Emerging Infectious Diseases
[Volume 5 No.4 / July - August 1999]


Commentary

Addressing the Potential Threat of Bioterrorism——Value Added to
an Improved Public Health Infrastructure

Joseph E. McDade
Centers for Disease Control and Prevention, Atlanta, Georgia, USA

The use of biological weapons was banned in 1972 by the
Convention on the Prohibition of the Deployment, Production, and
Stockpiling of Bacteriological and Toxin Weapons (1). Caches of
biological weapons still exist, however, and their illegal use in
military operations cannot be discounted entirely (2).

The threat of biological warfare seems remote to industrialized
nations, which have enjoyed decades of peace and prosperity. In
contrast, the threat of bioterrorism, in which biological agents are
used by extremists as weapons against civilian populations,
generates considerable anxiety. Although the likelihood of a
bioterrorist attack is difficult to predict, the consequences of a
successful attack could be devastating and cannot be ignored.
Unlike attacks involving conventional or even chemical weapons,
which could be readily detected and limited to a specific geographic
area, an attack with a biological agent (and the resulting symptoms
of exposed persons) could remain undetected for days, would be
widely scattered, and depending on the etiologic agent, might not
be identified immediately as a manmade event. Secondary cases
would confound epidemiologic investigations as well.

Regardless of the source, surveillance of infectious diseases,
detection and investigation of outbreaks, identification of etiologic
agents and their modes of transmission, and the development of
prevention and control strategies are responsibilities of public health
agencies. Acquiring and sustaining the capability for an adequate
response to bioterrorism requires thoughtful analysis and carefully
integrated planning by these agencies, as well as law enforcement
officials, emergency response physicians and other first responders,
the military, and others. New partnerships will need to be forged
and old ones strengthened.

Preliminary assessments of our nation's capabilities for responding
to possible bioterrorist attacks have identified many deficiencies.
From the public health perspective, these deficiencies include
inadequate surveillance systems; lack of rapid diagnostic
techniques; insufficient stockpiles and distribution systems of
antimicrobial agents and vaccines; inefficient communication
systems; and insufficient training of physicians, epidemiologists, and
laboratorians. The deficiencies may be more pressing in certain
disease areas than in others. Some diseases that are considered
bioterrorist threats, such as anthrax and plague, are no longer
important public health problems in most industrialized nations, so
the capabilities and capacities for responding to outbreaks of these
diseases may be at historic lows. These deficiencies in response
capacity can be traced to the 1960s and 1970s, when complacency
began to erode essential components of the public health
infrastructure. Since the early 1970s, at least 25 previously
unknown pathogenic agents and diseases have been identified, and
in recent years mounting resistance to antimicrobial agents has
confounded the treatment of many illnesses (3).

A strategic plan for reducing the consequences of new and
reemerging infectious diseases (4) proposes corrective measures for
addressing the infrastructure deficiencies: instituting better
surveillance systems, improving diagnostic techniques, developing
new vaccines and drugs, and conducting research and providing
training in several areas. The measures needed to prevent and
control emerging infections are strikingly similar to those needed to
check the threat of bioterrorism. Improving capabilities and
capacities for responding to one issue will almost certainly benefit
the other. For example, developing rapid diagnostic techniques that
would make it possible to quickly detect bioterrorist attacks
involving anthrax, plague, or Q fever would have considerable
usefulness in the routine clinical diagnosis of pneumonia.
Distribution systems set up to deliver antimicrobial agents and
vaccines after bioterrorist attacks would be indispensable in
delivering antiviral compounds and influenza vaccine during a large
pandemic. Surveillance and communication systems are
fundamental components of an adequate public health
infrastructure, so an electronic, integrated surveillance system based
on standard architecture and vocabulary would serve all needs.

A value-added approach to infrastructure development is not a new
concept in public health. In 1951, at the beginning of the cold war,
the Epidemic Intelligence Service (EIS) was founded at the Center
for Disease Control (CDC) (5,6). The EIS concept originated with
Joseph W. Mountin, founder of CDC, and was implemented by
Alexander D. Langmuir. Noting the "dearth of trained
epidemiologists," Langmuir proposed training a corps of young
physicians that could "investigate outbreaks of disease in strategic
areas." He also noted, "A broader but equally pressing need is to
make available competent epidemiologists to assist in the planning
and organization of the total civil defense program at all levels."
Langmuir also observed that while "this dearth exists even in
peacetime, defense needs exaggerate this deficiency."

In 1951, 22 young physicians and one sanitary engineer signed on
as EIS Officers at CDC, where they received several weeks of
instruction in epidemiology, biostatistics, and public health
administration and then served for 2 years as field epidemiologists,
either at CDC or in state health departments. EIS has been in
operation since then, and as the purview of CDC expanded beyond
infectious diseases, so have the size and composition of EIS and the
training of EIS Officers. Surveillance, outbreak investigations, and
research on the epidemiology of new diseases remain standard
activities, however. EIS has rarely had occasion to investigate
outbreaks caused by the intentional release of microorganisms
(7,8). However, as Langmuir predicted in 1951, the program has
increased public health preparedness and made important
contributions to the control of communicable diseases. EIS now has
more than 2,000 alumni, including nearly 200 scientists from
abroad. Many alumni have moved on to distinguished careers in
academia, industry, and clinical practice, but many others have filled
key positions at federal and state public health agencies. Trained to
consider diseases as problems of populations, EIS alumni remain a
valuable resource when disease outbreaks occur.

As in 1951, civil defense, and particularly the use of biological
agents against civilian populations, is of utmost concern. Efforts are
under way to improve the capabilities of the public health system
for detecting and responding to this threat. Also as in 1951, we
have an opportunity to ensure that improvements made in response
to the threat of bioterrorism have multiple uses and can be applied
to other public health emergencies. Planning efforts to date have
adopted this viewpoint. Developing a separate infrastructure for
responding to acts of bioterrorism would be poor use of scarce
resources, particularly if this infrastructure is never used. "Value
added" should be the watchwords of the current initiative.

References

  1. Smart JK. History of chemical and biological warfare: an
American perspective. In: Medical aspects of chemical and
biological warfare. Sidell FR, Takafuji ET, Franz DR, editors.
Washington: Office of the Surgeon General; 1997. p. 9-86. 
  2. Zilinskas RA. Iraq's biological weapons: the past as future?
JAMA 1997;278:418-24.
   3. McDade JE. Global infectious disease: surveillance and
response. Australian Journal of Medical Science 1997;18:2-9.
   4. Centers for Disease Control and Prevention. Preventing
emerging infectious diseases: a strategy for the 21st century.
Atlanta: U.S. Department of Health and Human Services; 1998.
   5. Langmuir AD, Andrews JM. Biological warfare defense. 2. the
Epidemic Intelligence Service of the Communicable Disease Center.
Am J Public Hlth 1952;42:235-8.
   6. Thacker SB, Goodman RA, Dicker RC. Training and service in
public health practice, 1951-90——CDC's Epidemic Intelligence
Service. Public Health Rep 1990;105:599-604.
   7. Torok TJ, Tauxe RV, Wise RP, Livengood JR, Sokolow R,
Mauvais S, et al. A large community outbreak of salmonellosis
caused by intentional contamination of restaurant salad bars. JAMA
1997;278:389-95.
   8. Kloavic SA, Kimura A, Simons SL, Slutsker L, Barth S, Haley
CE. An outbreak of Shigella dysenteriae Type 2 among laboratory
workers due to intentional food contamination. JAMA
1997;278:396-8.


Emerging Infectious Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA

URL: ftp://ftp.cdc.gov/pub/EID/vol5no4/ascii/mcdade.txt

Please note that figures and equations are not available in ASCII
format;  their placement within the text is noted by [fig] and [eq],
respectively.  Greek symbols are spelled out. The following codes
are used:  (ft) for footnote; (sup) for superscript; (sub) for
subscript;  >/= for greater than or equal to.