Bioterrorism Fears

 Texas Prepares for an Attack That Could Kill Thousands

Texas Medicine Logo

Cover Story -- September 2002

By  Ken Ortolon
Senior Editor

In the 1997 Tom Clancy novel Executive Orders , Arab terrorists unleash the deadly Ebola virus on an unsuspecting America. Distributed via aerosol devices set off in crowded convention halls, shopping malls, and other public places, the virus sickens or kills tens of thousands before the outbreak can be contained.

That was fiction, and some might have said the entire scenario was far-fetched. But that was before Sept. 11, 2001.

For Web sites dealing with bioterrorism, see September MedBytes.

In the aftermath of the suicide jetliner attacks that day and the deaths and illnesses caused by the anthrax-tainted letters that appeared in New York, Washington, D.C., and Florida a month later, physicians and public health officials across the country are rapidly gearing up to respond to just that type of bioterrorist event. While experts say Ebola is not the likely weapon a bioterrorist would choose, there is a real threat that anthrax, smallpox, or one of several other deadly biological agents could be used against the United States.

"I think it's very likely that there will be biologic agents used against us by our enemies," said Ronald R. Blanck, DO, president of the University of North Texas Health Science Center at Fort Worth and chair of Texas Medical Association's Task Force on Bioterrorism. "Is it going to happen? Yes. What's the organism going to be? I don't know."

On the Fast Track

Convinced the threat of biological weapons is real, the federal government is helping states prepare for a bioterrorist event and pushing a very aggressive schedule for preparedness planning. The Texas Department of Health (TDH) has received two federal grants of nearly $60 million to improve hospital preparedness and to beef up state and local health department laboratory facilities, disease surveillance capability, and other public health functions.

The first grant of $8.4 million came from the Health Resources and Services Administration (HRSA) to measure hospitals' readiness to deal with mass illnesses resulting from a bioterrorist event. Ron Hilliard, RN, coordinator of the TDH Bioterrorism Hospital Preparedness Program, says the first phase of the project surveyed all 570 hospitals in Texas to determine their level of preparedness. About $1.7 million of the grant was earmarked for carrying out that survey.

The remaining money will help hospitals improve their planning for bioterrorism response.

The hospital surveys went out in May. A total of 110 hospitals were asked to complete a comprehensive survey that measured general preparedness, community-wide planning, hospital management security, public relations, access to care, pharmacy stockpiles, bioterrorism incidents protection and recognition, medical treatment procedures, decontamination and infection control, training, and psychiatric services and crisis counseling. The remaining hospitals were sent a more general survey. Hospitals that completed the comprehensive survey included all hospitals designated as lead trauma facilities, as well as all military and veterans hospitals, and a cross section of state, children's, psychiatric, specialty, rehabilitation, and trauma- and non-trauma-designated hospitals in both urban and rural areas.

Temple emergency medicine physician David Morgan, MD, is TMA's representative on the Hospital Preparedness Planning Committee that reviewed the survey results. He says there were few surprises in the results.

"What the survey found was that the large hospitals seem to be better prepared than the smaller hospitals," said Dr. Morgan, medical director of the Central Texas Poison Center at Scott & White Memorial Hospital and Clinic and a member of the TMA bioterrorism task force. "The trauma hospitals are better prepared than the non-trauma hospitals."

Mr. Hilliard says the surveys showed that the overall level of planning did not go very deep.

"From the general assessment, it looked like hospitals were planning," he said. "But from the comprehensive surveys, when we started pulling down the layers, it didn't look like planning went down very far."

Many Texas hospitals have mass casualty plans but they may be inadequate to respond to large numbers of patients, Mr. Hilliard says.

"In general, those plans encompassed dealing with maybe five or 10 patients at a time, like from a major car accident or a bus wreck. But when we start talking about hundreds of patients, they have no plan for dealing with that. That's one of the focuses of the HRSA grant. How do you handle a surge of 500 patients?"

Mr. Hilliard says a proposal submitted to HRSA for phase two of the hospital preparedness project focuses on helping hospitals carry out the level of planning needed to handle a large-scale event. Particular emphasis will be paid to regional planning, he adds.

Building Capacity

The second grant, $51.4 million for public health preparedness, came from the U.S. Centers for Disease Control and Prevention (CDC). Specifically, funds are being distributed to local and regional health departments to build infrastructure, says state epidemiologist Dennis Perrotta, PhD.

"That's a real shot in the arm for Texas, both at the state and local levels, allowing us to build infrastructure, build capacity to respond to bioterrorism, and also the day-to-day activities of public health, such as responding to hepatitis or shigellosis outbreaks and all the other diseases we deal with," he said.

Some 70 percent of the money has been awarded to local health departments. Dr. Perrotta says the intent is to build epidemiology capacity at local health departments so they can more aggressively detect, track, and investigate disease outbreaks.

For example, $862,000 went to the Hidalgo County Health Department in the Lower Rio Grande Valley. That money will be used to hire 12 new staff members, including an assistant public health administrator, an epidemiologist, two public health technicians, four licensed vocational nurses, and four outreach workers. Hidalgo County Health Department officials say those staff members will be able to monitor infectious diseases more closely throughout the county.

The San Antonio Metropolitan Health District received $1.9 million of those funds. The money will go for hiring and training, improved disease tracking, and computer upgrades to speed dissemination of information in case of a bioterrorism attack, says district Director Fernando Guerra, MD.

The remainder of the CDC grant, Dr. Perrotta says, will be used by TDH to support local and regional efforts. For example, some of the funds will pay to improve laboratory capacity at nine laboratories throughout the state. That means TDH will have a network of 10 laboratories -- including the central laboratory at TDH headquarters in Austin -- capable of analyzing potential biological agents.

Dusting Off Old Laws

While TDH is working to beef up the capacity to respond, the Texas Legislature is looking at the adequacy of the laws under which public health officials would operate during a bioterrorism attack.

In June, the Senate Health and Human Services Committee approved recommendations to update the state's quarantine laws and allow the governor to declare a public health emergency.

Specifically, they would add a definition of public health emergency to both the Texas Disaster Act of 1975 and the Communicable Disease Prevention and Control Act, allow the health commissioner to impose area quarantines or control measures if a communicable disease is suspected, and authorize the commissioner to delegate such authority to local health officials. The recommendations also would extend disease control measures to property that might be infected, make infected individuals subject to court order, and improve the reporting of infectious diseases.

Sen. Mike Moncrief (D-Fort Worth), chair of the Health and Human Services Committee, said the statutory revisions are necessary "to provide the Department of Health with sufficient authority to respond effectively in a public health emergency."

Texas Commissioner of Health Eduardo Sanchez, MD, MPH, says the proposals, which will be presented to the legislature in 2003, were developed with input from TDH and a broad range of stakeholders, including TMA.

"These recommendations provide the means by which we can assure ourselves that in the event of a public health emergency, TDH and its partner health departments can do those things necessary to control the spread of disease and control physical entities that might be threats to the health of the public," Dr. Sanchez said. "In terms of quarantine, they do not grant new powers at all. They clarify some language and give the commissioner of health additional ability to delegate authority to local health authorities who are acting as the eyes and ears of TDH and the Board of Health."

While the committee's recommendations did not address the issue, TMA believes the state's "Good Samaritan" statute also needs to be revisited by the legislature to ensure adequate protection from liability for physicians who volunteer in a public health emergency. Dr. Blanck says TMA's bioterrorism task force is looking at the liability and quarantine issues, as well as how TMA can work with TDH to advocate for further public health infrastructure needs.

The Health and Human Services Committee also is expected to review the Good Samaritan statute and make recommendations for revisions when the legislature convenes in January.

Exploring the Nasty Bugs

While public health officials are gearing up to treat victims of a bioterrorism attack, academic physicians in Texas are launching increased efforts to research the deadly agents that might be employed in such attacks.

In October, The University of Texas Medical Branch at Galveston (UTMB) created a new Center for Biodefense to be a catalyst for research efforts on emerging infectious diseases. And in January, UTMB broke ground on a maximum biological containment, or Biosafety Level Four (BSL4), laboratory that will allow scientists there to research some of the most virulent biological agents. The lab is scheduled for completion in June 2003.

C.J. Peters, MD, director of both the Center for Biodefense and the BSL4 lab, says his goal for the new facilities is to decrease America's vulnerability to bioterrorism through a program of research and development centered on vaccines, as well as other drugs and medical countermeasures. He also sees the center and lab as a vital cog in helping Texas and the Gulf Coast region respond to bioterrorism. The laboratory will allow UTMB scientists to work with what Dr. Peters calls the "nastiest bugs."

"We want to improve the nation's readiness to deal with bioterrorism," said Dr. Peters, a member of the TMA Task Force on Bioterrorism. "There are a lot of different ways to do that, and we can't do them all. So we're trying to select areas where we can make a real contribution. We believe UTMB can do that, particularly with the viral hemorrhagic fevers and also with some other agents, such as anthrax, plague, and tularemia."

The Center for Biodefense will be a multidisciplinary umbrella organization that will pull together 25 researchers from UTMB's Center for Tropical Diseases and Sealy Center for Structural Biology.

"The Center for Biodefense will serve as a catalyst for research and development efforts at UTMB that address an urgent national need," Stanley M. Lemon, MD, dean of medicine, said in announcing the center in October. "In doing this, it will take advantage of a wide diversity of research strengths at UTMB, in fields ranging from basic molecular and structural biology, to animal models of infectious disease pathogenesis, to more applied aspects of vaccine development and evaluation within the recently established Sealy Center for Vaccine Research."

The center is still in its infancy, but Dr. Peters says researchers there already are seeking grant funding from agencies such as CDC and the National Institute of Allergy and Infectious Diseases.

The laboratory, which will look something like a submarine enclosed in a bank vault, will have 1,000 square feet of lab space and 1,000 square feet of space for storage of laboratory animals. Dr. Peters says the lab is "absolutely essential," particularly to the vaccine research they intend to conduct.

"If you want to see if a vaccine works at the first stages, you've got to inject an animal and then challenge it with a hot virus," he said. "There is no substitute for that, and that's got to be done in a biosafety level four lab."

In addition to its research activities, Dr. Peters says the lab and the Center for Biodefense will play a role in local, statewide, and regional bioterrorism response. Center officials already have talked with TDH staff about providing them with diagnostic expertise in the event of a disease outbreak. And, UTMB can use its telemedicine capabilities to link experts from the center with treating physicians at the site of any outbreak.

"What happens if there's a bioterrorism event in Wichita Falls or elsewhere? We're not going to have experienced physicians to fly out to these different places," Dr. Peters said. "So we're going to have to project our specialized resources to help the local people who are going to have to deal with it. Through telemedicine we can project out into the surrounding areas in Texas and literally all over the world."

The National Scene

Texas physicians' efforts to prepare for bioterrorism have not been limited to Texas. Several have been involved in bioterrorism response planning by the U.S. Department of Health and Human Services (HHS), Homeland Security Director Tom Ridge, the Federal Bureau of Investigation, the Secret Service, and other federal agencies.

Paul Pepe, MD, professor and chair of emergency medicine at The University of Texas Southwestern Medical Center at Dallas and medical director of the Dallas Metropolitan Medical Response System, says he and fellow UT Southwestern emergency medicine faculty member Kathy Rinnert, MD, an expert on weapons of mass effect, were asked to review and provide feedback on a hospital preparedness plan being developed by HHS. The plan provides models for local hospitals to follow in bioterrorism preparedness planning.

Dr. Pepe and Dr. Blanck also have been involved in a consortium of federal agencies and medical schools that is developing a standardized national bioterrorism training course.

"This came out of conversations with the U.S. Department of Health and Human Services," Dr. Pepe said. "We met with the people in the Office of Emergency Preparedness, and they said they needed training courses for primary care providers and first responders to bioterrorism."

The course, which will be called the Advanced Disaster Life Support course, will be based on a template similar to the American Heart Association Advanced Cardiac Life Support course and the American College of Surgeons Advanced Trauma Life Support course. The consortium hopes to roll out the pilot course this fall, Dr. Pepe says.

Dr. Blanck says physician education is critical. "Most physicians have never seen smallpox, anthrax, pneumonic plague."

The Prevention Basket

While millions of dollars and months of effort have gone into preparing to react to a bioterrorism attack, at least one Texas physician says too little attention has been paid to efforts to prevent it.

Saul B. Wilen, MD, president of International Horizons Unlimited, a San Antonio-based terrorism prevention think tank, says efforts to prevent terrorism have actually declined since Sept. 11.

"While the need for prevention efforts is increasing, the actual commitment by states and localities to terrorism prevention is declining," Dr. Wilen said. "A reassessment of how government agencies are expending their resources on antiterrorism efforts is needed."

Between Oct. 1, 2001, and May 31, 2002, International Horizons analyzed state and local antiterrorism efforts of four states and eight localities across the country. The analysis looked at all actions taken or proposed relating to terrorism, emergency management, effective communication, education efforts for staff and the public, resources management, and crisis response.

The data, presented to the U.S. Secret Service Task Force on Electronic Crimes and Terrorism in April, show that as of March 31, 80 percent of all efforts were solely reactive in nature. Only 5 percent of all efforts were directed at prevention. By May 31, reactive efforts had increased to 81 percent, while prevention efforts had dropped to 2 percent.

"Should we be responsive? Should we know how to treat if there is a treatment? Should we know how to isolate? Yes, yes, yes," Dr. Wilen said. "But we're putting all our eggs into one basket, and that's the responsiveness basket. We need to be putting half of our efforts into prevention."

That, Dr. Wilen says, is because our hospitals and public health departments don't have the capabilities to respond to a massive outbreak of a disease like smallpox.

"In Bexar County, serving 1.5 million people, Metropolitan Health District Director Fernando Guerra says his surge potential is 250 per day," said Dr. Wilen. "What good is that if you have 100,000 cases of smallpox? What if you have to quarantine 40,000 people in San Antonio? How are you going to do it?"

Dr. Wilen, who also recently spoke about terrorism prevention to the Western Governors Association and the National Governors Association, says prevention must include information, effective communication, education, and resources management. 

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at  Ken Ortolon.

SIDEBAR

TMA Knowledge Center Lists Bioterrorism Materials and Internet Resources

To quickly find books, articles, and Web site links to reliable resources on bioterrorism, click on the Knowledge Center's  hot topics bibliography.

To request items on the hot topics list, members can contact the Knowledge Center by filling out and submitting an online photocopy request form; by calling (800) 880-1300, ext. 1550, or (512) 370-1550; by faxing (512) 370-1634; or by sending an e-mail to  TMA Knowledge Center.

September 2002 Texas Medicine Contents
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