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Environmental sensors can help detect agents in large open areas.
Installed at especially sensitive targets or deployed around a suspicious
facility, such sensors could pick up evidence of illicit bioviolence prepara-
tions. However, weather conditions can disturb their measurements. Other
problems include “false positives” “ the sensor indicates the presence of
lethal agents when, in fact, there is nothing untoward. As pathogens are
everywhere, a sensor that can detect low concentrations of lethal agents
would likely pick up ambient germs. Yet, reducing its sensitivity risks
detecting an attack only after amounts of agent are so high that people
are already sickened.
The experience of the BioWatch system in the United States illustrates
some pitfalls of relying on sensors. At a cost of $129 million, sensors were
designed to detect agents at high-pro¬le events such as the Olympics.
These sensors are now used in over thirty cities with an annual cost of about
$2 million per city. However, the devices trap airborne particles in ¬lters
that are then collected and analyzed 24“36 hours later. This is not useful
as an immediate alarm system. Moreover, these systems require highly
pro¬cient maintenance by trained personnel to sustain continuous moni-
toring, and mishandling the devices could readily contaminate samples.8
Sensors are most effective for focusing on a few types of agents “ typi-
cally threats that experts believe pose the gravest danger, but they are less
effective for detecting rare or “engineered” agents. According to a recent
report, “Sensors would ideally be multifunctional, robust, low cost, accu-
rate, reliable, used with little training, able to remotely discern signals in a
high background environment, and would provide de¬nitive information
to decision makers and require little special care such as refrigeration or
power.”9 Sensors that are available now, however, are more likely to over-
look exotic agents. New technologies are being developed to address this
problem (see Box 7-2). Yet, striking an optimal balance between over- and
under-sensitivity is an enormous challenge.
Sensors™ greatest utility is in small devices that can be carried by emer-
gency responders and law enforcers. Every police ¬rst responder unit
worldwide could be equipped with such sensors for costs that are well
within acceptable levels. Although not designed for hardening targets, a
handheld sensor can help a responder rapidly determine if a suspected
site is contaminated. It might signal the need to deploy personal protective
168 BIOVIOLENCE: PREVENTING BIOLOGICAL TERROR AND CRIME


BOX 7-2. SOM E MODERN S EN SORS

r The Autonomous Pathogen Detection System (APDS, “BioWatch in a Box”) is de-
signed for use in critical or high-traf¬c areas such as airports, subways, and gov-
ernment installations. Collected samples can be immediately analyzed and results
sent to monitoring authorities.
r Differential Mobility Spectrometry (DMS) technology is “a sensitive, handheld
device that can detect multiple biological and chemical agents, even in the pres-
ence of interferents.”a
r Surface Plasmon Resonance (SPR) technology enables development of inexpen-
sive, portable biosensor systems for detecting microbes while minimizing risks of
false positives.b
r The Triangulation Identi¬cation for the Generic Evaluation of Risks (TIGER) biosen-
sor system, funded by the NIH and the CDC, detects emerging infectious diseases,
helps identify unexpected agents, and may be bene¬cial for large-scale testing of
food products.c
a Melisa D. Krebs et al., Detection of Biological and Chemical Agents Using Differential Mobility
Spectrometry (DMS) Technology, IEEE SENSORS JOURNAL, Vol. 5, No. 4, pp. 696“703 (2005).
b Scott D. Soelberg et al., A Portable Surface Plasmon Resonance Sensor System for Real-time
Monitoring of Small to Large Analytes, JOURNAL OF INDUSTRIAL MICROBIAL BIOTECHNOLOGY,Vol. 32,
No. 11, p. 669 (December 2005).
c Lawrence B. Blyn, Biosensors and Food Protection, FOOD TECHNOLOGY, p. 36 (February 2006).




equipment, to seal the site, or otherwise appropriately respond; hand-held
sensors could certainly boost responders™ con¬dence about how to cope
with suspect situations.
Innovative ¬lters and sensors can contribute to preventing bioviolence
if they are integrated with other facets of preparedness. This contribution
is likely to be more signi¬cant the more speci¬cally it is applied. Hoping for
broad protective umbrellas of sensors and ¬lters, however, is not realistic
for the foreseeable future.



RESPONSE INTERVENTIONS

Effective response is as valuable against bioviolence as it is for any emer-
gency (¬re, ¬‚ood, etc.) or any other type of terror attack. Many of the same
elements of response “ trained and equipped personnel with a clear com-
mand authority all following an elaborate plan “ apply to bioviolence. Crit-
ically, the essence of effective response is that it is not reactive; effective
response is a function of preparation. Response cannot be optimal if it
169
PUBLIC HEALTH PREPAREDNESS

is formulated only when the situation presents itself. Response needs to
be planned. If not, precious time and lives might be lost while isolated
bureaucracies try to make ad hoc and uncoordinated determinations.
Effective bioviolence response requires that multiple agencies coor-
dinate and promptly share information so that they know in advance
who should carry out particular tasks. Many experts routinely recommend
that nations should develop response plans with input from all relevant
bodies: health, medicine, law enforcement, transportation (land, air, and
sea), environmental protection, and the military. Indeed, the elements
of an effective response plan are well understood. It should designate
which agencies will be needed in an emergency, where these agencies
will be deployed, and what their responsibilities will be; private entities
should be engaged with incentives and reasonable liability protections.
These aspects of planning are commendable. Yet, suggesting that planning
should be comprehensive and inclusive is easy; assessing the implications
of that suggestion for different political, legal, and economic systems is
far more problematic; constructing a plan that is adjustable as conditions
warrant is, for most of the world today, a remote aspiration.
A bioviolence response plan must confront three unique demands.
First, bioviolence presents dif¬cult challenges of detection and analysis
that might not be satisfactorily overcome if personnel are inadequately
trained or equipped. Second, if an attack entails a contagious agent, ¬rst
responders must contain the attack™s consequences; carriers “ whether
culprits or victims “ must be isolated to stop the spread of disease. Third,
the extraordinary level of panic that disease typically engenders must be
considered. All emergencies incite fear, and violence accelerates that fear
precisely because it is caused by human malevolence. Yet, bioviolence will
likely raise panic levels to the point that fear becomes a chaotic force itself
unless authorities are prepared for it.
These three demands can be addressed, and progress can be made,
as the following discussion explains. But abstract exposition of rational
approaches should not disguise the fact that now and for the foreseeable
future, response planning is in many respects a self-congratulatory myth
perpetuated by developed nations™ of¬cials.


Detecting and Analyzing a Bioviolence Attack
Most emergencies are immediately detectable and understandable.
Whether a hurricane or planes ¬‚ying into skyscrapers, the event may be a
surprise but it rarely remains a secret. A bioattack, however, is an insidious
170 BIOVIOLENCE: PREVENTING BIOLOGICAL TERROR AND CRIME


BOX 7-3. CLU ES OF A B IOVIOLENCE ATTACK

r A disease caused by an uncommon agent (e.g., glanders, smallpox, viral hem-
orrhagic fever, inhalational or cutaneous anthrax), or an atypical (or genetically
engineered) strain of a disease without adequate epidemiologic explanation.
r Unusual presentation of the disease (e.g., inhalational anthrax or pneumonic
plague), unusual geographic or seasonal distribution of disease (e.g., tularemia
in a non-endemic area, in¬‚uenza in the summer), or an unexplained increase in
incidence of a disease.
r Atypical disease transmission through aerosols, food, or water, in a mode suggest-
ing deliberate sabotage (i.e., no other possible physical explanation).
r Unusual preponderance of a disease among a large, disparate population, unusual
clusters of disease, or appearance of illness in unusual patterns (e.g., measles
among adults).
r Higher morbidity and mortality in association with a common disease or failure of
patients to respond to usual therapy.
r Several unusual diseases coexisting in the same patient without any other expla-
nation.
r Outbreak of disease among persons exposed to a common environment (e.g., work-
ers in the same building or spectators of the same event).

SOURCE: See DOMESTIC WMD INCIDENT MANAGEMENT. Legal Deskbook (December 2003).



enigma. Initially, emergency rooms report they are teeming with many
patients showing atypical symptoms that natural disease processes can-
not explain. Police will not start to investigate until public health author-
ities notify them that the disease pattern suggests a criminal cause. The
inherent similarity between bioviolence and natural disease makes this
especially dif¬cult and tends to slow emergency response. (See Box 7-3 for
clues of a bioviolence attack.)
Technological innovation can contribute to making detection of a dis-
ease outbreak (whether natural or man-made) faster and more accurate.
Indeed, substantial resources and attention have been devoted to detec-
tion technology in the last few years,10 arguably more than to developing
uniform standards for effectively using innovative technology and cer-
tainly faster than the legal codi¬cation of those standards. For example,
linking communication nodes has proven easier than ensuring that diverse
users of those links enter complex data in a consistently usable format. In
the United States and comparably developed nations, the lack of such
standards has caused glitches and delays. Effective globalization of early
171
PUBLIC HEALTH PREPAREDNESS

detection techniques has proven to be a more severe challenge that to date
has received little more than polite acknowledgment.

Law Enforcement “ Public Health Cooperation
Police and public health share a major concern that a bioattack will not be
appreciated for what it is and that lives will be lost unnecessarily. It is crit-
ical that these two communities establish cooperative bonds in advance
to mutually reinforce their detection capabilities so as to minimize delays
from inef¬cient information exchange. Following an attack, these com-
munities will seek to identify the source of infection “ both the perpetrator
and the means of attack. Identifying the perpetrator is essential for crimi-
nal justice and to prevent further attacks. Moreover, assessing the means
of attack “ the type of agent, its form, its dissemination method, and its
likely dispersion path “ enables public health of¬cials to design a medi-
cal response strategy, select appropriate protective and decontamination
equipment, decide whether to evacuate or quarantine, and oversee effec-
tive recovery.
These responsibilities are overlapping. Law enforcers should under-
stand medical and epidemiological investigation procedures; public
health responders should preserve the crime scene. Cross-discipline train-
ing would introduce police responders to their public health counter-
parts. Sharing critical information on self-protection would reduce errors
and enable weaknesses to be addressed before they have tragic conse-
quences. In many nations lacking resources, however, this is more aspira-
tional than realistic. The international community should emphasize the
importance of police“public health coordination by establishing teams of
public health and law enforcement professionals and by equiping them
with rapid deployment capabilities including portable laboratories for per-
forming basic forensic analyses at the scene.
Coordination between law enforcement and health is improving in
highly developed nations. Some bioviolence response planners, con-
cerned about the lack of comparable preparation in developing nations,
are conducting training programs. Most notably, Interpol is encouraging
police throughout the world to reach out to public health and to estab-
lish bioresponse protocols. Interpol™s police training programs are the
¬rst truly global effort to connect these communities. There remains,
however, a widespread lack of mutual appreciation between public
health and law enforcement that could impede bioviolence response and
investigation.
172 BIOVIOLENCE: PREVENTING BIOLOGICAL TERROR AND CRIME

Biosurveillance
Health information networks that connect doctors, public health
providers, and emergency response personnel with near-instantaneous
data about disease outbreaks could help combat both natural pandemics
and bioviolence. Databases that receive data from emergency responders
should be connected to an incident command center so that law enforcers,
medical professionals, hospitals, and medical suppliers can receive near
real-time information.11
In April 2004, President Bush ordered the development of a strategic
plan to guide nationwide implementation of inter-operable health infor-
mation technology.12 In response, the U.S. Department of Health and
Human Services has been developing a national health security infor-
mation infrastructure,13 but the goal of having a pilot program opera-
tional by 2006 has not been met. Establishing massive linkages has proven
to be a substantial undertaking; there are multiple information systems
lacking a uniform standard and format for entering medical data. Local
networks have demonstrated success with experts believing that a med-
ical symptoms surveillance network could be achieved soon for $100“
200 million.
Biosurveillance networking might improve rapid detection of biovio-
lence, yet there are concerns that increasing electronic exchanges of health
information may lead to inappropriate disclosure of individuals™ personal
health records. The challenge, therefore, is to create and manage access
controls for large health databases, some of which must be classi¬ed, that
minimize risks associated with a breach in security. Protections for health
information should ensure that only the minimum data necessary is dis-
closed and only to those entities authorized to receive it, and individuals
should be entitled to have access and make changes to their own health
data.14

Microbial Forensics
A bioattack investigation team will have to identify what organism was used
and locate its source. Once samples are obtained from both victims and
the environment microbial forensics techniques can identify the inten-
tionally released pathogen™s “¬ngerprint.” Forensic investigators will have
to distinguish it from many pathogens that are naturally in the environ-
ment, including innocuous strains of the same disease agent. It would be
helpful, therefore, to have reasonably good data about what is “normal”
in particular environments so that if a crisis occurs, measurements can be
made against that baseline.
173
PUBLIC HEALTH PREPAREDNESS

Problems can arise concerning the rights of victims (or their families)
to resist having samples taken. In most jurisdictions, taking blood or tissue
samples from corpses does not present serious legal challenges, especially
when there is manifest evidence that the cause of death was unnatural.15
Taking samples from live victims, however, involves a careful balancing
of public safety interests with individual privacy rights. These issues are
addressed more fully in the following discussion of compulsory medical
interventions.
Samples must be properly collected, packaged, and stored lest
pathogens perish as ambient conditions change on the way to laboratory
testing. However, because a bioattack might not be instantly recognizable,

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