Biosurveillance: Detecting the Next 'Silent' Attack

Another biological event is all but inevitable. However, when that event will occur and whether it will be an intentional terrorist attack or a natural pandemic remains uncertain. Regardless, biological attacks are almost always “silent” attacks that escape the senses of their victims with no loud explosions, large clouds, or noxious chemical fumes to provide clues that an attack has occurred or is underway. They usually begin as quiet events during which a deadly pathogen is inhaled, ingested, or absorbed through the skin unbeknownst to the victim until symptoms later manifest themselves.

If the deadly biological agent is anthrax, the first few cases may be mistakenly diagnosed as a strain of influenza, because initial symptoms of the two diseases closely resemble each other. Actual declaration of a biological event would follow later as more information is gathered from other victims with similar symptoms and combined with additional information such as intelligence warnings or sentinel surveillance data. According to a statement by President Obama in a foreword to the 2009 National Security Council’s Strategy for Countering Biological Threats, the consequences of such an attack could be catastrophic – hundreds of thousands of lives at risk, up to $1 trillion in economic damage, and a major threat to U.S. national security – and public fear would ensue.

The pressing question, therefore, is whether local, state, national, or global communities are equipped and able to detect, diagnose, and respond to such an event. The 2001 anthrax attacks against the United States, shortly after the 9/11 terrorist attacks, caught the nation off guard and public health resources were quickly overwhelmed. Following those attacks, biological defense became a higher priority for government agencies both in the United States and overseas.

Numerous presidential directives were issued in which multiple agencies such as the Department of Homeland Security (DHS), the Department of Health and Human Services (HHS), and the Department of Defense (DoD) were charged separately with defending the U.S. homeland from bioterrorism threats. Among the notable programs that emerged were Biowatch, the Laboratory Response Network (LRN), and JBAIDS (Joint Biological Agent Identification and Diagnostics System). Each of these programs focuses on defending against an intentional bioterrorism attack, whether it is state-sponsored or from a rogue terrorist organization such as al-Qaeda.

“The Threat Still Exists” – Mainstream & More Accessible

Since 2001, there have been no known successful biological terrorist attacks, but the threat still exists and may be even stronger, primarily because the technological capability to produce bioweapons has become more mainstream and is more accessible. There have been some notable bioweapon attempts – including the ricin self-poisoning incident in 2008 by a home-grown terrorist in a Las Vegas motel room. A better known example, though, is the 1993 attack in Japan in which the Aum Shinrikyo cult released aerosolized, nonpathogenic anthrax in the Tokyo subway system. In addition, evidence uncovered since 2001 demonstrates that al-Qaeda was already planning to weaponize anthrax for another mass-casualty attack on America.

Although there have been no successful biological terrorist attacks in the past decade, there have been two significant naturally occurring biological “attacks.” The Severe Acute Respiratory Syndrome (SARS) outbreak in early 2003 killed over 900 people worldwide; and the H1N1 Flu Pandemic in 2009 was responsible for an estimated 17,000 deaths around the globe. Recognizing that natural outbreaks of disease are just as threatening, and just as damaging, as a deliberate attack would be, U.S. policy has evolved to include natural disease outbreaks alongside deliberate bioterrorist attacks, especially since the same biodefense resources currently in place – or being developed – can also be used to respond to natural outbreaks. Since the release, in 2009, of Presidential Policy Directive 2 and the National Strategy for Countering Biological Threats, the focus has evolved from a biodefense-centered to a more encompassing biosurveillance strategy.

Homeland Security Presidential Directive-21 (HSPD-21), issued in 2007, established a national strategy for Public Health and Medical Preparedness that defines biosurveillance as “the process of active data gathering with appropriate analysis and interpretation of biosphere data that might relate to disease activity and threats to human or animal health – whether infectious, toxic, metabolic, or otherwise, and regardless of intentional or natural origin – in order to achieve early warning of health threats, early detection of health events, and overall situational awareness of disease activity.”

Biosurveillance overlaps multiple jurisdictions – e.g., defense, human health, animal and plant health – and requires different departments of government to work together to generate actionable intelligence. After all, events that affect animals and plants not only threaten the nation’s food supply but also may provide warning of a pending human attack.

Implementing the Strategies, Bridging the Gaps

Today, as the several strategies mentioned above are still being implemented, more joint training exercises are being conducted that involve multiple government agencies – and several gaps are being bridged between the medical and nonmedical communities. For example, in 2009, the Department of Defense developed a point-of-care assay that was cleared by the FDA (Food and Drug Administration) for the detection of Coxiella Burnetti and flu assays for its JBAIDS platform. Army personnel are now able to use JBAIDS for more than simply a capability to detect a bioterrorist attack using environmental samples. These FDA-cleared assays are also being used to test soldier health for seasonal flu and Coxiella. This strategy will carry forward to DoD’s forthcoming Next Generation Diagnostics System (NGDS), in which desired requirements call for an FDA-cleared system that minimizes operator time – and in which soldiers with limited laboratory training can use the same equipment both to detect an intentional biological attack in an environmental sample and/or to diagnose diseases in Army personnel using a patient sample.

Future biosurveillance systems need to be agile, flexible, and scalable with the system designed to be used by nonscientific personnel such as Army personnel, first responders, and public health technicians as well as hospital laboratory personnel. However, designing a single instrument with these attributes will be a challenging and expensive task. The solution most likely will be supported through a “family of systems” approach, with a comprehensive detection strategy – instruments that are hand-held for field use, instruments that are ruggedized and flexible for mobile labs, and a confirmatory analysis component designed for a fixed lab setting – because a biological attack can come from anywhere.

Capability improvements will continue as long as biosurveillance remains in the forefront and the nation is not lulled into complacency. After all, effective biosurveillance is critical for detecting and diagnosing the next biological attack before it occurs in order to minimize its impact.