Bioterrorism, Public Health and the Law 
Law 801: Health Care Law Seminar
Professor Vernellia R. Randall

Disease Reporting as a Tool

 

Syllabus
Resources
Lesson Schedule
00: Intro to the Course
01: Intro to the Problem
02: Public Health System
03: Real Threat?
04: Public Health Law
05: Disease-Reporting
06: Quarantine
07: Model Act
08: Military Presence
09: Health Law Revisited

 

 Heather H. Horton, James J. Misrahi, Gene W. Matthews, and Paula L. Kocher

excerpted from: Heather H. Horton, James J. Misrahi, Gene W. Matthews, and Paula L. Kocher, Critical Biological Agents: Disease Reporting as a Tool for Determining Bioterrorism Preparedness, 30 Journal of Law, Medicine and Ethics 262 (Summer, 2002)

. . . In order to assess the nation's bioterrorism preparedness, as measured by its disease reporting laws, CDC's Bioterrorism Preparedness and Response Program commissioned a study of state and local laws requiring the reporting of diseases caused by specific biological agents. This article discusses the background, methods, and results of the study and suggests that states and localities would benefit from examining their existing disease reporting laws in light of bioterrorism concerns.

The CDC's strategic plan for bioterrorism has focused on the following five areas: preparedness and prevention; detection and surveillance; diagnosis and characterization of biological and chemical agents; response; and communication. The strategic plan has included, among other things: distance learning programs for health-care workers; the creation of a multilevel laboratory response network for bioterrorism; a national pharmaceutical stockpile of medical supplies to be used in an emergency; and a national electronic infrastructure to improve the exchange of emergency health information. While these efforts are an essential part of a coordinated federal response to a bioterrorist event, they are necessarily dependent on a strong and flexible public health system at the state and local level. Advanced laboratory tests and caches of medical supplies are useful only if public health officials are aware that a suspected release of a biological agent has occurred. It is therefore important not only that health-care providers be able to identify unusual patterns of disease or injury, but also that they report such unusual occurrences to appropriate public health officials to ensure a timely response.

CDC's study of disease reporting laws examined the reporting requirements for twenty-four biological agents (or the diseases caused by these agents): anthrax; botulism; brucellosis; cholera; Cryptosporidium; E. coli;] glanders; hantavirus; melioidosis; mycotoxins; plague; psittacosis; Q fever; ricin poisoning; Salmonella; Shigella; smallpox; staphylococcal enterotoxin B; toxic syndromes; tularemia; typhus fever; Vibrio cholerae; viral encephalitis; and viral hemorrhagic fevers. These particular agents are regarded as "critical biological agents" because of their potential to harm the public health if used in a terrorist act. In determining which biological agents were most critical, CDC sought the counsel of federal agencies, infectious disease experts, national public health experts, civilian and military experts, and law enforcement officials. [FN10] The following factors were considered in developing the list of agents:

    . morbidity and mortality;    . potential for distributing the agent population-wide based on the stability of the agent, ability to mass produce and distribute a virulent agent, and the possibility for person-to-person transmission of the agent;    . potential for public fear and potential civil disruption; and    . special public health preparedness needs based on stockpile requirements, enhanced surveillance, or diagnostic needs.]  The resulting list of critical biological agents was divided into three categories (Category A, B, and C), based on the level of public health importance. Terrorism experts are most concerned with Category A agents because they have the greatest potential for harm if used in a bioterrorist attack. These agents can be easily disseminated or transmitted person-to-person; cause high mortality; severely affect the public health; might cause public panic and social disruption; and require special action for public health preparedness. Six diseases are caused by Category A agents: anthrax; botulism; plague; smallpox; tularemia; and viral hemorrhagic fevers. [FN13] Each of these are analyzed in terms of their symptoms and known treatment in Table 1. [Table Omitted]Category B agents are less of an immediate bioterrorism concern because they are only moderately easy to disseminate and cause moderate morbidity and low mortality. [FN14] Nonetheless, there are recent examples of terrorists using Category B agents in the United States. In 1984, the Rajneeshee religious cult used Salmonella to contaminate restaurant salad bars, which sickened hundreds of people in Oregon. [FN15] Similarly, in the 1990s, members of an anti-government group (the Patriots Council) reportedly used ricin in an attempt to assassinate law enforcement agents in Minnesota. [FN16] Accordingly, Category B agents are important for bioterrorism preparedness and require enhancements of diagnostic capacity and disease surveillance. [FN17]

Category C agents include emerging pathogens that could beengineered for mass dissemination in the future, but are not presently likely to be used as a bioterrorist weapon. [FN18] These agents result in such diseases as hantavirus, typhus fever, and viral encephalitis. [FN19] Preparedness for Category C agents includes continued research to enhance disease surveillance, diagnosis, and treatment. [FN20]

. . .

FINDINGS

Table 2 indicates the number and percentage of the fifty-four jurisdictions surveyed that require (as of March 31, 2001) the reporting of particular diseases caused by critical biological agents.

  The study found that three of the six Category A agents -- anthrax, botulism, and plague -- are "reportable immediately" in the vast majority (89 percent, 96 percent, and 89 percent, respectively) of jurisdictions surveyed. Conversely, the other three Category A agents -- smallpox, tularemia, and viral hemorrhagic fevers -- are "reportable immediately" in less than half (39 percent, 46 percent, and 26 percent, respectively) of these jurisdictions.  The Category B agents cholera, Salmonella, and Shigella are "reportable immediately" or "explicitly reportable" in 100 percent of the jurisdictions surveyed. In contrast, glanders, melioidosis, mycotoxins, ricin poisoning, and staphylococcal enterotoxin B are "reportable immediately" or "explicitly reportable" in only a small percentage (6 percent, 4 percent, 4 percent, 9 percent, and 20 percent, respectively) of jurisdictions. The remaining Category B agents (brucellosis, Cryptosporidium, E. coli, psittacosis, Q Fever, toxic syndromes, and Vibrio cholerae) and all Category C agents (hantavirus, typhus fever, and viral encephalitis) are "reportable immediately" or "explicitly reportable" in a majority of the jurisdictions surveyed.  The study further showed that persons who have a mandatory duty to report diseases caused by critical biological agents usually are physicians and other health-care providers, laboratory directors, and hospital administrators. In addition, some jurisdictions mandate reporting by school principals (e.g., New Mexico), child care centers (e.g., South Dakota), nursing home administrators (e.g., Alabama), heads of families (e.g., Kentucky), personnel of food establishments (e.g., North Carolina), or anyone with knowledge of a case of a reportable disease (e.g., Montana). The entities to which persons must report are generally state, county, or local health agencies or other health authorities.  Disease reporting requirements, in most cases, can be found in state administrative codes, but may also be located in state statutes, rules and regulations of local boards of health, and municipal regulations. Furthermore, laws requiring the reporting of diseases caused by critical biological agents tend to be scattered among other disease-specific reporting laws, such as those requiring the reporting of measles or tuberculosis. Although this study did not systematically review penalty provisions, it was noted in a number of jurisdictions that non-compliance with disease reporting laws constitutes a misdemeanor punishable by fine or imprisonment. [FN22] . . DISCUSSION  Disease reporting laws may not only serve as an educational tool in highlighting what diseases society considers of national importance, but may also provide incentives for health-care providers to obtain the training and skills to diagnose and respond to those diseases. This study yielded important information about the status (as of March 31, 2001) of laws mandating the reporting of specific diseases associated with bioterrorism.  Because such laws, however, may raise practical and legal concerns for the public, patient, and physician, further research may be required in the following areas:    . the administrative burden in reporting diseases;    . penalties for non-compliance with the law;    . privacy rights affected by disease; and    . procedures for effective implementation of disease reporting requirements.  Since the study's completion, and especially in response to the 2001 anthrax attacks, some jurisdictions may have revised their disease reporting laws to include critical biological agents. Nonetheless, considering the study's findings, jurisdictions that have not already done so may wish to review their disease reporting laws in light of bioterrorism concerns. If existing laws do not require the reporting of diseases caused by critical biological agents, states may choose to revise or expand their disease reporting requirements to include such bioterrorism-associated diseases. In particular, states may decide to require the immediate reporting of diseases caused by Category A critical biological agents because of the extreme risk to public health that these agents pose if used as a bioterrorist weapon.  States considering revising their disease reporting laws may find useful the draft Model State Emergency Health Powers Act, a legislative template developed in 2001 by the Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities. [FN23] This draft model law, among other things, provides one example of a method to address which diseases or health conditions should be reported; who should be legally obligated to report; the manner and timeframe in which a disease should be reported; and the enforcement of disease reporting laws. [FN24]CONCLUSION

  The events of September 11 and the subsequent anthrax mailings have elevated protecting the public's health to the status of a national security issue. Thus, this study of laws mandating the reporting of specific diseases caused by critical biological agents may be considered one measurement of the nation's level of bioterrorism preparedness. In preparing the nation to respond to a potential bioterrorist event, disease reporting is a key element. Inadequate disease reporting requirements may lead to such harmful consequences as delayed recognition of a possible bioterrorism event, confusion over whether a particular disease is reportable, and an untimely and ineffective response to bioterrorism or other public health emergency. Accordingly, disease reporting laws are a crucial element in an overall plan for bioterrorism preparedness.

 
 
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Last Updated:
 11/30/2002

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