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A Review of federal Bioterrorism Preparedness Programs from a Public Health Perspective.
Subcommittee on Oversight and Investigations
Dr. Kathryn Brinsfield
Mr.
Chairman, members of the subcommittee, my name is Kathryn Brinsfield, MD, MPH. I am the Director of Research, Training, and Quality
Improvement for Boston Emergency Medical Services, a practicing Emergency
Medicine physician, and the Deputy Medical Commander of the National Disaster
Medical System's International Medical and Surgical Response Team- East.
I would like to thank you for inviting me here to speak on this topic. On
March 20, 1995, Sarin was released in the Tokyo Subway system.
The incident started at 7:55 am; the last patient was treated before
noon. On
September 11, 2001, the terrorist events at the World Trade Center killed over
6,000 and injured fewer than 2,000. The
last live victim was rescued within thirty-six hours. All
disasters are local. Terrorist
disaster response is a local response. Federal
programs have helped prepare localities for dealing with these disasters but
there is still more to do.
From
floods to fires to bombings, the initial minutes and hours of a disaster largely
determine the number of victims that will survive.
While federal response provides important relief in the forms of
specialized experience, credentialed personnel and supplies, the ability of a
locality to rescue, treat, transport and provide definitive care to its own
citizens weighs the balance between life and death. This
holds true for bioterrorism, although in nontraditional ways.
Treatment and stabilization of a terrorist event is dependent on
recognition that an event is underway, and recognition is dependent on the
ability of local responders and the local public health office. In
Boston, we are lucky to have a strong Public Health Commission, with Cabinet
level input into the operations of the city, and strong funding and support.
This has allowed our local CDC office to take the lead in organizing a
citywide hospital volume surveillance system, which has two years running
detected the onset of influenza in the state prior to laboratory isolation.
If this type of system can detect influenza, it should be able to detect
the flu like illness that may be a harbinger of bioterrorism.
In addition, we have been able to develop a consortium of Boston hospital
based infectious disease and emergency medicine providers, poison control center
representative, and zoo veterinarian, who meet quarterly, and have the ability
to share information and alerts over the Internet. Our recent exposure to the
West Nile Virus proved that Incident Command training for public health
professionals pays off, and that the Public Health Director can act as Incident
Command with Police, Fire and other city agencies participating in a Unified
Command Structure. Many
localities are not so lucky, and rely on antiquated information systems, scarce
personnel, and minimal recognition from the public safety agencies. In
bioterrorism, the ability to respond is dependent on the education and equipment
of the prehospital personnel and hospital providers.
In
Boston, we are also fortunate to have an emergency medical service with strong
city support. This has allowed us
to train all of our Emergency Medical Technicians and Paramedics to the
hazardous materials operations level and domestic preparedness EMS- technician
level. Even though the training
materials, and sometimes the training, are provided free to agencies, training
costs are not. We are also
fortunate to have respiratory protective equipment provided.
Annually recurring training and fit testing costs supported by the city
are close to a half million dollars a year for our small agency alone.
In an anthrax exposure for 1000 people, assuming the National
Pharmaceutical Stockpile arrives and can be unloaded in seventy-two hours, the
cost of antibiotics that must be on hand in a city to immediately treat exposed
victims is 25,000 dollars. In Boston, we are lucky to have funding through the HHS
Office of Emergency Preparedness MMRS program.
We are also fortunate to have the support of the local hospital
pharmacies, who have agreed to rotate this stock of antibiotics for us, so that
they do not out-date, wasting our investment if no event happened in two years
time. However, training and fit
testing costs are renewable and supported by federal funding; while these costs
may be small compared to a federal budget, they are large costs for local
agencies. We
are also fortunate to have a strong Conference of Boston Teaching Hospitals,
which has a long history of working together to improve health care in the city.
This organization supports a hospital disaster committee and hospital EMS
committee. These relationships
proved invaluable over the last five years, in pulling hospitals and physicians
into the terrorism planning process through EMS.
In addition, we applaud the local hospital CEO's, who have been long
sighted enough to recognize the importance of this issue, and provided funds for
the construction of decontamination areas and staff training in the emergency
departments. Many
private and hospital based EMS agencies do not have the funding or support to
receive the necessary training or equipment, or to stockpile the necessary
antibiotics. Many hospitals do not
work in this type of collaborative environment, and are not able to participate
in citywide planning. Few
physicians receive any training in bioterrorism.
Emergency Department and hospital overcrowding is a very real issue that
will only be exacerbated in an event of any magnitude.
Future preparedness funding should take these things into account. In
Boston, we consider ourselves fortunate to have been one of the initial cities
trained under the Domestic Preparedness program.
Although not perfect, the DP program did several things well. First,
it required all city public safety agencies to sit at the table, and submit a
unified training and equipment plan before the training would be scheduled.
Second, it trained the personnel locally, allowing city workers to
brainstorm at the breaks and in the sessions, and meet people they may be
working with in the event of a disaster. Third,
it provided an adequate awareness training of terrorism.
Finally, it allowed instructors and students to share information, and
gain knowledge of many other cities' plans. Unfortunately,
the program failed by its stand-alone nature, and its sometimes "foster
child" status among the various federal agencies who, at one time or another,
have been responsible for its implementation.
New programs need strong, clear federal leadership that reflects
interagency cooperation at the national level. Domestic
Preparedness was an awareness level program, and should have been followed by
more concrete information and coordinated planning guides.
Every locality is different, but every locality can learn some lesson
from each other. Planning guides
were produced separately by various agencies, and no other effort took into
account the need for fire, police, and emergency medical personnel to
collaborate on a single city plan. At
the time the program was started, the importance of bioterrorism, and the
delayed manner in which it would appear was not appreciated.
We now realize that in a bioterrorist incident, the Emergency Department
and Medical Clinic providers are truly the first responders.
In the initial DP bioterrorism tabletop exercise, cities were encouraged
to do an anthrax hoax letter drill, testing the fire department HAZMAT response,
but ignoring the hospitals and public health system.
In March of 1999 in Boston, we went against the tide and held a tabletop
with seven hospitals, all public safety agencies, and several state and federal
agencies participating that tested our ability to respond to a Pneumonic Plague
event. As
the events of September 11th have unfolded, many who were previously
skeptical are now requesting training. Let's
not lose this opportunity. Based on
the Boston experience, I recommend that
In
closing, I share with the committee that I was proud and honored to be a member
of the Massachusetts 1 Disaster Medical Assistance Team that responded to the
World Trade Center. Although as a
health care provider it was frustrating to have so few live victims to treat,
our mission to treat the rescuers was rewarding and awe-inspiring. Nonetheless,
I will be very happy if I never again find myself working across the street from
6000 dead. It is clear there is
only so much the medical response community can do in an event of this size.
My thoughts and hopes are with the law enforcement agencies that can
prevent these tragedies Thank
you.
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