19(6) Nursing Econmics 286-290 (2002)
In the aftermath of terrorist attacks on New York City, and
Washington, DC, on September 11, 2001, the United States is coming to
terms with new and urgently felt public health and safety concerns. As
military actions continue, government officials prepare for retaliatory
attacks. Concerns about bioterrorism and our ability to prevent and
react to the use of biological weapons are evident in our everyday
discussions, national news coverage, and congressional hearings. In
post-event analyses and emergency preparedness planning sessions, the
United States confronts not only the probability of terrorist's use of
biological weapons, but also the public health consequences.
In the process we are confronting the horror such weapons inflict and
our sense of vulnerability and self-determination to address this
threat. Even though national emergency preparations since the cold war
have included consideration of biological weapons, the post mortem on
emergency responses to the terrorist attacks on September 11, 2001, has
brought renewed concerns about bioterrorism. Today, and for the
foreseeable future, the U.S.
defense and public health agendas must both address bioterrorism.
The purpose of this article is to present the recent history and
legislative agenda emerging to prevent, monitor, and respond to
bioterrorism and accidental exposure to biological agents and toxins in
the United States.
The Problem of Bioterrorism
While the exact risks of experiencing a bioterrorism attack are
unknown, experts agree that the use of biological weapons could result
in large-scale, life-threatening epidemics (Henretig, 2001; Khan &
Ashford, 2001). Even a single exposure could result in local outbreaks
of difficult-to-diagnose disease and fatal disease outbreaks. And, given
the methods of exposure and the mobility of our population, local
outbreaks could spread widely. Unlike weapons that use explosives or
chemicals, attacks using biological weapons may occur silently and
covertly and, thus, be difficult and time consuming to detect. To
complicate the matter, public symptoms of biological exposure may be
delayed for days or weeks. Victims may initially present with diffuse
flu-like symptoms in geographically diverse areas, complicating the
surveillance and diagnosis of the agent disease. Thus, a strong public
health network is needed to gather early reports and diagnose what is
happening. Once detected, a massive public exposure could overwhelm
local health systems that must treat victims of an outbreak,
provide care for mass casualties, and prevent further disease.
Federal Response to Bioterrorism Threat
More than 20 federal departments and agencies have a role in
preparing or responding to public health and medical consequences of a
bioterrorist incident. In a domestic bioterrorism event, the Department
of Health and Human Services (DHHS) has special responsibilities,
including detecting the disease, investigating the outbreak, and
providing stockpiled drugs and emergency supplies in the large amounts
needed. Since the 1950s, the Centers for Disease Control and Prevention
(CDC) grew substantially due to its Epidemic Intelligence Service and
the promotion of epidemiologic 'surveillance.' Critics contend that the
CDC's biopreparedness efforts during this period fed the Cold War
climate, narrowed the scope of public health activities, and failed to
achieve sustained benefits for public health programs across the country
(Fee & Brown, 2001).
In recent years, DHHS has been working to deal with social and
bureaucratic challenges in developing an effective public response to
bioterrorism. Public officials and legislators have pondered these and
other factors in considering federal investments, emergency preparedness
plans, and infrastructure requirements to combat bioterrorism. The major
challenges are these: * Attacks using biological weapons produce a
'silent' attack, requiring an
improved public health communication network.
* Local response capability depends largely on national leadership,
resources, and coordination.
* Widespread public health consequences are probable.
During the Clinton Administration, Presidential Decision Directive
62, 'Protection Against Unconventional Threats to the Homeland and
Americans Overseas,' recognized the Federal Emergency Management Agency
as the lead agency for coordinating disaster consequence management. It
designated DHHS as the lead federal agency to prepare the national
response to medical emergencies arising from the use of biochemical
weapons. The Office of Emergency Preparedness located in the Office of
Public Health and Science houses the responsibility of coordinating the
response effort. In FY 1999, the Clinton Administration spent $158
million on bioterrorism preparations, adding $72 million to the effort
in FY 2000.
Early in the Bush Administration, Secretary of Health and Human
Services Thomas G. Thompson named Scott Lillibridge, MD, as special
advisor to lead DHHS's coordinated bioterrorism initiatives (DHHS Press
Office, August 16, 2001). Lillibridge previously coordinated the CDC's
bioterrorism response efforts and was seen as a credible, informed
advocate to strengthen federal planning and response efforts to
bioterrorism in civilian communities.
In the recent years, DHHS objectives established in response to the
bioterrorism threat have focused on:
* Improving the nation's public health surveillance network to detect
and identify biological agents.
* Strengthening medical response capabilities (especially at the
* Expanding the stockpile of pharmaceuticals (for future emergency
* Expanding research on biological disease agents and rapid methods
for their identification, improving treatments, and vaccines.
* Preventing bioterrorism by regulating shipment of hazardous
biological agents and toxins.
The 5-year bioterrorism response plan DHHS is now operating on
includes a range of activities to strengthen and enhance the nation's
preparedness. Since its inception, this planhas relied heavily on
cooperation with state and local health agencies as well as local
emergency medical response units. Among its key efforts has been the
creation of a vaccine and therapeutics 'stockpile.' To ensure the
adequacy of the stockpile, a 'surge' production capacity for
pharmaceuticals was developed in cooperation with drug manufacturers.
The plan also calls for research on the diseases, diagnostics, vaccines,
and treatment needed to address bioterrorism.
For FY 2002, the President requested (prior to September 11, 2001)
$350 million for DHHS to plan and respond to the medical and public
health consequences of a bioterrorist attack. Of this amount, $182
million was targeted for the CDC, $51 million was provided to the Office
of Emergency Preparedness, and $93 million was designated for research.
This level of funding represented an 18% increase over FY 2001 funding
levels. On October 18, 2001, DHHS Secretary Thompson announced that $1.5
billion was added to the 2002 budget for strengthening the nation's
ability to respond to and treat potential bioterrorism attacks.
Disease Surveillance and Public Health Network
To improve detection and respond to a wide range of infectious
disease threats, including possible bioterrorist incidents, CDC is
upgrading the nation's public health laboratory and epidemiological
capacity. Training and communications resources are being expanded
(including resources for state and local health agencies). This includes
the capacity to detect outbreaks of illness that might have been caused
by terrorists, improved laboratory identification and characterization
of causal agents for disease outbreaks, and improved electronic
communications among public health and other officials about outbreaks
and responses to them.
Medical Consequence Management
To develop medical response capabilities at local and national
levels, the Office of Emergency Preparedness (OEP) has been developing
and coordinating development of Metropolitan Medical Response Systems (MMRS)
across the United States since 1996. As of October 2001, OEP has
contracts with 97 communities, and is expected to add 25 more in FY
2002. Up to 200 MMRS will be developed over the next several years.
Recognizing that each metropolitan area has its own configuration of
emergency medical resources, current plans augment existing systems and
adapt them to meet the requirements of the disaster.
The MMRS emphasizes enhancement of local planning and response
capability, including hospital capacity, to care for victims of a
bioterrorist incident. MMRS systems provide designated communities with
structured operations, specially trained responders, special
pharmaceuticals, detection and personal protection equipment,
decontamination capabilities, communication, medical equipment and other
supplies, and enhanced emergency medical transport and emergency room
capabilities. The program includes optimizing interventions related to
early warning and surveillance, mass casualty care, and plans for mass
fatality management. Operational plans identify the local jurisdiction's
plan for federal health and medical augmentation assistance, including
the forward movement of disaster
victims (when local health care systems become overloaded) via the
National Disaster Medical System.
The National Disaster Medical System (NDMS), also led by the OEP,
involves a partnership of four federal agencies: DHHS, Departments of
Defense and Veterans Affairs, the Federal Emergency Management Agency (FEMA),
and the private sector. The NDMS has three components: direct medical
care, patient evacuation, and nonfederal hospital care. The NDMS
comprises more than 7,000 private sector medical and support personnel
organized into disaster teams. Teams are deployed to provide immediate
medical attention to the sick and injured during disasters, as well as
mortuary and veterinary care when local demands exceed local system
In addition to the private sector component of the NDMS, the
Commissioned Corps Readiness Force (CCRF) includes officers within the
U.S. Public Health Service available for immediate deployment to
disasters. Upon activation by the U.S. Public Health Service Surgeon
General, the CCRF can provide a variety of public health personnel from
physicians, nurses, pharmacists, environmental health officers, and
mental health officers to disaster-stuck communities.
National Pharmaceutical Stockpile
The role of the National Pharmaceutical Stockpile Program is to maintain
a national repository of lifesaving pharmaceuticals and medical material
that will be delivered to the site of a bioterrorism disaster in order
to reduce morbidity and mortality in those affected. The program
identifies, purchases, stores, and manages pharmaceuticals and medical
supplies and assists state and local jurisdictions in planning for
pharmaceutical use in response to a disaster (including a biological
disaster). The stockpile includes pharmaceuticals, intravenous supplies,
airway supplies, emergency medications, and bandages and dressings.
Materials are available in what is known as a 'push pack,' to be
available within 12 hours of the call to deploy from national
stockpiles. There are also provisions for pharmaceutical manufacturers
to release inventories committed, if needed, under prior agreement to
the federal government.
Research and Development
In the current 5-year plan, DHHS is increasing support for research
related to likely bioterrorism agents. An area of major emphasis
involving the NIH will be the generation of genome sequence information
on potential bioterrorism threats, especially for organisms causing
anthrax, tularemia, and plague. The results of such genomic research,
coupled with other biochemical and microbiological information, are
expected to help in the development of rapid diagnosis, new and improved
antibacterial and antiviral therapies, and the development of new
vaccines. In addition, NIH is
expected to support intensive work on a new smallpox vaccine.
Currently, DHHS has the responsibility to track and monitor shipment
of certain hazardous biological organisms and toxins. Through the CDC,
efforts will continue to ensure that all laboratories that ship or
receive specially identified biological agents are registered and in
compliance with federal requirements.
Current Challenges to Improve U.S. Response Capabilities
In testimony before the Senate Appropriations Subcommittee on Labor,
Health and Human Services, Education and Related Agencies on October 3,
2001, DHHS Secretary Thompson called for higher prioritization and
preparedness (Thompson, 2001). While complimentary of the recent
national response to the disasters in New York and Washington, DC, four
areas were identified for aggressive future intervention:
1. Improvement in the public health infrastructure (including
strengthening public health systems to ensure they are strong and
2. Pharmaceutical development and increased stockpiles (including the
addition of more 'push packs').
3. Food safety (including increased FDA monitoring and working to improve
food industry security related to food production and delivery).
4. Security (increasing the security of public health stockpiles,
institutions, and products).
Emergency Preparedness, Bioterrorism, and the 107th Congress
Prior to the terrorist attacks in New York and Washington, DC,
legislative activity in the 107th Congress was already evident,
targeting federal capabilities for improving national emergency
preparedness for disasters in general and for bioterrorism in
particular. Federal legislation relating to a variety of emergency
preparedness and bioterrorism planning and response is under
consideration. Among the most recent legislative activities have been
those associated with improving emergency capabilities and preparedness
and those improving homeland security.
On the heals of the September 11 disaster, the House and Senate
enacted H.R. 2888 (S. 1426) providing supplemental appropriations for
fiscal year 2001 for additional disaster assistance, for anti-terrorism
initiatives, and for assistance in the recovery from the tragedy. On
October 3, 2001, H.R. 3016 was introduced to amend the Antiterrorism and
Effective Death Penalty Act of 1996 with respect to the responsibilities
of the DHHS Secretary regarding biological agents and toxins. It amends
title 18 of the U.S. code with respect to such agents, and
clarifies system privacy requirements for new cable services targeted at
strengthening security at selected nuclear facilities. The legislation
was sponsored by Rep. William Tauzin (R-LA) and co-sponsored by Rep.
John Dingell (D-MI). It was referred to House committee on October 3,
and placed on the House calendar on October 16, 2001.
Homeland Security Legislation
A variety of federal initiatives related to improving homeland
security, including those providing for improved emergency preparedness
and those establishing new federal authorities and agencies to deal with
a variety of homeland security and emergency preparedness issues, have
Even as former Pennsylvania Governor Ridge assumes his new post as a
President-appointed Director of Homeland Security, legislation to
address a variety of homeland security provisions (including those
related to bioterrorism) are pending. Among these, H.R. 1158 provides
for the establishment of the National Homeland Security Agency.
Sponsored by Rep. William Thornberry (R-TX), the legislation was
introduced in March 2001 and referred to joint House subcommittees a
month later: The Subcommittee on Economic Development, Public Buildings
and Emergency Management and the Subcommittee on National Security,
Veterans Affairs, and International Relations (Government Reform
This legislation establishes a National Homeland Security Agency,
requiring the agency director to serve as an advisor to the National
Security Council to: (a) plan, coordinate, and integrate those U.S.
Government activities relating to homeland security, including border
security and emergency preparedness, and act as a focal point regarding
natural and man-made crises and emergency planning; (b) work with state
and local governments and executive agencies in protecting U.S. homeland
security and support state officials through the use of regional offices
around the country; (c) provide overall planning guidance to such
agencies regarding homeland security; (d) establish command and control
procedures for potential contingencies, including those that require
military resources; and (e) annually develop a federal response plan for
homeland security and emergency preparedness.
It transfers to the Homeland Security Agency the authorities,
functions, personnel, and assets of the Federal Emergency Management
Agency, U.S. Customs Service, Border Patrol of the Immigration and
Naturalization Service, U.S. Coast Guard, Critical Infrastructure
Assurance Office, the Institute of Information Infrastructure Protection
of the Department of Commerce, the National Infrastructure Protection
Center, and the National Domestic Preparedness Office of the Federal
Bureau of Investigation. Within the agency it establishes (a) separate
Directorates of Prevention,
Critical Infrastructure Protection, and Emergency Preparedness and
Response; and (b) an Office of Science and Technology to advise the
director with regard to research and development efforts and priorities
for such directorates. It requires the director to establish mechanisms
for the sharing of information and intelligence between the U.S. and
international intelligence entities.
In the aftermath of September 11, President Bush signed an executive
order creating the White House Office of Homeland Security. The new
Cabinet-level office is charged with formulating and coordinating a
national strategy to safeguard the United States from terrorism and to
respond to any future attacks. Ridge will coordinate the efforts of the
nearly 50 federal agencies and departments involved in counter terrorism
activities such as intelligence gathering, security, and preparing for
possible attacks. Although Ridge's position does not afford him
statutory authority over the budgets of these agencies, he will advise
the director of the White House Office of Management and Budget on
Emergency Preparedness Legislation
H.R. 2333, sponsored by Richard Burr (R-NC), co-sponsored by 13
others, was referred to House subcommittee in July 2001. Known as the
National Disaster Medical System Act, it amends the Public Health
Service Act to establish within
the Office of Public Health and Science, the Office of Emergency
Preparedness. It directs the DHHS Secretary to coordinate the activities
with respect to planning for and responding to public health emergencies
that burden the response capacity of state and local governments to the
degree they require the assistance of the federal government in
responding to emergencies.
H.R. 525, to amend the Robert T. Stafford Disaster Relief and
Emergency Assistance Act, provides for improved federal efforts to
prepare for and respond to terrorist attacks, and for other purposes.
Sponsored by Rep. Wayne Gilchrest (R-MD), the legislation was introduced
in February 2001 and referred to House committee for action in September
2001. The bill currently has 64 co-sponsors.
This legislation focuses on the Stafford Disaster Relief and
Emergency Assistance Act to expand coverage to acts of terrorism or
other catastrophic events known as 'major disasters' for purposes of
authorizing disaster relief. The bill would require the President
(current law authorizes the director of the Federal Emergency Management
Agency) to be responsible for carrying out federal emergency
preparedness plans and programs. It includes as a covered hazard,
domestic terrorist attacks involving weapons of mass destruction.
Further, it requires the President to ensure federal response plans and
programs are adequate to respond to the
consequences of terrorism directed against a target in the United
States. Provisions include ensuring the availability of equipment,
clothing, and facilities necessary for and within authorized emergency
Further, H.R. 525 establishes the President's Council on Domestic
Preparedness. It requires the council to: (a) publish a Domestic
Terrorism Preparedness Plan and an annual implementation strategy; (b)
designate an entity to assess the risk of terrorist attacks against
transportation, energy, and other infrastructure facilities; and (c)
establish voluntary minimum guidelines for preparedness programs. It
authorizes the council to attend meetings of the National Security
Council pertaining to domestic terrorist attack preparedness matters,
subject to the direction of the President.
In the Senate, S. 1543, was introduced by Bob Smith (R-NH) in late
September 2001 (no co-sponsors). The bill (referred to committee) amends
the Stafford Disaster Relief and Emergency Assistance Act to provide for
improved federal efforts to prepare for, and respond to, terrorist
attacks. Related to this matter, the Senate Health, Education, Labor and
Pension Committee, subcommittee on Public Health was scheduled to hold
hearings on Bioterrorism in October 2001.
The federal landscape and provisions to ensure an adequate and
successful response to an incident involving bioterrorism will require
strong federal leadership and new legislative authorities. It will also
require additional financial resources to prepare and coordinate local
communities, their public health and emergency response systems, and to
develop and implement effective disaster leadership and resource
mobilization. While we prepare for the threat of a disaster, we
nonetheless must strengthen our public health infrastructure and its
capabilities associated with biological monitoring, surveillance, and
diagnosis. Additionally, renewed efforts and additional resources
provided must address improved communication, without which early
detection and diagnosis will fail and the consequences to public health
disasters will be worsened. It is important that all nurses -- from
those who work in public health and emergency service settings to those
in community and hospital-based settings -- are aware of bioterrorism as
a public health threat and to the complexity and interrelated aspects of
strengthening homeland security, public agency collaboration, and public
health service infrastructure.
Between the time this manuscript was submitted and published, the following
new bioterrorism-related legislation was introduced.
* S.1486: To ensure that the United States is prepared for an attack
using biological or chemical weapons. Sponsored by Sen. John Edwards
* HR3153 (Sponsored by Rep. Rod Blagojevich, D-IL), S.1520 (Sponsored
by Sen. Evan Bayh, D-IN): To assist States in preparing for and
responding to biological and chemical terrorist attacks.
* S.1546: To provide additional funding to combat bioterrorism.
Sponsored by Sen. Pat Roberts (R-KS).
* S.1560: To strengthen United States capabilities in enironmental
detection and the monitoring of biological agents. Sponsored by Sen.
Daniel Akaka (D-HI).
* S.1561: To strengthen the preparedness of health care providers
within the Department of Veterans Affairs and community hospitals to
respond to bioterrorism. Sponsored by Sen. Daniel Akaka (D-HI).