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Emergency Preparedness and Response for Bioterrorism

The Occupational Safety and Health Administration (OSHA) defines bioterrorism as:

“The intentional use of microorganisms to bring about ill effects or death to humans, livestock, or crops.”

Bioterrorism that deliberately contaminates food for human consumption includes acts that target livestock and crops (agricultural bioterrorism or agroterrorism) and acts that target processed foods. Rural areas may be more vulnerable to bioterrorism events that target livestock and crops due to the presence of agriculture and industries that deliver food and water supplies to Americans.

Planning, Response, and Recovery Guidelines for Rural Hospitals and Healthcare Facilities

Rural hospitals and healthcare facilities play a crucial role in bioterrorism response. Illnesses related to an attack will often be diagnosed in a hospital or other healthcare facility. The Bioterrorism Readiness Plan: A Template for Healthcare Facilities, developed by the Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), provides recommendations for planning and responding to a suspected bioterrorism event. It also defines two types of scenarios, both of which rural healthcare facilities and partners should address:

  • Covert Event – People are unknowingly exposed. An outbreak is suspected only due to unusual disease clusters or symptoms. A covert attack will require investigation to be identified as an attack, and healthcare facilities will work closely with the Federal Bureau of Investigation to identify a bioterrorist attack.
  • Announced Event – People are warned that an exposure has occurred. In announced attacks, the healthcare facility's main role is to treat patients rather than actively contributing to an investigation to determine if an outbreak was intentional.

Reporting Requirements and Contact Information

Healthcare facilities should report suspected cases of bioterrorism to the appropriate personnel and officials, including but not limited to infection control personnel, healthcare facility administration, local and state health departments, and local law enforcement. Contact information for relevant personnel and officials should be included in an emergency preparedness plan.

Potential Agents

There are many kinds of biological agents that can be weaponized to cause harm. Bioterrorism agents are categorized by the risk they pose to national security.

  • Category A – These agents are of the highest priority because they have the potential to cause the most damage based on their potential to spread easily, impact public health, cause high rates of mortality, create public panic and social disruption, and require special public health response. Category A agents include anthrax, smallpox, and viral hemorrhagic fever, among others. The Bioterrorism Readiness Plan includes specific information and considerations for these types of agents.
  • Category B – The second-highest priority agents can be moderately easy to spread, cause moderate morbidity and low mortality, and require enhanced diagnostic and surveillance capacity. Category B agents include food safety threats, water safety threats, typhus fever, and more.
  • Category C – The third-highest priority agents are emerging agents that can be engineered for mass dissemination, such as Nipah virus and hantavirus.

Detection of Outbreaks Caused by Agents of Bioterrorism

When detecting bioterrorist outbreaks, it is important to move quickly. Laboratory confirmation may take days, particularly in rural areas where lab capacity may be limited. Response to suspected bioterrorist events should be initiated based on syndrome-based criteria, which is the combination of clinical symptoms consistent with a specific illness. Additionally, epidemiologic features should be used to determine whether an outbreak event is unusual and warrants concern, including an unusual increase in people seeking care, patients arriving from a common place, and large numbers of fatal cases. In any bioterrorist event, healthcare facilities should expect a surge of patients. Rural areas must plan for patient surge, since diagnostic and room capacity may be limited. For more information on preparing for an influx of patients, see The Role of Public Health and Health Systems, Facilities, and Providers in Emergency Preparedness and Response

Infection Control Practices for Patient Management

Well-organized patient management and infection control are critical to bioterrorism response, especially in cases where person-to-person infection can occur. Practices requiring special considerations include:

  • Isolation precautions
  • Patient placement and transport
  • Cleaning, disinfection, and sterilization of equipment and environment
  • Discharge management
  • Post-mortem care

A well-maintained stock of antibiotics in the pharmacy is critical for treating patients. Additionally, if needed, healthcare facilities should access the Strategic National Stockpile (SNS), formerly known as the National Pharmaceutical Stockpile (NPS), a supply of essential medical supplies that was initially created for bioterrorism response and has now expanded to include other emergencies.

Post-Exposure Management

Post-exposure management is critical to preventing further exposures. It consists of decontamination of patients and environment, prophylaxis and post-exposure immunization, and triage and management of large-scale exposures and suspected exposures. It is important to consider the psychological effects of bioterrorism, particularly for patients and healthcare staff.

Laboratory Support and Confirmation

Diagnostic confirmation of bioterrorism agents is important in identifying an attack. It is important to be aware of procedures for obtaining diagnostic samples, laboratory criteria for processing potential bioterrorism agents, and transport requirements. Particularly, it is important to note that due to limited laboratory capacity in rural areas, local labs may not be able to test for certain agents.

Patient, Visitor, and Public Information

Communicating with the public, patients, and visitors is an important aspect of responding to a bioterrorism-related outbreak. Information should be clear, consistent, and easy to understand. Additionally, limiting visitors during an outbreak is an important protective action. For more information, see Public Safety and Crisis Communication in an Emergency or Disaster.

Protecting Building Environments

In Guidance for Protecting Building Environments from Airborne Chemical, Biological, or Radiological Attacks, the National Institute for Occupational Safety and Health (NIOSH) provides recommendations for protecting buildings against bioterrorist and other attacks. Most importantly, preparedness planners should know their building and its systems, including HVAC (heating, ventilation, and air conditioning), fire protection, and life safety. Other recommendations are presented within four categories: things not to do; physical security; ventilation and filtration; and maintenance, administration, and training. It is difficult to predict which buildings may be targeted for a bioterrorist attack, but in rural areas, these might include any agricultural buildings and buildings with a lot of employees, such as manufacturing facilities.

Special Considerations for Rural Hospitals

Disease Surveillance

Disease surveillance is important to bioterrorism response because it would facilitate the identification of an outbreak that is outside of the normal disease occurrence, and an abnormal outbreak might be due to an intentional infection. However, small, rural communities may not have disease surveillance systems in place. A policy analysis brief, Perspectives of Rural Hospitals on Bioterrorism Preparedness Planning, informed by a panel of rural hospital representatives convened in 2003, noted that it may be impractical to implement disease surveillance systems because in small communities, the cluster of illness necessary to detect an outbreak may not be recognized.

Another report, Understanding the Role of the Rural Hospital Emergency Department in Responding to Bioterrorist Attacks and Other Emergencies: A Review of the Literature and Guide to the Issues, by the NORC Walsh Center for Rural Health Analysis, describes two kinds of surveillance systems: passive or active. Passive systems “rely on lab workers and hospital staff to report incidents or to convey data on illnesses to public health staff.” Active systems “provide a mechanism for public health practitioners to solicit information,” which “involves direct access to hospital records so that data are reviewed on a regular basis.” Surveillance systems promote collaboration between state health departments, local hospitals, EMS, law enforcement, and federal agencies, which is critical to bioterrorism response. However, rural health departments and hospitals may not have the staff capacity, such as a local epidemiologist, to initiate and maintain surveillance systems.

Laboratory Testing

Limited capacity for laboratory testing in rural areas may hinder response to bioterrorism. Local laboratories, such as hospital labs, may not be equipped to analyze more specialized specimens, such as those that may be used in a bioterrorism attack, and may be overwhelmed by a large attack. Although rural communities may defer to state public health and private labs, in a large enough attack, even these may become overwhelmed. It is important that partnerships focused on lab services be developed with public and private facilities for bioterrorism attacks and other emergencies, such as infectious disease outbreaks.

Lessons Learned from Historical Events

Salmonella Outbreak on Dalles, Oregon (1984)

In 1984, a community outbreak of salmonella affected patrons and employees of 10 restaurants and one grocery store in Dalles, Oregon, resulting in hundreds becoming ill. At the time, Dalles was a small town with a population of about 11,000. Because of its proximity to a major interstate highway connecting eastern and southern Oregon and Washington, there were a lot of visitors and restaurants. The local hospital became overwhelmed. There were more patients than beds, and laboratory capacity was exceeded.

For the hospital, this outbreak revealed a need to have plans in place that would increase hospital capacity both in terms of being able to treat an influx of patients and rapidly increase laboratory capacity. Hospitals can incorporate this into preparedness planning by practicing setting up tents for a patient surge and developing partnerships to help with laboratory needs, for example.

Oregon state health officials and the CDC investigated this event. Intentional contamination was initially considered, and epidemiological evidence was consistent with intentional contamination, but that hypothesis was rejected for several reasons, including the lack of apparent motive, no claim of responsibility, a lack of precedent, and that other hypotheses appeared more likely, among other reasons. When the investigation did not find evidence to support other potential causes, the spread of infection was attributed to poor food handling by employees. One year later, during a subsequent criminal investigation, the cluster of illnesses was confirmed as intentional contamination — an attack by members of the Rajneeshpuram commune.

This event highlighted the importance of collaboration among healthcare professionals, laboratories, and local and state health departments in routine reporting and disease surveillance. If a large, unusual outbreak is identified, the possibility of intentional contamination should be considered and independently investigated by law enforcement. Additionally, an incident report for this event, which might help inform response to future attacks, was never published out of fear that the event would be replicated.

Anthrax Attacks (2001)

Anthrax is a rare bacterial infectious disease that can be used as a bioterrorism weapon. In 2001, only a few days after 9/11, letters containing anthrax were mailed throughout the U.S. These attacks killed 5 people, and 17 others fell ill. Although letters were found in urban areas, there are important lessons learned by health officials that also apply to rural communities. The anthrax attacks revealed a need for laboratory processes, rapid diagnostics, and collaboration across public health departments, local hospitals, federal agencies, and other partners.

Resources to Learn More

Preparation and Planning for Bioterrorism Emergencies
Resources for planning and preparing for a bioterrorism attack.
Organization(s): Centers for Disease Control and Prevention (CDC)

Biohazard Exposure
Offers guidance on how to prepare for and work through a bioterrorism attack.
Organization(s): U.S. Department of Homeland Security (DHS),

California Hospital Bioterrorism Response Planning Guide
An overview of bioterrorism and response applicable to hospitals. Describes in detail bioterrorism agents and prevention/treatment and offers screening forms for each agent. Attachments include a communication plan, medical record review form, and other tools for effective response planning.
Author(s): Cahill, C.K. & Nikkel, R.
Organization(s): California Department of Health Services
Date: 2002

Disaster Preparedness and Response in Texas Hospitals: Part 1, Hospital Emergency Preparedness Planning: Bioterrorism Preparedness and Response
Planning guide for acute care hospitals as they prepare a bioterrorism response. Focus is on communication and coordination, security, medical operations, patient tracking, infection control, and pharmaceuticals.
Organization(s): Texas Department of Health, Texas Institute for Health Policy Research
Date: 3/2003

The Public Health Response to Biological and Chemical Terrorism: Interim Planning Guidance for State Public Health Officials
Provides guidance for state public health officials to determine the responsibilities of their departments in response to terrorist attacks. Discusses coordinating efforts with other government agencies, local health departments, and emergency management systems.
Organization(s): Centers for Disease Control and Prevention (CDC)
Date: 7/2001

Guidance for Protecting Responders' Health During the First Week Following A Wide-Area Aerosol Anthrax Attack
Offers recommendations for protecting personnel from exposure when responding to a wide-area anthrax attack to prevent them from developing the disease.
Organization(s): Administration for Strategic Preparedness and Response (ASPR)
Date: 9/2012

Guidance on Initial Responses to a Suspicious Letter / Container with a Potential Biological Threat
Presents recommendations for local responders when initially responding to suspicious letters or packages that may be a potential biological threat.
Organization(s): Federal Bureau of Investigation (FBI), Department of Homeland Security (DHS), Centers for Disease Control and Prevention (CDC)
Date: 11/2004

Protecting Building Occupants from Exposure to Biological Threats
Recommends how to configure and maintain commercial buildings to protect occupants from exposure to biological threats. Discusses intentional and naturally occurring biological threats, and inadequate protection to reduce risk of exposure.
Organization(s): Johns Hopkins Bloomberg School of Public Health, Center for Health Security
Date: 2008

Reference Manual to Mitigate Potential Terrorist Attacks Against Buildings
Offers detailed Information on how to mitigate physical damage to structural and non-structural components of buildings and infrastructure and reduce casualties from bomb, chemical, biological, and radiological attacks.
Organization(s): Federal Emergency Management Agency (FEMA)
Date: 12/2003