I am Dr. James M. Hughes, Director,National Center for Infectious Diseases, Centers
for Disease Control and Prevention (CDC). Thank you for the invitation to discuss the need
to enhance the public health capacity in the United States
to respond to the threat of
bioterrorism. I will provide a brief discussion of the current situation and then I will
describe the actions that CDC is taking to strengthen and modify our current public health
laboratories and disease surveillance and control to ensure an effective response to acts
of biological and chemical terrorism.
Vulnerability of the Civilian Population
In the past, an attack with a biological agent was considered very unlikely; however,
now it seems entirely possible. Many experts believe that it is no longer a matter of "if" but "when" such
an attack will occur. They point to the accessibility of information on how to prepare
biologic weapons and to activities by groups such as Aum Shinrykyo, which, in addition to
releasing nerve gas in Tokyo's subway, experimented with botulism and anthrax. In 1997,
the FBI investigated a situation in Las Vegas in which an individual was in possession of
the organism causing anthrax. Although he had an attenuated strain of anthrax used in an
animal vaccine rather than a virulent strain, the incident provided another reminder of
how easily a terrorist might cause serious illness and panic in a U.S. city.
An attack with a chemical agent is also increasingly likely. Such an attack might
involve the release of a noxious gas, such as a nerve gas, phosgene, or lewisite, or an
airborne chemical, such as hydrogen cyanide, chlorine, or pesticides, that can kill many
people. Early in an investigation, it may not be obvious whether an outbreak is caused by
an infectious agent or a chemical toxin; however, most chemical attacks will be localized,
and their effects will be evident within a few minutes. An attack using a chemical agent
will demand immediate reaction from emergency responders - fire departments, police, EMS,
and emergency room staff - who will need adequate training and equipment. In contrast,
when people are exposed to a pathogen like anthrax or smallpox, they will not know that
they have been exposed, and they may not feel sick for some time. This delay between
exposure and onset of illness, or incubation period, is characteristic of infectious
diseases. The incubation period may range from several hours to a few weeks, depending on
the exposure and pathogen.
The initial response to such a biological attack on civilians is likely to be made by
the public health community rather than by the military or emergency responders. Thus,
protection against terrorism requires investment in the public health system. This point
is underscored in a report, commissioned by the Department of Health and Human Services
Office of Emergency Preparedness and recently released by the Institute of Medicine and
the National Research Council, Chemical and Biological Terrorism: Research and
Development to Improve Civilian Medical Response, which stresses the need for
long-term public health improvements in surveillance and epidemiology infrastructure.
Copies of the report have been provided to the Subcommittees. The financial costs of these
improvements will be relatively modest. For example, without these investments, it has
been estimated that responding to an initially undetected and consequently uncontrolled
anthrax attack that results in infecting 100,000 people could cost $26 billion.
Public Health Leadership
As the nation's disease prevention and
control agency, it is CDC's responsibility to
provide national leadership in the public health and medical communities in a concerted
effort to detect, diagnose, respond to, and prevent illnesses, including those that occur
as a result of a deliberate release of biological or chemical agents. This task is an
integral part of CDC's overall mission to
monitor the health of the U.S. population.
In 1998, CDC issued Preventing Emerging Infectious Diseases: A Strategy for the 21st
Century, which describes CDC's plan for
combating today's emerging diseases and
preventing those of tomorrow. It focuses on four goals, each of which has direct relevance
to preparedness for bioterrorism: disease surveillance and outbreak response; applied
research to develop diagnostic tests, drugs, vaccines, and surveillance tools;
infrastructure and training; and disease prevention and control. This plan emphasizes the
need to be prepared for the unexpected -- whether it be a naturally occurring influenza
pandemic or the deliberate release of anthrax by a terrorist. Copies of this CDC plan have
been provided to the Subcommittee.
Strengthening Public Health Readiness to Address Bioterrorism
Increased vigilance and preparedness for unexplained illnesses is an essential part of
the public health effort to protect the American people against bioterrorism. Toward this
end, CDC, working in collaboration with State and local health departments, many other
public health partners, and other Federal agencies, has begun the effort to upgrade
national public health capabilities to respond to biological and chemical terrorism.
Further, because terrorists may employ a wide range of biological and chemical agents,
this country's infectious disease surveillance
networks must have enhanced capacity to detect unusual events, unidentified agents, and
unexplained illnesses. In addition, State and Federal epidemiologists must be trained to
consider unusual or rare threat agents when a suspicious outbreak occurs and be prepared
to address questions related to their transmission, treatment, and prevention.
Focus Areas For Public Health Action
In December 1998, CDC established the Bioterrorism Preparedness and Response Activity
(BPRA), to lead an agency-wide effort to prepare for and respond to acts of terrorism that
involve actual, threatened, or suspected uses of biological or chemical agents. BPRA is
charged with the coordination of CDC's
epidemiological and laboratory response following a suspected or actual attack and
response to health threats from unknown biological or chemical agents.
In February, in an effort to provide support and assistance to State and large
metropolitan health departments in enhancing their ability to be prepared for and respond
to a terrorist attack that involves a biological or chemical agent, CDC announced the
availability of nearly $41,000,000 in Public Health Preparedness and Response to
Bioterrorism cooperative agreement funds. This announcement, along with other extramural
and intramural strategies, focuses on strengthening four components of the public health
infrastructure to improve the national capacity to address biological and chemical
terrorism:
- Detection of unusual events.
Because the initial detection of a biological or
chemical terrorist attack will most likely occur at the local level, it is essential to
educate and train members of the medical community -- both public and private -- who may
be the first to examine and treat the victims. It is also necessary to upgrade the
surveillance systems of State and local health departments, which will be relied upon to
spot unusual patterns of disease occurrence and to identify any additional cases of
illness as the disease spreads throughout the community and beyond.
To enable States and major cities to build core capacity to monitor and detect
potential biologic and chemical threat agents, CDC will make up to 30 awards as a part of
the Public Health Preparedness and Response to Bioterrorism cooperative agreement. CDC
will also lead the development of new disease surveillance networks in hospitals and other
health care facilities and will evaluate new surveillance mechanisms to improve the nation's ability to detect low incidences of unexplained
illnesses.
- Investigation and containment of outbreaks
. The initial response to an outbreak
caused by an act of chemical and biological terrorism will take place at the local level.
In the most likely scenario, CDC -- as well as DOD and security agencies -- will be
alerted to a bioterrorist attack only after a State or local health department has
recognized a cluster of cases that is highly unusual or of an unknown cause. For this
reason, it is imperative that State and local health departments have sufficient resources
to conduct epidemiologic investigations.
Through the cooperative agreement and other mechanisms, CDC will provide State and
large metropolitan health departments with tools, training, and financial resources for
local outbreak investigations, and help develop rapid public health response capacity at
the local, State, and Federal levels. Additionally, in the event of a suspected or an
actual attack, CDC will be prepared to assist State health departments in identifying
threat agents and their modes of transmission, in instituting control measures, and in
providing consultation on medical management.
CDC is also working to establish a National Pharmaceutical Stockpile which will ensure
the availability of drugs, vaccines, prophylactic medicines, chemical antidotes, medical
supplies, and equipment that might be needed in a medical response to a biological or
chemical terrorist incident.
- Laboratory diagnosis.
In the event of a biological or chemical terrorist attack,
rapid diagnosis will be critical, so that prevention and treatment measures can be
implemented quickly. CDC will fund approximately 34 State and major metropolitan health
departments under the cooperative agreement to improve capacity to diagnose biologic
threat agents. At the same time, CDC will make up to four additional awards to enable
selected State health laboratories to function as reference facilities for the
identification of chemical threats. In addition to evaluating existing technology for
identifying priority biological agents, CDC will develop a Rapid Toxic Screen that can
assess exposure to 150 different chemical agents. CDC will develop guidelines and quality
assurance standards for the safe and secure collection, storage, transport, and processing
of biologic and environmental samples. Working with other federal partners, CDC will
develop a Rapid Assay and Technology Transfer laboratory to quickly identify pathogens and
chemicals that might be used by terrorists and to serve as a triage laboratory.
Finally, CDC is working with public health partners to plan the development of a
multi-level network of laboratories which will be used to provide the most immediate
diagnosis of a biological agent in the event of a suspected terrorist attack. This network
will ultimately include hospital laboratories, commercial reference laboratories, State
and local health laboratories, and highly specialized Federal facilities. It will not only
enhance public health capacity to address bioterrorism, but also contribute to the overall
public health capacity to address naturally occurring infectious diseases.
- Coordination and Communication.
In the event of an intentional release of a
chemical or biological agent, rapid and secure communications will be especially crucial
to ensure a prompt and coordinated response. Thus, strengthening communication among
clinicians, emergency rooms, infection control practitioners, hospitals, pharmaceutical
companies, and public health personnel is of paramount importance. In order to assure the
most effective response to an attack, CDC will work closely with The FBI, which will take
the lead in the criminal investigation of a terrorist attack, and with other government
agencies, including the Food and Drug Administration (FDA), National Institutes of Health
(NIH), DOD, and the Federal Emergency Management Agency.
In the event of a terrorist attack, we will need to ensure that the public is provided
with accurate and timely information. An act of terrorism is likely to cause widespread
panic, and on-going communication of accurate and up-to-date information will help calm
public fears and limit collateral effects of the attack.
Internationally, global health security will be enhanced as CDC, in collaboration with
the World Health Organization, responds throughout the world to reports of illnesses from
unusual pathogens, suspected bioterrorism, and other outbreaks that might threaten the
U.S. population.
Planning and Preparedness
CDC is working to ensure that all levels of the public health community -- Federal,
State, and local -- are prepared to work in coordination with the medical and emergency
response communities to address the public health consequences of biological and chemical
terrorism. CDC will assist States and major cities in developing local public health
bioterrorism preparedness plans that are well integrated into existing emergency response
plans at the local, State, and Federal level. CDC is creating diagnostic and
epidemiological performance standards for State and local health departments and will help
States conduct drills and exercises to assess local readiness for bioterrorism.
In addition, CDC, NIH, DOD, and other agencies are supporting and encouraging research
to address scientific issues related to bioterrorism. For example, for several of the
agents likely to be used as bio-weapons, we need to create rapid, simple, low-cost
diagnostic kits that can be used in the field to test large numbers of people exposed to a
biological or chemical agent within a short time frame. In some cases, new vaccines,
antitoxins, or innovative drug treatments are also required. Moreover, we need to learn
more about the pathogenesis and epidemiology of these rare diseases. We also have only
limited knowledge about how artificial methods of dispersion may affect the infection rate
or virulence of these diseases.
Disease Prevention
Disease experts at CDC are considering various strategies for preventing the spread of
disease during and after bioterrorist attacks. Strategies under evaluation include:
creating protocols for immunizing at-risk populations, isolating large numbers of exposed
individuals, and reducing occupational exposures; assessing methods of safeguarding food
and water from deliberate contamination; and exploring ways to improve linkages between
animal and human disease surveillance networks since threat agents that affect both humans
and animals may first be detected in animals.
CDC is enhancing its ongoing efforts to foster the safe design and operation of
Biosafety Level 3 and 4 laboratories, which are required for handling highly dangerous
pathogens.
Conclusions
In conclusion, the best public health method to protect, respond, and defend the health
of civilians against chemical and biological terrorism is the development, organization,
and enhancement of life-saving public health prevention tools. Such tools include expanded
State public health laboratory capacity, increased surveillance and outbreak investigation
capacity, and health communications and training at the local, State, and Federal levels.
The tools we develop in response to bioterrorism threats are "dual use"
tools. Not only will they ensure that we are prepared for man-made threats, but they also
ensure that we will be able to recognize and control the naturally occurring emerging
infectious diseases and the hazardous materials incidents of the late 20th century. A
strong and flexible public health infrastructure is the best defense against any disease
outbreak.
Thank you very much for your attention. I will be happy to answer any questions you may
have.
