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

Bioterrorism - A Renewed Public Health Threat


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


P.J. Maddox
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 local level).

* Expanding the stockpile of pharmaceuticals (for future emergency use).

* 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 capabilities.

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 prepared).

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 been proposed.

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 Committee).

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 departmental spending.

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 preparedness measures.

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.


Legislation Update

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 (D-NC).

* 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).


Related Pages:
Home ] Up ] Bioterroism and Public Health ] Biological Agents ] Dual Use or Poor Excuse? ] CDC Bioterrorism Preparedness and Response ] Will Bioterrorism Reshape Global Public Health? ] [ Bioterrorism - A Renewed Public Health Threat ] A Clear and Present Danger? ] Deaths and Illness--A Comparative Analysis ] The Requirements to Produce Biological Agents by Non-State Groups ] Potential of Use of Biological Weapons in the United States ] WHO Recommendations for Dealing with Bioterrorism ] Emerging Infectious Disease and Public Health (pdf) ] Facts about Biological Agents ]
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Home ] Syllabus ] Introduction to the Course ] Introduction to the Problem ] Public Health System ] Is Bioterrorism a Real Threat? ] Public Health Law and Bioterrorism ] Disease Reporting and Police Powers ] Quarantine and Police Powers ] Model State Public Health Law ] Military Presence and Public Health ] Public Health Law - Revisited ]
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