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 Nation’s 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 world’s 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 attention.


Public Health Leadership

As the Nation’s disease prevention and control agency, it is CDC’s 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 CDC’s 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 CDC’s plan for combating today’s 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 terrorism.


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 nation’s 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 unexplained.

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 attack.

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 sounded.

Thank you very much for your attention. I will be happy to answer any questions you may have.