Biological Attack Response The following diagram examine the response by authorities to a biological attack. It represents a general simplified framework for a response to biological terrorist incidents and is designed to highlight the differences and complexities associated with responses to a biological attack. In actuality, the response will be adapted to fit local conditions and will depend very much on the scale and type of a specific attack. Also, thia diagram assumes an ideal response in which each stage is carried out effectively, so that the next stage of the response can be engaged. In real life, if this does not occur, or unforeseen problems arise, the system might break down. This shows the importance of planning and training.

	Biological Attack Response Note: The time frame for each event - chemical and biological attack response - is different. To be effective, the response to a chemical attack must be implemented within minutes, while the response to a biological attack is likely to take place over days or weeks. Within each diagram, there is no fixed duration for each stage of response-some tasks can be rapidly performed while others take more time. This will also vary depending on the specific event; for example, in some cases, it may be possible to identify a biogical agent in 30 seconds, in others this may take up to several minutes.

	Covert Agent Release: Response to a biological attack differs considerably from that to a chemical attack; one key difference is the absence of an immediate EMS, police, or HAZMAT response. A biological attack could occur from an aerosol release of dangerous pathogens, surface contamination, or contamination of food and water. Despite the fact that the anthrax letters were an overt, declared biological attack, many people believe that most serious bioterrorist events will be covert in nature, in the sense that the perpetrators of the attack will not announce that an attack has taken place.

	Covert Agent Release: In any case, it is highly unlikely that a terrorist will announce that an attack has occurred, since a covert release: a) delays response and helps the attacker escape; b) hides the site of the attack and the extent of contamination; c) allows the disease to spread unchecked (in the case of a contagious agent like smallpox virus). That a terrorist attack has even occurred may not become apparent until some days after the covert agent release, when the agent is identified and an epidemiological investigation has been launched.

	Victims: The covert release of a biological agent may not have an immediate impact because of the delay between exposure to the agent and the onset of symptoms. Incubation periods of various diseases range from days to weeks. Initial symptoms of many of these diseases are also non-specific, resembling the flu. Victims may only seek medical treatment when symptoms become severe. Even after a specific disease is discovered, it may be some time before authorities realize that the outbreak is an intentional attack rather than a naturally occurring epidemic. As their symptoms worsen, most victims will seek treatment in a doctor's office or their local hospital.

	Doctor's Office: In the case of a biological terrorist attack, the doctor becomes a first responder. Early detection of unusual symptoms or patterns of illness by capable doctors is essential to minimize the impact of the bioterrorist attack. If presented with many ill patients suffering similar symptoms or even a single patient with acute or unusual symptoms, physicians will admit the patient(s) to the hospital for further treatment and most likely contact public health agencies. Doctors may also first send patients for tests conducted by private medical laboratories in order to determine their condition more accurately.

	Private Medical Laboratory: The private medical laboratory may discover the presence of a rare or unusual organism in the samples taken from a patient. This may result in a preliminary identification of the agent involved. In this case, the laboratory may inform public health authorities directly or report these results to the doctor, especially in the event of reportable diseases such as those caused by traditional biological agents. Even if the laboratory cannot identify the agent, this information can help the doctor make his decision to contact public health authorities and admit the patient to hospital. The private medical laboratory may also be receiving an unusually high number of samples or requests for specific tests. This may alert laboratory personnel to a potential outbreak and they will inform public health authorities.

	Report of Rare Disease or Puzzling Signs or Symptoms: The doctor or private medical laboratory will make a report of an unusual illness to the public health authorities, and the patient will be sent to a hospital for further treatment, together with information about the illness collected thus far.

	Report of Rare Disease or Puzzling Signs or Symptoms: Unusual signs and symptoms present in victims of a biological attack could include: · single cases of a rare disease (such as tularemia); · cases of a disease unusual for that time of year or that region; · large numbers of people ill with similar symptoms or disease; · failure of patients to respond to the usual treatment; or · several unusual diseases in the same patient without any reasonable explanation.

	Hospital (Primary Site of Treatment): The hospital will serve a variety of functions in a biological attack. Diagnosis For those victims presenting themselves directly to a hospital emergency room (ER), hospitals will be first responders. In this case, hospital staff will have to start the diagnostic process from scratch. ER staff and hospital infection-control personnel should look for many of the same signs mentioned in the "Report of Rare Disease or Puzzling Signs or Symptoms" section. In addition, for patients presenting themselves to an ER, symptoms are likely to be more severe, involving high fevers and rapidly deteriorating cases.

	Hospital (Primary Site of Treatment): Hospital staff members are also more likely than individual doctors to spot clusters of cases, especially in the event of many acute cases appearing in an otherwise healthy population. Hospitals have the capability to carry out microbiological tests and autopsies to determine a diagnosis. In certain cases in which hospitals cannot determine the identity of the pathogen, they may send samples to county or state health laboratories for further testing. Those patients admitted to the hospital by a private doctor will be accompanied by some information about the course of the illness thus far (such as response to treatments like

	Hospital (Primary Site of Treatment): antibiotics). For these patients, there may already be laboratory tests and a preliminary diagnosis. Notification Once a diagnosis is made and the biological agent identified, hospital staff will notify local, state, and potentially even federal public health agencies, if this has not already occurred. The hospital may also directly alert other local hospitals instead of waiting for this to be coordinated through the health department. Treatment and Mitigation The type of treatment will depend on the nature of the organism used in the attack.

	Hospital (Primary Site of Treatment): Some diseases are extremely contagious, while others are not. Bacterial infections can often be treated with the timely administration of antibiotics, whereas for many viral diseases, treatment is limited to symptomatic support. In a large-scale incident, the biggest problem likely to be experienced by hospitals is the overwhelming number of cases-this puts especially heavy demands on emergency rooms, intensive care units, support staff, and laboratory workers. Infection control issues may also complicate matters. In the case of very contagious diseases (such as smallpox), patients must be quarantined and hospital workers

	Hospital (Primary Site of Treatment): must use personal protective clothing and equipment. Hospitals themselves will be responsible for determining their own quarantine and the distribution of medicines within the hospital. Another problem that may be experienced is panic and fear in both the affected population and among health care workers once rumors of a bioterrorist attack emerge. Anxious citizens may inundate hospitals, and there is a danger that frightened health care workers will leave their posts, leading to understaffing.

	Prevention for Those at Risk: Prevention consists of all measures taken to prevent the onset or spread of illness. The type of prevention used will depend on the type of organisms. Generally speaking, for both viruses and bacteria, vaccines can be effective in preventing disease, whereas in the case of bacteria, antibiotics can also be used preventatively to limit the number of people who will develop disease. Who receives this preventive therapy depends on both the contagiousness of the disease and how the agent was dispersed (such as by aerosol, food, or water). In the case of non-contagious diseases such as anthrax, only those directly coming into contact with spores need take antibiotics. For contagious diseases like smallpox, vaccination needs to

	Prevention for Those at Risk: take place in a much larger segment of the population in order to prevent the disease from spreading from person to person. It is also important to give vaccinations or other preventive therapy to those working with infectious patients or related laboratory samples. Coordination of large-scale vaccination or antibiotic distribution programs would likely be undertaken by local public health agencies, together with the state and federal agencies such as the Centers for Disease Control and Prevention (CDC), which will coordinate the Strategic National Stockpile. At this stage, public relations and communication are vital to ensure that the correct people

	Prevention for Those at Risk: correct people receive prophylaxis, and that hospitals and distribution centers are not overwhelmed by large numbers of anxious people who have not been exposed to the agent. Infected or potentially infected people may have to be quarantined in the case of contagious organisms, which will be supervised by state and local public health officials.

	Local / State Health Department (epidemiological services & laboratories) / Advice on Diagnosis and Treatment: Local and state public health departments will be informed by doctors, private laboratories, or hospitals about suspicious disease activity. In the event of a bioterrorist attack, they are responsible for the following tasks: a) immediately investigating any report of a cluster of illnesses or other event that suggests an intentional release of a biologic agent b) collecting, transporting, and storing specimens appropriately before laboratory analysis can take place

	Local / State Health Department (epidemiological services & laboratories) / Advice on Diagnosis and Treatment: In the event of a bioterrorist attack, they are responsible for the following tasks: c) using state laboratories, which have experience with bioterrorism agents and outbreak investigations to support bioterrorism investigations, and conduct specialized testing for diagnostic purposes (these include members of the Laboratory Response Network) d) reporting immediately to the CDC if the results of an investigation suggest bioterrorism

	Local / State Health Department (epidemiological services & laboratories) / Advice on Diagnosis and Treatment: In the event of a bioterrorist attack, they are responsible for the following tasks: e) monitoring the outbreak as it occurs f) providing information to health care providers about treatment and infection control g) providing measured and timely information to the public about the extent of the threat h) together with federal agencies, coordinating a response to the event, including the acquisition and distribution of medical supplies and vaccination programs

	Academic, Military, and Federal Experts and Assistance: A true bioterrorism event in the United States will require national coordination and assistance with regard to resources, expertise, and informing the public. a) The FBI takes primary authority over conducting the criminal investigation as soon as there is evidence indicating that an outbreak of disease was brought about intentionally. Locally, the FBI WMD Terrorism Coordinator will lead the investigation. Public health authorities will still be in charge of the medical and public health aspects of the attack.

	Academic, Military, and Federal Experts and Assistance: b) The CDC (part of the Department of Health and Human Services) will assist local public health authorities with containing the outbreak and treating patients. c) The Strategic National Stockpile (administered by the CDC) can be activated to provide state and local health officials with extra medical supplies.

	Academic, Military, and Federal Experts and Assistance: d) Federal laboratories, such as the CDC, can be used to confirm the agent diagnosis and to assist with the investigation. When requested to do so, the Department of Defense, including the U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID) can also provide assistance. e) The National Disaster Medical System can mobilize its Disaster Medical Assistance Teams (DMATs).

	Academic, Military, and Federal Experts and Assistance: f) In certain areas, additional assistance can come from the Metropolitan Medical Response System (which is a federal program operating at a local level). g) Authorities may consult academics with expertise in specific agents. h) In addition to assistance from USAMRIID, the Department of Defense may provide equipment and expertise through its soldier biological and chemical command (SBCCOM) and other bodies. Again, these entities would provide such assistance only when requested by the civilian authorities.

	Academic, Military, and Federal Experts and Assistance: i) Other federal agencies that may be called upon for assistance, depending on the nature and scale of the attack, are the Federal Emergency Management Agency (FEMA), the Environmental Protection Agency (EPA), the Food and Drug Administration (FDA), the U.S. Department of Agriculture (USDA) and the U.S. Postal Service (USPS).