Biological and Chemical Terrorism:Strategic Plan for Preparedness and Response (2022)

Biological and Chemical Terrorism:Strategic Planfor Preparedness and Response (1) Biological and Chemical Terrorism:Strategic Planfor Preparedness and Response (2)

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Recommendations of the CDC Strategic Planning Workgroup

The following CDC staff members prepared this report:

Ali S. Khan, M.D.
Alexandra M. Levitt, M.A., Ph.D.
National Center for Infectious Diseases

Michael J. Sage, M.P.H.
National Center for Environment Health

in collaboration with the CDC Strategic Planning Workgroup

Samuel L. Groseclose, D.V.M., M.P.H.
Epidemiology Program Office

Edwin Kent Gray
Elaine W. Gunter
Alison B. Johnson, M.P.A.
Anne L. Wilson, M.S.
National Center for Environmental Health

David A. Ashford, D.V.M., M.P.H., D.Sc.
Robert B. Craven, M.D.
Robert P. Gaynes, M.D.
Stephen A. Morse, Ph.D.
Clarence J. Peters, M.D.
Richard A. Spiegel, D.V.M., M.P.H.
David L. Swerdlow, M.D.
National Center for Infectious Diseases

Scott D. Deitchman, M.D., M.P.H.
National Institute for Occupational Safety and Health

Paul K. Halverson, Dr.P.H., M.H.S.A.
Public Health Practice Program Office

Joseph Hughart, M.P.H.
Agency for Toxic Substances and Disease Registry

Patricia Quinlisk, M.D.
Iowa Department of Health
Des Moines, Iowa

Biological and Chemical Terrorism:Strategic Planfor Preparedness and Response

Recommendations of the CDC Strategic Planning Workgroup

". . . and he that will not apply new remedies must expect new evils; for time isthe greatest innovator. . . ."

(Video) #5A Preparing for Chemical Weapons Part one video

--The Essays by Sir Francis Bacon, 1601

Summary

The U.S. national civilian vulnerability to the deliberate use of biologicaland chemical agents has been highlighted by recognition of substantialbiological weapons development programs and arsenals in foreign countries, attemptsto acquire or possess biological agents by militants, and high-profileterrorist attacks. Evaluation of this vulnerability has focused on the role public healthwill have detecting and managing the probable covert biological terrorist incidentwith the realization that the U.S. local, state, and federal infrastructure isalready strained as a result of other important public health problems. In partnershipwith representatives for local and state health departments, other federalagencies, and medical and public health professional associations, CDC has developeda strategic plan to address the deliberate dissemination of biological orchemical agents. The plan contains recommendations to reduce U.S. vulnerabilityto biological and chemical terrorism --- preparedness planning, detectionand surveillance, laboratory analysis, emergency response, andcommunication systems. Training and research are integral components for achievingthese recommendations. Success of the plan hinges on strengthening therelationships between medical and public health professionals and on building newpartner-ships with emergency management, the military, and law enforcement professionals.

INTRODUCTION

An act of biological or chemical terrorism might range from dissemination ofaerosolized anthrax spores to food product contamination, and predicting when and howsuch an attack might occur is not possible. However, the possibility of biological orchemical terrorism should not be ignored, especially in light of events during the past 10years (e.g., the sarin gas attack in the Tokyo subway[1] and the discovery of military bioweapons programs in Iraq and the former Soviet Union[2]). Preparing the nation to address this threat is a formidable challenge, but the consequences of beingunprepared could be devastating.

The public health infrastructure must be prepared to prevent illness and injurythat would result from biological and chemical terrorism, especially a covert terroristattack. As with emerging infectious diseases, early detection and control of biological orchemical attacks depends on a strong and flexible public health system at the local, state,and federal levels. In addition, primary health-care providers throughout the UnitedStates must be vigilant because they will probably be the first to observe and reportunusual illnesses or injuries.

This report is a summary of the recommendations made by CDC's StrategicPlanning Workgroup in Preparedness and Response to Biological and Chemical Terrorism: AStrategic Plan (CDC, unpublished report,2000), which outlines steps for strengtheningpublic health and health-care capacity to protect the United States against thesedangers. This strategic plan marks the first time that CDC has joined with law enforcement,intelligence, and defense agencies in addition to traditional CDC partners to address anational security threat.

As a reflection of the need for broad-based public health involvement interrorism preparedness and planning, staff from CDC's centers, institute, and offices participatedin developing the strategic plan, including the

  • National Center for Infectious Diseases,
  • National Center for Environmental Health,
  • Public Health Practice Program Office,
  • Epidemiology Program Office,
  • National Institute for Occupational Safety and Health,
  • Office of Health and Safety,
  • National Immunization Program, and
  • National Center for Injury Prevention and Control.

The Agency for Toxic Substances and Disease Registry (ATSDR) is also participatingwith CDC in this effort and will provide expertise in the area of industrial chemicalterrorism. In this report, the term CDC includes ATSDR when activities related to chemicalterrorism are discussed. In addition, colleagues from local, state, and federal agencies;emergency medical services (EMS); professional societies; universities and medicalcenters; and private industry provided suggestions and constructive criticism.

Combating biological and chemical terrorism will require capitalizing on advancesin technology, information systems, and medical sciences. Preparedness will also requirea re-examination of core public health activities (e.g., disease surveillance) in light ofthese advances. Preparedness efforts by public health agencies and primary health-careproviders to detect and respond to biological and chemical terrorism will have theadded benefit of strengthening the U.S. capacity for identifying and controlling injuriesand emerging infectious diseases.

U.S. VULNERABILITY TO BIOLOGICALAND CHEMICAL TERRORISM

Terrorist incidents in the United States and elsewhere involving bacterialpathogens (3), nerve gas (1), and a lethal plant toxin (i.e., ricin)(4), have demonstrated that the United States is vulnerable to biological and chemical threats as well asexplosives. Recipes for preparing "homemade" agents are readily available(5), and reports of arsenals of military bioweapons(2) raise the possibility that terrorists might have accessto highly dangerous agents, which have been engineered for mass dissemination assmall-particle aerosols. Such agents as the variola virus, the causative agent of smallpox,are highly contagious and often fatal. Responding to large-scale outbreaks caused bytheseagents will require the rapid mobilization of public health workers, emergencyresponders, and private health-care providers. Large-scale outbreaks will also require rapidprocurement and distribution of large quantities of drugs and vaccines, which must beavailable quickly.

OVERT VERSUS COVERT TERRORIST ATTACKS

In the past, most planning for emergency response to terrorism has beenconcerned with overt attacks (e.g., bombings). Chemical terrorism acts are likely to be overtbecause the effects of chemical agents absorbed through inhalation or byabsorption through the skin or mucous membranes are usually immediate and obvious. Suchattacks elicit immediate response from police, fire, and EMS personnel.

(Video) #5B Preparing for Chemical Weapons part two video

In contrast, attacks with biological agents are more likely to be covert. Theypresent different challenges and require an additional dimension of emergency planningthat involves the public health infrastructure (Box 1). Covert dissemination of abiological agent in a public place will not have an immediate impact because of the delaybetween exposure and onset of illness (i.e., the incubation period). Consequently, the firstcasualties of a covert attack probably will be identified by physicians or other primaryhealth-care providers. For example, in the event of a covert release of the contagiousvariola virus, patients will appear in doctors' offices, clinics, and emergency rooms duringthe first or second week, complaining of fever, back pain, headache, nausea, and othersymptoms of what initially might appear to be an ordinary viral infection. As thedisease progresses, these persons will develop the papular rash characteristic ofearly-stage smallpox, a rash that physicians might not recognize immediately. By the time therash becomes pustular and patients begin to die, the terrorists would be far away andthe disease disseminated through the population by person-to-person contact. Only ashort window of opportunity will exist between the time the first cases are identified anda second wave of the population becomes ill. During that brief period, public healthofficials will need to determine that an attack has occurred, identify the organism, andprevent more casualties through prevention strategies (e.g., mass vaccination orprophylactic treatment). As person-to-person contact continues, successive waves oftransmission could carry infection to other worldwide localities. These issues might also berelevant for other person-to-person transmissible etiologic agents (e.g., plague or certainviral hemorrhagic fevers).

Certain chemical agents can also be delivered covertly through contaminated foodor water. In 1999, the vulnerability of the food supply was illustrated in Belgium,whenchickens were unintentionally exposed to dioxin-contaminated fat used to makeanimal feed (6). Because the contamination was not discovered for months, the dioxin, acancer-causing chemical that does not cause immediate symptoms in humans, wasprobably present in chicken meat and eggs sold in Europe during early 1999. Thisincident underscores the need for prompt diagnoses of unusual or suspicious healthproblems in animals as well as humans, a lesson that was also demonstrated by the recentoutbreak of mosquitoborne West Nile virus in birds and humans in New York City in1999. The dioxin episode also demonstrates how a covert act of foodborne biological orchemical terrorism could affect commerce and human or animal health.

FOCUSING PREPAREDNESS ACTIVITIES

Early detection of and response to biological or chemical terrorism are crucial.Without special preparation at the local and state levels, a large-scale attack withvariola virus, aerosolized anthrax spores, a nerve gas, or a foodborne biological orchemical agent could overwhelm the local and perhaps national public healthinfrastructure. Large numbers of patients, including both infected persons and the "worriedwell," would seek medical attention, with a corresponding need for medical supplies,diagnostic tests, and hospital beds. Emergency responders, health-care workers, andpublic health officials could be at special risk, and everyday life would be disrupted as aresult of widespread fear of contagion.

Preparedness for terrorist-caused outbreaks and injuries is an essentialcomponent of the U.S. public health surveillance and response system, which is designed toprotect the population against any unusual public health event (e.g., influenza pandemics,contaminated municipal water supplies, or intentional dissemination ofYersinia pestis, the causative agent of plague[7]). The epidemiologic skills, surveillance methods,diagnostic techniques, and physical resources required to detect and investigate unusualor unknown diseases, as well as syndromes or injuries caused by chemical accidents,are similar to those needed to identify and respond to an attack with a biological orchemical agent. However, public health agencies must prepare also for the special featuresa terrorist attack probably would have (e.g., mass casualties or the use of rareagents) (Boxes 2-5). Terrorists might use combinations of these agents, attack in more thanone location simultaneously, use new agents, or use organisms that are not on thecritical list (e.g., common, drug-resistant, or genetically engineered pathogens). Lists ofcritical biological and chemical agents will need to be modified as new informationbecomes available. In addition, each state and locality will need to adapt the lists to localconditions and preparedness needs by using the criteria provided in CDC's strategic plan.

Potential biological and chemical agents are numerous, and the public healthinfrastructure must be equipped to quickly resolve crises that would arise from abiological or chemical attack. However, to best protect the public, the preparedness effortsmust be focused on agents that might have the greatest impact on U.S. health andsecurity, especially agents that are highly contagious or that can be engineered forwidespread dissemination via small-particle aerosols. Preparing the nation to address thesedangers is a major challenge to U.S. public health systems and health-care providers.Early detection requires increased biological and chemical terrorism awareness amongfront-line health-care providers because they are in the best position to reportsuspicious illnesses and injuries. Also, early detection will require improved communicationsystems between those providers and public health officials. In addition, state andlocalhealth-care agencies must have enhanced capacity to investigate unusual eventsand unexplained illnesses, and diagnostic laboratories must be equipped to identifybiological and chemical agents that rarely are seen in the United States. Fundamental tothese efforts is comprehensive, integrated training designed to ensure core competencyin public health preparedness and the highest levels of scientific expertise amonglocal, state, and federal partners.

KEY FOCUS AREAS

CDC's strategic plan is based on the following five focus areas, with each areaintegrating training and research:

  • preparedness and prevention;
  • detection and surveillance;
  • diagnosis and characterization of biological and chemical agents;
  • response; and
  • communication.

Preparedness and Prevention

Detection, diagnosis, and mitigation of illness and injury caused by biologicaland chemical terrorism is a complex process that involves numerous partners andactivities. Meeting this challenge will require special emergency preparedness in all citiesandstates. CDC will provide public health guidelines, support, and technical assistanceto local and state public health agencies as they develop coordinated preparednessplans and response protocols. CDC also will provide self-assessment tools for terrorismpreparedness, including performance standards, attack simulations, and other exercises.In addition, CDC will encourage and support applied research to develop innovativetools and strategies to prevent or mitigate illness and injury caused by biological andchemical terrorism.

Detection and Surveillance

Early detection is essential for ensuring a prompt response to a biological orchemical attack, including the provision of prophylactic medicines, chemical antidotes, orvaccines. CDC will integrate surveillance for illness and injury resulting from biologicaland chemical terrorism into the U.S. disease surveillance systems, while developingnew mechanisms for detecting, evaluating, and reporting suspicious events that mightrepresent covert terrorist acts. As part of this effort, CDC and state and local healthagencies will form partnerships with front-line medical personnel in hospital emergencydepartments, hospital care facilities, poison control centers, and other offices to enhancedetection and reporting of unexplained injuries and illnesses as part of routinesurveillance mechanisms for biological and chemical terrorism.

Diagnosis and Characterization of Biological andChemical Agents

CDC and its partners will create a multilevel laboratory response networkfor bioterrorism (LRNB). That network will link clinical labs to public health agencies inall states, districts, territories, and selected cities and counties and to state-of-the-artfacilities that can analyze biological agents (Figure 1). As part of this effort, CDC willtransfer diagnostic technology to state health laboratories and others who willperforminitial testing. CDC will also create an in-house rapid-response and advanced technology(RRAT) laboratory. This laboratory will provide around-the-clock diagnostic confirmatoryand reference support for terrorism response teams. This network will include theregional chemical laboratories for diagnosing human exposure to chemical agents andprovide links with other departments (e.g., the U.S. Environmental Protection Agency, whichis responsible for environmental sampling).

Response

A comprehensive public health response to a biological or chemical terroristevent involves epidemiologic investigation, medical treatment and prophylaxis foraffected persons, and the initiation of disease prevention or environmentaldecontamination measures. CDC will assist state and local health agencies in developing resourcesand expertise for investigating unusual events and unexplained illnesses. In the event ofa confirmed terrorist attack, CDC will coordinate with other federal agencies in accordwith Presidential Decision Directive (PDD) 39. PDD 39 designates the Federal Bureau ofInvestigation as the lead agency for the crisis plan and charges the FederalEmergency Management Agency with ensuring that the federal response management isadequate to respond to the consequences of terrorism (8). If requested by a state healthagency, CDC will deploy response teams to investigate unexplained or suspicious illnessesorunusual etiologic agents and provide on-site consultation regarding medicalmanagement and disease control. To ensure the availability, procurement, and delivery ofmedical supplies, devices, and equipment that might be needed to respond toterrorist-caused illness or injury, CDC will maintain a national pharmaceutical stockpile.

Communication Systems

U.S. preparedness to mitigate the public health consequences of biological andchemical terrorism depends on the coordinated activities of well-trained health-care andpublic health personnel throughout the United States who have access to up-to-theminute emergency information. Effective communication with the public through the newsmedia will also be essential to limit terrorists' ability to induce public panic and disruptdaily life. During the next 5 years, CDC will work with state and local health agenciesto develop a) a state-of-the-art communication system that will support diseasesurveillance; b) rapid notification and information exchange regarding disease outbreaksthat are possibly related to bioterrorism; c) dissemination of diagnostic results andemergency health information; and d) coordination of emergency response activities.Through this network and similar mechanisms, CDC will provide terrorism-related trainingto epidemiologists and laboratorians, emergency responders, emergency departmentpersonnel and other front-line health-care providers, and health and safety personnel.

(Video) Chemical Attacks – What You Should Know

PARTNERSHIPS AND IMPLEMENTATION

Implementation of the objectives outlined in CDC's strategic plan will becoordinated through CDC's Bioterrorism Preparedness and Response Program. Programpersonnel are charged with a) helping build local and state preparedness, b) developing U.S.expertise regarding potential threat agents, and c) coordinating response activitiesduring actual bioterrorist events. Program staff have established priorities for 20002002regarding the focus areas (Box 6).

Implementation will require collaboration with state and local public healthagencies, as well as with other persons and groups, including

  • public health organizations,
  • medical research centers,
  • health-care providers and their networks,
  • professional societies,
  • medical examiners,
  • emergency response units and responder organizations,
  • safety and medical equipment manufacturers,
  • the U.S. Office of Emergency Preparedness and other Department of Healthand Human Services agencies,
  • other federal agencies, and
  • international organizations.

RECOMMENDATIONS

Implementing CDC's strategic preparedness and response plan by 2004 willensure the following outcomes:

  • U.S. public health agencies and health-care providers will be prepared tomitigate illness and injuries that result from acts of biological and chemical terrorism.
  • Public health surveillance for infectious diseases and injuries --- includingevents that might indicate terrorist activity --- will be timely and complete, andreporting of suspected terrorist events will be integrated with the evolving,comprehensive networks of the national public health surveillance system.
  • The national laboratory response network for bioterrorism will be extendedto include facilities in all 50 states. The network will include CDC'senvironmental health laboratory for chemical terrorism and four regional facilities.
  • State and federal public health departments will be equipped withstate-of-the-art tools for rapid epidemiological investigation and control of suspectedor confirmed acts of biological or chemical terrorism, and a designated stockof terrorism-related medical supplies will be available through anational pharmaceutical stockpile.
  • A cadre of well-trained health-care and public health workers will be availablein every state. Their terrorism-related activities will be coordinated through arapid and efficient communication system that links U.S. public health agenciesand their partners.

CONCLUSION

Recent threats and use of biological and chemical agents against civilians haveexposed U.S. vulnerability and highlighted the need to enhance our capacity to detectand control terrorist acts. The U.S. must be protected from an extensive range ofcritical biological and chemical agents, including some that have been developed andstockpiled for military use. Even without threat of war, investment in national defenseensures preparedness and acts as a deterrent against hostile acts. Similarly, investment inthepublic health system provides the best civil defense against bioterrorism. Toolsdeveloped in response to terrorist threats serve a dual purpose. They help detect rareor unusual disease outbreaks and respond to health emergencies, including naturallyoccurring outbreaks or industrial injuries that might resemble terrorist events intheir unpredictability and ability to cause mass casualties (e.g., a pandemic influenzaoutbreak or a large-scale chemical spill). Terrorism-preparedness activities described inCDC's plan, including the development of a public health communication infrastructure, amultilevel network of diagnostic laboratories, and an integrated disease surveillancesystem, will improve our ability to investigate rapidly and control public health threatsthat emerge in the twenty first century.

References

  1. Okumura T, Suzuki K, Fukuda A, et al. Tokyo subway sarin attack; disastermanagement, Part 1: community emergency response. Acad Emerg Med 1998;5:613-7.
  2. Davis, CJ. Nuclear blindness: an overview of the biological weapons programs ofthe former Soviet Union and Iraq. Emerg Infect Dis 1999;5:509-12.
  3. Török TJ, Tauxe RV, Wise RP, et al. Large community outbreak of Salmonellosis causedby intentional contamination of restaurant salad bars. JAMA 1997;278:389-95.
  4. Tucker JB. Chemical/biological terrorism: coping with a new threat. Politics and theLife Sciences 1996;15:167-184.
  5. Uncle Fester. Silent death. 2nd ed. Port Townsend, WA: Loompanics Unlimited, 1997.
  6. Ashraf H. European dioxin-contaminated food crisis grows and grows [news].Lancet 1999;353:2049.
  7. Janofsky M. Looking for motives in plague case. New York Times. May 28, 1995:A18.
  8. Federal Emergency Management Agency. Federal response plan. Washington,DC: Government Printing Office, 1999. Available at <http://www.fema.gov/r-n-r/frp>.Accessed February 3, 2000.

Figure 1

1

Biological and Chemical Terrorism:Strategic Planfor Preparedness and Response (3)
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Box 1

BOX 1. Local public health agency preparedness

  • Because the initial detection of a covert biological or chemical attack willprobably occur at the local level, disease surveillance systems at state and localhealth agencies must be capable of detecting unusual patterns of disease orinjury, including those caused by unusual or unknown threat agents.
  • Because the initial response to a covert biological or chemical attack willprobably be made at the local level, epidemiologists at state and local health agenciesmust have expertise and resources for responding to reports of clusters of rare,unusual, or unexplained illnesses.
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Box 2

BOX 2. Preparing public health agencies for biological attacks

Steps in Preparing for Biological Attacks

  • Enhance epidemiologic capacity to detect and respond to biological attacks.
  • Supply diagnostic reagents to state and local public health agencies.
  • Establish communication programs to ensure delivery of accurate information.
  • Enhance bioterrorism-related education and training for health-care professionals.
  • Prepare educational materials that will inform and reassure the public duringand after a biological attack.
  • Stockpile appropriate vaccines and drugs.
  • Establish molecular surveillance for microbial strains, including unusual ordrug- resistant strains.
  • Support the development of diagnostic tests.
  • Encourage research on antiviral drugs and vaccines.
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Box 3

BOX 3. Critical biological agents

Category A

The U.S. public health system and primary health-care providers mustbe prepared to address varied biological agents, including pathogens that arerarely seen in the United States. High-priority agents include organisms that pose arisk to national security because they

  • can be easily disseminated or transmitted person-to-person;
  • cause high mortality, with potential for major public health impact;
  • might cause public panic and social disruption; and
  • require special action for public health preparedness (Box 2).

Category A agents include

  • variola major (smallpox);
  • Bacillus anthracis (anthrax);
  • Yersinia pestis (plague);
  • Clostridium botulinum toxin (botulism);
  • Francisella tularensis (tularaemia);
  • filoviruses,
    • Ebola hemorrhagic fever,
    • Marburg hemorrhagic fever; and
  • arenaviruses,
    • Lassa (Lassa fever),
    • Junin (Argentine hemorrhagic fever) and related viruses.

Category B

Second highest priority agents include those that

(Video) Chapter 40 Terrorism Response and Disaster Management

  • are moderately easy to disseminate;
  • cause moderate morbidity and low mortality; and
  • require specific enhancements of CDC's diagnostic capacity andenhanced disease surveillance.
Category B agents include
  • Coxiella burnetti (Q fever);
  • Brucella species (brucellosis);
  • Burkholderia mallei (glanders);
  • alphaviruses,
    • Venezuelan encephalomyelitis,
    • eastern and western equine encephalomyelitis;
  • ricin toxin from Ricinuscommunis (castor beans);
  • epsilon toxin of Clostridiumperfringens; and
  • Staphylococcus enterotoxin B.
A subset of List B agents includes pathogens that are food- or waterborne.
These pathogens include but are not limited to
  • Salmonella species,
  • Shigella dysenteriae,
  • Escherichia coli O157:H7,
  • Vibrio cholerae, and
  • Cryptosporidium parvum.

Category C

Third highest priority agents include emerging pathogens that couldbe engineered for mass dissemination in the future because of

  • availability;
  • ease of production and dissemination; and
  • potential for high morbidity and mortality and major health impact.
Category C agents include
  • Nipah virus,
  • hantaviruses,
  • tickborne hemorrhagic fever viruses,
  • tickborne encephalitis viruses,
  • yellow fever, and
  • multidrug-resistant tuberculosis.
Preparedness for List C agents requires ongoing research to improvedisease detection, diagnosis, treatment, and prevention. Knowing in advance whichnewly emergent pathogens might be employed by terrorists is not possible;therefore, linking bioterrorism preparedness efforts with ongoing disease surveillanceand outbreak response activities as defined in CDC's emerging infectiousdisease strategy is imperative.*

* CDC. Preventing emerging infectious diseases: a strategy for the 21st century.Atlanta, Georgia: U.S. Department of Health and Human Services, 1998.
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Box 4

BOX 4. Preparing public health agencies for chemical attacks

Steps in Preparing for Chemical Attacks

  • Enhance epidemiologic capacity for detecting and responding tochemical attacks.
  • Enhance awareness of chemical terrorism among emergency medicalservice personnel, police officers, firefighters, physicians, and nurses.
  • Stockpile chemical antidotes.
  • Develop and provide bioassays for detection and diagnosis of chemical injuries.
  • Prepare educational materials to inform the public during and after achemical attack

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Box 5

BOX 5. Chemical agents

Chemical agents that might be used by terrorists range from warfare agentsto toxic chemicals commonly used in industry. Criteria for determiningpriority chemical agents include
  • chemical agents already known to be used as weaponry;
  • availability of chemical agents to potential terrorists;
  • chemical agents likely to cause major morbidity or mortality;
  • potential of agents for causing public panic and social disruption; and
  • agents that require special action for public health preparedness (Box 4).
Categories of chemical agents include
  • nerve agents,
    • tabun (ethyl N,N-dimethylphosphoramidocyanidate),
    • sarin (isopropyl methylphosphanofluoridate),
    • soman (pinacolyl methyl phosphonofluoridate),
    • GF (cyclohexylmethylphosphonofluoridate),
    • VX (o-ethyl-[S]-[2-diisopropylaminoethyl]-methylphosphonothiolate);
  • blood agents,
    • hydrogen cyanide,
    • cyanogen chloride;
  • blister agents,
    • lewisite (an aliphatic arsenic compound, 2-chlorovinyldichloroarsine),
    • nitrogen and sulfur mustards,
    • phosgene oxime;
  • heavy metals,
    • arsenic,
    • lead,
    • mercury;
  • Volatile toxins,
    • benzene,
    • chloroform,
    • trihalomethanes;
  • pulmonary agents,
    • phosgene,
    • chlorine,
    • vinyl chloride;
  • incapacitating agents,
    • BZ (3-quinuclidinyl benzilate);
  • pesticides, persistent and nonpersistent;
  • dioxins, furans, and polychlorinated biphenyls (PCBs);
  • explosive nitro compounds and oxidizers,
    • ammonium nitrate combined with fuel oil;
  • flammable industrial gases and liquids,
    • gasoline,
    • propane;
  • poison industrial gases, liquids, and solids,
    • cyanides,
    • nitriles; and
  • corrosive industrial acids and bases,
    • nitric acid,
    • sulfuric acid.
Because of the hundreds of new chemicals introduced internationallyeach month, treating exposed persons by clinical syndrome rather than byspecific agent is more useful for public health planning and emergency medicalresponse purposes. Public health agencies and first responders might render themost aggressive, timely, and clinically relevant treatment possible by usingtreatment modalities based on syndromic categories (e.g., burns and trauma,cardiorespiratory failure, neurologic damage, and shock). These activities must be linkedwith authorities responsible for environmental sampling and decontamination.

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Box 6

BOX 6. Implementation Priorities Regarding Focus Areas for 2000-2002

Preparedness and Prevention
  • Maintain a public health preparedness and response cooperative agreementthat provides support to state health agencies who are working with local agenciesin developing coordinated bioterrorism plans and protocols.
  • Establish a national public health distance-learning system thatprovides biological and chemical terrorism preparedness training to health-careworkers and to state and local public health workers.
  • Disseminate public health guidelines and performance standards onbiological and chemical terrorism preparedness planning for use by state and localhealth agencies.

Detection and Surveillance

  • Strengthen state and local surveillance systems for illness and injuryresulting from pathogens and chemical substances that are on CDC's critical agents list.
  • Develop new algorithms and statistical methods for searching medicaldatabases on a real-time basis for evidence of suspicious events.
  • Establish criteria for investigating and evaluating suspicious clusters of humanor animal disease or injury and triggers for notifying law enforcement ofsuspected acts of biological or chemical terrorism.

Diagnosis and Characterization of Biological and Chemical Agents

  • Establish a multilevel laboratory response network for bioterrorism thatlinks public health agencies to advanced capacity facilities for the identificationand reporting of critical biological agents.
  • Establish regional chemical terrorism laboratories that will providediagnostic capacity during terrorist attacks involving chemical agents.
  • Establish a rapid-response and advanced technology laboratory within CDCto provide around-the-clock diagnostic support to bioterrorism response teamsand expedite molecular characterization of critical biological agents.

Response

  • Assist state and local health agencies in organizing response capacities torapidly deploy in the event of an overt attack or a suspicious outbreak that might bethe result of a covert attack.
  • Ensure that procedures are in place for rapid mobilization of CDCterrorism response teams that will provide on-site assistance to local healthworkers, security agents, and law enforcement officers.
  • Establish a national pharmaceutical stockpile to provide medical supplies inthe event of a terrorist attack that involves biological or chemical agents.
  • Establish a national electronic infrastructure to improve exchange ofemergency health information among local, state, and federal health agencies.
  • Implement an emergency communication plan that ensures rapiddissemination of health information to the public during actual, threatened, or suspected actsof biological or chemical terrorism.
  • Create a website that disseminates bioterrorism preparedness andtraining information, as well as other bioterrorism-related emergency information,to public health and health-care workers and the public.
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(Video) Medical Response to Biological Warfare and Terrorism (Part 1)

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Biological and Chemical Terrorism:Strategic Planfor Preparedness and Response (4)

Videos

1. Strategies to manage terrorism responsive measures
(Shu Fen Tan)
2. Emergency Response to Terrorism Lecture
(EMS University)
3. Policy Talk: Preventing Pandemics and Bioterrorism
(Schar School of Policy and Government)
4. Presentation Part III: Handbook of Terrorism Prevention and Preparedness
(International Centre for Counter-Terrorism)
5. Biological Warfare and Terrorism: The Military and Public Health Response (Part 6 of 6)
(PublicResourceOrg)
6. Terrorism Response and Disaster Management
(FVCC EMS Programs)

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