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key evidence might initially appear to be routine medical data. The need
for specialized collection and handling of samples might be appreciated
only after it becomes clear that an attack has occurred. Microbial forensic
investigators must also protect the chain of custody of evidence to ensure
that samples can be used effectively to prosecute offenders. A missing
link or an undocumented examination by someone handling the sample
could break the chain, perhaps rendering the evidence inadmissible at
trial.16 To ensure that this does not occur, tamperproof containers should
be used with a bar-coded label, and information about collected samples
should immediately be entered into a secure database.17 Standard oper-
ating procedures need to be established with responders trained to meet
these challenges. Fortunately, these procedures are well understood and,
with the tools of modern genomics, are ever improving in many countries.
(See Box 7-4.) These tools and procedures need to be globalized.
Notably, in March 2007, a signi¬cant new G-8 initiative has drawn
attention to the challenges of disease forensics in the global environment.
These eight richest and most powerful nations sponsored a workshop to
identify methods of sampling and to consider issues related to multina-
tional sharing of forensic information. This exercise is noteworthy not only
for whatever substantive contributions it might offer to improve detection
and response capabilities but because these leading States are taking an
initial step to augment preparedness in connection with bioviolence and
other disease threats.

Containing Contagion
First responders are trained to be heroes, to run into dangerous situ-
ations and help victims. This instinctive response, however, might be
exactly wrong amid a bioattack because unprotected responders could be


r HUMAN PATHOGENS “ Molecular Diagnostic Methods for Infectious Diseases; Approved
Guideline “ Second Edition, The National Committee on Clinical Laboratory Stan-
dards (NCCLS).
r ANIMAL PATHOGENS “ The Signi¬cance of Surveillance to Safeguarding American Ani-
mal Health, APHIS Fact Sheet, Veterinary Services (July 2003); and National Animal
Health Monitoring System, Animal and Plant Health Inspection Service, U.S. Depart-
ment of Agriculture.
r FOOD PATHOGENS “ United States Food Safety System, U.S. Food and Drug Adminis-
tration, U.S. Department of Agriculture (March 3, 2000).
r PLANT PATHOGENS “ Plant Health: Crop Biosecurity and Emergency Management, Ani-
mal and Plant Health Inspection Service, U.S. Department of Agriculture; and Plant
Protection and Quarantine: Importation of Plants for Planting, Protocols and Criti-
cal Issues, USDA Animal and Plant Health Inspection Service, U.S. Department of
r PATHOGEN CHAIN OF CUSTODY “ Guidance on Initial Responses to a Suspicious Letter /
Container with a Potential Biological Threat, Federal Bureau of Investigation, Depart-
ment of Homeland Security, Centers for Disease Control and Prevention (November
2, 2004).
Safety WMD Response “ Sampling Techniques and Guidelines (Participant Manual),
National Center of Biomedical Research and Training, Academy of Counter-Terrorist

exposed to the disease. Moreover, the objective in most crises is evacuation
(e.g., NYPD entering the World Trade Towers on 9/11), but in a bioattack
it might be more appropriate to keep people inside. The already exposed
victims might have to be kept away from the larger population that might
yet be unaffected.
Interpol™s Bioterrorism Prevention Program is training police to
respond in these circumstances. It recommends that every nation develop
a specially trained cadre of police ¬rst responders to implement defense,
evacuation, decontamination, and ¬rst aid. These responders must be
trained to use protective equipment; clearly, there is little point to invest
in such equipment unless responders know how to use it properly. Albeit
rightly focused, the scale of the challenge facing policing responders far
exceeds the Interpol Program™s limited resources.
First responders also include public health personnel who must treat
victims and limit the spread of disease. There must be enough trained

personnel available in the event of an attack, enough supplies to distribute
to victims, and a plan for mobilizing and allocating resources during emer-
gency conditions. Depending on the agent, medical personnel might have
to administer antibiotics or vaccines to responders, but these medical
personnel might be overwhelmed with civilian victims (to say nothing of
protecting themselves). An effective plan should provide personal pro-
tective equipment including respiratory protection to these responders;
equipped personnel are less likely to shirk responsibility during a bioat-
tack out of fear of exposure. The protective equipment must eventually
be brought to a decontamination facility that, again, must have multiple
capabilities for dealing with various agents.
Wealthy nations are aggressively developing and distributing protec-
tive equipment, but not all equipment is appropriate for all biothreats.
For most developing nations, the public health infrastructure is insuf¬-
cient to address crushing natural disease threats much less to prepare
for bioviolence. Having a variety of equipment on hand to meet an unpre-
dictable and low-probability event is unrealistic. Even in the United States,
public health advocates complain that 90 percent of the ¬rst $3.8 bil-
lion that Congress appropriated for biothreats was devoted to vaccine
stockpiling, leaving only $350 million for improving public health infra-

Compulsory Vaccination for First Responders
Should ¬rst responders be vaccinated now, before there is an attack? There
is obvious logic to pre-attack vaccination. First responders must react
immediately and would not have time to get vaccinated much less to wait
for the vaccine to take effect. They must, for everyone™s welfare, be able to
work at the scene. Vaccination not only limits the spread of a bioattack but
can assure ¬rst responders that, by offering assistance, they would not risk
harm to them or their families.
There are two critical objections against pre-attack vaccination: 1) with
so many potential disease agents, which diseases should responders be
vaccinated against? and 2) many vaccines have serious side effects, and
these side effects might be unevenly distributed among subpopulations.
The most clich´ d suggestions for how best to cope with these objections
are better communication and risk assessment. Of course, it is impera-
tive to communicate risks associated with vaccines and to inform health
care workers why they are being vaccinated. Moreover, risk assessment
is mandatory because policy makers deciding who should be vaccinated
with what vaccines are aware that informed health care professionals will

carefully scrutinize their decisions. But bioviolence risk assessment is not
easy. Among the relevant factors are:

1. How likely is a bioviolence attack?
2. If a bioviolence attack occurs, how likely is it that any particular
disease agent will be in¬‚icted?
3. For any particular disease agent, how effective might an available
vaccine be?
4. How quickly can a vaccine be applied and take effect?
5. What are the costs and side effects of an available vaccine?
6. Can costs and side effects be reduced by selective allocation to
particular responders?
7. Will a particular vaccine have wide-spectrum bene¬ts against var-
ious diseases or will its bene¬ts be limited to a single disease?

Occasionally these questions might lead to a consensus answer; most
often, they do not. Moreover, there may be more logic in their conception
than in their execution. For example, in the anthrax attack of 2001 in which
¬ve people died, thousands of people who were not likely at risk of exposure
were encouraged to take prophylactic antibiotics (mainly Cipro). Problems
arose from the government™s poor communication as to why prophylactic
medicines were necessary, who should have received them ¬rst, and how
they corresponded to the actual threat level.19 A recent study concerning
costs and bene¬ts of anthrax vaccine questioned the value of pre-attack

[The] net health bene¬t and cost-effectiveness depended critically on the
probability of an attack and on the proportion of the population exposed
during the attack. For a large metropolitan U.S. city, vaccination provides
reasonable value for the health care dollar only when the probability of
clinically signi¬cant exposure reaches about 1 in 200 (for example, when
the probability of attack is 0.01 and the probability of exposure during an
attack is 0.5, the joint probability of clinically signi¬cant exposures would
be 0.005 or 1 in 200). Our ¬ndings highlight the inherent dif¬culties in
decision making about anthrax vaccination. Several factors in¬‚uence the
probability that an individual will receive a clinically signi¬cant exposure
during an attack, including the quantity of spores released, method of
dissemination, and environmental factors (such as geography, wind con-
ditions, and time of day of the dispersal).20

A more systemic dilemma of pre-attack vaccination pertained to the
Bush administration™s plan to support smallpox vaccinations even though

the WHO, the CDC, and other public health authorities have long opposed
mass inoculation with vaccines that can endanger some recipients. Phase 1
of the plan was to vaccinate half a million armed forces personnel and half
a million health care workers. Phase 2 was to vaccinate ten million emer-
gency responders. However, the program was pulled due to political and
safety pressures. Most health care professionals chose not to participate
in the program “ less than 8 percent of the original half a million workers
in Phase 1 participated. Indeed, despite efforts to not vaccinate persons
who might have a heightened risk of suffering adverse effects, 145 per-
sons experienced serious effects resulting in hospitalization, permanent
disability, life-threatening illness, and at least three deaths.21
Many medical experts believe that because smallpox spreads slowly,
it would be better to vaccinate only after a ¬rst case is detected and then
only medical workers in close contact with infected patients. In view of the
rare but potentially fatal effects of the vaccine, “[a]ny policy that increases
vaccinations will lead to an increase in morbidity and mortality associated
with vaccinia.”22 An Institute of Medicine committee later reasserted the
traditional opposition to pre-attack smallpox vaccination, citing not only
the health risks but the drains on other ¬nancial, medical, and personnel
resources.23 Further:

The smallpox vaccinations harmed others beyond those who suffered
side effects. Considerable public health resources were used in the cam-
paign. . . . During the height of the smallpox vaccination effort, a number of
state health of¬cials complained that important work, including tubercu-
losis screening and standard children™s inoculations, had to be scaled back.
The siren song of dual use “ that bioterrorism funding would strengthen
public health infrastructure “ has shown itself to be an empty promise, as
preparedness priorities have weakened rather than strengthened public

All of these considerations might lead to precisely the opposite result
from what is intended. They may counteract or even negate the advan-
tage of encouraging ¬rst responders to participate. Mandatory pre-attack
vaccination could induce workers to quit at the training stage. Health
care workers such as nurses and physician assistants might resist pre-
attack vaccination, especially if the vaccination carries substantial risks
and the likelihood of the type of attack that the vaccination is aimed to
protect does not appear imminent. Widespread discussion of the risks
associated with medicines may also arouse suspicion toward mass vac-
cination programs among support workers receiving little recompense

(e.g., ambulance drivers, clerical workers, and other entry-level health care
assistants). More broadly, terms like “compulsory or mandatory vaccina-
tion” sound inherently pejorative especially in societies where informed
consent, freedom from undue government coercion, and bodily integrity
are upheld as fundamental rights.
The anthrax and smallpox experiences highlight these challenges. With
anthrax, poor communication and information sharing led people at low
risk to seek medical interventions and people at higher risk to be wary of
them. With smallpox, the vaccine™s risk persuaded many targeted health
care workers to opt out of the program. At minimum, therefore, any pro-
gram of pre-attack vaccination for health care workers must be accompa-
nied with clear guidelines of the risks involved, data on which populations
may have a heightened risk, and measures that would not reveal the medi-
cal conditions of those unwilling to participate in the program. Also, mea-
sures should be in place to compensate for any unforeseen consequences
of pre-attack vaccinations.

Placement of Victims
Having suf¬cient hospital space and other medical facilities is obviously
critical, yet it is a luxury that is rarely available even in developed nations,
much less in developing nations. During more conventional emergencies,
the lack of such facilities might call for temporary conversion of schools
and community centers. In a contagious bioattack, however, there are
concerns about exposing public spaces to a victim™s af¬‚iction; the goal
is to limit human-to-human transmission of the disease.25 Health care
providers must shift from doing what is best for individual patients to what
is best for other patients inside the hospital as well as for the surrounding
population and beyond.26 Infected victims might have to be isolated from
everyone else, including family and friends. There is a real potential for
disruption as parents demand access to sick children, as the ill who are
treatable seek to escape con¬nement next to terminal patients, as short-
ages of supplies or space seem (with or without justi¬cation) to be unfairly
allocated among particular groups.
On the basis of information available during the crisis, a specially
adapted triage process would need to divide the public into ¬ve cate-
gories, those who are: 1) susceptible but not exposed; 2) exposed but not yet
infectious; 3) infectious; 4) removed by death or recovery; and 5) protected
by vaccination or prophylactic medication.27 Susceptible persons, likely
the largest category, should be evaluated and sheltered-in-place. Exposed

persons should receive time-sensitive vaccinations and antibiotics. Infec-
tious persons should receive supervised care in inpatient, negative-
pressure isolation. Persons who are removed (or next of kin) should receive
assistance to deal with stigma, survivor guilt, and other issues. Vaccinated
persons should receive con¬rmation of their protection and may serve as
critical personnel for surge capacity.
Hospitals should deal predominantly with exposed and infectious
individuals.28 Isolating these groups in the hospital could reduce trans-
mission to the rest of the community. However, modern hospitals are not
designed to accommodate a large number of highly contagious patients.
Experts have identi¬ed the need to cohort patients, adjust HVAC systems,
and use personal protective gear to protect health care providers and
patients from infection. Alternative care sites such as schools and com-
munity centers could be used to decrease the demand on hospitals, but
these sites do not have the capabilities to manage respiratory support,
intravenous medication, and supplemental oxygen.29 These alternative
care sites might more usefully function as primary triage sites, sites for
limited supportive care, locations for isolation, and recovery clinics.30 All
this should, of course, be pre-planned. Amid widespread panic, there will
be little opportunity to consider how to allocate scarce space among untold


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