bob BIOTERRORISM:JEROME M. HAUER; Congressional Testimony 03-25-1999 Senate Testimony Jerome M. Hauer Director, Mayor's Office of Emergency Management City of New York Biological terrorism is an emerging and significant issue of national and international scope. While preventing terrorists from perpetrating these horrific acts is properly the function of our law enforcement agencies, dealing with the consequences of a biological terrorism incident will inevitably fall first and foremost on a city's local responders as well as the local public health and medical community. I would like to address the challenges that cities face in preparing for biological terrorism and how the Federal government can best assist us. In New York City we approached the challenge of responding to biological terrorism by rigorously analyzing how these events would evolve and modularizing the different components of our planning process. The first step of our analysis was determining the nature of the threat facing us. Threat While historically there are many examples of biological agents being used as weapons, and we know that many nations have had, or still have, aggressive biological weapons programs, the covert use of biological agents to infect large populations in a modern society is technologically difficult. The ability to manufacture, to cultivate the organisms in large quantities, is fairly easy. The ability to take those large batches of organisms and change them into a form that is deliverable, to actually weaponize them, is far more problematic. Lastly, to effectively disseminate these weaponized organisms is also difficult. Chemical vs. Biological The nature of the civilian threat of biological agents is different than the one facing the military. The military model of "NBC," nuclear, biological, and chemical warfare, does not apply to civilians in cities. The natures of chemical, biological, and radioactive agents are inherently so different that we must avoid linking them too closely and instead must take radically different approaches to managing the consequences of their release. In discussions across the country over the past few years, the subject of biological terrorism was hard to focus on because so many think and refer to the subject as "chem/bio" as if they were simply variations on a theme rather than two distinct entities. It is distressing that to this day many cities are still approaching biological terrorism with the same methodology they use for chemical terrorism. Chemical agents, in general, are highly toxic and most victims will become symptomatic within seconds to minutes. This necessitates an emergency public safety response to what is essentially a hazardous materials incident. In New York City we have enhanced our hazardous materials response, improved our ability to decontaminate victims, and provided antidotes to our EMS units so they can initiate treatment in the field. This response model, however, does not apply to biological agents. It is absolutely crucial that we understand that biological agents do not affect people as quickly as chemical agents: people exposed to a biological agent will not show any signs for days, if not weeks. There is no "flash and bang" when a biological agent is released and there is no rationale for a "lights and siren" response to most forms of biological terrorism. The Three Attack Forms Our analysis in New York City showed that a biological terrorism event could present in three distinct ways: a package or site- specific event, a clandestine release, or a credible threat. Cities must plan and prepare for each of these attack forms and the Federal government must understand how it can best assist localities for each of these. Package/Site-Specific Event A biological terrorism event may take the form of the delivery of a package suspected of containing a biological agent, such as the recent spate of "anthrax letters" across the nation, or as a specific site, such as a clandestine laboratory. It is for only these limited incidents that our first responders have the primary role. These site-specific incidents are the only type that requires our police, fire, and EMS responders in the early stages; these incidents are essentially a modification of the standard hazardous materials response. However, as has been demonstrated by the recent anthrax hoaxes, site-specific biological terrorism incidents are simultaneously criminal investigations, hazardous materials incidents, and public health emergencies. Biological terrorism forces us to develop new approaches to managing field incidents. While based on a traditional hazardous materials response, these incidents require an increased horizontal integration of the local first responder community, police, fire, EMS, and the local public health experts, as well as a vertical integration with Federal agencies. As a demonstration of our commitment to a multidisciplinary approach, in New York City we have actively involved our Department of Health in the response to biological incidents because they are the experts in public health and communicable diseases. We have trained a number of Department of Health personnel in hazardous materials response so that they can perform an on-scene evaluation of a package or letter suspected of containing biological agents. Conversely, we took our Fire Department's hazardous materials team for a day at a Department of Health laboratory where introduced them to basic concepts in biology and the nature of bacteria and viruses, and then showed them different types laboratory equipment that they may encounter in the field if they were to find a clandestine laboratory. The necessity for an integrated response system leveraging off of existing resources, which traditionally have not been members of the public safety/first response community, is highlighted in the response to a clandestine release of a biological agent. Clandestine The clandestine release of a biological agent by terrorists presents the greatest challenge for it can potentially affect more people than any other form of terrorism. Unless they are found in situ prior to release, this is a massive public health emergency that will be recognized and responded to by our medical and public health communities. New York City hosted a number of tabletop exercises based on the clandestine release of anthrax and learned a great deal about the response to biological terrorism. The most important lesson we learned about the evolution of the clandestine release of a biological agent was the need for a sensitive and timely public health surveillance system. The first sign that a biological terrorism agent has been released may be when people begin developing symptoms and become ill. The earlier that we recognize that a biological agent was released, the earlier we can initiate treatment. We have a window of opportunity during which we can positively affect the outcome by reducing morbidity and mortality. However, the longer it takes for us to recognize that an event has occurred, the greater the morbidity and the greater the number of unnecessary deaths. The key to exploiting this window of opportunity is early recognition. Recognizing that a biological agent was clandestinely released requires constant vigilance in evaluating the morbidity and mortality rates within a city. For the past year, New York City has been performing a daily evaluation of EMS runs, deaths, and emergency hospital admissions. This program, known as the Citywide Daily Health Indicators, is being used to develop indicators and trigger-points so that we can rapidly recognize a higher than expected morbidity or mortality rate. This program has been developed for the express purpose of providing the city with the largest possible window of opportunity to treat potentially exposed victims. It is important that local public health authorities in every community develop sensitive, specific, and timely surveillance systems for identifying increases in morbidity and mortality. For those cities with large commuter populations, it is critical that local public health systems be integrated with regional systems and that clear communications procedures be developed to ensure that all jurisdictions have timely access to the data. Lastly, it is imperative that the linkage and relationship between our public health system and the medical community be strengthened: local physicians and nurses are, many times, the eyes and ears of the public health investigators. Our communities' health care providers must learn to recognize the symptoms of the most threatening biological agents. In medical school, students are trained that "when you hear hoofbeats, think horses but remember the zebras." Anthrax and smallpox are "zebra diagnoses;" we must ensure that our medical community knows the zebras that are out there and who to call when they find one because time is of the essence. When a biological agent release takes place, the window of opportunity to begin prophylaxing the exposed population is about two days. As a result of our tabletops and analysis of the progression of a hypothetical biological terrorism incident, the need for adequate amounts of pharmaceuticals was identified. In the era of managed care, capitation, and cost containment, the amount of medications and medical equipment on-hand in hospitals has dropped precipitously. Many hospitals have only a one-week supply of medicine, based on normal patient volume, at any given time. The need for national pharmaceutical stockpiles, placed in regions throughout the country, is critical. Furthermore, we must address the issue of vaccines. There is no civilian access to the anthrax vaccine because all supplies have gone to the Department of Defense, there is no effective vaccine for some of the biological agents, and we have only about six million doses of smallpox vaccine nationally, a vaccine stock which is now about twenty years-old and of unknown efficacy. The shortfalls in our pharmacopoeia must be aggressively addressed on a national level. On the local level, the logistical aspect of medications is quite large. On the supply side, simply buying massive amounts of medications would not be prudent. In New York City, for one example, we would have to buy 75 million tablets of ciprofloxacin, the first-line antibiotic for the prophylaxis against anthrax. We must avoid falling into the old Civil Defense mentality and learn to leverage existing resources. We have looked at creating a supply "bubble" within the current hospital pharmacy system. Rather than simply buying huge amounts of drugs, we have examined purchasing more drugs than the current one-week on-hand supply, but less drugs than would be used by the end of their shelf-life. This would entail a small investment, an investment that would provide us with more medications located within the community but without the threat of a huge supply of drugs that would be thrown out in a couple of years. The only costs entailed with this are the initial purchase and the on- going, minimal, costs of maintaining an inventory. The benefit is that these medications could be accessed immediately for local distribution in order to start rapidly prophylaxing the population. In New York City, we have developed two paradigms for rapidly prophylaxing the exposed population: bringing medications to people in a program we term "Canvass," or bringing people to the medications in a program we refer to as "Points of Distribution" (POD). With a nighttime population of 7.5 million people, distributing a five-day supply of ciprofloxacin through our POD System, the first stage of treatment, would require 45,344 personnel citywide to dispense 75 million tablets within 48 hours. If we had to do this through home delivery in the Canvass Program, it would require 41,562 personnel in Manhattan alone. While we must be prepared to swiftly prophylax the exposed population so that they do not become ill, we must also be prepared to treat those who do become sick and those who succumb to the disease. Another challenge facing us is how to support the hospital system in the event of catastrophic numbers of casualties. We must be prepared to treat large numbers of victims who will be presenting at the hospitals. In New York City we have been working with our hospital community to design a system which can both expand rapidly to deal with the massive influx of patients as well as to establish a system for integrating the responding Federal medical assets. We have begun identifying large facilities in proximity to each of the 59 9-1-1 hospitals which can be converted into what we term "Alternate Care Facilities" (ACFs) and be used for caring for the overflow from the nearby hospital. We have also located large open areas within the city which can be used for establishing temporary "Casualty Collection Points" (CCPs). Theses CCPs will be used by Department of Defense field hospitals and the Public Health Service's Disaster Medical Assistance Teams (DMATs). The CCPs will be used to further augment the capacity of the city's hospital system. Augmenting the capacity of our hospitals is crucial. Many hospitals throughout the country were overflowing with patients this past flu season. Some hospitals had patients in their Emergency Departments for days on end and critical equipment, such as ventilators, were in such short supply that units had to be flown in from across the United States. This past flu season should serve as a wake-up call to the medical community: this was simply a natural flu outbreak. How is the medical community going to respond to a premeditated catastrophic event? It is interesting to note that in conjunction with developing an expandable system for treating patients, we have also had to develop methods for dealing with catastrophic numbers of fatalities. We have developed a system for requesting refrigerator units, cooling warehouses and converting them into Alternate Morgue Facilities (AMFs), and integrating the fatality management system with the law enforcement and vital records' systems to ensure proper tracking of the deceased. The guiding principles for New York City has been to leverage off of existing programs and to be flexible. Of course, New York City is a unique environment, but the principles which we have developed can be applied to other communities. For example, using the same POD model but applying it to a community of 100,000 people shows that a more typical American city would need to establish three PODs and deploy about 654 personnel in order to prophylax the entire community using one-million tablets of ciprofloxacin. Additionally, we have designed this system to rely upon minimally trained personnel: this must be a high-performance, rapid thru-put system and it is not predicated on using large numbers of physicians, nurses, and other health care professionals. This system uses a few, strategically placed, medical experts to supervise a large operation using a protocol-driven system implemented by a non- professional staff taken from the local community. The local responders, local public health authorities, local medical community, and local governmental officials will bear the responsibility for managing the consequences of a biological terrorism incident. Cities must understand that there will be no significant Federal assistance for at least 18 hours and cities must be prepared to be self-sufficient for at least that long a time. Cities have the responsibility for recognizing an incident and initiating the response. We will have the job of creating the infrastructure which the Federal resources will "plug-into" so that we can deploy those assets effectively and efficiently. There will be no Federal "9-1-1" response and instead Federal assets will be used for long-term patient care, management of the deceased, logistical support, disaster funding assistance, and investigation. Of these, the investigation of the criminal threat and activity is a constant process and will play a role an assessing the credibility of the threat of a biological terrorism incident. Credible threat One of the more challenging forms of biological terrorism is the credible threat. What if a city was to determine that it is faced with the threat of the release of a biological agent? Who determines the credibility? What resources should be alerted? What, if any, resources should be propositioned? These are important questions that must be dealt with prior to an event. While historically our law enforcement agencies have had the sole responsibility for evaluating and countering the threat from criminals, including terrorists, managing the consequences of the release of a biological agent is outside of their expertise. In an era when we are confronted with a criminal act that may affect thousands, hundreds of thousands, or even millions, and with a limited window of opportunity to treat the victims, it is essential that the restrictive philosophy of law enforcement agencies yield to a more open sharing of information with both the experts in public health and medicine, and those who will actively manage the consequences of an incident. I say this with the utmost of respect for my colleagues in law enforcement and with an understanding of the necessity for managing information and keeping confidences. However, we must learn to strike a balance between the need for confidentiality and the logistical challenge of medicating a million, or more, exposed people in 48 hours and treating catastrophic numbers of sick people. Conclusion The response to all incidents starts at the local level. We must avoid the old Civil Defense mentality of creating new and unique systems that aren't used on a regular basis. Instead, we must leverage our existing systems and prepare them to expand into high-performance, coordinated, multidisciplinary organizations. The United States has a public health infrastructure; let us leverage the current public health infrastructure into a highly sensitive and specific instrument for recognizing incidents of biological terrorism. We should support our public health agencies so they can become the local and regional points-of- contact for monitoring the health of our citizens in close partnership with the medical community. Our medical community, especially the hospitals, must be prepared to treat the victims of a biological terrorism attack. We must assist the hospitals in training and support them in their efforts to develop the ability and capacity to deal with catastrophic numbers of patients. The medical community must take the lead in developing new and better vaccines and creating innovative systems for accessing and then delivering life-saving medications to victims in a timely and effective manner. The response to a biological terrorism incident will be from the bottom up: local public health or medical providers will probably be the first to recognize an event. Cities will initiate the response, be self-sufficient in the first-stages of an incident, and will develop the infrastructure that the Federal government will integrate with in order to support the local effort.