Earlier this year during a radio interview with Federal News Radio, Tara O'Toole, MD, MPH, undersecretary for science and technology- designate at the Department of Homeland Security, was asked what she would tell President Obama if given the chance.

Her reply: "There is a possibility, a real possibility, there could be the equivalent of a bio-Katrina on his watch."

But was this statement cause for alarm or simply an educated guess with little information to back the hypothesizing? In either case, is the United States healthcare system prepared for a potential bio-Katrina?

"Based on most real world events-extensively drug-resistant tuberculosis entering the country, the chaos surrounding H1N1 and the overall inability to track food borne illnesses-we're not even close." This was the ominous warning sounded by Michael J. Hopmeier, president, Unconventional Concepts Inc., Mary Esther, FL.

Hopmeier has been active in developing and deploying numerous guidelines and procedures, including security and public health issues associated with mass gatherings, and preparedness and response programs supporting population response to disasters and critical incidents. His career has focused on mass gathering and complex event response, training and preparedness, chemical and biological incident response, combat casualty care and medical support, crisis response and management, unconventional pathogen countermeasure programs, federal agency protective measures, counter-terrorism and integrated federal and civilian disaster response.

He asserted the largest problem hospitals face during a mass biological attack is typically hospital administrations have "no idea of what can be done, only what the government wants communities to have (e.g., be prepared for 100,000 casualties)." It's useless data, he said, not based on reality. "There's no way of determining the 'best' approach to deal with a pandemic, only poor guesses and past experience."

Limited and Manageable
To Tee L. Guidotti, MD, MPH, DABT, the outlook is slightly less grim. He doesn't think the United States is facing a bio-Katrina in the first place, "if that means an overwhelming disaster from a well-coordinated bioterrorist attack."

Guidotti is an international consultant with Occupational and Environmental Health and Medicine, Washington, DC. He recently retired from the Department of Environmental and Occupational Health, School of Public Health and Health Services, The George Washington University Medical Center, Washington, DC.

He has focused his career interests primarily on occupational and environmental health. A certified specialist in internal medicine, lung diseases and occupational medicine, his primary research interests are air quality, inhalation toxicology, and occupational and environmental lung diseases. He has devoted his career in environmental health to understanding issues of ecosystem disturbance and their relationship to human health.

"My feeling, and it is only that, is if there is another assault in the near term, it will be limited and manageable. In the long term, anything can happen," he said.

A 2007 ASCP report, "Chemical Terrorism: How Prepared Are the Clinical Laboratories?" found less than half of those surveyed think their laboratory could effectively respond in a hazardous chemical emergency. The results showed:

• Sixty percent understood the laboratory's roles and responsibilities in an external hazardous chemical exposure emergency situation, but less than half indicated their laboratory could effectively respond.

• Only one-third responded that their laboratory had adequate resources in the clinical pathology area, and less than one-fourth had adequate resources in the anatomic pathology areas to recover and ship a high volume of tissues or body fluid samples in a hazardous chemical emergency.

• Only 35 percent of the laboratories had a written protocol for collecting specimens from patients with suspected exposure to chemical agents.

• Only half the respondents were familiar with various categories of chemical warfare agents and the medical consequences of exposure to them.

• Only 20 percent were familiar with patient laboratory test results correlating with exposure to chemical warfare agents and had quick chemical warfare reference guides available in the laboratory.

Given these statistics, Guidotti said the best antidote is to ensure your facility has a strong and realistic bioterrorism preparedness plan in place. "The risk is remote but real and if you have no plan, you will not serve your patients, your staff nor your community and probably will not survive as an institution. Many hospitals take the attitude that because they are already operating on the edge, they should not divert resources or energy to worrying about this. If something happens, they think the CDC or other institutions in the region will step in and save the day. Maybe they will, but the public will not accept irresponsible denial of the risk," he said.

Better Off?

Guidotti said if a well-coordinated bioterrorist attack occurred, the United States would not be defenseless.

"Few agents work so quickly and completely they would incapacitate an entire city or district.

"The challenge would be to identify what is happening soon after the assault occurred and to deliver treatment and supportive care for the duration of the risk of infection for potentially large numbers of people," he said. "For the most likely pathogen, which is still anthrax, this would be difficult but it is feasible. We are far better prepared than we were in 2001."

Matthew T. Patton is a consulting editor of ADVANCE.

Q:? How often should mock drills occur? Some hospitals seem to have them more frequently than others.

A:? "Mock drills should occur annually on some aspect of emergency preparedness. They should focus on chemical, biological, radiological, nuclear, high-yield explosives threats, about every fourth year, alternating with drills on other, more likely risks," said Tee L. Guidotti, MD, MPH, DABT. "The point is to develop an all-threats response capability, not to train exclusively or even predominantly for bioterrorism."

Q: What are the weakest links in our country's bioterrorism and emergency preparedness systems?

A: Tee L. Guidotti, MD, MPH, DABT, identified three areas of concern:

1. Resources. There's a lack of low-tech, simple measures to deal with common problems (e.g., the "white powder" problem: ruling out that white powder in a mailing might be anthrax).

2. Funding. Underinvestment in the mainstream public health system, which is the essential system for response. We put too much money into special-purpose programs and not enough into strengthening the system as a whole.

3. Priorities. Priorities have been politicized. For example, distribution of anti-terrorism funds is not appropriate to need.

Lethal Weapons

The CDC categorizes biological agents according to the risk they pose to the public. Those posing the highest risk, because they can be easily disseminated and could result in high mortality, are classified as Category A. These agents include bacteria and viruses causing diseases such as:

• anthrax,

• botulism,

• plague,

• tularemia,

• smallpox and

• viral hemorrhagic fever (such as hantavirus and ebola).

-www.labtestsonline.org

Limiting the Spread

The anthrax-by-mail attack after the Sept. 11 terrorist attacks has conditioned our general mindset to assume bioterrorism would and could only be directed at humans, but the possibilities are much greater, suggested René J. Buesa, HTL(ASCP), retired histotechnologist, Mirimar, FL.

"Imagine the following scenarios: the introduction of a crop pest to disrupt the food supply, or the introduction of a communicable disease to poultry or cattle farms. Neither has anything to do with hospitals. State veterinary hospitals and the FDA would be the line of defense in these two cases."

He said one way to attack humans is the arrival (especially by air) of suicide terrorists infected with smallpox to later mingle with large accumulations of people, like in a subway, aiming to spread the disease. "At this point is when the hospital could start to play a role, teaching the emergency department staff to distinguish this type of disease eradicated in most countries. Most any other type of contagious disease would not be feasible because of long incubation periods."

He explained the first line of real defense against any bioterrorism attack will be the emergency department, and the rest will be prophylactic measures working to limit the spread amongst patients and personnel.

"Our fundamental line of defense is at the country's borders, not at our hospitals," he added.

-Matthew T. Patton