RAND Report Critique: Bioterrorism and Public Health Preparedness

Introduction: Federal Preparedness and Bioterrorism Simulations

As discussed in the RAND report, in major cities across the country, the federal government helped stage simulated biological, chemical, and radiological (dirty bomb) attacks to mobilize local officials for emergency response. Police, firefighters, and emergency medical teams rehearsed the rescue of afflicted civilians, played by community volunteers. Domestic preparedness was far from standard. Local government leadership determined the degree of participation, the plans for mobilization, and what resources would be requested from the federal government — whether new computers, police cars, ambulances, or support for personnel and training. This paper examines further scenarios to evaluate the RAND report's findings with regard to bioterrorist attacks and infectious diseases.

The starting assumption of the RAND report was that an exemplary practice should be "technically sound, effective, replicable, and sustainable." As practices were reviewed, however, it became clear that many had only recently been implemented and that there was scant evidence of their effectiveness as individual preparedness measures. In some cases, there was a lack of evidence for an entire category of practices — for example, syndromic surveillance (RAND Report). In 2000, to test whether domestic preparedness legislation was improving national readiness, Congress asked the Justice Department and FEMA, together with the National Security Council, to stage an exercise that would mobilize top government officials in a simulation of an attack response.

The exercise, called TOPOFF (for "top officials"), was directed by the established defense contractor SAIC (Science Application International Corporation). Costing around $10 million, TOPOFF simulated a mustard gas attack in Portsmouth, New Hampshire — where the response went smoothly — and a scripted plague aerosol attack in Denver, Colorado. The Denver exercise produced chaos; locating mortuaries to store fictive cadavers was a major problem and brought out the critical difference between a limited chemical attack and one involving a contagious disease. This difference was important. An explosion or chemical attack would be immediately evident and localized (Neergaard, 2011).

Emergency Response Exercises: TOPOFF and Dark Winter

A disease outbreak, by contrast, could go undetected at first and then persist over weeks. Patients could leave the attack locale without realizing they were infected, fail to understand the gravity of their illness, and — if the disease were contagious — potentially spread and prolong the epidemic. In July 2001, another bioterrorist simulation, called Dark Winter, emphasized the contagious disease threat even more forcefully, on the scale of war. Held at Andrews Air Force Base, Dark Winter was a tabletop exercise based on a fictional pandemic of smallpox; the scenario condensed thirteen days of events into two. The invited participants and actors were Washington political insiders.

For example, Senator Sam Nunn, a key sponsor of domestic preparedness legislation, played the part of the president. The script, written largely by staff at the Johns Hopkins Center for Civilian Biodefense Studies, illustrated a worst-case scenario in which smallpox spread across the nation while insufficient vaccine was available to stop it. The U.S. military had to intervene to curtail violence and social breakdown. A worldwide pandemic was then added to the scenario.

The Dark Winter scenario was later criticized by scientists at the Centers for Disease Control and Prevention (CDC) and other infectious disease experts for its exaggerated contagion rates and its lack of emphasis on proven, simple ways to curtail epidemics — such as home care, wearing face masks, hand washing, and, perhaps most importantly, avoiding hospitals where transmission rates would soar. In practice, the exercise served more as political rhetoric. Two weeks later, its organizers and participants testified before Congress in support of increased funding for stockpiling smallpox vaccine and for domestic response training.

The exercise demonstrated that the scale of an imagined bioterrorist attack could vary greatly depending on the scriptwriters and their intentions. During 2002, polls indicated that the American public became increasingly intimidated by the possibility of a nationwide smallpox outbreak. Among experts, concern about a future smallpox outbreak — perhaps involving a new strain — had a direct impact on indefinitely delaying the WHO's scheduled date (December 31, 2002) for destroying the U.S. and Russian reserves of the virus, the last known in the world. No case of smallpox had been recorded since 1979, following the WHO eradication campaign. Experts who viewed basic science as the key to bioterrorism defense envisioned the development of antiviral drugs to replace current vaccines, which — although valuable — were already contraindicated for people with compromised immune systems. Political justification for the delay was found in fears that Saddam Hussein or North Korea's Kim Jong-il might use smallpox as a last-stand weapon (Frist, 2002).

"The needs assessment enabled the Department of Health to coordinate risk communication procedures locally, regionally, and statewide by creating a plan that integrates the protocols already in place with the anticipated communication needs for an emergency" (RAND Report).

By this reckoning of future threats, it could be argued that smallpox stocks should be preserved for research purposes. Donald A. Henderson, a leader of the WHO smallpox eradication campaign and founder of the Johns Hopkins unit that organized Dark Winter, disagreed. His solution was for the government to destroy the virus and stockpile enough smallpox vaccine to counteract an American pandemic. The smallpox virus itself is not used in making the present vaccine; better vaccines, Henderson argued, could be developed without retaining the virus. A report from the Institute of Medicine disputed the wisdom of destroying the virus, and in agreement, the WHO delayed the extinction of smallpox. Developing nations most vulnerable to smallpox reemergence protested. At the same time, the U.S. government moved forward with the production and stockpiling of the smallpox vaccine in the event of a bioterrorist attack on America.

Conclusion

As the RAND report identified: "With the continuation of the funding for public health preparedness, it is anticipated that state and local public health departments will continue to develop new practices and refine existing ones, in an effort to meet the critical benchmarks and capacities outlined in the funding guidance. We recommend that DHHS continue to review and evaluate these efforts as a means of updating this repository over time and maintaining relevance with the evolving needs of public health departments."

Identifying these risk factors posed practical problems. For example, the CDC estimated that around 300,000 Americans were unknowingly HIV-infected. The smallpox vaccination guidelines suggested HIV testing but did not insist on this precaution. In addition, after the shot, the vaccine site could shed virus cells and cause illness — called "contact vaccinia" — that could be dangerous to others. Throughout 2003, a small number of reported adverse reactions to the smallpox vaccine caused a drop in public participation. Unexpected heart symptoms were particularly alarming. Among the 250,000 soldiers vaccinated for the first time by March 31, fourteen individuals — ranging in age from twenty-one to thirty-three — suffered heart problems, including myocarditis, pericarditis, or both. The 100,000 soldiers being revaccinated reported no such inflammatory problems. Overall, the military remained positive about the smallpox vaccine program. By late March 2003, just under thirty thousand civilians had been vaccinated nationally — a small fraction of those expected to participate.

Three of these volunteers had heart attacks, two of them fatal, and seven others suffered other heart-related problems. The CDC characterized the three first responders — aged fifty-five to sixty-four — who suffered heart attacks as already having clearly defined risk factors, such as high cholesterol levels, cigarette smoking, and a previous history of heart trouble. The same appeared true for a fifty-five-year-old member of the National Guard who died of a heart attack five days after being vaccinated. The distinction between the vaccine causing heart failure and its contributing to heart failure was lost on many.

The threat of terrorists attacking with smallpox aerosol seemed more remote than these reported illnesses and deaths, especially as the Iraq war was declared over in May 2003 and the threat of bioterrorism faded from the news. Fifteen states immediately halted their vaccination programs, and many hospitals independently withdrew participation. The federal government stayed committed to the program, although the intelligence data supporting this commitment — always vague — remained unspecific. In July 2003, the CDC was given $100 million to dispense to states to improve participation rates. The Johns Hopkins physicians who had organized the Dark Winter scenario remained optimistic about the smallpox campaign as a means of reducing the risks of bioterrorism.

Fauci, A. S. (2003). Bioterrorism preparedness: NIH smallpox research efforts. U.S. Department of Health and Human Services. Retrieved October 22, 2011, from

Frist, W. (2002). The political perspective of the bioterrorism threat. In S. L. Knobler, A. A. F. Mahmoud, & L. A. Pray (Eds.), Biological threats and terrorism: Assessing the science and response capabilities (p. 29). National Academy Press.

Neergaard, L. (2001, October 24). Postmaster: Anthrax threatens mail. The Washington Post. Retrieved October 21, 2011, from http://www.washingtonpost.com/wp-srv/aponline/20011024/aponline090115_002.html

Tanielian, T., Ricci, K., Stoto, M. A., Dausey, D., Davis, L. M., Myers, S., Olmsted, S., & Willis, H. H. (2005). Exemplary practices in public health preparedness. RAND Corporation. Retrieved October 21, 2011, from http://www.rand.org/content/dam/rand/pubs/technical_reports/2005/RAND_TR239.pdf