Question:

Critically evaluate the readiness and the effectiveness of the U.S. Healthcare delivery system in responding to a widespread bioterrorism event; propose changes as appropriate to your analysis.
The length of the paper should be approximately 8�10 pages, not including the reference page. Use the format below just for (FYI)
? Introduce the issues.
? Define the problems.
? Search the literature.
? Analyze the problems.
? Offer possible solutions, more than five.
? Propose two solutions.
? Develop implementation plans.
? Justify why/how if your solutions will solve the identified problems.

Answer:

Bioterrorism

Introduction

Bioterrorism is the threatened or deliberate use of viruses, bacteria, and toxins to cause fear, disease, or death. Other than human beings, bioterrorists could also target food crops, livestock, and environmental resources such as water reservoirs. In the US, the issue of likelihood of bioterrorist attacks has been a subject of immense interest in recent years. It is widely thought that it is rather difficult for a bioterrorist attack to be carried out on a large-scale basis. The procedures involved in the dispersion of a biological agent with the ability to infect large numbers of people are highly complicated, mainly in terms of technical expertise. One of the most frequently cited example is that of Japan, where a terrorist group has on 8 different occasions dispersed airborne anthrax and botulism formulations across Tokyo, the country’s capital, without any illness being reported.

This story of Tokyo was given wide coverage by the international media. As a precaution, widespread prescriptions of antibiotics were made in efforts to prevent anthrax infections. These efforts underscored the need for public awareness campaigns to enable people understand the risks that bioterrorism poses to their health and lives. Indeed, it should be borne in mind that a major attack can have devastating effects, hence the need for planning and preparedness.

One of the most widely discussed incidents of bioterrorism in the US is the 2001 Anthrax Attacks (Wolper, 2011). In these attacks, the bioterrorists attack individuals through the US Postal Service. These attacks caused immense fear among postal workers. The workers were worried not just about the possibility of being infected, but also the response mechanisms that were being adopted in the country’s healthcare system. One of the main sources of fear was that researchers would use them as experimental ‘guinea pigs’ in the process of dealing with the anthrax menace. This fear was caused largely by contradictions on the advice given by different physicians, disagreements among the country’s public health agencies regarding whether or not to recommend vaccines, and conflicting from international media and non-governmental organizations.

Definition of problems

The main problem in this paper is the likelihood of large-scale bioterrorist attacks in the US. This problem is related to many other problems, and key among them is the level of preparedness of the country’s healthcare system in dealing with such a large-scale act of bioterrorism. In this regard, it is important to assess the efforts that health authorities at the local, state, and federal levels make to ensure preparedness for such an attack. Some of the bodies whose preparedness is critical for the fight against bioterrorism include the Public Health Service, the Centers for Disease Control and Prevention, and various County Public Health Offices. Regarding the operations of each of these institutions, the main problem would be on whether the surveillance that they routinely conduct is effective in deterring bioterrorism.

The example of the 2001 anthrax attacks is normally cited frequently owing to the fact that it is the most recent bioterrorist attack to be carried out on a large-scale basis in recent years. However, there are many other biological agent (disease) threats, and in most cases, debates are normally on how they are spread and the available treatment options. The point of departure in all these debates, however, is that theoretically it is possible to engineer any infectious agent for deliberate use as a terror weapon.

While it is not possible to predict which microbes a terrorist may opt to use, the disease threats that concern most public health officials in the US include inhalational anthrax, cutaneous anthrax, smallpox, botulism, pneumonic plague, viral hemorrhagic fevers, and tularemia. Inhalational anthrax is caused by the inhalation of bacterial spores into one’s lungs. On other hand, cutaneous anthrax causes intestinal and skin disease. In contrast, smallpox is a viral disease whose main symptoms include aches, fever, vomiting, and vomiting. Botulism is caused by the ingestion or inhalation of a bacterial protein. It is one of the most lethal toxic compounds in existence today.

In the case of pneumonic plague, the bacterium responsible is associated with the so-called ‘Black Death’. Its main symptoms include chills, fever, and cough. For viral hemorrhagic fevers, different viruses are responsible. Severe infection may cause death as a result of complications caused by shock and massive breeding due to extensive damage to blood vessels. These viruses are extremely dangerous because contact with the body fluids of an infected person is enough to cause infection. The only available vaccine is that of Yellow Fever; in the case of other vaccines, research is still ongoing. No antibiotic has been found to treat any of the aforementioned viral infections.

Clearly, the problem of immunization emerges as a major challenge in the preparedness efforts of healthcare providers (Mondy, 2003). Since vaccines against some of these diseases are yet to be developed, the US is in a situation of vulnerability. This vulnerability manifests itself particularly on the part of the country’s ordinary citizens. For example, the anthrax vaccine is only being provided to military personnel as well as those who are likely to come into contact with anthrax in its natural form in the course of their work. Moreover, physicians recommend the use of this vaccine only among people aged between 18 and 65.

The problem of immunization is slightly different with regard to small pox. The last case of small pox in its natural state was reported in 1977 (Hillel, 2004). This explains why the US stopped routine immunizations against the disease in the 1970s. Since then, many drug companies have stopped manufacturing the vaccine. However, there is suspicion that some groups or countries may have stolen smallpox virus stocks from the former Soviet Union. The main problem here is on who should be given the few remaining doses of the vaccine since it is difficult to determine who terrorists may target with it.

Other problems that healthcare experts have to grapple with include citizens’ desire to have antibiotics for use in case there is a bioterrorist attack, the availability of the so-called National Pharmaceutical Stockpile, and what people should do in the event of exposure to infectious bio-agents (Mondy, 2003). These problems are addressed in this paper, and the form the basis of literature search, analysis, solutions, implementation plans, and justifications.

Literature search

In this paper, literature search is focused on four key sources of articles: medical literature, government documents, and emergency management literature. The articles sought are those that describe the likelihood of bioterrorist events, bioterrorism preparedness plans, evaluations of systems of healthcare delivery, vaccination strategies, and evaluations of prior responses to national disasters in the US. Specific emphasis, though, is on describing and evaluating the programs that the US administration put in place in response to the 2001 anthrax attacks.

Analysis of problems

The first problem that stakeholders in the US healthcare system face is that of determining the likelihood of large-scale bioterrorist attacks. Various federal bodies have assessed the likelihood of a large-scale bioterrorist attack in the US. These bodies include the Department of State, the Central Intelligence Agency, the National Intelligence Council, the Defense Intelligence Agency, and the Defense Science board (Revere, 2011). All of them have arrived at the conclusion that there is a current and real threat of a biological large-scale biological attack on the US soil (Revere, 2011). The Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism went on to note that the US is unprepared and therefore vulnerable to an attack of this nature. The Commission pointed out to the likelihood of a weapon of mass destruction being used on either the US or somewhere else by 2013.

On the question of preparedness, there are many factors to be put into consideration, including those relating to healthcare delivery and national security (Niska, 2005). In recent times, the US administration has been putting more emphasis on strategies and programs of preventing nuclear terrorism; bioterrorism is rarely considered a high priority issue. In its report World at risk, the Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism faulted the US administration for failing to take the steps that are necessary for the protection of the country against the threats of bioterrorism (Johnstone, 2010).

In the World at Risk report, the federal administration is viewed as lacking the right response mechanisms as far as biological threats are concerned. On the same light, it lacks a national plan for the coordination of local, state, and federal efforts in the event of a bio-terror attack. Moreover, it lacks the operational and technical capabilities needed for the country to respond adequately to a bio-terror attack. The report also lamented the administration’s lack of capacity to carry out environmental cleanup in the wake of a large-scale biological attack.

In 2005, healthcare experts warned that if a major US city was to be attacked using Bacillus anthracis, tens of thousands of people would be killed, hundreds of thousands would be sickened, and billions of dollars would be lost in economic damages. From the perspective of the country’s healthcare delivery system, one of the core challenges is ensuring that the right environmental decontamination strategies are put in place.

Decontamination entails removing or inactivating hazardous substances, such as a biological agent, from all contaminated environments and surfaces, including buildings, air, water, skin, and clothing, with the aim of preventing the occurrence of adverse health events (Schur, 2004). The decontamination process occurs in three phases: sampling and testing, containment and mitigation, and decontamination and confirmatory testing (Gottron, 2011). The sampling and testing phase is about detecting the presence of a particular biological agent while the containment phase is about determining the best decontamination methods. The decontamination and confirmatory testing phase entails the use of appropriate technologies for use when cleaning all the contaminated areas and disposing of contaminated materials. Specialists in the healthcare delivery system have to set up criteria for determining when the decontamination process is complete and when the area is ready for re-inhabitation.

Research on biological decontamination is still ongoing, and the main contributing institutions in the US are the EPA (Environmental Protection Agency) and DHS (Department of Homeland Security) (Hanfling, 2004). Other federal agencies that contribute to this research include the CDC (Centers for Disease Control and Prevention) and the USDA (US Department of Agriculture). In some cases, some of these agencies come together to form interworking research groups. An excellent example is the Interagency Microbial Risk Assessment Guideline Working Group, which was established through joint efforts between the CDC and the EPA.

At this point, it is imperative to assess the ways in which the country’s healthcare delivery system responded to the Anthrax Attacks in 2001. Epidemiologists were deployed to work hand in hand with police detectives in the shared goal of finding and stopping the terrorists responsible for the dispersion of disease-causing biological agents. The 2001 anthrax attacks resembled conventional disease outbreaks only that no transmission links could be established between infected and susceptible persons in order to relate one case with other. Rather, each of the cases was independently generated by terrorists who put anthrax spores in letters before sending them through the country’s postal system. The epidemiologists who worked together with police detectives from the Federal Bureau of Investigations were sourced from the CDC.

The CDC engaged with the public in numerous ways, including interviews with media reporters, updates in the MMWR (Morbidity and Mortality Weekly Report), and professional talks and presentations. It is during the second update on the MMWR that earlier incidences of Bacillus anthracis were attributed to intentional dispersion as opposed to a conventional outbreak. Subsequent updates addresses issues such as management of exposure to anthrax, onset times of different anthrax cases, adverse events that can occur in the event of mass treatment as a way of putting anthrax under control.

Other issues addressed through the same medium included criteria for determining who qualified for preventive anthrax treatment, mass treatment of postal employees with potential exposure to the biological agent, and vaccination and therapy procedures for people with exposure to anthrax spores. Almost a year after the first incident of anthrax outbreak was reported, for instance, there was an update on offering medical protection to workers tasked with the responsibility of ensuring that buildings contaminated with B. anthracis are safe for re-inhabitation.

Possible solutions

In light of the problems analyzed, seven possible solutions are presented. Out of these seven possible solutions, two most appropriate solutions are proposed.

1. The federal administration should put in place the right response mechanisms for each of the main potential sources of bioterrorism, namely inhalational anthrax, cutaneous anthrax, smallpox, botulism, pneumonic plague, viral hemorrhagic fevers, and tularemia.
2. There is need for a comprehensive national plan for coordinating local, state, and federal efforts in the event of a bio-terror attack.
3. The operations of the country’s healthcare delivery system should be streamlined to create room for the possibility of occurrence of bioterrorist attacks.
4. The healthcare delivery system should be managed in such a way that it would be easy to offer preventive treatment solutions to victims without compromising the existing healthcare facilities and operations.
5. The healthcare delivery system should also be restructured in such a way as to bring on board federal bodies with the administrative capacity to carry out environmental cleanup in the wake of a large-scale biological attack. The most qualified federal agencies in this case are the EPA and CDC.
6. More resources need to be directed towards decontamination research. With the right research and technologies in place, it should be easy for the right environmental decontamination strategies to be put in place. It would also be easy for the right microbial risk assessment (MRA) procedures to be followed by the relevant federal healthcare delivery agencies.
7. Other than the conventional epidemiological research, the Department of defense ought to lead concurrent research for military purposes, seeing as it is that the military has to play a leading role in the event of major terrorist attacks.

Two solutions proposed

Of these seven possible solutions, two are most appropriate. The first proposed solution is the one requiring the federal administration to establish the appropriate response mechanisms, in an explicit way, for each of the main potential sources of bioterrorism, namely inhalational anthrax, cutaneous anthrax, smallpox, botulism, pneumonic plague, viral hemorrhagic fevers, and tularemia. During the 2001 Anthrax Attacks, many shortcomings in the healthcare delivery system became inherent as far as response to a large-scale bioterrorist attack is concerned. The federal administration was preoccupied with other sources of terror threats, notably weapons of mass destruction.

The second proposed solution is that of harnessing more federal resources towards decontamination research and preparedness. The research should endeavor to come up with the appropriate criteria for determining which decontamination procedures are required as well as the specific procedures for carrying out these decontamination activities.

Implementation plans for the proposed solutions

In both proposed solutions, the implementation plans put in place should be founded on six core elements: strategic planning, risk assessment, bio-surveillance, research and development, medical countermeasures, and procurement and distribution channels. On strategic planning, the federal administration should allocate all the resources needed for various departments and agencies to maintain a sense of preparedness to bio-terror attacks. Similarly, the agencies and departments need to be equipped with capabilities for risk assessment, bio-surveillance, and the establishment of the appropriate countermeasures for each of the bio-agents that bioterrorists can use on the country on a large-scale basis. The same implementation plan should apply on the second proposed solution, which addresses decontamination research and preparedness. In this proposed solution, priority should be on research and development as well as procurement and distribution channels at federal, state, and local levels.

Justification for the proposed solutions

These proposed solutions will no doubt contribute to increased preparedness in the face of an increased threat of bioterrorism in the US. This is because they provide for not just the allocation of resources at various levels (federal, state, and local) but also the appropriate management and research procedures that would needed to be tapped into in the event of a bioterrorist emergency. This is evident in the way these proposed solutions address a wide range of healthcare related issues, including medical countermeasures, bio-surveillance, and epidemiological and vaccination research.

With these proposals in place, policymakers at the federal, state, and local levels will have a platform on which to peg preparedness programs. Indeed, a proactive approach is the best long-term strategy in this quest for awareness and preparedness, considering the devastating impact that a large-scale bio-terror attack may have on citizens.

 

References

Gottron, F. (2011) Federal Efforts to Address the Threat of Bioterrorism: Selected Issues and Options for Congress, Washington, D.C.: Congressional Research Service.

Hanfling, D. (2004) Making Healthcare Preparedness a Part of the Homeland Security Equation, Topics in Emergency Medicine, 26(2), 128-142.

Hillel W. (2004) The Pitfalls of Bioterrorism Preparedness: The Anthrax and Smallpox Experiences, American Journal of Public Health, 94(10), 1667-1671.

Johnstone, W. (2010) Bioterror: Anthrax, Influenza, and the Future of Public Health Security, New York: Greenwood Publishing Group.

Mondy, C. (2003) The Role of an Advanced Practice Public Health Nurse in Bioterrorism Preparedness, Public Health Nursing, 20(6), 422–431.

Niska, R. (2005) Bioterrorism and Mass Casualty Preparedness in Hospitals: United States, 2003, CDC Advanced Data Journal, 364(2), 1-16.

Revere, D. (2011) Public Health Emergency Preparedness and Response Communications with Health Care Providers: A Literature Review, BMC Public Health, 11(2), 337-391.

Schur, C. (2004) Perspectives of Rural Hospitals on Bioterrorism Preparedness Planning, Walsh Center for Rural Health Analysis, Policy Analysis Brief, April 2004, No. 4, 1-6.

Wolper, L. (2011) Health Care Administration: Managing Organized Delivery Systems, Toronto: Jones and Bartlett Publishers.