BioSecurity 2003 explores progress made—and challenges that remain

Research is being conducted, teams are being built, priorities are being reassessed and reordered—and information exchanges like those fostered by the BioSecurity 2003 conference in Washington, DC are becoming part of the fabric of a new culture of security, medical preparedness, and emergency response.But the underlying impression left by these three October days of status updates, lessons learned, and technological revelations is that the global community of health care professionals and government officials engaged in biosecurity efforts is a work-in-progress. Energetic minds and great ideas have not yet cohered to form an answer to the bioterrorist threat that exists around the world. Not yet—but they are getting there.

The diversity of professionals who presented ideas or gathered in Washington to hear them says much about the complexity of this challenge. Infectious disease experts talked about the SARS outbreak, and discussed how modern technologies play a role in both the spread and containment of epidemics. Technologists demonstrated the latest in detection and surveillance tools, going beyond the nuts and bolts of this new machinery to how each has been designed to deal specifically with the unique motivations and tactics of terrorists. And professionals from fields such as emergency medicine, psychiatry, and communications approached a question that, two years after the 9/11 attacks, is still being asked: when prevention efforts fail and disaster strikes, what then?

Dr. David Heymann: International health regulations are “outdated.”

Disease and disaster
The conference, which ran from October 20-22, began on a positive note, as keynote speaker David Heymann, Executive Director for Communicable Diseases at the World Health Organization (WHO), explained that disease does not have to spell disaster. As witnessed by the relatively swift response of outlets like FluNet and the Global Public Health Intelligence Network to SARS, the existing biosurveillance infrastructure does a good job of identifying unusual health situations. Heymann also pointed out that only a few weeks passed between when China’s Guangdong district revealed an occurrence of atypical pneumonia in February 2003 to when WHO, which follows and verifies all outbreaks, issued the first international alert on March 12.

International health regulations, however, are “outdated,” according to Heymann, and ineffective in preventing the spread of disease in a world where international trade and travel mean more chances for disease to spread between continents and countries. But modernity also plays a role in responding to outbreaks—communications tools such as video conferencing and email helped health officials quickly disseminate information around the world to frontline care providers.

SARS hit the world community at its own pace, spreading from person to person through contact. But what about a disease unleashed upon a community by a terrorist group whose aim is to infect as many people as possible? Dr. Raymond Strikas, who coordinates smallpox preparedness efforts at the U.S. Centers for Disease Control (CDC) and Prevention’s National Immunization Program, said that although the United States is “much better prepared to manage a smallpox outbreak” now than it was two years ago, prevention efforts have come up against “public complacency” regarding this issue. Last December, U.S. Secretary of Health and Human Services (HHS) Tommy Thompson announced that an initial group of more than 439,000 first responders had been targeted for smallpox vaccination. Strikas, who attempted to dispel rumors that the smallpox vaccination program had ceased, admitted that only about 38,000 civilians had been vaccinated, and that “obviously the targets were not achieved.”

The shortfall of the vaccination program has resulted in a change in direction for the CDC. Instead of focusing on meeting target figures for individual vaccinations, the agency, said Strikas, is now working with state and local colleagues to determine how many teams—made up primarily of health care personnel from participating hospitals who would evaluate, manage, and treat smallpox cases—would be required to respond to an outbreak. He pointed out that $2.5 billion have been allocated to states to support their smallpox preparedness efforts.

Asked to assess the current smallpox threat, Strikas said, “Concerns remain regarding the location of the Russian supply of the pathogen and also with the severity and consequences of an outbreak.”

Dr. John Marburger: “We cannot improve regulations without strengthening relationships across diverse agencies.”

A culture of shifting priorities
Lingering concerns were a common theme of the conference. Dr. John Marburger, director of the White House’s Office of Science and Technology Policy, sounded a clear warning during his keynote speech when he said that the anthrax attacks of October 2001 sent “two ambiguous messages: our society is vulnerable to bioterrorism, and we are unprepared.” But he followed that statement with a note of progress: “Much remains to be done, but a substantial framework has been created that will make further action easier, and clear directions have been established to guide the next steps.”

Marburger discussed the challenges facing federal, state, and local governments to meet minimum preparedness mandates designed to better train and equip first response, public safety, and medical care providers. He introduced new collaborations between the Department of Homeland Security and the Department of Health and Human Services designed to facilitate rapid communication and decision-making, and accelerate the development of counter-measures. He concluded his address with a sentiment that was echoed throughout the conference by members of various fields: “We cannot improve regulations without strengthening relationships across diverse agencies.”

A keynote address by Dr. Lester Crawford illustrated the culture—and mission—shift of the U.S. Food and Drug Administration (FDA), which has not, until recent years, been viewed as a defense-related agency. As Dr. Miles Shore, one of the event’s organizers, pointed out when introducing Crawford, there is an immense terrorist opportunity in food contamination, and “the FDA is charged with protecting the nation from agri-terrorism.”

Dr. Lester Crawford: “Basically, the whole culture of the FDA has changed since 9/11.”

Crawford said that the FDA has always been interested in the economic and psychological impacts of bioterrorism and food-borne hazards, and he alluded to a number of incidents to show the effects, including cyanide-tainted apples in Chile, an intentionally contaminated salad bar in Oregon, and the devastation of Mad Cow disease, from which the UK beef industry has struggled to recover. These and other events have led the FDA to look more closely at food safety events as possible terrorist activities. Since 9/11, the FDA has committed large financial and other resources to the establishment of a new FDA command center which completes numerous and regular HHS agri-terrorist test scenarios, including war scenarios. “Basically, the whole culture of the FDA has changed since 9/11,” he said. “There is now a need to re-train the FDA labor force, particularly the field workforce. We are now moving toward a ‘risk-based’ system of operation throughout the entire agency—in the field and throughout headquarters.”

John Eldridge, editor of Jane's Nuclear, Biological, and Chemical Defence (UK), talked about the challenges of detection. “We must continually compile and synthesize the latest information in the area of technological solutions,” he said. The information he presented on detection efforts focused as much on understanding terrorists as on methods for exposing them and preventing terrorist acts. Eldridge said that 90 percent of all recent bioterrorist events were committed by people who held a grudge. He exhorted the audience to study the intentions to terrorists to understand their motivations.

At the scene of the crime
What if prevention fails? A bomb explodes in a crowded train station. A virus is set loose in a community. When we talk about preparedness, what is it that we are preparing ourselves for? As a number of sessions emphasized, good intentions like those expressed during the conference do not necessarily constitute a good response to bioterrorism. As Dr. Susan Briggs, director of the HMI Trauma and Disaster Institute and assistant professor of surgery at Massachusetts General Hospital, explained, in the aftermath of a disaster, many resources—people, equipment, and supplies—are wasted due to a lack of planning, coordination, and real understanding of what is required. Briggs exposed four myths of disaster response that she believes have hindered emergency medical response planning. The first myth is that all disasters are different, particularly those involving terrorism. The second myth is that traditional organizational and command structures can be translated to disaster response. For example, while the CEO of a company may be best suited to guide the vision and goals of the organization, another employee may possess the core competencies required to lead an effective disaster response. The third myth Briggs exposes is the notion that effective surge capacity is based on well-intentioned and readily available volunteers. Fourth, Briggs dispelled the myth that politics don’t dictate disaster response. “Politics, more than lack of personnel, supplies, and equipment, limits the effectiveness of disaster preparedness and response to today’s complex disasters.”

Keynote speaker Dr. Robert Ursano made it clear that the mental health impact of terrorism and other violent acts can far outreach the physical. Ursano is chairman of the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He began by exploring this abstract term—terrorism—that has been employed by so many people for so many different purposes since 9/11, with its true definition often left behind. The goal of terrorism, said Ursano, is not the harm that befalls its victims, but the fear it instills in the greater community. The attacks on the World Trade Center towers and the Pentagon did more than take lives at those two sites—they made people all over the United States wonder if they would face a similar fate in their own community. “Terrorism and disasters not only touch those directly affected, but, in fact, span across time and geography,” said Ursano.

Terrorism not only kills, it disrupts. A major disaster—and this goes for natural disasters such as earthquakes as well—will typically divert public health resources to the immediate catastrophe, often at the expense of more mundane, but no less important programs or services. Ursano said, “After the large scale disasters you’ll find social services have been sucked away to other areas or are not longer available.”

Bringing the key ingredients together
The common thread running through the entire three-day conference was the importance of communication and cooperation. Agencies must talk to one another. Experts must share information. Government officials with competing agendas must be creative with limited funding and resources. There is no doubt that the infrastructure, knowledge, and training programs to combat, prevent, and respond to bioterrorism are being developed. But work remains to be done to translate objectives and information into budgets, communication, and plans of effective action.

BioSecurity 2003 was organized by Harvard Medical International, Harvard Medical School, Harvard School of Public Health, and MediaLive International, Inc. To learn more about BioSecurity 2003 and explore other issues regarding bioterrorist prevention, preparedness, and response efforts, visit the conference website at www.biosecuritysummit.com.