Conclusions of the Advisory Meeting on Bioterrorism

Introduction

The terrorist acts of 11 September 2001 in the United States of America have generated numerous inquiries from the Organization's Member States about the consequences and response that countries should prepare for in case future events of this nature should take place.

In response to Member States concerns, the Director, Dr. George A.O. Alleyne, convened a consultation meeting of experts on bioterrorism from the Region of the Americas. The purpose of the consultation was to examine current and future challenges and opportunities facing PAHO and to provide recommendations for the Organization's technical cooperation in regard to prevention, control, and response to threats or acts of bioterrorism.

This meeting took place at PAHO Headquarters, on 24 October 2001. This document provides a summary of the group's discussions, and the recommendations issued by the participants, both for the countries and the Secretariat. The list of participants is included in Annex I.

Background

The bioterrorism attack in the United States of America in October 2001 has generated numerous inquiries from Member States to PAHO about the deliberate use of biological agents to cause harm. As well there have been several reports of suspected anthrax contamination, which are disrupting the normal operation of public health services.

Biological weapons are devices used intentionally to cause disease or death through dissemination of microorganisms or toxins in food and water, by insect vectors, or by aerosol. Potential targets include humans, food crops, and livestock. Unlike nuclear, chemical, and conventional weapons, the onset of a biological attack is insidious. Recent incidents and investigations of terrorism, coupled with a rising number of hoaxes, have created a sense of urgency for addressing emergency preparedness, and the medical and public health capacity for dealing with a biological attack. Given the global economy, an outbreak anywhere in the world may be considered a threat to virtually all nations. The occurrence of infectious disease outbreaks involving biological weapons presents major challenges to already fragile national health systems. The ability of many nations to cope with endemic infectious diseases has been complicated by emerging infectious diseases such as human immunodeficiency virus, hantavirus pulmonary syndrome, West Nile encephalitis, Hong Kong influenza, Escherihia colii O157:H7, and an increasing number of antimicrobial-resistant microorganisms. Dramatic increases in the volume and speed of travel and commerce further complicate infection control efforts by creating novel scenarios for the intentional or unintentional spread of infectious diseases. Advances in biotechnology increase concern for bioterrorism relating to the possible misuse of genetic research for the development of more potent biological weapons and the spread of new infectious diseases.

Several microorganisms have been identified as serious enough threats to warrant preparation by the public health system: Bacillus anthracis (anthrax), smallpox, Yersinia pestis (plague), Clostridium botulinum (botulism), Franciscella tularensis (Tularemia), and hemorrhagic fever viruses.

Combating bioterrorism requires the leadership of the national civil defense disaster management committee with direct involvement of medical and public health professionals. Establishing a more effective national and regional strategy against bioterrorism will have the additional benefit of improving response to natural infectious disease outbreaks and new or emerging diseases.

Summary of Discussions

In his opening remarks, Dr. George A. O. Alleyne, Director of the Pan American Health Organization (PAHO), welcomed the participants and thanked them for their willingness to support and guide the Organization in the orientation of its technical cooperation in regard to prevention, control and response to threats or acts of bioterrorism.

Dr. Alleyne remarked on the vision of the Organization's founders, which made the object of the Pan American Sanitary Code, among others, "the prevention of the international spread of communicable infections of human beings; the promotion of cooperative measures for the prevention of the introduction and spread of disease into and from the territories of the signatory Governments […], and the standardization of the measures employed at places of entry, for the prevention of the introduction and spread of the communicable diseases of man, so that greater protection against them shall be achieved and unnecessary hindrance to international commerce and communication eliminated." These objectives remain as relevant today as they were in 1924, when the Code was written.

The Director indicated that until now, PAHO had cooperated with Member States to prevent in-country spread of disease, and trans-border cooperation among countries for the same purpose. As a result, considerable capacity has been developed to detect and contain the spread of disease, as well as to deal with and mitigate the effects of natural disasters. However, countries of the Region must now prepare to respond to the challenge posed by bioterrorism. This new challenge includes being aware of the nature, magnitude and potential of the hazard.

The decision to convene the meeting was a response to the urgency posed by Member State's concerns about bioterrorism and its consequences for national, global, and especially, regional public health. Given the Organization's experience in dealing with infectious diseases and disaster preparedness, and its lack of knowledge on bioterrorism, this meeting was a first step in our preparations for events of that nature.

Following the Director's introduction, the discussions included an update of PAHO's response to emerging and reemerging diseases (EID), and disaster preparedness. The first one has included strengthening national surveillance beyond disease reporting. This has been achieved by establishing subregional networks for surveillance with laboratory support; mechanisms to facilitate rapid information exchange among countries, and field epidemiology training; and by constituting rapid response teams to investigate outbreaks and determine its etiology. In addition, countries are preparing contingency plans for emerging infectious diseases with the assistance of PAHO and other partners in the Region. Technical cooperation among countries has been sponsored for this purpose. However, one area that has not been strengthened and needs more involvement is medical care, including emergency room care.

PAHO has a long tradition in technical cooperation involving response to disasters. In fact, in every country there is a structure to deal with disasters, which assigns responsibilities for the response to major crises. In the health sector, there are disaster response programs to address any kind of disaster. These programs should now integrate the response to the new threat posed by bioterrorism. Given that structures for crisis management are in place, it may be that strengthening them is all that is required.

A summary of the conclusions that emerged from the general discussions follow:

• It was recognized from the United States' experience that in this area the Organization and member States are treading a new, unknown territory, and that this is a learning experience for all involved.
• Preparedness for the threat of natural and man made disasters and the surveillance of emerging and reemerging infectious diseases provides some preparation for dealing with bioterrorism.
• It is possible that biological damages won't be apparent until the affected population seeks emergency room services due to sickness. First respondents in these cases will be hospitals, especially, emergency health care personnel.
• Epidemics of unknown etiology often induce panic and cause damage beyond the disease itself.
• It is the health sector that must deal with consequences: hospitals, emergency personnel, and therefore, it must be included early in the planning for these situations. Although the hospital capacity may be a concern in a bioterrorism situation, emergency plans in Latin American countries include procedures to make beds available during emergencies.
• Public information is a key part of the response to emergency situations. Governments must provide complete and accurate information to prevent panic.
• Six health threats have been identified as serious enough to warrant preparation: smallpox and anthrax in first place, followed by plague, tularemia, botulinum toxins, and hemorrhagic fevers.
• Containment of the source of contamination (clean up) should be taken care of by disaster preparedness structure in each country.

Points regarding anthrax: Anthrax does not spread from person to person, but can be made into a powder that can, with relative ease be made into a form that is readily dispersed. It requires that cases are detected as early and as fast as possible; emergency room personnel must be trained and alert. Health departments must provide coverage around the clock. The public health system must be strengthened and include knowledgeable staff in infectious diseases, in more or less the same way as required for EID. A network of laboratories is necessary to identify infectious agent.

There are two approaches in dealing with anthrax. In the present situation, a good vaccine is not currently available. The United States of America has stepped up its research on new anthrax vaccines. Currently the best response to exposure is prophylaxis with antibiotics for 60 days after exposure. Anthrax is greatly sensitive to a wide array of antibiotics other than Ciprofloxacine. Penicillin and doxycycline are recommended.

Points regarding smallpox: Discussion around smallpox included risk evaluation, international cooperation to deal with its threat and vaccine production. Currently, large populations have no immunity to smallpox; the number of individuals susceptible to the infection is larger than ever, given that immunization stopped over a quarter of a century ago, and very few people may have natural immunity. Although smallpox is more difficult to release, if it were released, its hazard potential would be much higher than that of anthrax. Smallpox would become an immediate international problem. Countries which in the past had the capacity to produce smallpox vaccine no longer are able to do so, and regaining that capacity would require training and revision of production procedures. An international initiative is necessary to re-establish capacity for smallpox vaccine production if it became needed.

In the United States, it was decided to restart the production of smallpox vaccine. The strain to be used is the traditional one, i.e., the New York Board of Health strain. Two or maybe three sites will produce vaccine. The question arose about whether other countries in the Region would rely on the United States' supply of the vaccine should smallpox reemerge in the Region.

Recommendations

Two sets of recommendations were issued by the group. The first addressed national preparedness, and the second, PAHO's technical cooperation in the Region of the Americas.

Regarding national preparedness, recommendations deal with general preparedness, surveillance, and laboratory capacity:

General

• The threat of bioterrorism should be included in every country's plan and structure to deal with disasters. These plans should be multisectoral and supported by training of all sectors and desktop simulation exercises.
• These plans should cover detection, diagnosis and response.
• Plans should include an inventory of human and physical resources available.
• Countries should be prepared to provide up to date and accurate information relevant to the protection of public health.
• Countries should share information on results of epidemiological investigations and cooperate with each other in the response to events.
• Countries should have expert commissions on bioterrorism by creating new ones or preferably by using and expanding existing disaster preparedness bodies.

Surveillance

• Countries should take steps to enhance their ability to detect, identify, investigate and respond rapidly to reports of emerging infectious diseases. This may include the establishment of rapid response teams.
• Health care providers should receive training in diagnosis and reporting of clinical presentations consistent with man made epidemics, beginning with emergency room personnel, followed by primary health care staff.
• There should be specific written procedures for the safe handling and transportation of infectious disease materials.
• Treatment guidelines should be available to address the biological agents discussed.

Laboratory capacity

• Laboratory networks should be improved for the diagnosis of agents potentially used in bioterrorism.
• Laboratory biosecurity should be strengthened to prevent theft, misuse, contamination or improper handling of these agents.
• There should be national and international quality control of laboratory diagnosis.
• Laboratory personnel should be trained in the recognition of findings suggestive of bioterrorism agents.
• Transfer of infectious samples among laboratories should be done according to established guidelines and confirmed by sending and receiving institutions.

PAHO's technical cooperation

PAHO should:

• Provide authoritative, current information to countries on events related to bioterrorism, which could be used in the preparation of national plans.
• Make recommendations for prophylaxis and treatment of anthrax.
• Together with countries of the Region, explore the potential for production of smallpox vaccine, including update of good manufacturing practices (GMP) for production.
• Support countries in the development of national plans to address bioterrorism.
• Provide training to countries in the surveillance, laboratory and information aspects related to the response to agents used in bioterrorism.
• Identify reference laboratories for confirmation, training, and provision of reagents.
• Promote the development of rapid diagnostic tests and availability of diagnostic reagents for anthrax and other potential agents of bioterrorism.
• Support quality control and proficiency testing in the laboratory for diagnosis of agents of bioterrorism, including the provision of an inventory of reagents available for this purpose.
• Support cooperation among countries, including through subregional networks.
• Coordinate rapid response to support countries to deal with bioterrorism

CONSULTATION MEETING ON BIOTERRORISM
Division of Disease Prevention and Control
WASHINGTON, DC
24 October 2001

LIST OF PARTICIPANTS