SCOTT R. LILLIBRIDGE, M.D.
NATIONAL CENTER FOR INFECTIOUS DISEASES
CENTERS FOR DISEASE CONTROL AND PREVENTION
DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS,
AND INTERNATIONAL RELATIONS
COMMITTEE ON GOVERNMENT REFORM
U.S. HOUSE OF REPRESENTATIVES
September 22, 1999
I am Scott Lillibridge, from the National Center for Infectious Disease, Centers for
Disease Control and Prevention (CDC). Thank you for the invitation to discuss enhancing
national public health capacity to respond to bioterrorism. I will describe the actions
that CDC is taking as part of the DHHS Plan for Health and Medical Preparedness, to
increase public health preparedness, enhance laboratory services, and expand disease
surveillance to improve our Nations response to this important issue.
Vulnerability of the Civilian Population
In the past, an attack with a biological agent was considered very unlikely; however,
now it seems entirely possible. Many experts believe that it is no longer a matter of
"if" but "when" such an attack will occur. They point to the
accessibility of information on how to prepare biologic weapons and to activities by
groups such as Aum Shinrykyo, which, in addition to releasing nerve gas in Tokyo's subway,
experimented with botulism and anthrax.
An attack with an agent such as smallpox could pose threats to large populations
because of the potential for person-to-person transmission, enabling spread to other
cities and states. Such a disease would quickly culminate in a nationwide emergency.
International involvement would be sure to follow. The control of such an epidemic
requires a coordinated effort of the entire public health community.
CDC has significant experience in responding to explosion and chemical related
terrorism events and emergencies. Chemicals are plentiful and many of the worlds
worst disasters have involved the release of industrial compounds. However, special risks
are attendant with biological terrorism. For example, when people are exposed to a
pathogen like plague or smallpox, they may not know that they have been exposed, and they
may not feel sick for some time. This delay between exposure and onset of illness, or the
incubation period, is characteristic of infectious diseases. The incubation period may
range from several hours to a few weeks, depending on the exposure and pathogen. During
this period, patients may continue to travel, visit family and friends, or attend public
meetings at a time when they may be highly contagious. Consequently, a disease may be well
established in the population before the first cases appear ill and require medical
Public Health Leadership
As the Nations disease prevention and control agency, it is CDCs
responsibility to provide national leadership in the public health and medical communities
in a concerted effort to detect, diagnose, respond to, and prevent illnesses, including
those that occur as a result of bioterrorism or any other deliberate attempt to harm our
citizens. This task is an integral part of CDCs overall mission to monitor the
health of the U.S. population. This mission unfolds every day in various forms, such as
outbreak response, concern for worker safety, and critical work in global health.
In 1998, CDC issued Preventing Emerging Infectious Diseases: A Strategy for the 21st
Century, which describes CDCs plan for combating todays emerging diseases
and preventing those of tomorrow. It focuses on four goals, each of which has direct
relevance to preparedness for bioterrorism: disease surveillance and outbreak response;
applied research to develop diagnostic tests, drugs, vaccines, and surveillance tools;
infrastructure and training; and disease prevention and control. This plan emphasizes the
need to be prepared for the unexpected -- whether it be a naturally occurring influenza
pandemic or the deliberate release of anthrax by a terrorist. Copies of this CDC plan have
been provided to the Subcommittee previously.
CDC is continuing to build on these efforts. An example of this is the strategic plan
that CDC is developing with its partners to define the specific activities that will need
to be conducted over the next several years to ensure that the country is prepared to
respond to any threat or actual act of bioterrorism.
Strengthening Public Health Readiness to Address Bioterrorism
Unlike an explosion or a tornado, in a biological event, it is unlikely that a single
localized place or cluster of people will be identified for traditional first responder
activity. The initial responders to such a biological attack will most likely include
county and city health officers, hospital staff, members of the outpatient medical
community, and a wide range of response personnel in the public health system. Thus,
protection against terrorism requires investment in the public health system. This point
is underscored in a report, commissioned by the Department of Health and Human Services
Office of Emergency Preparedness (OEP) and recently released by the Institute of Medicine
and the National Research Council, Chemical and Biological Terrorism: Research and
Development to Improve Civilian Medical Response, which stresses the need for
long-term public health improvements in surveillance and epidemiology infrastructure.
Increased vigilance and preparedness for unexplained illnesses are an essential part of
the public health effort to protect the American people against bioterrorism. Toward this
end, CDC, working in collaboration with State and local health departments, many other
public health partners, and other Federal agencies, has begun the effort to upgrade public
health capabilities locally and nationally to respond to biological and chemical
Areas For Public Health Action.
As part of CDC's overall bioterrorism plan, in September 1999 CDC is providing
approximately $40,000,000 through cooperative agreements with State and large metropolitan
health departments to enhance preparedness and response to a terrorist attack involving a
biological or chemical agent. This program, along with other extramural and intramural
strategies, focuses on strengthening components of the public health infrastructure to
improve the national capacity to address biological and chemical terrorism:
Detection of unusual events - Public Health Surveillance. Because the
initial detection of bioterrorism will most likely occur at the local level after a period
when patients have incubated the disease, it is essential to educate and train members of
the medical community -- both public and private -- who may be the first to examine and
treat the victims. State and Federal epidemiologists must be trained to consider unusual
or rare threat agents when a suspicious outbreak occurs and must be prepared to address
questions related to their transmission, treatment, and prevention. It is also necessary
to upgrade the surveillance systems of State and local health departments, which will be
relied upon to identify unusual patterns of disease occurrence and to locate any
additional cases of illness as the disease spreads throughout the community and beyond.
CDC will promote the development of new disease surveillance networks which will better
link critical health care facilities and components of the emergency medical system to
public health agencies. CDC will also pilot and evaluate new surveillance systems to
improve the nations ability to detect low incidences of unexplained illnesses or
track critical health resource utilization.
Investigation and containment of outbreaks. In the response to an
outbreak caused by an act of bioterrorism, the most likely scenario will be that CDC -- as
well as DOD and security agencies -- will be alerted to the event only after State or
local health officers, medical practitioners, or other workers in the health sector have
identified and validated a cluster of cases that are highly unusual and potentially
For this reason, it is imperative that State and local health departments have
sufficient resources to conduct disease outbreak investigations. Through the cooperative
agreements and other mechanisms, CDC will provide State and large metropolitan health
departments with tools, training, and financial resources for local outbreak
investigations, and help develop rapid public health response capacity at the State and
local levels. Additionally, in the event of a suspected or an actual attack, CDC will
assist in identifying threat agents and their modes of transmission, in instituting
control measures, and in providing consultation on medical management.
To ensure the ready availability of drugs, vaccines, prophylactic medicines, chemical
antidotes, medical supplies, and equipment that might be needed in a medical response to a
biological or chemical terrorist incident, CDC is working to establish a National
Pharmaceutical Stockpile, to be utilized when necessary and appropriate to contain the
spread of disease in the outbreak.
Laboratory diagnosis. In the event of a biological or chemical terrorist
attack, rapid diagnosis will be critical, so that prevention and treatment measures can be
implemented quickly. In fiscal year 1999, CDC is providing cooperative agreement
assistance to State and major metropolitan health departments to improve capacity to
diagnose biologic threat agents. In addition, CDC is making additional awards to enable
selected State health laboratories to function as reference facilities for the
identification of chemical threats. CDC will also evaluate existing rapid assay technology
for identifying critical biological agents and develop rapid toxic screening that can
assess whether humans have been exposed up to 150 different chemical agents. CDC will
develop guidelines and quality assurance standards for the safe and secure collection,
storage, transport, and processing of clinical samples.
Finally, CDC is working with public health partners such the Association of Public
Health Laboratories to implement a network of laboratories which will be used to provide
the most immediate diagnosis of biological and chemical agents in the event of a suspected
terrorist attack. This network will ultimately include hospital laboratories, commercial
reference laboratories, State and local health laboratories, and highly specialized
Federal facilities. It will not only enhance public health capacity to address
bioterrorism, but also contribute to the overall public health capacity to address
naturally occurring infectious diseases.
Coordination and Communication. In order to assure the most effective
response to a bioterrorism event, CDC works closely with Department of Justice, including
the FBI and the National Domestic Preparedness Office. In addition, there is ongoing
coordination with OEP, the Food and Drug Administration, the National Institutes of Health
(NIH), the Department of Defense (DOD), the Federal Emergency Management Agency, and many
other partners in this process.
Internationally, global health security will be enhanced as CDC, in collaboration with
the World Health Organization, the Department of State, and various ministries of health,
responds to reports of unexplained illnesses, unusual pathogens, and other outbreaks that
might threaten the lives of U.S. citizens.
Strengthening communication among clinicians, emergency rooms, infection control
practitioners, hospitals, pharmaceutical companies, and public health personnel is of
paramount importance. The Health Alert Network component of the CDC state and local
preparedness initiative will provide a robust national electronic platform for
communications, information access, delivery of targeted health alerts, and distance
learning for use by public health officials working to detect and response to bioterrorism
and other unexplained health threats.
In the event of an intentional release of a chemical or biological agent, rapid and
secure communications will be especially crucial to ensure a prompt and coordinated public
health and medical response. Further, in the event of such an attack, we will need to
ensure that the public is provided with accurate and timely information. An act of
terrorism is likely to cause widespread panic, and on-going communication of accurate and
up-to-date information will help calm public fears and limit collateral effects of the
Preparedness and Planning.
CDC is working to ensure that all levels of the public health community --
Federal, State, and local -- are prepared to work in coordination with the medical and
emergency response communities to address the public health consequences of biological and
chemical terrorism. CDC will assist in developing local public health bioterrorism
preparedness plans that are well integrated into existing emergency response plans at the
local, State, and Federal level. CDC is creating diagnostic and epidemiological
performance standards for State and local health departments and will help States conduct
drills, exercises, and laboratory readiness for bioterrorism.
CDC is working to assure that first responders are better prepared against biological
and chemical exposures. CDC has significant experience in the areas of detector
technology, personal protective equipment, including protective clothing and respirators,
and the necessary training to work in hazardous environments. The challenge before us is
to expand these capacities to better protect first responders from perils of biological
and chemical terrorism.
In addition, CDC, NIH, DOD, and other agencies are supporting and encouraging research
to address scientific issues related to bioterrorism preparedness. The overall strategy
for such research is coordinated through the Research and Development subgroup of the
Interagency Weapons of Mass Destruction Preparedness Group. For example, for several of
the agents identified as possible threats for bioterrorism, we need to create rapid,
simple, low-cost diagnostic kits that can be used in the field to test large numbers of
people exposed to a biological or chemical agent within a short time frame. In some cases,
new or enhanced vaccines, antitoxins, or innovative drug treatments are also required.
Moreover, we need to learn more about the pathogenesis and epidemiology of these rare
diseases. We also have only limited knowledge about how artificial methods of dispersion
may affect the infection rate or the harmful nature of these agents.
Disease experts at CDC are considering various strategies for preventing the spread of
disease during and after bioterrorist attacks. Strategies under evaluation include
creating protocols for immunizing at-risk populations, isolating large numbers of exposed
individuals, and reducing occupational exposures; assessing methods of safeguarding food
and water from deliberate contamination; and exploring ways to improve linkages between
animal and human disease surveillance networks since threat agents that affect both humans
and animals may first be detected in animals.
CDC is enhancing its ongoing efforts to foster the safe design and operation of
Biosafety Level 3 and 4 laboratories, which are required for handling highly dangerous
pathogens. In addition, CDC is helping to limit access to potential terrorist agents by
administering the Select Agent Rule, Additional Requirements for Facilities
Transferring or Receiving Select Agents (42 CFR Section 72.6), which regulates
shipments of certain hazardous biological organisms and toxins.
In conclusion, the best public health method to protect, respond to, and defend the
health of our citizens against the adverse health effects of terrorism is the development,
organization, and enhancement of life-saving public health tools. Expanded public health
laboratory capacity, increased surveillance and outbreak response capacity, and health
communications and training, with focused public health preparedness resources at the
state and local level are necessary to ensure we will be able to respond when the alarm is
Thank you very much for your attention. I will be happy to answer any questions you may