Southern California Plans Defenses against Bioterror Attack
How can local government get information soon enough to control the spread of the disease if we are hit with a bioterrorist attack? What stockpiles are there of vaccines and protective clothing? How do you decontaminate people or buildings that have been exposed? How can you treat large numbers of people who have highly contagious diseases with a high mortality rate without spreading the disease to your medical staff?
Published: Wednesday, June 05, 2002
More than 200 doctors, state and local officials, police, hazardous materials specialists, germ warfare scientists, and scholars met at the University Synagogue in West Los Angeles for a two-day conference May 29 and 30 on how to prepare for the threat of bioterrorist attacks. Participants ranged from the top State of California and Los Angeles County officials in charge of crisis management in the event of an attack to the chief Russian and American scientists who had run each country's bioweapons programs until they were shut down some decades ago.
The conference was sponsored by Center of Medical Multimedia Education Technology (COMMET), and cosponsored by UCLA's Burkle Center for International Relations as well as several other concerned groups including the Los Angeles Terrorism Early Warning Group (TEW).
The conference was chaired by Dr. Peter Katona, assistant professor of Clinical Medicine at UCLA and a member of the Los Angeles County Bioterrorism Task Forces. In his opening remarks Katona noted that "fanatics have always been around, but today there are new technologies, and a new religious fervor that lacks the constraints of previous decades."
He noted that only 2% of 14,000 cargo containers entering the United States every day are inspected. That 15-20 of about 100 potential microbial agents have actually been developed, and 18 countries have them. "They are very cheap to produce compared to nuclear weapons."
"There have been major disturbances in the 'force'": The Oklahoma City bombing, the first World Trade Center bombing in 1993, sarin gas in Tokyo. We are witnessing a paradigm shift, a period of global instability: Eastern culture vs. Western, rich vs. poor, Judeo-Christian vs. Muslim, America lovers vs. America haters."
Katona pointed out that diseases, even when not deliberately spread, have had a devastating impact in the past, greater than any war. Most people know about the Black Death in Europe in the 14th century, that killed 25 million people, or the smallpox Cortez gave to the Aztecs in Mexico, that killed 4-7 million. But how many have heard of Justinian's plague, that killed 100 million in Asia minor and southern Europe in the 6th century, or the native-based hemorrhagic fevers in Mexico that killed up to 80% of population--12-15 million--a generation after Cortez?
Smallpox is a prime candidate for deliberate terrorist use. It was eradicated by the World Health Organization in 1967-1977. The last recorded case in the world was in 1977 in Somalia; the last case in the United States was in 1949. In the Middle Ages a quarter of the population was killed by smallpox, and as late as 1951, 64,000 died of it in India.
Peter Katona pointed out how the fear of bioterrorism far exceeds its actual impact: 4 letters, 22 cases of anthrax, and 5 deaths created public health chaos. Tens of thousands of courses of antibiotics were prescribed, there were massive decontamination headaches, and lots of money was spent, all without any of the mass deaths that this kind of bioagent is capable of.
Thus far the countries that have bioweapons have been reluctant to use them. Japan in 1936 to1945 had a bioweapons program and killed 3,000-5,000 U.S. POWs with anthrax. Russia had enough anthrax to kill the whole population of the earth, but never used it. Iraq had 19,000 liters of botulinum toxin and 8,500 liters of anthrax, but didn't use them for fear that the United States or Israel would use nuclear weapons on Baghdad. The United States has not used biological weapons against humans, but it has killed half a million Cuban hogs with bioweapons, Katona reported. Washington ran an offensive biological program until 1969--and one of the leading scientists who operated it, Bill Patrick, spoke at the conference.
More ominously, with the democratization of technology, its cheapening to the point that small groups or even individuals can afford it, entities less accountable than states are coming into posession of biological warfare materials. "The Aum Shinrikyo cult in Japan used chemical, not biological, weapons in their sarin gas attacks on the Tokyo subway. But they also purchased a ranch in Australia to experiment with biological agents," Dr. Katona told the conference. "They had tried to use anthrax but they were unskilled. They tried to kill a judge by shooting anthrax into his apartment from the next building, but the attempt failed." It is presumed that private terrorist groups such as Al Qaeda are capable of purchasing or developing infectious agents that can be used for attacks in the United States. How to prevent this, or how to respond if prevention fails, was the business of this meeting.
Gregory Treverton: The Typology of the New Terrorist
The first speaker of the day was Gregory Treverton, a senior policy analyst at the RAND Corporation, who has worked with the Senate Select Committee on Intelligence, the National Security Council, and has been vice-chairman of the National Intelligence Council.
We were taken by surprise on September 11, he said, despite some advance warning from intelligence agents, because interpreting data depends on the current mind set. "We were looking for bombs on planes, not planes as bombs. Even those of us who wrote terrorist scenarios really didn't think the terrorists would do it. We had relatively happy endings to previous terrorist attacks. The worst things that could happen didn't. So we didn't see the evidence of the people in flight schools. It is easier to see it in hindsight."
Terrorism is the tactic of the weak against the strong. "Hence it is asymmetric," Treverton said. "It involves the deliberate targeting of noncombatants. It seeks a stun effect, terrorism as theater." Terrorism is an element in many conventional struggles. "There is a continuum, not a sharp break, the context does matter. One person's terrorist is another's freedom fighter."
Still, there is something new in the current generation of terrorists. "In the 1970s and 1980s the terrorists were secular, they had an agenda to negotiate. Bin Laden's aims are so apocalyptic that they cannot be negotiated. We have seen a shift from secular-political to apocalyptic, from defined, limited purpose, want something, to very grand purposes or revenge, from violence for stun but limited, to no limit on violence."
Understanding our adversary is key: "We need to not turn them into cardboard characters. Bin Laden is a good manager and charismatic, very patient, he learns from his failures. Remember that World Trade Center 1 was 8 years earlier. He had ABC teams: The A team hit on September 11. His B teams were turned loose with some money to free lance--perhaps Reid the shoe bomber. The C teams received venture capital, to fund initiatives from other terrorists. Al Qaeda has sent money to other terrorists to go out and do bad things."
Treverton examined possible responses to the terrorists. He suggested 4 possibilities: Accommodation, punishment, blocking recruitment, and increased surveillance.
"First is accommodation. This is a nonstarter. There is no way to accommodate the objectives of the present terrorists."
Punishment. "Perhaps this is also a nonstarter. If it only creates martyrs then it plays into the hands of the terrorists. Courts and jails have little effect and they are costly and time consuming. Then there is punishment for harboring terrorists. This can be counterproductive in the case of many states that may do so unwillingly. It can be accompanied by a carrot to help them build more open societies."
Possible block points. "We could try to cut off recruiting. This is inherently hard. While the source of recruits is not infinite, it is large, even in the United State. It is said we should work on the sources of terrorism, but this is iffy and very long term. For example, improving the position of women in the Arab world can result in more Arab men ready to get on airplanes and crash into our buildings."
Monitoring movement of new recruits can be more promising. "We can watch their bases and staging areas. The European staging areas were very important, not only the camps in Afghanistan. Are there U.S. equivalents? Apparently not yet. Afghanistan will be a powerful lesson. But it was as much co-opted by Al Qaeda as having decided to harbor it. We will need to have a long-term presence in the area as a carrot."
Treverton pointed to sensitive issues in attempting to monitor potential terrorist staging in the U.S.: "There are concerns about civil rights in monitoring. Profiling. The key is looking for combinations of people and activities, especially outside the box. This raises thorny issues. Our existing capacity is very weak-- giving Mohammad Atta a visa after he was a martyred terrorist is one example."
This is new terrain for us as a nation, he said. "Past successes set us up to fail now. Distinctions such as foreign vs. domestic are more problematic today. The CIA is barred from domestic intelligence and law enforcement. This worked fairly well during the cold war but doesn't work well now. In late August the CIA sent a cable saying 2 of the (later) hijackers were in the country. The FBI said, what should we do about it? The FBI didn't do much. No one told the FAA to look for them, since it is not a law enforcement agency. No one told the airlines, since they are private companies, not government."
Treverton said that he expected little useful to come from Office of Homeland Security headed by Tom Ridge. "The fate of all government czars is to have enormous responsibility but no authority and very little budget. They have a bully pulpit but nothing more. If this is serious it should be made a cabinet post."
Gregory Treverton was asked a question much on the minds of many Americans: "Should the U.S. be more sensitive to injustices and inequalities that promote hatred abroad?"
"Yes," he replied, "but this is very long term. And it is difficult to untangle the elements. Some of the hatred against Americans is because we are top dog. Some is also a clash of civilizations. Some of this comes from a general resentment because of a number of bad centuries for Islam, going back to declines and defeats that we could not possibly have been responsible for."
Miriam Cotler: The Ethics of Counterterrorism
Miriam Cotler is chair of the Department of Health Sciences at California State University, Northridge. "I have been teaching medical ethics for 17 years," she said as introduction some moral questions: "How can we counter terrorism ethically? Given terrorist attacks, why shouldn't we violate our own laws in order to win?"
Answering her own questions, Cotler said that some acts are permissible under some circumstances, but some are morally wrong and should never be committed. "This is unlike a war. In a real war there are rules of engagement, we have expectable behaviors, we know who the enemy is, there are rules to not kill civilians, and even though this is often broken, it is the rule that is supposed to govern war."
Terrorism, she said, "is always a violation of law and of the rules of war. Terrorists do not want to coexist. They do not differentiate the innocent from the enemy. They are for their good but do not recognize our good. So there is no basis for negotiation. This makes them criminals. But countering them is a slippery slope -- a little bit of this and a little bit of that. How do we define the boundaries?"
Cotler suggested that there is a Western bioethical health model. It begins with the recognition that we are "a society of moral strangers. We come from different ethnic, religious, and ethical beliefs. There is not a commonly shared moral standard. Our rules are designed to honor the individual while letting the institution function. In medicine this includes informed consent, reporting requirements, the right of people to give permission to be touched. The relation between human rights and patients' rights is obvious to those of us involved in medical practice."
Public health involves both protections of individuals and protections of society. "When should someone's driving privileges be revoked? When should businesses be closed as a public hazard? Courts ruled that public interest overrode the right to refuse to be vaccinated. This precedent was later used to justify sterilization of a woman erroneously diagnosed as an imbecile.... We have not much progress where community and individual rights differ."
War raises these issues to a different, more violent, level. "In war soldiers have a right to kill. The rules are about how and who they should kill. A basic rule is, kill if you have to but don't inflict unnecessary suffering. Soldiers are instructed not to kill civilians. These rules have as their purpose the ability to resume normal relations after the war. Terrorism is different. Its aim is annihilation and its goals do not include peaceful coexistence after the struggle. There is no acknowledged need to live together. There is no prospect of living together in peace in the future."
Bioterrorism is unusual in that countering it requires cooperation between the criminal justice system, a law enforcement agency, and the public health system, which is not.
"At one extreme there is good intelligence, cooperation between agencies. We also look to employ an effective spy network able to respond promptly. We need to be able to retaliate quickly to destroy infrastructure.
"At the extreme other end are detainment of persons, searches without authorization, trials without legal safeguards. We have seen noncitizens detained without due process. Terrorists seek to provoke such extreme reactions. It is unwise for us to suspend civil liberties. We need to counter terrorism with the pubic health model."
The Emergency Health Powers Act of October 2001 states that a declaration of an emergency by a state government can place all medical facilities under state control. "It also criminalizes refusal to be tested. Authority under this act is much too broad. Health care professionals, not political functionaries, are trained to handle medical emergencies. There should be a new cooperation but this law is one way only."
One problem with mandatory treatment, Colter said, is that many of the most vulnerable who do not want to be compelled to accept treatment just disappear, with the opposite of the result intended.
When Is Torture Justified?
Cotler examined the reasons why torture might be justified in trying to stop a terrorist attack. "Alan Dershowitz has advocated the right of the state to use torture in terrorism cases. Suppose you know that a bomb is about to go off and you have detained suspects who could tell you where it is? Do you torture them?"
Cotler says no. "Don't make this decision based on whether or not it will work. First, this is the rationale of torturers everywhere. It falsifies the problem. Having done it once, you are soon asked to repeat the act. Soon it becomes commonplace. How can we protect people from excesses if torture warrants are issued? How does the judge know how much torture is enough?"
The ticking bomb theory assumes the suspect will talk. "They may not do so. They may be ready to become martyrs. Torture becomes a means of spreading fear, not gathering information. It will lose us the war for legitimacy. Over time torture means losing empathy for our victims and our souls die. We are a nation of laws and due process. It is our strength, not our weakness. There is always a temptation to invoke security as a reason to abridge liberty."
The Makers of the Plague
In the course of the conference two of the scientists most responsible for creating the agents of "germ warfare" offered their secrets on what bio agents are, how they are made, and what they can do. These were Kenneth Alibek (nee Kanatjan Alibekov), former First Deputy Director of Biopreparat, the Soviet offensive bioweapons program, and Bill Patrick, his American counterpart, former head of product development for the U.S. offensive biological weapons program. Their reports were equally chilling.
Kenneth Alibek: From Plaguemeister to the Search for a Universal Antidote
Ken Alibek spoke on the first day. Now a mild-mannered professor of microbiology at George Mason University, he once headed the operations side of the supersecret Soviet biological warfare program. He worked under the sinister General Kalinin. The American biowarfare program was ended in 1969 by Richard Nixon. The Soviets responded by making their efforts more secret. One of Alibek's coworkers was murdered when he tried to quit, and this was after the collapse of USSR in 1991. Alibek visited the United States shortly afterward and had the opportunity to see first hand that the U.S. program was really dead--something strongly denied by his superiors in Russia. At great personal risk, Alibek then went public with revelations about the secret Russian installations, forcing Yeltsin to admit the existence of the program. Hundreds of tons of bioweapon material were destroyed and the majority of facilities have been verified to have been closed down. But General Kalinin remains an active figure in Russia and some Russian facilities have not been inspected. More worrisome, some 6,500 Russian bioweapons technicians and scientists left the project and have gone on to other jobs. They remain a potential talent recruitment pool for well-financed terrorist groups in other countries.
Alibek began by enumerating six types of biological agents that can and have been weaponized: bacterial, viral, rickettsial, fungal, toxins, and bioregulators. Examples of bacterial agents include bubonic plague, Ebola, and hemorrhagic fever. Viruses include smallpox. Rickettsial diseases include louse-borne typhus fever. Toxins include botulism. Bioregulators are less common as potential weapons. The Soviet Union tried to weaponize certain neurotransmitters, which can suppress particular reactions. The actual stable of Soviet bio weapons included smallpox, plague, anthrax, Q fever, Marburg, tularemia, glanders (a bacterial disease of domestic animals, weaponizable because it requires very few organisms to produce an infection), and VEE (Venezuelan equine encephalitis, an alphavirus).
Tularemia, glanders, and VEE were operational and meant for use close to front lines. They were not meant to kill but to incapacitate enemy troops.
"Anthrax," Alibek said, "was developed by the USSR in huge amounts. Q fever was produced until 1990, after which it was replaced by Marburg." Marburg is a hemorrhagic filo virus, similar to Ebola.
Alibek divided bio weapons into dry and wet types, as the delivery systems for the two are quite different. Among dry varieties he listed tularemia (a bacterial infection transmitted by a very small number or organisms, which can be but usually is not fatal), anthrax, brucellosis (a bacterial infection of farm animals), and Marburg.
Liquid types are mainly smallpox, plague, a wet version of anthrax, and VEE.
"Dry weapons are more effective," Alibek declared. "They can be stored for long periods of time, and have a low decay level. But dry is more difficult to manufacture. Liquid is easier to manufacture but difficult to deploy."
Alibek listed the principal means a standing army would use to deploy these materials:
"There can be aviation bombs with biological bomblets for strategic and medium bombers. Or spray tanks installed on medium bombers. Then there are multiwarhead ballistic missiles with bomblet warheads or Cruise missiles with special disseminating devices. Typically a bomblet group contains 100-110 bomblets, each containing half a kilo of payload."
Soviet Capacity for Megadeath
The Soviet biowarfare program, Alibek said, was organized under the Ministry of Defense. It produced a numbing 1,000 plus tons of anthrax annually, of which about 200 tons were usually stockpiled. Some 100 tons a year were produced and 20 tons stockpiled for plague and smallpox. Some 200 tons a year were produced of tularemia; and 100 plus tons each of brucellosis and VEE.
Compared to these quantities, the October-November anthrax attacks in the United States "involved maybe 5 grams of anthrax." Biological weapons, Alibek added without apparent intentional irony, "have a large psychological effect also in terrifying people."
Of all the available bioagents, Ken Alibek felt that smallpox was probably the most devastating. Historically it could kill as much as 30% of the population in an affected area, and even those people today who were vaccinated in childhood have long since lost their immunities.
The most effective way to spread a bio agent, he said, is if it is airborne. Aerogenous infections include anthrax, plague, epidemic typhus, Marburg, and smallpox. "Effectiveness depends on several factors," Alibek said. "These include choice of agent, deployment method, formulation, and manufacturing process."
Anthrax, though potentially deadly on inhalation, is not contagious between people. In Sverdlovsk in a 1979 accident, 64 people died by direct inhalation. "If used in an explosive anthrax will produce an infected zone, with a wider contaminated zone. In case of plague, the infected zone is followed up by additional new infection zones. Not everyone in the zone gets infected. In the case of smallpox, however, it is highly contagious. There would be a huge number of secondary foci, and the great majority in the aerosol cloud will get infected."
These effects could be compounded if civil authorities were slow to recognize that this was a bioweapon attack. "The target population could be large and poorly defined. The scale may not be immediately apparent. The biological agent used may not be immediately identified. It would take time to identify what agent was used."
Defense against Bioweapons
Ken Alibek laid out steps for defending after an attack. "Technical steps," he said, "include detection, identification, physical protection, disinfection, and vector control: disinsection [eliminating insects pests], and deratization [eliminating potentially infected rodents and other small animals]. On the medical level there is a need for prophylaxis, urgent pre- and post-exposure prophylaxis, and treatment."
Alibek further divided the needed response into several sub steps, which he called scientific, medical, tactical, and logistical. As an example, he took anthrax. "The scientific response is the vaccine. The medical response is to side effects--some people will die from vaccination. Tactically, it must be decided at what time point do we make the decision to vaccinate everybody? It takes multiple shots over six months. Logistically, do we have the capability to manufacture multiple doses for the entire population, that is, billions of doses?"
Clearly it would take a huge number of scientists to make serious preparation for each of the major bio warfare agents that might be used. "It has not happened so far. Now there is about $80 million devoted to this, but it is not enough."
Realistically it may not be possible to prepare against all of the potential agents. "It might take 10 years to develop a vaccine against plague; it might take 15 years to develop a vaccine against Marburg. This could cost tens of billions of dollars and still not guarantee protection, as once a vaccine is developed the terrorists can move on to the next agent for which you do not have a vaccine."
The Universal Antidote
Kenneth Alibek is looking for an end run around this cul de sac. The approach he is studying is nonspecific immune stimulation and immunomodulation. In effect, boosting the immune system to such high defense levels that it can resist almost any bacteria or virus, the universal antidote. "This would also make a contribution in therapy of cancer and sepsis," Alibek said.
With total funding of $15 million he and his collaborators have developed a common defense against anthrax and smallpox, using a biomodulator. "We have reached a 90-100 percent protection. The immune system has specific immunity and nonspecific immunity. If we can modulate nonspecific immunity to the point of eliminating the pathogen it can prevent infection from a wide range of agents. This is something you do in advance; it is not possible as a treatment after infection has happened. We think modulating nonspecific immunities has the greatest promise."
A questioner in the audience then asked if nonspecific immunities could be raised through nutrition without the use of special drugs. Alibek replied that this could be done to a limited degree. "Betacarotine, vitamins B and C, affect the immune system. Selenium and zinc also, among minerals; copper sometimes. If you take them it doesn't say that you can resist all possible pathogens, but when you are older it can re-raise your baseline to what it was when you were younger. The great majority who died of Japanese encephalitis in Europe were elderly with compromised immune systems."
The Anthrax in the Letters
Kenneth Alibek expressed a high level of professional contempt for the skills of the anthrax mailer who hit the Hart Office Building and suggested that the quality of their product was greatly exaggerated by the press. "I was given samples of the anthrax," he said. "It is not true that only a highly sophisticated lab could produce the quantities used. I know some very primitive production techniques that can produce the large volume of spores that was used in the U.S. mail attacks."
As for the small size of the particles as evidence of weaponization, Alibek suggested that this happened in the Post Office itself after the letters arrived. "There was an additional milling process: it took place in the mail cancellation machine itself as the product went through the rollers. The product at the end was more sophisticated than what arrived in the letter." There was a claim at one point that one of the letters may have come from a different, higher level, source because the particles were smaller. Alibek said of this, "One of the letters was misdelivered, to the State Department, and was run through the roller machine a second time when it came back. Naturally, it contained smaller particles afterward."
Bill Patrick: The Secret of a Good Bioweapon
Although he spoke on the second day of the conference, the comments by Bill Patrick, folksy doyen of the American germ-warfare establishment, really belong here with his Russian counterpart. Patrick is a microbiologist who worked as a central figure in America's bioweapons program from 1951 to 1986. The offensive section of the program was closed down in 1969. He is now a germ-warfare consultant (his business card displays a skull and crossbones). The New York Village Voice refers to him irreverently as Dr. StrangeBug.
Grandfatherly and gravel voiced, Patrick eschewed the computerized Power Point presentations favored by all of the other speakers. He described himself as a dinosaur as he pulled out a sheaf of hand-scrawled overhead transparencies on the kill radius of various deadly toxins and slapped them down on the old-fashioned projector.
"There are four issues in success of BW [the insider's jargon for biological warfare]," Patrick said for openers. The four are agent, meteorology, munition, and delivery. "In the anthrax letter scare," he said with a chuckle, "delivery and munition were the post office."
The secret of a good bioweapon, he confided to the audience, is in the munition, in the physics of the primary aerosol. "After an initial period of equilibration, large particles fall out. The small particles, 1 to 5 microns, remain airborne and behave as a gas, can enter lungs."
On the whole, he said, there has been a tendency in the past to exaggerate the danger of contamination of an area hit by a bio agent. "Not too long ago the army believed that any object downwind of the aerosol would have to be decontaminated. As long as a primary aerosol is airborne it passes over equipment. They do not need to be decontaminated. You breathe it in because you are a vacuum, an air pump."
Patrick had some suggestions if you are caught outside when a germ warfare attack takes place. He described a test the military conducted with noninjurious spores: "For test subjects standing in the open 100 meters downwind of release, there were large numbers of spores on the nose, but not on their clothes. Unless they are breathed in, particles tend to flow around objects. When the subjects turned their backs to the aerosol and used a handkerchief over their noses, there were no spores around the nose, just one spore on an eyebrow. Turning your back to the aerosol reduces the probability of infection. Using any cloth to breathe through further reduces infection. Five layers of toilet paper is very efficient in screening the primary aerosol. The difficulty, of course, is knowing when the primary aerosol is coming."
The next lesson is that the smaller the particle the more deadly it is. "In the case of tularemia, using 1-micron particles, it takes 2.5 cells of tularemia to kill a guinea pig; a monkey will die with 14 cells; for human, 10-52 cells is an infecting dose, giving a 50% infection rate. As particle size increases, larger numbers are needed. It's the small particles that will get you."
Wherever the primary aerosol has passed through before it settles or disperses, the ground and objects on it are relatively free of particles. "They verified this by having helicopters stir up the dust after the aerosol passage. When they tested dust raised, they found no secondary reaerosolization of the residue."
Patrick reported another test, 20 miles upwind of naval ships. "There was no contamination on the outside of the ships, but they found high concentrations in the ships' air handling systems for a while, then it dissipated. So there was a spike at the 12 minute mark. Within 32 minutes there was nothing in the atmosphere of the ship. Air handling is very efficient in ships. The aerosol acts as a gas and is dispersed."
Fire fighters, he said, have been told to turn off the air system in a building if an aerosol is suspected. "That's not necessarily a good idea. When we tested with 8 grams of particles in the air handling system of a government building, it built up for an hour and a half, but was cleared out in about 2 hours. There was no residue on walls and surfaces, it behaved as a gas. You should let the air system run to clear the building out."
If the spores came in through a letter, however, "the pattern would be entirely different--it's not an aerosol issue then."
What Happens to Big Particles that Precipitate Out at the Outset?
Bill Patrick described studies in 1950s on inefficient, large-particle aerosols. In one test, 60 liters of contaminant were disseminated in an outdoor area. "They tested one hour after contamination by driving a tractor with a beater through the contaminated area and testing at various heights. They found 67 spores at the 1 foot level, 2 at 3 feet, 1 at 5 feet. There was nothing at any level after 5 hours. Using a denser contaminant, at 60 million spores per liter, contamination at 1 foot at 1 hour was 2,150, at 3 feet 62, at 5 feet, 22. So contamination depends on the density of the original aerosol. Adhesive force binds particles to terrain, which reduces infectiousness." Even denser concentrations are possible, which have a longer dispersal time, but generally aerosol contaminants disperse within 48 hours. This is not true of powders in contained spaces.
The Magic of Freeze Dried Bioweapons
In 1959 it was discovered how to create a freeze-dried powder of agents. Unlike ordinary powders, the freeze dried powders "have secondary aerosol characteristics. They continue indefinitely to be easily blown into new clouds because of their secondary aerosol characteristics. In contrast liquid had almost no secondary aerosol characteristics."
A liquid agent requires a great deal of energy to disseminate, compared to a powder.
"Particle size," Patrick said, "is the key to biological warfare. You have to have small particles." 53 1-micron particles equal just 1 5-micron particle. And not only do you have fewer particles in the same volume, but it takes many more of the bigger particles to infect. The larger the particles, the larger the number of particles needed for infections; at 11.5 microns it takes 23,000 particles to infect a guinea pig.
"Why is this?" Bill Patrick asked rhetorically. "Because the lung has defense mechanisms and you need the right particle size to get past it! You need 5-micron or smaller particles if you are going to infect."
Another Take on the Anthrax Letters
Bill Patrick also had some professional disdain for the press accounts of the anthrax contained in the letters to Senate Majority Leader Tom Daschle and Sen. Patrick Leahy. "They claimed the material was milled to get a smaller particle. You don't mill, because milling causes rough surfaces that lead to reagglomeration!"
As for the claimed improvement in the quality of the anthrax between the Daschle and Leahy letters, "The labs that did the analysis had no experience with biological warfare. Suspending the powder in water, as they did, destroys the integrity of the original agent." Patrick's opinion was that the anthrax in the Leahy and Daschle letters was high quality but not weapons grade, and was produced on a small scale.
How Do You Clean the Stuff Up?
Bill Patrick offered a short film of himself instructing first responders on how to clean up a freeze dried bioagent powder. "This stuff is free flowing, electrostatic free, small particles. It has beautiful flow characteristics." Here is a man who takes pride in his work.
Weapons grade powder, he warned, is very hard to wet, but that is the first step. In the film he demonstrated, first using an ordinary garden hose ("You'd better be wearing protective clothing if you ever have to try this," he cautioned).
As the water hit the powder on the ground it immediately rose into the air in a new dust cloud. He repeated the effort with a little garden sprayer, and finally with a watering can. In each case the dust cloud reappeared, although smaller each time. "Good weapons grade powder is hydrophobic," he concluded.
The way to do it is to prepare a strong soapy solution containing bleach, and to gently lay towels wet with the solution over the powder. "Leave the towels on the powder for 2 hours, then pour more of the solution over the towels, let stand for 2 hours. Now the powder is fully wet."
If the contamination is inside a building, Bill Patrick proposed the use of paraformaldehyde. "Then use a buddy system to decontaminate each other with a garden sprayer with soap and water. The runoff does not need to be captured. The dilution factor in an ordinary drain will take care of the problem."
Dr. Jonathan Fielding: New Initiatives in Disease Surveillance and Preparedness Training for Los Angeles County
The conference got down to the meat of its business with Dr. Jonathan Fielding, MD, Director of Public Health, Los Angeles County Department of Health Services. Fielding reported on the state of preparedness of County medical personnel.
"Our job is health assessment and epidemiology," he said. "The critical issues are planning, surveillance, and getting an early warning." The County started its Bioterrorism Unit in 1999. It is part of the Terrorism Early Warning (TEW) Group with the FBI and local law enforcement.
"Our first response is likely to be analysis of data to determine if the situation is unusual. If we get a lab confirmation, then we alert the medical community, identify the source of the outbreak and the at-risk persons." Most doctors in Los Angeles have never seen a case of anthrax, smallpox, or plague. "We need to train special response teams," Fielding said. "We have to participate in exercises for different scenarios, develop interagency protocols."
The key first step is the speed with which an attack can be confirmed. "We need to do rapid assessment, rapid confirmation of the agent, then mobilize the laboratories, alert the medical community, the ERs, other labs. Then we have to determine possible quarantine, assess environmental contamination, and access biological stockpiles as necessary."
"We have to maintain pharmaceutical stockpiles and medications," Fielding said. "We must ensure emergency medical support and staff, and know where they are and how to call them to the location where they are needed. We also have to manage hospital diversion during an emergency."
There are 4,000 square miles in Los Angeles County, from very dense to very rural areas. "We have a highly mobile population. We will have challenges. Victims may disperse after an attack. We need to have a strategy to use the news media to alert victims. We have to expect that victims may present at geographically dispersed medical offices and hospitals."
New Levels of Surveillance of Reports of Suspicious Illness
An expected complication is that early signs and symptoms are often nonspecific. The medical and lab community are not familiar with rare bioterror diseases. Fielding reported that the County "has been establishing syndromic surveillance, providing training to increase awareness, enhancing collaboration between the medical community and public health agencies."
The County has set up obligatory reporting on suspicious illness by all County medical facilities, with twenty-four hour a day staffing to receive the reports and initiate a response. They have also established coordination with the coroner to get reports of suspicious deaths.
Four large hospitals are participating in the Volume-based County Hospital Surveillance System. They log visits in 4 syndromes: respiratory (possible anthrax), acute rash with fever, neurologic syndromes, and encephalitis.
"We are also developing a project to look at animal illness and death surveillance," Fielding reported. His agency plans to increase veterinary surveillance through a web-based reporting system. He outlined still more extensive options for data gathering being considered for the future. These include monitoring school absenteeism, 911 calls, and pharmacy dispensing of pharmaceuticals, starting with agents for the treatment of influenza.
Lessons from the Anthrax Letters
Fielding said that his office has drawn a number of conclusions from the national scare around the 4 anthrax letters. "They had an inadequate internal communication system. You need real time communication with most physicians. Further, a public communication strategy is essential, and you have to have fulltime central coordination. We are spending a lot of effort on communication. For example, we are collecting the email addresses of all doctors in Los Angeles County."
The Los Angeles County Department of Health Services is also developing questionnaires that can standardize information received so that it can be quantified rapidly. And they are doing this in many of the languages spoken in the County. They have appointed a full time central coordinator to bioterror preparedness.
In addition to knowing when you have been hit, you also have to have materials to respond with and personnel trained in their use. The County authorities have recently enlarged their pharmaceutical stockpiles and decontamination capacity, as well as lab capacity.
"We now schedule regular disaster exercises involving several County departments and the mobilization of public health nurses, health centers, communicable disease specialists, lab, and medical staff. Recent exercises have focused on chemical and biological agents. We are also training nurses-- we don't want to sound the alarm and have nobody show up to serve because they are scared for themselves."
The County has received funding of $24.6 million to improve its assessment, surveillance, and epidemiology. One target has been to expand laboratory capacity. The county now has the capability to do rapid testing and identification of biological agents. They are also training local labs for bioterrorism preparedness. There are plans to relocate and renovate County Health's own primary lab. To promote public awareness the agency has set up a website on Bioterrorism Preparedness and Response: www.labt.org.
Will Victims Be Quarantined?
Several people in the audience asked questions about the County's policy on forcible quarantine of persons exposed to a bioterror agent. Dr. Fielding responded, "This is very difficult. We have thought about having a single hospital to take the largest group of victims in such an emergency. Private hospitals are reluctant to agree because of the contamination and exposure of their staffs. The County hospitals are understaffed. One possibility it to use a nonhospital to take a large number of people and call the medical personnel to that location."
He concluded by saying, "I can assure you that the first smallpox case would not be a local matter, it would be an international matter. But we would still be the ones on the spot who would have to handle it."
Laurene Mascola: Every White Powder in the World Was Anthrax
From this point on the conference focused closely on how to respond in a bioterror emergency. The next speaker was Dr. Laurene Mascola, chief of Acute Communicable Disease Control for Los Angeles County. Her first advice was "Don't smoke. All those who died of anthrax were long-term smokers."
The problem with bioterror agents, she said, is that they are not detectible by ordinary senses. "They can be used in enclosed spaces--sporting events, subways, convention halls. They are the most toxic thing there is per weight, and go undetected until there are numerous insidious casualties. They have the potential for widespread illness in unprecedented numbers."
Depending on the size of the strike, there are limited therapeutic stockpiles. "Treatment is complicated by the need for special protective measures for medical care, clinical lab, and autopsy. And the event itself sows panic among the ill, the exposed, and healthcare providers."
Public fears are an important part of the aftermath of a strike. "After Washington," Mascola said, "every white powder in the world was anthrax. The cornstarch put in some magazines to make the pages turn, the talcum powder on baby changing tables, the powdered dust from opening Kleenex boxes--my office was overwhelmed with calls for 3 months, when anthrax had not been seen west of the Mississippi."
How Anthrax Works
Prior to October 4 it was assumed that it took 8,000 to 10,000 spores to cause an anthrax infection. After October 4, she said, it is assumed that very low numbers, even one spore, can cause anthrax. Pre-October 4, "policy was not to decontaminate a building after exposure. After October 4, offices are scrubbed and fumigated before they are deemed safe enough to enter. No one proposes to leave the anthrax residue in place."
Dr. Mascola traced the course of an anthrax infection. "Spores enter the skin, GI tract, or lung. The spores germinate in macrophages, the core of the body's immune system. Once that obstacle is destroyed, the spores are transported to regional lymph nodes where they begin the local production of toxins. This leads to edema and necrosis, bacteremia and toxemia. You have to stop it at the macrophages stage or no antibiotic can help you. Overwhelming sepsis leads to death."
Before October 4 there had been no suggestion that spores could leak through paper (envelopes). "Post Oct 4, cross contamination of mail was one of the most unexpected epidemiological findings." Previously the Post Office used blowers to clean mail handling equipment. "This just spread the spores. Now the blowers have been replaced with a vacuum process."
Dr. Mascola had some suggestions for anyone who might be infected. She recommended doxycycline rather than cipro as a more effective antibiotic. Given the usual long wait time to see a dermatologist, she suggested that people with lesions suspected to be anthrax use a digital camera to send pictures by email to a dermatologist to get a quick diagnosis.
Smallpox: The Biggest Threat
The United States is holding 95 million doses of smallpox vaccine. The starting point for assessment, Dr. Mascola said, is that no one can count on any existing immunity. "Even those of us who were vaccinated probably are not safe. Ten years is the safe life of a vaccine. Smallpox historically killed about 30% of those exposed, and today we have a more immunocompromised population than in the past."
The vaccine is clearly not worse than the disease, as some diehards have argued in the past. But it is not completely without risk. Approximately 1 person per million who is given the smallpox vaccine will die of it. Mascola said that people who have been exposed need to be vaccinated within 4 days to have a chance of preventing or lessening the effect of the disease.
Smallpox runs its course in 17 days. Patients, she said, remain infectious until all scabs have separated. This also means that those who have been exposed to the disease need to be isolated for 17 days afterward before they can be given a clean bill of health.
"The response procedure," Mascola said, "is to vaccinate and monitor a ring of people around each suspected and confirmed case. Those infected should be quarantined in a facility. Their close contacts should be sent home and instructed to stay there for 17 days. Household members are at the greatest risk. All household members should be vaccinated unless there are strong health contraindications."
It is not common, she said, for this kind of infection to be spread by casual contact on planes or buses.
And the contacts of the contacts? The boyfriend of a household member? Mascola recommended waiting until the first level contact showed symptoms before extending the ring out another level.
Two Elected Officials
City Councilman Jack Weiss and County Supervisor Zev Yaroslavsky both addressed the conference. Both have been involved in local disaster preparedness, including for the possibility of various kinds of terrorist attacks. "There is no upside to being involved in threat preparedness," Weiss said. "There are substantial downsides: money for this comes from things your local constituency want. If something bad does happen, the fingers get pointed at you if anything is less than optimal in the response."
He reported that the City of Los Angeles has purchased thousands of escape masks for the fire department and allocated funding to allow the police and fire departments to each have a full-time representative on the staff of the Terrorism Early Warning Group.
Zev Yaroslavsky was cautious in what he could promise. "Our capability to respond to a public health crisis is very limited," he said. Before September 11, "the public health people were relegated primarily in our mind to restaurant inspections. On September 10 if you had asked me what preparations we had made for smallpox or anthrax I would have had to laugh because it was not even on our minds. Now it is on everybody's mind. I think it is just a matter of time before we experience suicide bombings in our country. It is likely we will see a biological attacks here in our country. We have to think way outside our box. We are vulnerable in a number of areas."
Steven E. Koonin: There would Be Casualties in the Thousands
A final speaker of the day was Steven E. Koonin, provost and professor of theoretical physics at the California Institute of Technology and an adviser to the federal government on civilian biodefense. Koonin participated in a team that drafted a 1999 report for the Defense Advanced Research Projects Agency (DARPA), the central research and development organization for the Department of Defense, on possible scenarios for a bio attack in the United States.
"Most of our scenarios remain highly pertinent to the current threat level today," he said. Koonin recounted three of their disaster suppositions. The first envisioned the release of anthrax at 10 stations in the New York subway system. "Four million people use the system every day. At a 1% infection rate, we estimated that 40,000 people would be infected, and, if the attack were covert and antibiotics were not given promptly, most would die. We also expected that all 4 million would show up for screening."
The second scenario supposed that smallpox was released in an air duct of an airplane. "There would be no event, no responders. The passengers would disperse to their destinations and connecting flights, and 30% of those who were unvaccinated would die, along with the same percentage in new foci created where they went."
The third scenario imagined a ricin attack by a domestic militia on a government building in Minneapolis. "There is no known treatment. Victims die in 3 days after inhaling. The effects are very rapid. There would be casualties in the thousands."
Koonin offered a few points: "Often there is no 'event.' Threats may be frequent, but we will only know when one was real a considerable time afterward." Public health, he said, "is ill-prepared to detect or respond. Moreover, there is no surge capability. Most hospitals are already run at capacity."
The best defense, he suggested, was better intelligence. His 1999 report had advocated strengthening the public health information system to aid in prompt detection of a bio agent. Much of the data needed to recognize an emerging threat already exists, collected for some other purpose. "We need to do data mining in the existing health system. This means emergency room admissions, school absences, pharmacy sales, workplace absences. Look for anomalies."
Koonin suggested two improvements on existing systems. First, that there be units established that would conduct regular sampling in public places: of drinking fountains, public phones, public bathrooms. Second, that it was important to find ways to rapidly tell people that they are not infected. He proposed cheap disposable sampling kits including nasal swabs, urine, feces, and saliva testing, with whatever new technology is needed to offer quick presymptomatic diagnosis.
John Sullivan: The Terrorism Early Warning Group
On the second day of the conference those in the audience who were not familiar with this initiative had a chance to get a close look at the Terrorism Early Warning Group. A report on its structure and activities was made by Sergeant John P. Sullivan, TEW's Officer in Charge.
The TEW was founded in 1996 as an interdepartmental organization to improve preparedness against terror attacks in Los Angeles County. Today it has a full-time staff of 16, each made available to TEW by an existing agency. It has 70 part-time staff members. Its headquarters is in the Emergency Operations Bureau of the Los Angeles County Sheriffs Department.
Sullivan began by saying that there are aspects of the current wave of terrorism that confound the traditional response community. "The terrorism that most of us know came together in the 1970s, political terrorism, they used guns and bombs. The older groups could have had the capability for more serious attacks. The IRA could have used chemical attacks, but their aims were more limited and they chose not to. We will see bombs, like the suicide bombers, which are very difficult to detect. Large vehicle bombs. There is the example in Israel where a truck bomb was detonated at a natural gas facility. That is a low tech attempt that could have a large impact."
Today's no holds barred terrorists have different origins than most of those in the past. "States are rational actors and can be restrained even when they use these methods. Terrorism is changing. There is a variety of actors, not just separatists or state sponsored agents. Now there are religious terrorists, and political guerrillas linked to drug trafficking, and millenarian cults. The religious nexus may be the most dangerous because of mass validation of its goals. If you can say it is a sacramental act to go forth and kill, you can have people embrace a higher order of devastating acts. In postmodern terrorism there is a blurring of the distinction between crime and war. The military is not designed to operate within the United States. This is a truly profound conflict with people who want a total change in our society, and the fight is domestic as well as foreign. The distinction between domestic and foreign has less and less meaning."
Sullivan examined some of the organizational problems of responders to an event. "Knowing if it is intentional or not is problematic, especially in the early stages. There is a lack of personal protective equipment (PPE) and internalization of the doctrine for its use: we neither have it nor are we prepared to wear it for any prolonged period of time. Unless gas masks are a very good fit they are no use against aerosol biological agents."
There are issues of crowd control. "You can't quarantine Los Angeles County. What amount of force is appropriate to keep victims in one place? In an anthrax hoax event in the Van Nuys courthouse it cost $500,000--for the fire department, bulldozers, and police. It is problematic to shoot victims to keep them from leaving. It is more efficient to use prophylaxis. There is a federal quarantine authority, but it has generally been used on animals or on people entering the country."
In a real attack the forces of public order will have to be prepared to act with imperfect information. "We have 8,000 cops in my department and about 45,000 in L.A. County. In an event of this size this is a small force. In the fog of war it is hard to know what is happening. Commanders want perfect knowledge, but you can't wait to make decisions. It requires a high level of self-confidence to act with very limited information. 70% accuracy in intelligence is the gold standard, but you may have only 40% knowledge when you have to act."
Networking Law, Fire, Health, and Emergency Management
Sullivan described the TEW as a network that integrates local and federal agencies for the purpose of critical infrastructure protection. "Our adversary is networked. They are pulling together groups that are linked and can go through their decision process rapidly. We do not have a single hierarchy."
The TEW is working to develop localized as well as coordinated sources of information. "Most information comes from the bottom up, not from the government: this guy next door has funny smelling boxes and strange people coming in at all hours. We need to fuse surveillance by police with that by public health agencies, and on one computer screen, not fifteen. We need to fuse epidemiological intelligence with other intelligence streams. We have tried to do that in L.A. County with the TEW Group."
Public health officials are the first to declare the existence of an outbreak, but they need to have regular ties with the police and sheriff's department so they know who to call in law enforcement who have an emergency structure of action in place. "Decontamination needs to be provided quickly not only at the scene of initial contamination but at the hospitals where people will go."
"From its first meeting," Sullivan said, "TEW has been a cooperation of some 40 agencies: FBI, police, fire, public health. We watch for telltale signs of planned attacks and want to interdict them if possible. In Israel you couldn't predict the first suicide bombing, but you could then predict number 2 and 3."
TEW at this point is a Los Angeles County organization, but new groups are being organized in San Diego, Sacramento, and other cities. TEW has subgroups for water supply, for nuclear, for chemical, and for biological. They are starting a suicide bomber group and are bringing in Israeli police to provide advice. They are producing "playbooks" -- standardized response information folders -- on each of these eventualities that can be used to provide orientations to people and officials elsewhere.
Sullivan reported that TEW has its own field teams ready to deploy as well as hazmat technicians with video equipment to bring feed of an event back to headquarters for analysis. It collects intelligence from multiple sources, and does extensive training, exercises, and gaming. "We have done a live agent exercise at the Dugway Proving Grounds in Utah, and do exercises in Los Angeles with simulated agents. We have a civil battlelab for simulating national strategy for emerging threat issues, including riots and disturbances as well as terrorist attacks."
Dr. John Celentano: "He Asked to Be Patched Up and He Returned to the Pit"
What medical facilities does Los Angeles have and how adequate are they for a serious emergency. Dr. John Celentano, Disaster Medical Officer for the County of Los Angeles Emergency Medical Services Agency, tried to answer the question.
"There are 80 acute care hospitals in the County," he said, "that is, 911 receiving hospitals, where paramedics take patients. Five of those are owned and operated by the County. There are 40 or 50 more that are not 24 hour and do not have emergency services. We have 300 medical intensive care units (paramedics) in the County."
Looking beyond local resources there are 40 Disaster Medical Assistance Teams (DMATs) in the country. These are local teams, usually 35-person field-deployable volunteer medical personnel, under the control of the U.S. Public Health Service. DMATs are deployed to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours. "DMATs can be deployed anywhere in the country," Celentano said. "Ten were sent to Los Angeles County after the Northridge earthquake."
At a still higher level there are three federal National Medical Response Teams (NMRTs) trained to deal with weapons of mass destruction. One is in Los Angeles.
Medical Supply Caches
Dr. Celentano reported on a variety of caches of emergency pharmaceuticals. "There are 2 local caches, one owned by the federal government through the Veterans' Administration; the other is owned by the County. These are sufficient to handle 1,000 plus casualties of a terrorist incident. They can handle more for certain kinds of incident."
There are three still larger caches of pharmaceutical/medical supplies maintained by the federal government. "One is on the West Coast, one in the Midwest, one on the East Coast. These are very large. The West Coast has prophylaxis for 2-3 million people. It is huge. It occupies 5,000 square feet of floor space in a warehouse. It can be delivered by truck to a county unit in case of serious emergency."
Since 9-11 Los Angeles County has received funds from the Board of Supervisors for 5 more caches including decontamination and personal protective equipment gear. One cache is at each county hospital. "With these we can handle the first 24 hours before the federal pharmaceutical cache arrives. We also have about $30,000 for each of the acute care hospitals to develop decon capabilities and Personal Protective Equipment."
Public Health: Hospitals and Medical Services
The County Department of Health Services is broken into two pieces, hospitals and medical services.
"The problem with the hospitals in an emergency is saturation," Celentano said. "Today there is a 95% bed occupancy compared to 75% 12 years ago, as well as there being fewer beds. We will fill the beds that are available and try to maintain standards by using the military to evacuate to hospitals in other counties or states, rather than overcrowding by setting up folding cots or anything like that."
Training for Decontamination
"We expect to need to wear protective gear in a bio emergency," Celentano said. "This means learning how to wear it, and then learning how to decontaminate casualties before admitting them to the hospital to avoid shutting the hospital down. OSHA regulations and EPA regulations have standards for workplace safety gear, but they say nothing about gear for hospital personnel in emergency situations."
The first job has been to choose among several levels of available protection. "Level A is a moon suit, completely sealed with its own atmosphere. Hazmat people wear these, they are not usable for hospital personnel."
Level B decon suits are made of materials that provide heavy splash protection and include an air tank. The County has chosen Level C gear for hospital emergency decontamination units. This provides a face mask with a blower and HEPA filter, but not self-contained air, and a light-weight suit that offers full skin protection. "Hospital receiving areas--the parking lots--have this head to foot gear to receive victims," Dr. Celentano said. "There are at least 4-5 suits per hospital. We are buying this equipment."
In an emergency the hospital receivers will set up a decon corridor in the parking lots. "We need to take clothes off people, giving showers with detergent soap, scrub with a closed cell sponge (no brushes to avoid skin abrasion), use detergent to dissolve fat-soluble adherents. We will strip clothing off and hose people over inflatable yard pools, the small kind that children set up on summer days. We chose Level C gear rather than the heavier types because personnel have to be able to don and doff skin protection equipment and respiratory gear frequently and on short notice. Our Level C gear has a hood with a powered air sucker. This provides positive pressure in the hood to keep stuff out. The body of the gear is chemical protective suits, throwaway afterward."
Three Weeks at Ground Zero
John Celentano knows this stuff from life as well as training exercises. He and his wife served for three weeks at Ground Zero at the World Trade Center in New York beginning October 28. 20 of the 40 national DMAT teams rotated into the area for shifts. Dr. Celentano and his wife were there with the Los Angeles team.
"The cloud from the Trade Center could asphyxiate people who were caught in it," he recalled. "The fire burned for almost 12 weeks. The Los Angeles team got there 4 weeks after it started. Everybody had to wear a filter mask. One aftermath was the 'WTC cough.'"
The mission objective of the DMAT was to provide health care services to all personnel at the WTC site, and to prophylax 8,000 postal workers in the New York Post Office.
"We staffed two field clinics in tents at the edge of site. We treated them for minor injuries, or sent them to a local hospital. We had a 5-bed capacity of our 'Liberty Street Clinic.'"
One fire fighter came in with one finger almost torn off. "He asked to be patched up and he returned to the pit." The Los Angeles DMAT also did vehicle maintenance for electric vehicles, generators, and heaters. It provided hourly reports to federal and New York authorities.
"We treated about 40 patients a day, most for dust and fume irritation, cuts, scrapes, and eye injuries-- there were lots of those. We also sent postcards and letters to American children who wrote to "Ground Zero."
David Pegues: UCLA Hospital in a Potential Emergency
UCLA was represented at the conference not only by the conference chair, Dr. Peter Katona, but by the chair of the UCLA Hospital's Task Force on Bioterrorism Preparedness. Dr. David Pegues reported on how the hospital, one of the largest in the region, could respond in a serious emergency.
"Los Angeles health care is already stretched to the breaking point," he said. "Nevertheless, health care workers have gone out of their way to learn a lot in the last few months about responding to terrorist threats."
There are 34 million people in California, one eighth of the entire U.S. population. There are 480 hospitals in the state, half of which are nonprofit, a third of which are for profit, and the rest run by one or another level of the government.
"Bed availability is very low, almost a crisis." Even a comparatively small crisis can put a great strain on public health resources. "In October and November, 2001," Dr. Pegues said, "1,500 samples of suspicious substances were analyzed by public health labs nationally; 6,000 samples were triaged without having to undergo lab analysis. Public health labs were overwhelmed across the country. It is clear that a big influx of victims would overwhelm the UCLA health care system."
The hospital has been actively evaluating its capacity to triage, isolate, quarantine, and decontaminate and treat victims of a biologic attack. One question that hospital administrators have been looking at is how to increase staff in an emergency. "We are in a physician rich area, but nurse poor," Pegues said. The UCLA Hospital is part of a 19 clinic network of primary care providers. But while in an emergency the other 18 may send patients on to UCLA, the UCLA Hospital is the high end of its associated medical providers and has no one else to refer patients to.
The Task Force on Bioterrorism Preparedness has examined what kind of demands may be placed on its existing medical equipment. For example, inhalation anthrax and plague can induce respiratory failure. Normally patients who cannot breathe on their own are intubated and placed on a respirator. "There are 1,100 mechanical ventilators in L.A. County," Pegues said. UCLA has about 100 of them. "They cost $35,000 each for additional ones. We can't afford them and have no place to put them." What would they do, then? "Patients with these conditions need short-term intubation. We are buying $6 disposable air bags. This is the standard of care in many developing countries, where patients are kept alive by family members who hand operate the air bags. UCLA has bought 100 and will expand to 1,000. We will have staff members or volunteers squeeze the bags for the needed time."
In most cases decontamination won't be necessary for BT agents, Dr. Pegues said. "It is unlikely that victims will present immediately following an exposure event. An exception would be if the release was announced in advance."
The hospital plans if there is a need for decontamination to have the victims remove their clothing and put it in plastic bags, then shower with soap and water. Personnel would use disinfectant or bleach for environmental decontamination. Vaccination is appropriate for only a few bio agents--inhalation anthrax and smallpox. Others use antibiotics.
What Do You Do with Highly Contagious Patients?
One of the most difficult problems is treating patients with a disease that is contagious through the respiratory tract. Inhalation anthrax, tularemia, and botulisms are not contagious. The big problems are with the bugs that are: smallpox, plague, and HFV (viral hemorrhagic fevers such as Ebola).
"UCLA Hospital has 10 rooms for isolation of respiratory communicable disease," Pegues said. These special rooms have an air system that can generate negative pressure to precipitate exhaled particulates. "These 10 rooms are on 8 floors. There is no isolation ward for multiple patients. We can only isolate 10 individuals, and would still have to vaccinate several thousand workers because of routine cleaning and handling. We need special biocontainment facilities for disposal of materials that have been in contact with smallpox." Dr. Pegues suggested that his hospital "might put smallpox patients in tents outside, as even one would be very difficult to care for inside and ten is the absolute limit."
There are 550 beds at the UCLA medical center and an additional 220 beds at affiliated Santa Monica Hospital. "We already have outstripped capacity. We have on occasion had to set up extra beds in halls," Pegues said.
Dr. Pegues raised other concerns for which there are not yet answers: "Where does the water go after decontamination? Who will perform autopsies? The L.A coroner says they will not participate in autopsies of persons who have died of contagious diseases. How will we maintain security or isolation of contagious patients when there are 100 entrances to CHS [UCLA's Center for Health Sciences]?"
The UCLA Hospital is conducting training in using personal protective equipment and the use of decontamination systems. There is special training for high risk employees: mail, security, and emergency management personnel.
In reply to a question, Dr. Pegues affirmed that it is UCLA policy to provide vaccinations where this is the indicated treatment for families of all UCLA employees if they are able to get to the campus in an emergency situation.
Alvin Toffler: We Need Smaller, More Diverse Institutions to Survive
The sobering conference closed with a videotaped interview with futurist Alvin Toffler, author of the influential book Future Shock, by conference organizer Dr. Peter Katona.
Attempts to predict the future shape of things have generally been notoriously off the mark, but Toffler remains game to try. He began by suggesting that we are seeing "an emerging third wave civilization colliding with the old first and second wave civilizations." He explained that the first wave was preindustrial agrarian. "Fighting was constant and short, face to face, fighters had to go back to the soil." The second wave was our own familiar industrial society, where "the machine age gave us the machine gun."
Toffler defined the new third wave as knowledge based. He predicted a lengthy period of violence in this transition. What is different about the third wave formation, in Toffler's view, is the centrality of small, mobile, international groups in place of fixed states and their ponderous bureaucracies. "The second wave type of conflict was based on the massed forces of state to state warfare aimed at mass destruction. In the third wave we will see pinpoint warfare, small teams, small groups, a lot of different types of conflict."
Toffler suggested that the rapid electronic communication and high speed travel that permit small groups to strike suddenly in distant parts of the globe are symptoms of a new form of decentralized organization that is the natural type for "third wave" civilizations and should be deliberately adopted by our domestic institutions.
"Max Weber," he said, "saw bureaucracy as a very efficient way to organize people. It was, as long as things were linear, but their response time is too slow. Their efforts to continually enlarge the organization are misplaced. They cannot cope with these disparate on-again off-again threats. The obverse of this is smaller, more diverse. Corporations set up cost centers, subunits that have decision-making responsibility.
"There have been many cases like the Phoenix FBI agents of predictions ignored. The hierarchy has grown so tall with so many gatekeepers who refuse to pass information up the line as needed that the system is choking on its own internal complexity. I think we'll make it but we'll make it a lot better if we are prepared to restructure our institutions. Particularly our intelligence agencies, but the same is true of our political systems, our hospitals, our police forces. These systems worked well as long as we were an industrial society and economy. We are no longer that, we are something new that the world has not seen before."
For further information, contact Dr. Peter Katona: (310) 440-0767