Ebook: Strengthening National Public Health Preparedness and Response to Chemical, Biological and Radiological Agent Threats

We are glad to present the proceedings of the North Atlantic Treaty Organization's Advanced Study Institute, Strengthening National Public Health Preparedness and Response for Chemical, Biological and Radiological Agents Threats, held in Skopje, Republic of Macedonia, on June 19 to 29, 2006. We are grateful to the NATO Science Programme both for sponsoring its ASI series, and for recognizing the global importance of public health preparedness against terrorism and weapons of mass destruction.

With gratitude we recognize and thank those organizations whose funding made the Institute possible. Funding for participants came from NATO in the form of a conference grant. The Institute was sponsored by the University St. Cyril and Methodius, Skopje, Macedonia, which also provided logistical support, a hospitable atmosphere, tours of Macedonian national health facilities, and host country events. The Hotel Continental, Skopje, was our venue; it provided lodging, meals, all meeting rooms, and a fine overall setting for the ASI. Additionally, many participants' travel costs were funded in part or in whole by their own organizations.

We were honored to have had such a fine roster of military and civilian public health experts from NATO nations and NATO Partner nations. The number of participants included a rich variety of experts in all aspects of the program, who excellently represented a broad array of eligible countries. A core panel of participants contributed to final discussions and conclusions of the Institute. New relationships and collaborations were forged during this Institute. The recorded product is represented in this book, but perhaps more valuable were the new relationships and potential joint projects made possible in Skopje.

The scheduled format of the ASI was as follows: there were two morning sessions and two afternoon sessions daily. Presentations were organized according to scientific discipline, with these groupings – the American Medical Association's (AMA) two-day Basic Disaster Life Support course; biological, radiological and chemical threats; computer simulation and emergency planning; information security – approach and management; biodefense; risk communication; health policy; public health law and preparedness; “special needs” populations in preparedness planning; special topics; and psychological aspects of disasters. There was also a brief avian influenza table-top exercise.

We believe that this report's data, recommendations, and conclusions are neither final nor all-inclusive. The participants' group experience and knowledge regarding public health emergencies has continued, driven by those ongoing, always-changing terror threats that promise to kill, maim and disrupt the lives of the civilized world. We plan continued dialogue on the recommendations found herein, and hope that future similar workshops will occur.

Finally, we urge that that this Institute's recommendations are accepted and implemented by clinicians, researchers, and other scientists motivated by special interest in public health preparedness, as well as by national and NATO leaders and policy

makers who are positioned to make a difference. Public health response to emergencies requires extensive, coordinated, considered efforts of the combined military and civilian public health resources of all NATO nations and NATO Partner nations.

Curtis Cummings, Carol Larach

The world through globalization has become interconnected and economically interdependent. Disasters such as the Indonesian Tsunami, the Pakistan Earthquake, and recent events in the United States of America (USA) such as Hurricanes Katrina and Rita demonstrate the need for an internationally accepted standardized response to disasters. Global public health issues like Severe Acute Respiratory Syndrome (SARS), risk of pandemic influenza as well as acts of terrorism worldwide reinforce the importance of strengthening the international capabilities of disaster response. The American Medical Association (AMA), through the National Disaster Life Support Foundation (NDLSF) is providing leadership in this area by providing a standardized disaster preparedness education and training program that is targeting the wide scope of healthcare providers and disaster response personnel. The international community is being encouraged to collaborate with the NDLSF in establishing global standards for disaster education and training. In the quest to do the greatest good for the greatest number of potential survivors in any disaster, it is imperative that the global healthcare community be able to seamlessly integrate in joint responses. The ability to work together effectively is largely dependant upon our fundamental education and training in disaster preparedness. A review of these topics was presented at the 2006 Advanced Study Institute (ASI) Course: Strengthening National Public Health Preparedness and Response for Chemical, Biological, and Radiological Agents Threats held in Skopje, Republic of Macedonia on 20 June 2006.

The 21^st century has already forecast a continuum of health security challenges that will strain current medical and public health systems. The world must now prepare for an influenza pandemic similar to the 1918 Spanish flu, the scale of which has the potential to cause catastrophic global losses to populations, civil infrastructures and economies. NATO is uniquely positioned to guide and inform regional planning, detection and response efforts to promote global health security. In June 2006, a NATO Advanced Studies Institute (ASI) in Skopje, Macedonia convened 60 participants from 11 countries over the course of two weeks to address strategies to mitigate and contain global public health and health security threats. Four key areas were identified in which NATO's leadership will be vital: convening future meetings of medical and public health experts with government officials to foster collaborative regional disease control efforts; developing health information systems to promote disease surveillance, detection and reporting; facilitating regional training and exercises to create an effective and interoperable workforce; and educating leaders in core issues relating to health security and population protection.

Effective communicable disease control relies on efficient, high-quality disease surveillance. A well-functioning disease surveillance system provides information for planning, implementation, monitoring, and evaluation of public health programs. The National Center for Disease Control and Medical Statistics of Georgia carries out surveillance on communicable and non-communicable diseases (including especially dangerous pathogens). The chain of notification and reporting of diseases in the country is established. All institutions and providers rendering health care services to the population must notify the local public health service whenever they diagnose, suspect, or even receive positive laboratory results. US DoD Defense Threat Reduction Agency (DTRA) has started implementation of a project to improve surveillance systems (standardized and repeatable disease monitoring systems, mobile epidemiological response teams and secure transportation of infectious agents), improve communications and information technology (including electronic communicable disease reporting system), improve biosafety and physical security of central reference laboratories and the safe transportation of pathogens, and collaborate on establishing new national rules and regulations relating to BWPPP.

Public health systems in the US and many other countries are poorly prepared for severe (Actually we handle the majority well!) natural and man made disasters. Teachers and public health educators across the country and worldwide have only limited materials to educate their students on the risk and risk factors of West Nile virus, avian flu, bioterrorism, and other disasters. The Global Network Supercourse group provides a model that can help to exchange educational materials rapidly and at low cost. The Supercourse group (Do you capitalize “group?”) developed a large number of scientific lectures on public health preparedness and disasters, and made them available through the Supercourse network of over 38,000 scientists 151 countries. This article describes a novel approach of; i-Prevention, the application of the Internet to prevent bioterrorism and other threats. Additionally, the paper outlines the concept of community watch and its applicability to the modern era of the Internet technologies. A neighborhood watch is where people in communities ban together to watch over each other, the neighbors, and communities are deterrents against crime. The principles of the neighborhood watch can be established on the Internet, with a Global Health network neighborhood watch to act as a deterrent against bioterrorism and other disaster, and mitigate the damage should an attack occur.

The field of public health preparedness encompasses many important areas, including preparedness programs in responding to bioterrorism, mass casualties, chemical emergencies, natural disasters, radiation emergencies, and infectious disease outbreaks. The strength of these programs lies in its shared mission to strengthen public health training and workforce development, especially in the areas with limited access to scientific literature and the Internet. The majority of public health emergencies can be prevented and/or mitigated with improved access to scientific literature, open access software, and open access educational modules. Getting information to the right people at the right time is essential. Today, access to information usually implies access to a reliable computer. Contrary to some myths, one does not need the most expensive computer and fastest Internet connection in order to access and utilize high quality educational materials. Computers that often get disposed in U.S. and other developed countries can be used just as effectively as the latest and greatest machines for access to the information. The key to improved access to information is a functional computer. The key to functional computer is oftentimes not hardware, but its software, configuration, user awareness, and attitude towards computer usage. This chapter will discuss how to protect and tune a computer for optimal performance without needing to buy a new one. It will also outline how older machines could be effectively used to access public health preparedness information online.

Essential Information Security (InfoSec) problems are discussed and common myths formulated, including that InfoSec development must be identical everywhere; that every entity has to protect its own assets; that confidentiality is the most important element of InfoSec; that terrorists are the only and most crucial adversaries technical tools provide infuse; that mathematics is nothing but cryptography; that the goal is to spend as little on security as possible and that it would be nice if security paid for itself; that standards are void and complicated; that IT team should create the InfoSec system; and that outsourcing is the solution as they know everything. InfoSec myths also apply to the Emergency Preparedness and Response (EPR) field. EPR could better implement Information Security practice and vice versa, stimulate InfoSec development and thus enrich each other. For both, InfoSec and EPR, strong international, cross-agency and interdisciplinary approaches with focusing on information sharing instruments are needed to counteract chemical, biological, radiological and nuclear threats.

Education is paramount to preventing all forms of diseases and conditions. Supercourse is a project designed to create a free lecture library of PowerPoint prevention lectures. To date, over 38000 academic faculty from approximately 150 countries with over 2600 available free PowerPoint lectures have participated to integrate Internet-based education into prevention of all forms of diseases and terrorism/bioterrorism. Biological agents are the oldest of the nuclear, biological, and chemical (NBC) triad and have been used by governments in warfare for over 2,500 years [1]. The objective of this chapter is to outline some scientific facts about bioterrorism, to understand terrorism and to help prevent bioterrorism. More specifically, our aim is to: (1) provide information about bioterrorism on the Supercourse collection of lectures; (2) show that terrorism/bioterrorism has had a long history; (3) demonstrate that bioterrorism has occurred worldwide, including in the countries of the Former Soviet Union (FSU); and (4) to conclude that terrorism/bioterrorism, while terrifying, is rare. However, we must be concerned, not paralyzed by fear, and be ready to fight all forms of terrorism/bioterrorism.

Modeling is generally used to study complex systems. Furthermore, computer simulation of models is a popular way to examine and study analytically intractable models. While these practices are quite popular, it is important to use them judiciously. Models can be created that cannot be verified or validated. Furthermore, using simulation results without proper analysis can lead to false claims. Also, an emerging field of modeling, agent-based modeling, is a field that deserves special attention due to the complexity of the behaviors modeled. Agent-based models define rules for agents to follow and their interactions are then simulated to observe the effects of their resultant behavior. An agent-based model of epidemic spread through a population is presented which leads to some unintuitive results regarding the effects of immunization.

Munitions and Explosives of Concern (MEC), including CBRN Unexploded Ordnance (UXO), pose a significant health hazard to human health and the environment. Contamination from training, violent war fighting, and emplacement activities is world-wide and estimated in millions of acres. Mitigating the physical and chemical hazards of MEC within NATO and its Partnering Countries, including areas within the Balkan Peninsula, will be extensive and cost tens of billions of dollars. Conceptual site modeling (CSM) within the environmental community has been a tool for environmental remediation specialists to help ascertain contaminant footprints, determine most likely transport and exposure pathways, identify exposed populations (human and ecological), and focus remediation/restoration efforts. These same CSM principles have been applied to UXO remediation efforts. However, recently, new tools have been developed by the United States (U.S.) Department of Defense (DoD) through the U.S. Army Corps of Engineers (U.S. ACE) to support data collection and management of MEC response at Munition Recovery Sites (MRS). Novel application of these tools, either alone or in tandem, can be used to develop advanced and strengthened CSMs. Application of these tools could play a key role in better understanding the true nature of MEC/UXO, thereby improving response efforts at MRS by NATO and Partnering Countries. This paper explores the potential application of these tools specifically in strengthening the CSM for munition response, and proposes approaches that could be potentially used to improve the public health preparedness and efficient response to CRBN MEC within the Balkan Peninsula.

The aim of this report is to develop consensus-based recommendations formeasures to be taken by medical and public health professionalsif Crimean-Congo hemorrhagic fever (CCHF) viruses are used as biological weaponsagainst a civilian population. CCHF is a viral haemorrhagic fever of the Nairovirus genus, family Bunyaviridae. CCHF virus is a tick-borne virus that causes a severe hemorrhagic disease in humans with a case fatality rate of approximately 30%. Although primarily a zoonosis, sporadic cases and outbreaks of CCHF affecting humans do occur. The disease is endemic in many countries in Africa, Europe and Asia. Recently, Turkish populations have suffered from Crimean – Congo Hemorrhagic Fever about four years. CCHF has been seen some of the cities in Turkey since 2002. Recommendations for limiting the spread of CCHF, in cases of natural outbreaks or terrorist spread, include.

To introduce the topic of chemical agents, we discuss their place in the context of terrorist use of weapons of mass destruction, their recent uses on human populations, and the approach to national and international response. Despite international treaties and efforts to control the spread of chemical agents, these weapons remain a real threat. Both chemical agents and industrial hazardous materials can be used by terrorists. The public health system must be ready for chemical attack by having proper plans, infrastructure and supplies, and public health surveillance systems all in place. Improved and increased research in medical countermeasures, information sharing and coordination, education and training programs represent the key words to manage this emerging priority.

Despite international treaties with strong verification measures that aim to prohibit and prevent the use of weapons of mass destruction, nevertheless some countries and terrorist groups have developed, produced and used such weapons. Successful management of casualties from chemical warfare agents strongly depends on fast and appropriate medical treatment, on the ability of first responders to take proper action, and on new and more effective counter-measures. Although the general principles of clinical toxicology, such as decontamination, stabilization, patient evaluation and symptomatic treatment are similar for many toxicants, chemical warfare agents deserve special attention because their very high toxicity, rapid onset and multiple organ involvement with lethal evolution. This report describes briefly the toxicity and the medical management of mass casualties with chemical warfare agents. Characteristic diagnostic signs and therapeutic schemes for these agents are described. The importance of the knowledge of medical and emergency personnel as well as that of military nuclear, biological or chemical (NBC) unit preparedness and improving research in the field of chemical warfare are emphasized.

The most effective means of defending against chemical warfare agents, whether in war or as result of terror, are by use of primary and secondary prevention. The main goal of medical prevention programs is to minimize human loss by reducing the number of casualties, by teaching advanced medical programs in order to assure a proper response, and to develop new and effective countermeasures. The toxicity, medical management, characteristic diagnostic signs, and treatment of casualties with vesicant, blood, choking and incapacitating agents are described. The importance of improved research and learning processes for medical and emergency personnel as well as of military nuclear, biological and chemical (NBC) unit preparedness in the chemical agent field are emphasized.

In the last century, the deliberate use of chemical warfare has inflicted mass casualties and remarkable psychological consequences on the public. A historical summary of the most relevant chemical warfare agents is reported, as well as the main advantages and disadvantages to the use of chemical weapons in warfare or terrorist attacks in the beginning of the 21^st century. Toxic aggressives are described according to their physiopathologic effects on the human body. Some prevalent key myths about chemical weapons are discussed and discredited. Even though the risk of use of chemical agents for warfare purposes has diminished over the past years, these weapons still represent a potential threat in episodes of national and international terrorism. Accurate information and basic training campaigns for civilian populations can reduce anxiety levels, improve the general preparedness, and limit the terrorists' capacity for harm.

Training programs for first responders do not adequately address the psychological effects of biological and chemical terrorism. Bioterrorism, being one of the most complex forms of terrorist attack, affects in remarkable ways the life of both survivors and first responders due to the very high impact of uncertainness of the consequences of the event. Cooperation with multidisciplinary experts such as psychologists, chemists, and toxicologists, will certainly enhance support and education for first responders.