Early Warning: The Front Line of Biodefense

by Patrick Rose

Even before the post-9/11 “anthrax letter” attacks against the United States, some experts believed that a bioterrorism attack was not merely possible but highly probable. Since then, significant improvements in U.S. recognition and mitigation strategies have emerged, several different attack scenarios have been written and analyzed, and thousands of planning documents have been drafted to prepare the nation for another potential biowarfare attack. One result of these efforts is that the nation’s biological threat-reduction and medical countermeasures capabilities have improved significantly during the past decade.

Whether the resulting technological advances and/or improved intelligence-gathering capabilities have dissuaded terrorists from launching another biological attack against the United States, though, is still not clear. Nonetheless, significant progress has been made at the federal and state levels of biodefense, thanks in large part to several initiatives establishing new and more effective response standards for potential biological disaster situations. However, the 2009 H1N1 influenza pandemic severely tested the nation’s efforts, revealed serious gaps in the response system, andentified significant areas where additional planning and preparedness measures still must be developed.

Moreover, although several federal agencies and organizations – primarily the National Academy of Sciences’ Institute of Medicine of the National Academies, the U.S. Department of Health & Human Services (HHS), the Food and Drug Administration (FDA), and the U.S. Centers for Disease Control and Prevention (CDC) – play key roles in supporting the capabilities needed to detect and respond to a bioterrorist event, past and pending budget cuts may impair the current biosecurity countermeasure efforts made by these and other agencies.

Early Detection vs. the Surprise Element Improving the technologies needed for predicting, detecting, andentifying a biological attack is only one component of the nation’s overall biodefense process. During the response phase of a biological attack, doctors, nurses, and other healthcare providers must not only have available to them the effective medical countermeasures systems and equipment needed, but also should be properly trained to mitigate the spread of an infection – and thereby decrease the morbidity and mortality rates. It is particularly important during periods of scarce resources, though, that investments also be made to raise awareness among healthcare workers, who individually and collectively must be well versed in recognizing the signs of possible contagion among arriving patients.

Although most current bioterrorism efforts focus on anthrax and other toxic agents, the ability to recognize the early visible signs of these agents is of critical importance to keep the “surprise element” from overwhelming the nation’s disease-surveillance systems. However, addressing the numerous challenges involved in incorporating preparedness training into the nation’s healthcare-delivery system would be a daunting task, primarily because of the time, personnel, and funding required for such training. Nonetheless, when an ill person seeks assistance from a medical professional, that healthcare provider is in a strategic position to recognize the onset of what might well be a developing and more widespread problem. He or she therefore must fully understand and be able to take the proper steps needed to effectively address the serious risks involved.

At present, although most current medical practice involves the one-on-one patient care provided during a typical day, little if any training is required for recognizing unusual symptoms, implementing the treatment and isolation protocols required, and preparing for the crisis standards of care mandated should a medical surge or pandemic situation arise. After seeing 20 or more patients in a given day, a physician or nurse may not readily remember the specific symptoms encountered earlier in the day, or over the past few days, thus missing an organophosphate poisoning, for example, or a case of toxic gas inhalation.

Compounding this problem is the fact that specific training in disaster management for students in most U.S. medical and nursing programs is, for most practical purposes, nonexistent. Numerous task forces have been formed, and their recommendations have been published – and some training programs developed – in the aftermath of several catastrophic events that have occurred over the past decade. But those resources are not necessarily being well used, or even implemented, throughout the nation’s entire spectrum of healthcare agencies and organizations.

The Training Gap & Some Possible Solutions To close this training gap, several forward-looking suggestions for rigorously implementing existing programs have been made, including the following:

  • Using initiatives similar to the crisis-management training programs developed and used by the American Red Cross to train its volunteer healthcare workers and raise awareness in the use of crisis standards of care;
  • Integrating the rotation of medical residents into existing programs that will expose them to public health and emergency preparedness education/experience; and
  • Putting greater emphasis on early training and awareness programs to help healthcare workers understand their responsibilities andentify symptoms that might be out of the norm.

Greater investments inentifying early warning signs at the healthcare level would greatly mitigate the consequences of, and possibly even help deter, future bioterrorist attacks. Raising awareness also can reduce the “terror” factor that undermines the public’s trust in the government’s ability to protect the American people. When everyday citizens do not know how to react during an attack, the first place they usually turn to is the nearest healthcare facility. For that reason alone, and because healthcare workers are usually among the first to see those victimized by a biological attack, it obviously would be advantageous for them to be able, among other things: (a) toentify that an attack may have occurred; (b) to initiate the appropriate response mechanism required; and (c) to notify the appropriate government agencies.

Subsequently, those same citizens can develop greater trust and confidence in the care and advice received from healthcare workers, which in turn will help abate public fears related to the attack itself. According to a 2007 report from the Center for New American Security, “Many will ignore federal inputs if they are inconsistent with comments from state, local, and private officials, or from personally trusted individuals such as their doctors, their ministers, and their friends.” With the efficacy of existing detection systems such as Biowatch – an “early warning” program managed by the Department of Homeland Security Office of Health Affairs – the next logical step would be to both augment and expand current syndromic surveillance systems and, at the same time, develop and train a new generation of healthcare workers with the aptitude to detect and respond to a bioterrorism attack.


For additional information on: The Center for New American Security, 27 June 2007, “After an Attack: Preparing Citizens for Bioterrorism,” visit

The U.S. Centers for Disease Control and Prevention (CDC), visit

The U.S. Food and Drug Administration (FDA), visit

The National Academy of Sciences’ Institute of Medicine, visit

The U.S. Department of Health & Human Services (HHS), visit

_________________________ Patrick Rose is a Senior Policy Analyst with the Center for Health & Homeland Security and a Fellow in the 2012 of Emerging Leaders in Biosecurity Initiative at the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC). At the Center for Health & Homeland Security, he is part of the Exercise and Training Division working on the Homeland Security Exercise and Evaluation Program with various state and federal agencies. He also provides subject matter expertise to international delegations through the Senior Crisis Management Training, working in cooperation with the U.S. State Department Office of Anti-Terrorism Assistance. He has a Ph.D. in Microbiology and Immunology and is Adjunct Assistant Professor at the University of Maryland School of Medicine, Department of Epidemiology and Public Health.

Additional contributions to this article were made by: Moulaye Haidara of the University of Maryland School of Medicine, a fourth-year medical student at the University of Maryland School of Medicine, who has been actively engaged in international public health initiatives on the epidemiology of infectious diseases such as malaria and tuberculosis. Haldara also has been heavily involved in matters related to the building of competent public health systems in West Africa, with special focus on unprepared and still developing healthcare systems. He plans, after graduation, to continue his medical training with a residency in Ophthalmology.