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.
