had been "clearer lines of authority."
Whether or not Leyton's wish may come true in the case of a bioweapons attack, all of the speakers agreed on one thing: the value of preparing for bioterrorism. Bartlett concluded his presentation by saying, "Whatever we can learn about bioterrorism, we can apply to influenza, West Nile virus, and a variety of different epidemics in a system that currently has almost no surge capacity."
