Volume 27-04
15 February 2001

[Table of Contents]

BIOTERRORISM AND PUBLIC HEALTH

Bioterrorism can be described as the use of a microorganism with the deliberate intent of causing infection in order to achieve certain goals. With increased availability of biologic agents and the technical information required to produce them, bioterrorism may become the weapon of choice in the future. The implications for public health in the event of infection of even small numbers of people are considerable and carry different responsibilities for municipal, provincial, and federal government departments.

The Laboratory Centre for Disease Control (now part of the Public Health Agency of Canada), Health Canada, hosted an invitational meeting - Bioterrorism and Public Health - on 27 - 28 March, 2000, in Ottawa, to discuss the public health-related scientific and planning issues surrounding bioterrorism and the roles and responsibilities of each level of organization and government.

This report is a compressed summary of the discussion during the meeting and reflects the situation at that time. The text does not necessarily reflect the official view of Health Canada.

The Threat

An expert panel convened by the US Centers for Disease Control and Prevention (CDC) in 1999 considered that the six microorganisms posing the greatest public health threat were Variola major (smallpox), Bacillus anthracis (anthrax), Yersinia pestis (plague), botulinum toxin (botulism), Francisella tularensis (tularemia), and filovirus/arenavirus (hemorrhagic fevers).

Terrorist acts that make use of biologic agents differ in a number of ways from those involving chemicals. Microorganisms may be released silently and without immediate effects. The spread of disease cannot be controlled until there is awareness of the signs of infection and identification of the agent. If the organism is easily spread from person to person, as in the case of smallpox, the number of casualties could run into the tens of thousands. The probability that such an attack will take place in Canada has been deemed to be low, but if there is an attack the consequences could be calamitous. For example, projections based on a CDC model using Canadian data predicts, that, under certain conditions, an anthrax attack on 100,000 Canadians would result in 50,000 anthrax cases, 32,875 deaths, 332,500 hospitalization days, and a cost of $ 6.5 billion.

Without preparation for bioterrorist activities at all levels of government, emergency services will be uncoordinated and inefficient, communication will be fragmented, and panic among the public will be very probable. One of the more important aspects of the response to terrorist acts involving deadly microorganisms is the speed with which the response plan goes into effect. Delay results in greater numbers of infected people.

There is substantial synergy between preparations for an outbreak of infectious disease that is not due to bioterrorism (e.g. pandemic influenza) and preparations for a bioterrorist event.

The Federal Responsibility

The Government of Canada has primary responsibility for the criminal aspects of terrorist incidents, and the provincial governments are responsible for consequence management in the aftermath. There are currently two mechanisms in place for a federal response to bioterrorism. The National Counterterrorism Plan (NCTP) provides coordinated policy and operational options principally from an incident management perspective. The National Counterterrorism Consequence Management Arrangements (NCTCMA) ensure an organized federal response to the consequences of a bioterrorist attack if the incident is beyond the capabilities of the provincial/territorial authorities. Health Canada has specific roles in both the NCTP and the NCTCMA.

Municipal Plans

At the municipal level, authorities in Toronto, Montreal, Ottawa-Carleton, Windsor, and Vancouver (municipalities that were represented at the meeting) have had to deal with potential biologic or chemical threats or to tighten security measures in preparation for international meetings in the region. Emergency response plans are being developed and are at various stages of progress.

Components of an Effective Response in Canada

Protocols for suspicious packages: The appropriate protocol to go into effect initially in the event of a package (e.g. box, letter) that might contain bioterrorist material depends upon the nature of the incident (e.g. whether a note has been left or a telephone call made, whether the package is opened or unopened, whether the contents are visible, whether they are leaking, whether people have been exposed, whether an explosive risk exists). A particular challenge will be to determine whether an unopened, non-leaking package contains a chemical or a biologic agent, since there is no facility or laboratory in Canada equipped to identify both a "war chemical" (e.g. sarin) and a biosafety level (BSL) 4 biologic agent.

Command and control: Within the command and control structure, critical decisions are made, resources allocated, notifications carried out, and information provided that will be used for public communication. The local command structure will be the prime source of action initially, but this is embedded within the regional, provincial/territorial, and federal structures that are in place to deal with emergencies. As well, multiple response agencies at the scene of the incident - public safety, criminal investigation, public health, HAZMAT teams - must be adequately managed.

Training/awareness: There is a need for training/awareness regarding bioterrorism recognition and response at a number of levels (e.g. first responders, emergency room physicians, infectious disease specialists). There are various options available for awareness enhancement and training.

Surveillance: The first case of disease may be suspected and reported by an observant health care provider. However, early detection of a clustering of symptoms or disease in a population may require a continuous, real-time surveillance system of appropriate geographic locations (e.g. in hospital emergency departments, among physicians in the community, in pharmacies, and in laboratories). Sentinel surveillance would be useful in detecting clusters of cases rather than the initial infection. A consultation network needs to be in place so that if a physician, public health official, or laboratory worker is the first to suspect an unusual case of disease, then he or she knows whom to contact locally, and if necessary further consultation is available along the chain.

Laboratory detection: Whether BSL 3 facilities are currently equipped for characterizing rare biologic agents is debatable. Issues with respect to BSL 3 capability include whether the laboratory has Standard Operating Procedures (SOPs) in place that are specific to these agents; trained staff who can recognize (microbiologically) the agents; advanced identification methods; expertise in virology; ability to do toxin assays in-house or to perform molecular characterization; staff trained in legal "chain of custody" issues; and enhanced security for particular organisms. There are few reagents available commercially for rapid detection of the agents that might be used in a bioterrorist attack.

Prophylaxis: Prophylaxis considerations in the event of a bioterrorist incident include assessment of the population exposed to the microorganism and those most likely to be affected; primary and secondary spread; whom to vaccinate or provide with antibiotics; storage and distribution of equipment/supplies; availability of vaccines or antibiotics; possible use of unlicensed products (through the Special Access Program); availability of trained personnel; record-keeping of vaccines or antibiotics dispensed; and informed consent.

Preventing secondary infection: The isolation, decontamination, and quarantine precautions necessary to prevent secondary infection will depend upon the agent involved. National guidelines could be developed for subsequent modification by hospital infection control committees so that individual hospitals would have an established policy on the necessary procedures to be put in place.

Stockpiling: The National Emergency Services Stockpile (NESS) is funded and held by Health Canada and overseen by the Emergency Services Division. It includes 165 "field hospitals" of 200 beds each, some of which are stored across the country, to be deployed as requested by the provinces. All drugs are held in Ottawa or are under vendor-managed inventory. There are no vaccines. The NESS was not specifically designed to respond to a bioterrorist event. Decisions need to be made as to whether to expand the Canadian stockpile and, if so, what to include in it and where to position it.

Next Steps

While it is important to garner political attention for bioterrorism preparedness, there is a need to begin the preparation process now rather than wait for several years before bioterrorism is recognized politically as a possibility and funding is given.

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