Author Topic: CSIS 2005 WhitePaper "Model Operational Guidelines for Disease Exposure Control"  (Read 13499 times)

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Offline birther truther tenther

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Model Operational Guidelines for
Disease Exposure Control

Draft as of November 2, 2005
A Draft Prepared by:
The Center for Strategic & International Studies
Homeland Security Program
This document is a draft of Model Operational Guidelines for Disease Exposure Control. It is intended to provide states, cities and counties with guidelines to slow or stop the spread of contagious disease when vaccines or other medical countermeasures are unavailable. The guidelines seek to do so by: (1) describing the tools available to public officials for controlling the spread of disease; (2) discussing key policy issues that should be considered; and (3) suggesting protocols to consider for developing specific plans.
Over the next three months, CSIS will collaborate with the various stakeholders in reviewing and refining this document to ensure that it reflects the best technical, public health, and emergency operations thinking to plan for an outbreak.

For More Information Please Contact:
David Heyman
Director and Senior Fellow
Homeland Security Program
Center for Strategic and International Studies
1800 K Street, NW Washington, DC 20006

1 This document was prepared thanks to the generous support of The Stuart Family Foundation. [INSERT:  Look up "Truman Anderson" on a search engine to learn more about the Stuart Family Foundation]

Assistant Secretary, Office of Policy: David Heyman

David Heyman is the Assistant Secretary for Policy at the U.S. Department of Homeland Security. Previously, he served as a Senior Fellow and Director of the CSIS Homeland Security Program where he led the CSIS' research and program activities in homeland security, focusing on developing the strategies and policies to help build and transform U.S. federal, state, local, and private-sector homeland security institutions.

Heyman is an expert on terrorism, critical infrastructure protection, bioterrorism, and risk-based security. He has led or contributed to a number of studies on aviation security, nuclear security, bioterrorism preparedness, and pandemic flu planning. He also was the principal architect of, and helped run, "Steadfast Resolve," a cabinet-level tabletop exercise that examined critical decision making at the National Security Council and Homeland Security Council during the next potential terrorist attack. Heyman also is an adjunct professor in security studies at Georgetown University.

Heyman has served in a number of government positions, including as a senior adviser to the U.S. Secretary of Energy and at the White House Office of Science and Technology Policy on national security and international affairs. Prior to that, he was the head of international operations for a private-sector software/systems engineering firm developing supply-chain management systems for Fortune 100 firms. He has worked in Europe, Russia, and the Middle East.

Heyman has authored numerous publications, including "America's Domestic Security" in Five Years After 9/11 (CSIS, 2006); Model Operational Guidelines for Disease Exposure Control (CSIS, 2005)—which has been utilized by cities and states across the country and was the basis for some of the government's pandemic flu planning guidance; DHS 2.0: Rethinking the Department of Homeland Security (CSIS/Heritage Foundation, 2004); and Lessons from the Anthrax Attacks (CSIS, 2002). Heyman has testified before a number of committees in Congress and has appeared in various media outlets including NPR, CNN, BBC, FOX News, and the NewsHour with Jim Lehrer.

Offline birther truther tenther

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Prior to that, he was the head of international operations for a private-sector software/systems engineering firm developing supply-chain management systems for Fortune 100 firms.

From my research, and I am asking you guys to use a search engine and confirm it on your own, that the "software/systems engineering firm developing supply-chain management systems" that David Heyman worked for was RGTI Systems Software based in New York, NY.  RTGI was bought out by BDM International Inc based out of McLean, VA, (BDM is right DOWN THE STREET/WALKING DISTANCE to Booz Allen Hamilton's HQ!!!)  BDM uses Enterprise Architecture software to manage their supply chain systems!!!

So this Heyman guy is involved with enterprise architecture, supply chains, flu pandemic planning, CSIS, John P Holdren's office, DHS, and the National Security Council.  Holy s**t!

Offline birther truther tenther

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Page 40 of PDF

Community Quarantines
In community quarantine, all persons in a specific area or region, where a high community-wide case count has been identified or where there is potential for widespread exposure, are quarantined. Movement of persons within the community is limited to the area of quarantine—a number of houses, a building complex, a neighborhood, or groups of buildings and/ or neighborhoods. Community quarantine is implemented by arranging a perimeter—a controlled access area—around the region of concern.
In outbreaks where health officials have a good understanding of the pathology of the disease and nature of the outbreak, authorities and the public may be more confident that they have delineated the correct boundaries for community quarantine. More likely, however, there will be considerable uncertainty involved in the determination of the precise geographic area to quarantine, which consequently may present greater challenges to public officials trying to reassure an anxious and potentially confused public, who may already be skeptical about the government’s ability to manage the crisis and protect them from further harm. Lastly, because community quarantines are the most sweeping form of quarantine, they will likely be the most difficult to implement and enforce.

Legal/ Political
Quarantine is one of the more politically sensitive tools that can be employed for disease exposure control. The decision to separate and restrict movement of persons who, for all intents and purposes, are well (by definition they are not ill, but may have been exposed to someone or something that could infect them) raises a number of legal, ethical and ultimately political questions that must be weighed carefully.
To the extent possible quarantines should be voluntary. Governments should take steps to induce voluntary compliance by providing adequate care and support so as to help those in quarantine not feel abandoned, psychologically isolated, or unduly burdened. This may require provision of food, health care, the capacity to communicate with friends and family outside of the quarantine, and perhaps even entertainment. It may also require provision of some financial incentives, such as reimbursement for income lost during quarantine (for more discussion on inducing voluntary compliance, see chapter on Toolkit for Compliance).
For various reasons, individuals who should be quarantined may not wish to be quarantined. Such individuals may resist quarantine because, for example, they believe they are not sick (or likely to become sick), because they cannot afford to be unpaid for a short period of time, or leave their family unattended; or because they fear being confined in proximity to people who they believe may infect them.
In these cases, to protect the public from infection by a possible carrier of disease, officials will need to legally order and enforce the quarantine of individuals. Involuntary quarantine, however, may be viewed as a violation of personal liberty and equivalent to criminal detention. The greatest challenge to officials, then, is balancing the interest of the public being protected from disease, with their interest in preserving individual liberty.
In general, public interest can supersede individual rights in order to achieve a common good; but actions to do so must be ethical, even-handed, transparent for all stakeholders, provided for and carried out in accordance with the law, and strictly necessary to achieve the objective. Furthermore, there can be no less intrusive and restrictive means available to reach the same objective.84
Under these circumstances, a social compact forms the basis of action: public health officials have an obligation to restrict certain individual rights to protect the health and well-being of the community; and citizens have a civic duty to comply with them in order to protect their family, friends and the broader health of the community85. When quarantines are required, public officials should inform the public of the threat to their health, communicate the known risks, provide full information about the need for public action, and describe how the government will support individuals whose movement has been restricted. They will also need to ensure that proper legal authorities and procedures are in place to remove and detain suspected or confirmed cases, contacts, or carriers who are or may be endangering public health. Laws that establish the legal basis for government action in these cases must also provide that quarantines can be applied almost anywhere, and not restricted just to hospitals.

Who to Quarantine?
Anyone who has been exposed or potentially exposed to the infectious agent causing an outbreak should be quarantined.  Identifying individuals who may have been exposed may not be easy or even possible. When possible, health officials will need to do the hard work of tracing contacts—tracking down all those who have been in close contact with someone who is known to be sick or infected, and/ or tracking down all those who were in the vicinity where exposure may have occurred (either from the release of a pathogen, or from interaction with known sick or suspected cases)—and quarantining them.
When the source of possible infection is known, contact tracing is straightforward, though potentially resource-intensive. Individuals or groups who were exposed or potentially exposed may be asked to stay at home (home quarantine), or to quarantine at a designated facility (facility quarantine). The larger challenge will be quarantining when the source of infection is unknown or there is widespread community transmission. Under these circumstances, it may be difficult or impossible to trace exposures, and larger-scale community quarantine should be contemplated.
There is much debate and little agreement about the feasibility and utility of large-scale quarantines. For the most part, this is because in large, heavily-trafficked urban areas with international transportation hubs, people come and go so rapidly that it is virtually impossible to identify who was in a certain location at a certain time at the moment of exposure.
That being said, all cities are different; all disease outbreaks unique. The question of large-scale quarantine feasibility will need to be assessed on a case-by-base basis, with consideration of a range of factors related to the degree and speed by which a disease may spread. Such factors include: disease pathology; type of outbreak (deliberate or naturally occurring; if deliberate, single or multiple releases); city size; city density, public transportation volume; level, frequency, and access to transportation (air, land, and sea); scale and frequency of public gatherings; and social customs (e.g., shaking hands, cheek-kissing, wakes at funerals). While few tools exist, it is possible to model these factors from city to city and provide some data for decision-makers to assess the possible spread of an outbreak, and inform decisions on the size and shape of large-scale community quarantines.86 Walden and Kaplan have developed an approach for real-time estimation of the size and time of a bioterror attack,87 from case report data, that is simple enough to implement in a spreadsheet. Their model can help estimate the spread of disease during the first generation of cases for a single-source attack.
In cases where the likelihood of disease spread is high or uncertain, or resources to implement large-scale quarantines simply unavailable, more aggressive tools should be contemplated, including initiating restrictions on community activities, and asking the public to shelter-in-place until the scale of the outbreak is determined (see Community Restrictions and Sheltering below). 

Offline Satyagraha

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Page 40 of PDF

Community Quarantines

 ... More likely, however, there will be considerable uncertainty involved in the determination of the precise geographic area to quarantine, which consequently may present greater challenges to public officials trying to reassure an anxious and potentially confused public, who may already be skeptical about the government’s ability to manage the crisis and protect them from further harm. Lastly, because community quarantines are the most sweeping form of quarantine, they will likely be the most difficult to implement and enforce.

Legal/ Political
Quarantine is one of the more politically sensitive tools that can be employed for disease exposure control. The decision to separate and restrict movement of persons who, for all intents and purposes, are well (by definition they are not ill, but may have been exposed to someone or something that could infect them) raises a number of legal, ethical and ultimately political questions that must be weighed carefully.

... Involuntary quarantine, however, may be viewed as a violation of personal liberty and equivalent to criminal detention. The greatest challenge to officials, then, is balancing the interest of the public being protected from disease, with their interest in preserving individual liberty.

In general, public interest can supersede individual rights in order to achieve a common good; but actions to do so must be ethical, even-handed, transparent for all stakeholders, provided for and carried out in accordance with the law, and strictly necessary to achieve the objective. Furthermore, there can be no less intrusive and restrictive means available to reach the same objective.84

Who to Quarantine?

... In cases where the likelihood of disease spread is high or uncertain, or resources to implement large-scale quarantines simply unavailable, more aggressive tools should be contemplated, including initiating restrictions on community activities, and asking the public to shelter-in-place until the scale of the outbreak is determined (see Community Restrictions and Sheltering below). 

The DHS and other agencies dedicated to 'protecting' the American public NEVER mention the violation of constitutional rights; and by what law they are allowed to violate individual rights, and in what circumstances. They simply and frequently talk about the 'sensitive legal issues', and they always make a statement to the effect that 'we must be careful about the rights of individuals' - without explaining exactly how they intend to protect individual rights.

You can read this PDF in terms of a recipe for handling "Disease Exposure", or you can read this document, along with all of the other documents posted to this forum - the documents describing the control grid, the surveillance economy, the FEMA camps, the revolution in military affairs, and the cybernetics agenda, and see the real 'value' of this outline to those who are afraid of the 2nd amendment. Get a good disease scare going, and you have everyone marching in line to quarantine... the H1N1 False Flag Pandemic may have been a beta test for something they plan to carry out; a bio-terror false flag that would enable 'justifiable' control (takedown) of large geographic sectors of the country. The 'hidden home-grown' terrorist in the form of a virus or bacteria (can't see the little turban and beard)...

So let's cut to the chase - get to the real purpose of this paper: further along on page 64 ...


II. Enforcing Compliance

When individuals fail to comply with disease exposure control measures—despite public appeals or incentives offered—government officials must consider other more coercive means for enforcing compliance. These can range from warning would-be violators with the prospect of punishment, instituting active monitoring within certain perimeters of communities for possible offenders, and punishing noncompliance with fines and even forcibly detaining and/ or imprisoning violators.

Key Considerations

Law Enforcement

Public safety officers, police, public health officers with police authorities, and other law enforcement officials will have the primary responsibility of enforcing compliance to disease exposure control measures. The National Guard, as long as they are not federalized and thus not bound by posse comitatus, may also support efforts to enforce compliance. Four key issues should be considered: who’s in charge, what are the rules of engagement, how do you ensure proper protective measures, and what other enforcement issues must also be addressed.

Who’s in Charge. Although public health would likely be the lead agency for managing an outbreak crisis response, law enforcement officials will play a major supporting role in enforcing quarantines and other exposure controls. Specific roles and responsibilities would be determined in collaboration with public health officials but may include: establishing perimeters and maintaining access controls around certain buildings or areas of a city; managing crowds; providing security for medical facilities, health care providers, and shipments of medical supplies; overseeing transportation of affected populations to and from quarantine facilities; and supporting the provision or delivery of medical, food, or other essential services.

Rules of Engagement. One question that surfaces immediately in discussions on enforcing restrictive measures is when and if lethal force should be employed to protect a vulnerable public from potentially infectious individuals fleeing quarantines? The answer is “no.” First, a guiding principle of law enforcement is to use the least force necessary to subdue possible threats. Second, non-lethal force can be equally as effective as lethal force, without risking the tragic consequences of wrongful arrest or undermining public trust. Third, it is important to understand as rules of engagement are contemplated, that exposure control measures can be effective even if compliance is not 100%. In fact, the benefit of quarantines and other similar restrictive measures tend to reach their maximum benefit at a compliance rate of about 90%.95 So while public compliance with control measures is vitally important, enforcement does not have to be absolute for programs to be effective.

In all instances in which law enforcement officials may engage the public, they should do so with full knowledge of the risks posed to them by infected individuals, and what measures they can and should take to protect themselves from infection. Protocols will be needed for enforcement officers on how to deliver quarantine orders and control access to and from a quarantine facility or area (e.g., stand so many feet away; wear specific protective gear, etc.). Enforcement officers may also need to be prepared to answer a number of key questions:

- What conditions dictate who should be quarantined? For how long?
- What are the rights of families separated by quarantine?
- What punishment will be meted out to escapees?
- Can there be court appeals of quarantined status? How will they work?
- Can there be voluntary quarantine entry?
- What are the rights of foreign nationals?
- Can you hold public health officials liable?
- What are the rights of families regarding burial/ cremation?
95 Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS), Version 2 (CDC). January 8, 2004.

To better provide health information to those receiving quarantine orders, health officials may also join enforcement officers to deliver orders.

Protective Measures.
Law enforcement responsible for enforcing restrictions will need to receive education on the disease, on the risks presented by engaging those infected, guidance and training on appropriate protective gear, and will need to recognize that if they engage potentially infected individuals, they too will have to be quarantined, perhaps away from their family.

Other Enforcement Issues.
Responding to opportunistic crime. While supporting the activities of managing the response to a large-scale infectious disease outbreak, law enforcement officials will still need to respond to common criminal activity, including the possibility of an increase in opportunistic crime—thefts, looting, and other criminal acts that seek to exploit the health emergency.

Coordinating a criminal investigation with other agencies. If it becomes apparent that instances of disease may not be the result of natural causes, the FBI must be notified. The FBI, acting on behalf of the Attorney General, has lead responsibility for criminal investigations of terrorist acts. The Department of Homeland Security in coordination with the U.S. Department of Health and Human Services maintains the overall lead in managing the incident response.96 Law enforcement and Public Health officials will need to coordinate with one another and hold joint investigations (epidemiological and forensics) in the event of a deliberate outbreak. Even if the outbreak is widely believed to be naturally occurring, law enforcement officials will likely remain vigilant for any signs that it was indeed deliberate.

Perimeters and Active Monitoring

To keep quarantined individuals in—and healthy individuals out—officials will need to establish controlled access into and out of quarantined areas. Well-controlled access will diminish the likelihood of additional exposures and allow resources to be devoted to other aspects of the response. It also affords temporary access for health care workers and response personnel as needed.
In some cases, access control may be limited to just a single building.

When several buildings are at risk or when community quarantines are warranted, access control may be best accomplished by establishing a secured perimeter with one (or at most a few) entrances/exits. While such restrictions are difficult to imagine, and may well be difficult to implement, it is useful to note that the use of perimeters to restrict movement of the public is not at all uncommon in urban settings. During parades, demonstrations, fires, crime scenes, or for protection of special visitors, law enforcement personnel routinely restrict movement into and out of sensitive areas. Access control for large-scale quarantines could build on those procedures.

Officials must issue appropriate credentials for entry and exit, and strictly enforce the perimeter for anyone who lacks proper credentials. To guard against fraud, credentials should be linked to biometrics and possibly re-formatted on a daily basis. The credentialing process would likely be administered by a central agency—preferably the lead agency responsible for managing the crisis (e.g., office of emergency management). This agency would need to manage the creation and dissemination of access passes, and establish protocols to handle daily exceptions and special requests. It would also need to coordinate with law enforcement or other officials responsible for maintaining the perimeter. Since persons who prematurely leave quarantine also pose a risk transmission to the community, passes are needed to allow those who have completed quarantine to leave the quarantine facility or area.

Key elements of a perimeter include…

1. Transmission Zone within a perimeter
2. Guarded checkpoints/ Monitoring stations/ Access controls
3. Barriers to control flow of traffic
4. Barriers and patrols to enforce flow of pedestrian traffic
5. Protective Zones just outside of perimeter as a buffer for delivery of goods to Transmission Zone and decontamination of people/ transport leaving the Transmission Zone
6. Zones just outside of the buffer/ Protective Zone

Key activities inside the Protective Zone …

1. Credentialing for access to hot zone
2. Monitoring and observation of persons moving between hot and warm zones
3. Supporting the delivery of basic goods and essential services
4. Protecting health care professionals
5. Facilitating sanitation and decontamination activities
6. Maintaining public order
7. Transfer of Goods
8. Decontamination of People
9. Decontamination of Delivery Vehicles, other vehicles
10. Decontamination of Sanitation vehicles
11. Issuance of PPE
12. Possible support of mental health counseling services
13. Ensuring perimeter enforcement
14. Supporting transportation to/ from quarantine facilities

Activities outside the Protective Zone…

1. Gathering goods for delivery
2. Developing information/ guidelines/ public messages and establishing special hotlines/ information dissemination hubs
Movement between Transmission Zone and Protective Zone…
1. Possible transport of symptomatic to isolation
2. Removal of waste
3. Provision of goods
4. Movement of law enforcement/ health care providers/ EMS and service providers

Monitoring of individuals in Transmission Zone…

Officials have a number of technologies available for monitoring and observation. Factors to consider when deciding which technologies to use include the number of personnel required, total expense, overall effectiveness, legal authorities required, and likelihood of public compliance.

A key balance will be between the cost of sophisticated tools and the personnel required for less sophisticated measures. More sophisticated tools may be too costly to implement, but personnel-intensive mechanisms may suffer from a lack of available and trained personnel. Home visits will require much more personnel than remote monitoring and observation techniques. And remote techniques such as epic or electronic tagging will require installation of cameras or other technology that significantly increases labor. Although trained nursing or other medically trained persons will be best qualified to monitor (as well as to deal with the questions posed by a population of people who will likely be quite frightened), monitoring call centers may also be staffed by trained volunteers when personnel runs short. Thus it may be of greater use to concentrate on methods—such as phone calls—that focus on monitoring for symptoms with the goal of quickly identifying and treating those who become sick.

Possible technologies include:

1. Phone calls. Daily (or twice-daily) phone calls are perhaps the most efficient way to monitor quarantined persons for compliance and symptoms. Evasion tactics, however, may include use of “call forwarding,” use of a cell phones, and household members pretending to be the person in question.

2. Home visits. Though resource intensive, in-person visits may be the most effective means of monitoring and observation. Officials performing house calls would confirm identification, check for symptoms, and verify compliance with home quarantine.

3. Web-based monitoring. Although persons can be required to submit information over the web, there is no guarantee that this information will be correct and, in the absence of biometrics, it may be difficult to confirm identity over the web.

4. Video monitoring. Video monitoring (also called Electronic Picture or E-pic) allows visual identification and real-time symptom assessment and ensures that the person being monitored is indeed at home. In cases like SARS where temperature is a reliable indicator of potential infection, health officials can require that those being monitored also take their temperature under observation.97

5. Electronic tagging. Usually reserved only for those who have demonstrated noncompliance, electronic tags may be fitted around the wrist or the ankle, and will set off an alarm if the wearer strays too far away or outside of his/her home. The alarm will also be set off should the wearer tamper with the sensing mechanism.

Punishing Noncompliance

Possibly the most severe form of enforcement, punishing noncompliance includes issuing fines, imposing jail time and using physical force to compel compliance. In many cases the threat of force will be enough to ensure compliance, and the use of force or punishment should be reserved only for those cases when efforts at inducing compliance have failed.

Fines are perhaps the least intrusive means of enforcing compliance, but also may be the least effective. During the SARS outbreaks, fines were issued for breaking quarantine, spitting, and other violations of community-based restrictive measures. Non-lethal force should be considered for cases posing a danger of violence, a breakdown in public order, or a serious risk of danger to health of the community.

The option of jailing would-be violators presents a unique challenge. Prisons or jails do not in general have hospital level infection control measures in place, nor AIIR isolation wards. Officials would not introduce an infected person or even a potentially infected individual into the general prison population. Consequently, secure alternative facilities would need to be established or specific jail facilities would need to be cleared for violators. In the US, where prison capacity is already stretched, finding an existing prison or jail facility or clearing prisoners from one facility for violators would be problematic.


All of this could have easily come (and likely was copied directly) from a military document describing how to take down an urban area; a city - like maybe Fallujah - or any other city in Iraq or Afghanistan. They've been practicing for years. And now we have the structure here in the US - everything is in place to implement the 'suggestions' outlined in the PDF.

If we did not live in a fascist oligarchy, measures to deal with biological 'disease exposure' could be seen as good preparation for an outbreak of smallpox, or avian flu, or (pick any disease - check out Plum Island, or the missing bioweapons at Ft.Detrick). But we do not live in a nation governed by representatives of the people - we live in a country with a government that was effectively overthrown in 1913, and attempts to take it back were met with deadly force (see JFK assassination). So we can't trust that the procedures they outline in documents like this are 'for our own good'. Nothing we have seen from this government (and I speak of both sides of the right/left paradigm) has been good for the people.

Thanks to birther truther tenther for posting this document: when we see a false-flag bioterrorist attack beginning, we'll know the drill.
And  the King shall answer and say unto them, Verily I say unto you, 
Inasmuch as ye have done it unto one of the least of these my brethren,  ye have done it unto me.

Matthew 25:40

Offline Satyagraha

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Congressional Commission: Bio-Terror a Bigger Worry Than Nukes

"... it is far more likely that in the next three to four years we will have a bio-terrorist event
 somewhere in the world, possibly in the United States."

- Randall Larsen
Executive Director, WMD Commission

Randall Larsen’s resume:
National Security Advisor, Center for Biosecurity, University of Pittsburgh Medical Center, 2004–present
Vice president and corporate officer (1 of only 5) of a 400-person consulting firm, 2000–2003
Department chair and professor of strategy at the National Defense University, 1998–2000
US Air Force colonel and former commander of America’s VIP fleet of aircraft at Andrews AFB, Maryland, 1996–1998
And  the King shall answer and say unto them, Verily I say unto you, 
Inasmuch as ye have done it unto one of the least of these my brethren,  ye have done it unto me.

Matthew 25:40

Offline SongBird

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Thanks Pilikia, between you and AI, Dig the sifter, and the rest were introduced to worlds only imagined.

Offline ekimdrachir

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There was a planned pandemic in 2006


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Congressional Commission: Bio-Terror a Bigger Worry Than Nukes

"... it is far more likely that in the next three to four years we will have a bio-terrorist event
 somewhere in the world, possibly in the United States."

- Randall Larsen
Executive Director, WMD Commission

Randall Larsen’s resume:
National Security Advisor, Center for Biosecurity, University of Pittsburgh Medical Center, 2004–present
Vice president and corporate officer (1 of only 5) of a 400-person consulting firm, 2000–2003
Department chair and professor of strategy at the National Defense University, 1998–2000
US Air Force colonel and former commander of America’s VIP fleet of aircraft at Andrews AFB, Maryland, 1996–1998

Col. Randall Larsen

Exclusive Representation

    * Homeland security Advisor for CBS News
    * Director of the Institute for Homeland Security
    * Analyst & Commentator on "Larry King Live," "Jim Lehrer News Hour," and "Oprah"

Keynote Fee : $5,001 - $10,000 plus expenses  Fee Note

Travels From: VA

Bioterrorism: Myth or Reality?

Some call it the greatest threat America will face in the 21st century; others say it is grossly over-hyped. Who is right? What priority should America place on biodefense? Will a biodefense program better prepare America for the public health and medical challenges of the 21st century, or will it divert valuable resources? Colonel Larsen, the former Chairman of the Department of Military Strategy and Operations at the National War College says, "In the 21st century, public health will be as important to national security as the Department of Defense was in the 20th century. Research and development for new vaccines and treatments are perhaps more important today than R&D for new weapons systems in the Pentagon."
Our Own Worst Enemy

In this program, based on his upcoming book of the same name, Colonel Larsen explains why government (and sometimes, corporate) over-reactions to 9-11 may be a greater threat to the American economy than al Qaeda. What are the real threats, and what is the hype? What are the challenges and opportunities for corporations in this new security environment? With the common sense of an Indiana corn farmer, the insights from more than a decade of study in homeland security, combined with an entertaining delivery, filled with insider stories that range from sobering to hilarious, this former vice president and corporate officer tells you what America's business leaders need to know about security in the 21st century.
Safe, Comfortable, Reliable

For two years, Colonel Randy Larsen commanded America's fleet of VIP aircraft at Andrews AFB, Maryland. He provided a clear and concise vision for the 1,000 people he commanded: "We provide safe, comfortable, reliable air transportation to America's leaders." This was a 24/7 operation that routinely had air crews and planes on six different continents in more than a dozen time zones. Larsen shares his thoughts on executive leadership, the challenges of customers who expect perfection every day, team building, motivation and most of all, an intense focus on safety and quality. Insightful, inspiring and entertaining.
Biosecurity in the 21st Century

Biosecurity will change many aspects of our lives in the 21st century. It has three key elements. First, it will be one of the economic dynamos that drives the global economy in the 21st century. The biotechnical revolution will revolutionize economic development as dramatically as the industrial revolution did in the 19th century. Second, proper investments can leverage this technology to make quantum improvements in both public health and medical care delivery, not only for Americans, but for all people. Third, there will unfortunately be a dark side to the biotechnical revolution that will include bio-terrorists, bio-hackers, and bio-errors in addition to the naturally-occurring bio-threats we will face. Harnessing the power of the biotechnical revolution can provide America the bio-defenses required for combating both the natural and man-made threats.
Asking the Right Questions About Homeland Security

Colonel Randall Larsen, USAF (Ret), author of OUR OWN WORST ENEMY (Grand Central Publishing, September 2007), and former Chairman, Department of Military Strategy and Operations at the National War College, explains how leaders in both the public and private sectors continue to ask the wrong questions about homeland security. Larsen's list of wrong questions include: "How do we prevent terrorists from smuggling nuclear weapons into America?" "How do we prevent biological terrorism?" "Why aren't we preparing our major cities for rapid evacuations?" Colonel Larsen explains why these are the wrong questions, and then identifies the right questions that he has developed from more than 13 years of study in this field. His presentation is filled with insider stories ranging from sobering to hilarious (including the day he smuggled a weapon of mass destruction into a meeting with Vice President Cheney). This speech is jam-packed with take-home value for corporations, local communities, and families.
Corporate Responsibility and Homeland Security

From the Fortune 100s to small businesses, Larsen's message has great appeal and take-home value. He explains how both the private and public sectors have been focused on the wrong questions in the post 9-11 world, and argues that corporations, large and small, must understand that building resilience to man-made and natural threats must be a higher priority than the traditional security focus of buying gates, gun, guards and gadgets. This speech is based on research from his next book: The Investor's Guide to Homeland Security. The "investors" are stockholders and taxpayers who deserve the best return on their investments - something most are not receiving today.
Speaker Information

    * Two days after 9-11, when VP Cheney wanted a briefing on the threat of bio terrorism, he called Randy Larsen

    * During the anthrax crisis of Oct 2001, Larry King needed an expert; he called Randy Larsen-6 nights in a row

    * When the Deputy Secretary of Agriculture wanted help in developing a counter terrorism program at USDA, he called Randy Larsen

Colonel Randall Larsen, USAF (Ret), is the Founding Director of The Institute for Homeland Security. He previously served as Chairman of the Department of Military Strategy and Operations at the National War College.

Colonel Larsen began his studies of homeland security in 1994 while on a one-year fellowship at the University of Pittsburgh Graduate School of Public and International Affairs. Today, Congressman Chris Cox, Chairman of the House Homeland Security Committee calls him, "One of America's top authorities on homeland security." One of the first witnesses to testify before the 9-11 Commission, Colonel Larsen has served as an expert witness to the Senate Armed Services, Senate Judiciary, House Government Reform, House Homeland Security, and House Budget Committees since 9-11. In March of this year, he ran a two-day workshop at Wye River for 28 members of the House Homeland Security Committee.

Colonel Larsen has also provided private briefings and tutorials on a wide range of Homeland Security topics to numerous members of Congress, including Senators Kennedy, Warner, Kyl, Feinstein, Roberts, Cornyn, Graham, as well as members of the Bush Administration, including Vice President Cheney and Secretary Ridge. Additionally, he served on the 2003 Defense Science Board Summer Study on Homeland Security, and is a member of the Council on Foreign Relations.

An internationally renowned leader in war gaming and executive simulations, Colonel Larsen and his war-gaming skills have been referred to as a "national treasure" by Former Deputy Secretary of Defense John Hamre. The knowledge and conclusions derived from these exercises have led to the implementation of new programs and policies by the Administration and Congress.

Colonel Larsen is the author of several publications, including The Executive's Desk Book on Corporate Risks and Response for Homeland Security, What Corporate America Needs to Know About Bioterrorism, and Defending the American Homeland 1993-2003. His newest work, Our Own Worst Enemy: Why Our Misguided Reactions to 9-11 Might be America's Greatest Threat, is scheduled for release on 9/11 2005.

The Homeland Security consultant to CBS News since March 2003, Colonel Larsen is also a frequent guest on radio and television, including CBS, NBC, ABC, CNN, BBC, NPR, "Jim Lehrer News Hour," FOX News Channel, "Larry King Live," and "Oprah." His analysis and opinions have recently appeared in The Washington Post, The Wall Street Journal, The New York Times, The Chicago Tribune, USA Today, Christian Science Monitor, The Los Angeles Times, Newsweek, Time, and Business Week.

A veteran of 32 years served in both the Army and Air Force, Colonel Larsen's flying career began when he was a 19-year-old Cobra pilot in the 101st Airborne Division. He flew 400 combat missions in Vietnam. He also served as military attache at the US Embassy in Bangkok, the chief of legislative liaison at the US Transportation Command, and the commander of America's fleet of VIP aircraft at Andrews AFB MD. His decorations include the Legion of Merit, Distinguished Flying Cross, Bronze Star, 17 awards of the Air Medal (3 with "V" Device for Valor), and the South Vietnamese Cross of Gallantry.

"Excellent presentation on Biological WMD - exceptional and stimulating - great delivery - best in the nation on this subject!"

- SR Government Executives

"America's leading expert on homeland security!"

- Congressman Chris Cox, Chairman of House Homeland Security Committee

"We had a packed house and you were clearly the hit of the day. My boss asked me to package this program and replicate it on a global basis!"

- Oracle

Statement of Randall J. Larsen to the National Commission on Terrorist Attacks Upon the United States
April 1, 2003

Mr. Chairman, distinguished members, I appreciate the opportunity to appear before this committee. Let me begin with my bottom line.

My first recommendation is that your focus should be on the future, not the past. And when I say the future, I am not talking about next year. That will not allow sufficient time to make the substantial changes that are required. Furthermore, your focus should be on how America failed, not which individuals or even which organizations failed. Let me explain.

Whenever people ask me why I went to Vietnam, I answer, "Why did you send me?" I did not volunteer, and I was not old enough to vote. I actually had little to do with it.

The same type of response might be appropriate for why our systems failed to prevent the attacks of 9-11. You should not seek to assign blame to those who worked within the system. We, the American people, gave them a system that was terribly flawed for the mission required.

We did not intend to give them a flawed system. The system began with the creation of the Central Intelligence Group by President Truman, and evolved through the National Security Act of 1947, the covert actions of the 1950s, the domestic intelligence abuses of the 1960's, and the reforms that came out the Church hearings. It was designed for the Cold War. But in 1993, at the World Trade Center, international terrorism came to America, and the nature of the threat changed. Unfortunately we did not change the apparatus meant to protect us.

As the former CEO of General Electric, Jack Welch, has noted, "When the outside is changing faster than the inside, the end is near." On 9-11, we reached the end of an era--an era when we could afford to have a solid firewall between intelligence and law enforcement, and an era where battlefields were "over there."

Even though I have been studying homeland security for nearly a decade, I did not fully understand how seriously flawed this system had become. Last year I spent six months working on the follow-up to the DARK WINTER exercise. Many of you have probably heard of DARK WINTER. The effort was led by John Hamre from CSIS, Tara O'Toole from Johns Hopkins, and me. It was a two-day exercise in June 2001 that simulated a smallpox attack on the United States homeland. Senior national security figures such as Sam Nunn, David Gergan, Jim Woolsey, Bill Sessions, and Governor Frank Keating played key roles in this exercise. We have briefed the results of this exercise to key leaders including Vice President Cheney, Secretary Ridge, and numerous members of Congress.

Many of these same senior national security leaders participated in the two-day SILENT VECTOR exercise in October 2002. SILENT VECTOR was a joint effort led by John Hamre and Phil Anderson from the Center for Strategic and International Studies and Dave McIntyre and me for the ANSER Institute for Homeland Security. SILENT VECTOR was a unique homeland security exercise, because in the scenario, the attack never occurred.

The participants, who were acting as the Homeland Security Council, were provided increasingly specific and credible information of an impending attack. We wanted to see what actions these senior participants would take. What would be the economic impact of these attacks? In some of the scenarios we examined during our preparation; we discovered that over-reactions by the government could cause more economic damage than the actual attacks. In the exercise, we learned that it is very difficult to estimate the economic impact of these actions.

The terrorists were planning an attack on critical energy and chemical infrastructure on the East Coast of the United States. Intelligence information, primarily focused on activities outside the United States, provided a continuing stream of details from numerous sources and methods in several countries and regions. Law enforcement information, from the Federal and local levels was provided to the decision makers and even included one "walk-in" who had developed cold feet. A third stream of information was provided to the participants. This information assessed the vulnerabilities of various types of infrastructure and the potential consequences of various types of attacks.

What the organizers and participants of SILENT VECTOR found so surprising is that there is no agency within the US government that serves as a fusion center for these three data streams. Yet, it is this type of fusion that would be required to allow senior elected and appointed officials to decide how to use their limited resources to defend our homeland.

Should extra security be placed at nuclear power plants or chemical storage faculties? Could attacks on gas pipelines turn off the heat on the East Coast during a very cold winter? What about liquefied natural gas storage facilities--are they more of a threat than a nuclear power plant or several rail cars filled with chlorine gas? Which would be easiest to attack? Which would be the most significant threat to the most people?

Since an organization to fuse information from three independent data streams did not exist last spring, the planners of SILENT VECTOR created one for the exercise. Could the attacks have been detected and thwarted if this type of organization existed prior to 9-11? America had intelligence information of training classes in an old airliner in Salmon Pak, south of Baghdad. At this site, terrorists were trained how to hijack airliners using only short knives. Had this intelligence information been fused with information from the FBI and FAA, America might have had the opportunity to thwart the 9-11 attacks.

If a fusion center had been equipped with sophisticated data-mining capabilities, that Florida State Trooper who stopped Mohammad Atta in July 2001 for a routine traffic violation might have discovered that Atta was a person of interest to the CIA, the Treasury Department, and FAA. Even as late as the morning of 9-11, appropriate information systems and data-mining technologies could have identified three of the hijackers who were on terrorist watch lists, four more who listed the same address as those on watch lists, three more who had made frequent phone calls to those addresses, and two more who had previously used Mohammad Atta's frequent flier number.

Would a fusion center armed with this type of technology have prevented 9-11? No one can know. But this we do know--and this is not from Randy Larsen, but General Dwight David Eisenhower: "The right system will not guarantee success, but the wrong system will guarantee failure."

On 9-11, America had the wrong system in place to defend our homeland.

My advice: do not focus your efforts on the individuals or organizations that were given the wrong system. Fix the system. Do not focus your efforts on next year. Look five years down the road. Describe which threats you will address. You cannot build a system capable of protecting America from all threats. If we do not establish priorities, the greatest threat will become uncontrolled spending. Do not waste your time on systems that could prevent car bombings. They will not threaten the survival of our nation. Your two top priorities should be nuclear weapons and sophisticated biological weapons. Genetically engineered biological weapons will be the greatest threat America faces in the coming decades.

Your goal should be to design for America a system that will fuse intelligence information, law enforcement information, and vulnerability assessments along with the enormous amount of data in the commercial sector that is available to banks and other corporations, but not necessarily to those who are charged with defending America. This system will also need to deliver timely information to its users--everyone from the President to the police officer on the beat in New York City and the public health officer in Hays County, Texas. And without question, the information provided to various users must be acceptable within our constitutional and cultural values--no easy challenge, but it will be our best investment in security.

Furthermore, this system will be of great value not only in the prevention mode, but also for mitigation and response. This system will be critically important for the Department of Homeland Security in determining where and how to best spend their funds for training, education, and equipment. These decisions should be based on threats and vulnerabilities, not politics as usual.

Today, I see no organization within the new Department of Homeland Security
or the Terrorism Threat Intelligence Center that can perform this function. Start with a blank piece of paper.

Thank you, and I look forward to your questions.

Randy Larsen is an ANSER Vice President and the Director of the Institute for Homeland Security, a not-for-profit public-service research institute. He is a member of the Defense Science Board (2003, DoD's Role in Homeland Security), and serves as a member of the editorial board for the quarterly journal Bioterrorism and Biosecurity: Biodefense Strategy, Practice, and Science (Johns Hopkins University).

Since September 11, 2001, numerous senior government officials, including Vice President Cheney and Governor Ridge, have sought his advice and counsel. He has served as an expert witness in hearings held by the Senate and the House of Representatives and provided informational briefings to numerous Members of Congress, the military, the Intelligence Community, and business audiences. His recent speaking engagements include the Council on Foreign Relations, the Foreign Policy Association, the International Institute for Security Studies (London), the German Marshall Fund (Brussels), the Young Presidents' Organization, the Washington State Police Chiefs Annual Conference, numerous universities, and World Affairs Councils. He is also a frequent guest commentator on national television and radio, including the Jim Lehrer NewsHour, CBS News, ABC World News Tonight, MSNBC, and Larry King Live, plus NPR, CNN, ABC, NBC, CBC and BBC radio.

He is a co-author of The Executive's Desk Book on Corporate Risks and Response for Homeland Security, published by the National Legal Center for the Public Interest (March 2003). He and his staff developed and teach graduate courses in homeland security at George Washington University, Johns Hopkins School of Arts and Sciences, and the National War College. During the past eight years, he has written and lectured extensively on the subjects of asymmetric and biological warfare and the 21st-century challenges of homeland security. He previously served as the Chairman of the Department of Military Strategy and Operations at the National War College, as a government advisor to the Defense Science Board (2000, Intelligence Requirements for Homeland Defense), as a research fellow at the Matthew B. Ridgway Center for International Security Studies (1994-1995), and as a fellow in the Massachusetts Institute of Technology Seminar XXI program (1999-2000).

He was a co-developer of the nationally acclaimed Dark Winter exercise. Key players in this exercise included the Governor of Oklahoma, Frank Keating; former Senator Sam Nunn; special assistant to four presidents David Gergen; former Director of Central Intelligence Jim Woolsey; and former FBI Director William Sessions.

In June 2000, Colonel Larsen retired following 32 years of military service in the Army and Air Force. His assignments included 400 combat missions in Cobra gunships in Vietnam and duties as a military attaché, legislative assistant, and commander of America's fleet of VIP aircraft at Andrews Air Force Base in Maryland. His military decorations include the Defense Superior Service Medal, the Legion of Merit, the Distinguished Flying Cross, the Bronze Star, 17 Air Medals, and the South Vietnamese Cross of Gallantry. He has a Master of Arts degree in National Security Studies from the Naval Post Graduate School.


  • Guest

ANSER Institute for Homeland Security

The ANSER Institute for Homeland Security is a not-for-profit public- service research organization examining a new set of national security challenges. Initiated and funded by ANSER's Board of Trustees in October 1999 and formally established in April 2001, the Institute believes that preparing for these new challenges will require a determined, integrated effort at every stage of the process: deterrence, prevention, preemption, crisis management, consequence management, attribution and response.

The ANSER Institute for Homeland Security is leading the debate through executive-level education, public awareness programs, workshops for policy makers and online publications: a weekly newsletter (with 15,000 subscribers) and the Journal of Homeland Security, which features articles by senior government leaders and leading homeland security experts.
President and CEO
Dr. Ruth David, Ph.D

In October 1998, Dr. David became president and chief executive officer of ANSER, an independent, non-profit, public service research institution that provides research and analytic support on national and transnational issues. In November 1999, Dr. David initiated ANSER's Homeland Defense Strategic Thrust to address the growing national concern of multi- dimensional, asymmetric threats from rogue nations, sub-state terrorist groups, and domestic terrorists. In May 2001, the ANSER Institute of Homeland Security was established to enhance public awareness and education and contribute to the dialog on a national, state, and local level.

From September 1995 to September 1998, Dr. David was Deputy Director for Science and Technology at the Central Intelligence Agency. As Technical Advisor to the Director of Central Intelligence, she was responsible for research, development, and deployment of technologies in support of all phases of the intelligence process. She represented the CIA on numerous national committees and advisory bodies, including the National Science and Technology Council and the Committee on National Security. Upon her departure from this position, she was awarded the CIA's Distinguished Intelligence Medal, the CIA Director's Award, the Director of NSA Distinguished Service Medal, the National Reconnaissance Officer's Award for Distinguished Service, and the Defense Intelligence Director's Award.

Previously, Dr. David served in several leadership positions at the Sandia National Laboratories, where she began her professional career in 1975. Most recently, she was Director of Advanced Information Technologies. From 1991 to 1994, Dr. David was Director of the Development Testing Center that developed and operated a broad spectrum of full-scale engineering test facilities.

Dr. David is a member of the President's Homeland Security Advisory Council, the National Academy of Engineering (NAE), and the Corporation for the Charles Stark Draper Laboratory, Inc. She serves on the National Security Agency Advisory Board, the National Research Council Naval Studies Board, and the Senate Select Committee on Intelligence Technical Advisory Group. She previously served on the Defense Science Board, Department of Energy Nonproliferation and National Security Advisory Committee, and the Securities and Exchange Commission Technical Advisory Group. She is a former adjunct professor at the University of New Mexico and has technical experience in digital and microprocessor-based system design, digital signal analysis, adaptive signal analysis, and system integration. She is an Associate Fellow of AIAA, a Principal on the Council for Excellence in Government, a Class Director for the AFCEA International Board of Directors, and a member of Tau Beta Pi Engineering Honor Society and Eta Kappa Nu Electrical Engineering Society.

Dr. David received a B.S. degree in Electrical Engineering from Wichita State University (1975), an M.S. degree in Electrical Engineering from Stanford University (1976), and a Ph.D. in Electrical Engineering from Stanford University (1981).

Dr. David frequently provides speeches, interviews, lectures, briefings, and articles on the many facets of homeland security. She is the coauthor of three books on Signal Processing Algorithms and has authored or coauthored numerous papers.

She has also been recently appointed to the Presidents Homeland Security Advisory Council.

And was an “observer” of the biological weapons simulation “Dark Winter”

Randy Larsen

Randy Larsen is the Randy Larsen is the Director of the Institute for Homeland Security at ANSER, a nonprofit public-service research institute. He previously served as the Chairman of the Department of Military Strategy and Operations at the National War College where he continues to teach the Homeland Security course. He has also served as a government advisor to the Defense Science Board and as a research fellow at the Matthew B. Ridgway Center for International Security Studies. During the past eight years, he has written and lectured extensively on the subjects of asymmetric and biological warfare, and the 21st century challenges of homeland security.

Larsen's recent speaking engagements include: the Council on Foreign Relations, the International Institute for Security Studies, the German Marshall Fund, the Royal United Services Institute, several World Affairs Councils, plus numerous military, counter proliferation, and intelligence conferences. He is also is a frequent guest commentator on national television and radio shows including: the Jim Lehrer News Hour, CBS News, ABC's Nightline, Larry King Live, plus NPR, CNN, ABC, NBC, CBS, and BBC radio.

He currently serves as a member of the editorial board for the quarterly journal, BIOTERRORISM and BIOSECURITY: Biodefense Strategy, Practice and Science. He was the co-developer of the nationally-acclaimed DARK WINTER exercise which simulated a major bioterrorism event in the United States. Key players in this exercise included the current Governor of Oklahoma, Frank Keating; former Senator Sam Nunn, special assistant to five presidents, David Gergan; former Director of Central Intelligence, Jim Woolsey; and former FBI Director, William Sessions.

In June 2000, Colonel Larsen retired following 32 years of military service in both the Army and Air Force. His assignments included 400 combat missions in Cobra helicopter gunships in Vietnam, duties as a military attaché, legislative assistant, and as the commander of America's fleet of VIP aircraft at Andrews Air Force Base in Maryland. His military decorations include the Defense Superior Service Medal, the Legion of Merit, the Distinguished Flying Cross, the Bronze Star, 17 Air Medals, and the South Vietnamese Cross of Gallantry. He has a Master of Arts degree in National Security Studies from the Naval Post Graduate School.

Contact Information:
Phone: (703) 416-3597
Email: [email protected]

And was a member of the “exercise staff” of “Dark Winter”

Deputy Director
Col. Dave McIntyre, PhD. (USA, Ret.)

Dr. David McIntyre is the Deputy Director of the ANSER Institute for Homeland Security. Since joining the Institute, he has authored numerous articles, briefings, and think pieces on Homeland Security, to include several available on the web at He has appeared regularly as a strategy and Homeland Security expert on FOX national news and Washington DC television (WUSA), as well as MSNBC, CNN's Crossfire, Voice of America, the US State Department's "Dialogue" series, Australian national television, and the Canadian Broadcasting Network.

In June 2001 Dr. McIntyre retired as a colonel after a 30 year Army career, culminating with eight years on the faculty of the National War College, National Defense University, the last three as Dean of Faculty and Academic Programs. As a faculty member, he taught courses in National Security Strategy, Military Strategy and Operations, Asia-Pacific Security, and strategy and culture. He also served as the Director of Research and Writing, and directed the incorporation of homeland security into the curriculum starting in 1999. For the previous six years, he worked pol-mil and strategic issues in the Office of the Army Chief of Staff in Washington, DC, and as the speechwriter for the Commander-in-Chief, United States Pacific Command, in Honolulu, Hawaii. As an armor officer, he was Airborne, Ranger, and Jumpmaster qualified, with ten years of joint experience. He served in airborne and armored cavalry units in both the United States and Germany, and on the faculty of the English Department at West Point.

Dr. McIntyre holds a BS in Engineering from West Point, an MA in English and American literature from Auburn University, and a Ph.D. in Political Science from the University of Maryland. He is a graduate of the US Army War College and the National War College.

Contact info:
Cell: 571-278-3397
Office: 703-416-4748
Fax: 703-416-1306

Office: [email protected]

Home: [email protected]

Senior Fellow
Peter Roman, PhD.

Peter J. Roman is a Senior Fellow at the ANSER Institute for Homeland Security and an Associate Professor of Political Science at Duquesne University. He is author of Eisenhower and the Missile Gap (Cornell University Press). Dr. Roman has authored numerous articles on national security and defense policy, including: "Ike's Hair Trigger: U.S. Nuclear Predelegation, 1953-1960," in Security Studies; "The Joint Chiefs of Staff: From Service Parochialism to Jointness," in Political Science Quarterly; and "Is There A Gap Between Civilian and Military Leaders? If So, Does It Matter?," in Feaver and Kohn, The Civil-Military Gap And American National Security In the 21st Century (Forthcoming: MIT Press, 2001). Dr. Roman has served as a Distinguished Visiting Professor at the National War College, Washington, DC and taught at the University of Wisconsin-Madison, the University of Alabama, and the University of Colorado-Boulder.

Dr. Roman is writing a book with David Tarr on the role of the Joint Chiefs of Staff in national security policy making. He is also currently researching and writing a study on the relationship between organizational design and homeland security professionalism. Dr. Roman earned his MA and PhD at the University of Wisconsin-Madison.

Contact Information:
Phone: (703) 416-1304
Email: [email protected]

And was an “observer” of the biological weapons simulation “Dark Winter”

Editor-in-Chief: Journal of Homeland Security
Alan Capps

Research Analyst / Editor-in-Chief: Homeland Security Newsletter
John Wohlfarth

And was a member of the “exercise staff” of “Dark Winter”

Operations Manager
Sonita Almas

Steve Dunham
Board of Advisors
Dr. Jay C. Davis (Chairman)

Jay Davis is National Security Fellow at the Center for Global Security Research at Lawrence Livermore National Laboratory. For the three years prior to rejoining Livermore in July of 2001, he served as the founding Director of the Defense Threat Reduction Agency of the United States Department of Defense. Dr. Davis received his BA in Physics from the University of Texas in 1963, his MA in Physics from the University of Texas in 1964, and his Ph.D. in Physics from the University of Wisconsin in 1969. From 1969 to 1971, he was an Atomic Energy Commission Postdoctoral Fellow in nuclear physics at the University of Wisconsin. At Livermore since 1971, he has worked as a research scientist and as an engineering manager, having led the design and construction of several unique accelerator facilities used for basic and applied research.

In the 1970's, he was principal scientist and project manager for the design and construction of the Rotating Target Neutron Source-II Project, building the most intense 14 MeV neutron sources in existence, used for nine years by the US and Japan for fusion materials testing. In the 1980's he became the founding Director the Center for Accelerator Mass Spectrometry, building the most versatile and productive AMS lab in the world. CAMS is used by all nine campuses of the University of California and several hundred international users. He played a major role in the application of AMS to the biosciences, particularly in low-level toxicology and in dose reconstruction from events such as Hiroshima, Nagasaki and Chernobyl. In 1994, he was asked to merge several research organizations at Livermore to create the Earth and Environmental Sciences Directorate. In 1998, he became the first Director of the Defense Threat Reduction Agency, integrating DoD's technical and operational activities to deal with WMD.

Davis has numerous publications on research in nuclear physics, nuclear instrumentation, plasma physics, accelerator design and technology, nuclear analytical techniques and analytical methods, and treaty verification technologies. He holds patents on spectrometer technologies and methods for low-level dosimetry of carcinogens and mutagens, and for the study of metabolic processes. He has been a scientific advisor to the UN Secretariat, several US agencies, and has served on advisory committees for the Lawrence Berkeley National Laboratory, the Australian Nuclear Science and Technology Organization, and the Institute for Nuclear and Geologic Sciences of New Zealand. Davis participated in two UN inspections of Iraq in the summer of 1991, and was selected as the only non-UN member of the team that briefed the UN Security Council after the confrontation at Fallujah on June 28, 1991 that produced the conclusive evidence of Iraqi evasion of the inspection process and violation of the Non- Proliferation Treaty.

Davis was Phi Beta Kappa and a Junior Fellow of the College of Arts and Sciences at Texas. He is a Fellow of the American Physical Society and was one of its Centennial Lecturers in its Hundredth Anniversary Year. For his contributions to national security during his tenure at DTRA, he was twice awarded the Distinguished Public Service Medal, DoD's highest civilian award. His current interests are homeland defense, nuclear and biological forensics, applications of accelerator technologies to multi-disciplinary research, and strategic planning and management of change in organizations. He has been married to Mary McIntyre Davis for thirty-eight years. They have two married children and a grandson.

Mr. Michael J. Bayer
U.S. Army Science Board

Michael J. Bayer is a consultant in private enterprise strategic planning, acquisitions and mergers. Mr. Bayer began his career in public service in 1977 when he was appointed Counsel to a Republican Representative from Ohio; he went on to serve as the Congressman's Executive Assistant until 1981.

Leaving the Hill, Mr. Bayer was appointed Deputy Assistant Secretary for Congressional Affairs at the U.S. Department of Energy. In 1982, he became Secretary Malcolm Baldridge's Associate Deputy Secretary of Commerce. In November of 1984, Mr. Bayer returned to the private sector accepting the position of Counselor to the United States Synthetic Fuels Corporation.

In 1985, Mr. Bayer went on to the Panhandle Eastern Corporation, a Fortune 200 Company headquartered in Houston, Texas, where he was responsible for the Company's regulatory and legislative matters. In January of 1990, Mr. Bayer was named Counselor to President Bush's Commission on Aviation Security and Terrorism (Pan Am 103). There he was responsible for organizing a comprehensive investigation of domestic and international aviation security systems. In October of 1990, Mr. Bayer was appointed by the President and confirmed by the United States Senate as the Federal Inspector for the Alaska Natural Gas Transportation System (PAS III), serving in that position until April, 1992. His responsibilities included oversight of the construction and initial operation of the 4,800-mile Alaska natural gas pipeline.

Mr. Bayer currently serves as Chairman of the U.S. Army Science Board and as a Member of the Defense Science Board. In addition to his corporate directorships, he serves as a Member of the Advisory Board of the Association of the United States Army where he chairs AUSA's Land Warfare Committee. He is a Member of the John Carroll Society and the National Ski Patrol.

Mr. Bayer has previously served as a Member of the Board of Visitors of the United States Military Academy (Appointed by President Reagan), a Trustee of Washington's Source Theater (Chairman of the Board (1989-91), a Member of the Board of the Potomac Community Theater, a Member of the Army Science Board (1990-92), and a Member of the Board of Directors of The American Heart Association (Nation's Capital Affiliate).

He has also served on a number of non-partisan task forces to improve the management and efficiency of the Department of Defense. Most recently the Secretary's Defense Reform Task Force (1997), The Congressionally directed review of the Department's Experimentation and Transformation (1999), and the review of the Economic Health of the Defense Industrial Base (2000).

Dr. John Gannon
Head of Intelligence unit of Dept for Homeland Security
(note: exact title uncertain as position was only confirmed 15th August 2002)

John C. Gannon is Vice-Chairman of Intellibridge Corporation, a Washington firm that provides web-based analysis to corporate and government clients. Previously he served as Chairman of the National Intelligence Council (1997-2001) after serving for two years (1995-1997) as the Deputy Director for Intelligence, Central Intelligence Agency. In June 1998, Mr. Gannon was also appointed the Assistant Director of Intelligence for Analysis and Production.

From 1992 until 1996, Mr. Gannon was the Director of the Office of European Analysis in the Directorate of Intelligence (DI). Before that, he held many assignments in the DI, including various management positions in the Office of European Analysis and tours on the staff of the President's Daily Brief, in the Office of Economic Research, and as a Latin America analyst.

Mr. Gannon served as a Naval Officer in Southeast Asia and later, while in the Naval Reserves, was an instructor of navigation at the Navy Officer Candidate School in Newport, Rhode Island. He has been active in civic affairs in Falls Church, Virginia, serving on the City Council and Planning Commission (as Vice Chairman and Chairman). Early in his career, Mr. Gannon taught social studies and science in a secondary school in Jamaica as a member of the Jesuit Volunteer Corps. He also taught high school in Saint Louis.

Mr. Gannon earned a Ph.D. and an M.A. in history from Washington University in Saint Louis and a B.A. in psychology from Holy Cross College in 1966. His graduate studies focused on Latin America, and his doctoral dissertation documented the evolution of political parties in Jamaica. He speaks Spanish.


Admiral Harold W. Gehman Jr.

Admiral Harold W. (Hal) Gehman, jr., USN (ret), completed over 35 years of active duty in the U.S. Navy in October 2000. His last assignment was as NATO's Supreme Allied Commander, Atlantic and as the Commander in Chief of the U.S. Joint Forces Command, one of the United States' five geographic Unified Commands.

Gehman was born in Norfolk, Va. on 15 October 1942 and graduated from Pennsylvania State University with a BS in Industrial Engineering and a commission in the Navy from the NROTC program. A Surface Warfare Officer, he served at all levels of leadership and command in guided missile destroyers and cruisers. During the course of his career, Gehman had an unusual five sea commands in ranks from Lieutenant to Rear Admiral.

Admiral Gehman served in Vietnam as Officer in Charge of a Swift patrol boat and later in Chu Lai as Officer in Charge of a detachment of six Swifts. His staff assignments were both afloat on a Carrier Battle Group staff and ashore on a fleet commander's staff, a Unified Commander's staff and in Washington DC on the staff of the Chief of Naval Operations (four tours).

Promoted to four-star Admiral in 1996, he became the 29th Vice Chief of Naval Operations in September 1996. As VCNO he was a member of the Joint Chiefs of Staff, formulated the Navy's $70B budget and developed and implemented policies governing the 375,000 people in the Navy.

Assigned in September 1997 as SACLANT and CINC US Joint Forces Command he became one of NATO's two military commanders and assumed command of all forces of all four services in the continental U.S. and became responsible for the provision of ready forces to the other Unified CinCs and for the development of new joint doctrine, training and requirements.

Dr. John J Hamre

John Hamre was elected CSIS president and CEO in January 2000. Before joining CSIS, he served as U.S. deputy secretary of defense (1997-1999) and under secretary of defense (comptroller) (1993-1997). As comptroller, Dr. Hamre was the principal assistant to the secretary of defense for the preparation, presentation, and execution of the defense budget and management improvement programs.

Before serving in the Department of Defense, Dr. Hamre worked for ten years as a professional staff member of the Senate Armed Services Committee. During that time he was primarily responsible for the oversight and evaluation of procurement, research, and development programs; defense budget issues; and relations with the Senate Appropriations Committee.

From 1978 to 1984, Dr. Hamre served in the Congressional Budget Office, where he became its deputy assistant director for national security and international affairs. In that position, he oversaw analysis and other support for committees in both the House of Representatives and the Senate.

Dr. Hamre received his Ph.D., with distinction, in 1978 from the School of Advanced International Studies, Johns Hopkins University. His studies focused on international politics and economics and U.S. foreign policy. He received a B.A., with high distinction, from Augustana College in Sioux Falls, South Dakota, in 1972, emphasizing political science and economics. He also studied as a Rockefeller Fellow at the Harvard Divinity School.

Dr. Hamre is married to the former Julia Pfanstiehl, and they reside in Bethesda, Maryland.

He was also a member of the “exercise staff” of the “Dark Winter” simulation

He is also a commissioner with `The Commission on the Future of the U.S. Aerospace Industry’

(see) aerospace_commission.htm

Mr. Phil E. Lacombe

Phil Lacombe is President of the Information and Infrastructure Protection (IIP) Sector within Veridian. IIP provides information and infrastructure protection services to U.S. military and intelligence community. The Sector provides a range of network protection services including vulnerability assessment, forensics and network security architecture, design, operation and management. IIP also provides computer emergency response capabilities.

Mr. Lacombe has been with Veridian since February 1998. Prior to being named a Sector President, he was the corporation's Senior Vice President for Assurance, and Senior Vice President for Policy and Communications. Before joining Veridian, Mr. Lacombe was the Director of the President's Commission on Critical Infrastructure Protection (PCCIP), a position he held from September 1996 to February 1998.

Before joining the Commission, Mr. Lacombe was the Managing Director of the Aerospace Education Foundation, a not-for-profit institution providing educational programs nationwide. Mr. Lacombe also served as the Special Assistant to the Chairman of the Commission on Roles and Missions of the Armed Forces from July 1994 through August 1995. He was responsible for drafting the Commission's report.

In January 1994, Mr. Lacombe retired with twenty years service as a colonel in the US Air Force. His assignments in the Air Force included Speech Writer to Secretary of Defense Weinberger, Assistant to the Commander of Air Force Systems Command, Counter Narcotics Strategy at the National Drug Policy Board in the Office of the U.S. Attorney General, and Director of Public Affairs for US and Air Force Space Commands and the North American Aerospace Defense Command.

He is a graduate of the National War College, Air Command and Staff College and Squadron Officers School. He has a Master's Degree in Journalism from the University of North Carolina and a BA from the University of Massachusetts.

Dr. Joshua Lederberg

Dr. Joshua Lederberg, a research geneticist, is Sackler Foundation Scholar and President- emeritus at the Rockefeller University, one of the world's leading scientific institutions devoted to biomedical research. Dr. Lederberg was educated at Columbia and Yale University, where he pioneered in the field of bacterial genetics with the discovery of genetic recombination in bacteria. Because of their simple structure and rapid growth, bacteria have afforded geneticists a fruitful field for research, which has also ripened recently into many medical and industrial applications. In 1958, at the age of 33, Dr. Lederberg received the Nobel Prize in Physiology of Medicine for this work and subsequent research on bacterial genetics.

Dr. Lederberg has been a professor of genetics at the University of Wisconsin and then at Stanford University School of Medicine, until he came to the Rockefeller University in 1978. A member of the National Academy of Sciences since 1957, and a charter member of its Institute of Medicine, Dr. Lederberg has been active on many government advisory boards, such as NIH study sections and the National Advisory Mental Health Council, and has served as Chairman of the President's Cancer Panel.

In recent years, he has been particularly active as a consultant in national security affairs, and has served on such bodies as the Defense Science Board, the CNO Executive Panel, the Intelligence Community's Proliferation Policy panels, and the Commission on Integrated Long Range Strategy, with particular concern for problems of biological weapons proliferation. Since 1972, when he served as advisor to the US delegation at the UN Committee on Disarmament in Geneva during the negotiation of the Biological Weapons Convention, he has been particularly concerned with arms control and other preventative and defensive measures.

Dr. Lederberg has been awarded numerous honorary Doctor of Science M.D., and Doctor of Military Medicine degrees, as well as a foreign membership of the Royal Society, London. He retired as president of the Rockefeller University in July 1990, and continues his research activities there in chemical mutagenesis in bacteria.

Ms. Judith Miller

Judith Miller is a partner at Williams & Connolly LLP, advising on a wide range of business and governmental issues, including corporate and individual officer counseling, and complex civil, and business-related criminal, litigation. She returned to the firm in January 2000, after serving as the General Counsel for the Department of Defense for over five years. As General Counsel, Ms. Miller was the Chief Legal Officer for more than 6,000 lawyers at the Department. She was responsible for advising the Secretary and Deputy Secretary and their senior leadership team on a wide range of legal and policy issues, including mergers and acquisitions, international affairs and intelligence matters, operations law, acquisition and business reform, major procurements, significant litigation and investigations, globalization, computer security, alternate dispute resolution, as well as personnel, fiscal, environmental, and health policy issues.

She took the lead in dealing with the Department of Justice on all significant issues affecting DoD, and also dealt extensively with the Department of State, the National Security Council, the Department of Commerce (on export and encryption issues), and the Federal Trade Commission. Previously at Williams & Connolly, Ms. Miller's counseling and litigation practice included civil and criminal litigation and investigations related to defense procurement, healthcare, and financial institutions; and complex torts. She also has extensive experience in the representation of corporations and corporate officers in corporate compliance and ethics programs, and related investigations.

Prior to Williams & Connolly, Ms. Miller clerked for Judge Harold Leventhal, U.S. Court of Appeals for the D.C. Circuit, and Associate Justice Potter Stewart, Supreme Court of the United States. She was an Assistant to the Secretary and Deputy Secretary of Defense in the Office of the Special Assistant from 1977 to 1979. Ms. Miller also served in 1994 as a member of the Advisory Board on the Investigative Capability of the Department of Defense. Ms. Miller is a member of the Defense Science Board, the Executive Council of the American Society of International Law, and the ABA Standing Committee on Law and National Security. She has spoken at the National Association of Attorneys General annual Conference on Supreme Court practice, and received that organization's Volunteer Recognition Award for sustained assistance to the states in preparation for arguments before the Supreme Court of the United States. She contributed the "Implementing Change" chapter to Carter & White, Keeping the Edge: Managing Defense for the Future (MIT Press 2001).

In January 1997, Secretary Perry awarded her the Department of Defense Medal for Distinguished Public Service. Secretary Cohen awarded her the Bronze Palm to that medal in 1999. She is a recipient of the Department of the Army's Decoration for Distinguished Public Service and was also an honoree of the Marine Corps. In September 1997, Beloit College presented Ms. Miller with the Beloit College Distinguished Service Citation in recognition of her service to her community, her profession, and the College. The National Law Journal also recognized her in 1998 as one of the "50 Most Influential Women Lawyers in America."

Ms. Miller graduated summa cum laude from Beloit College in 1972 (where she has been a member of the Board of Trustees since 1978) and from the Yale Law School in 1975.

She also played a reporter for the “The New York Times” in “Dark Winter”

Dr. Michael C. Moriarty

Dr. C. Michael Moriarty, Associate Provost and Vice President for Research at Auburn University, earned his PhD in Physiology and Biophysics at the University of Rochester; his M.S. degree in Engineering Physics and Mathematics from Cornell University; and his B.S. degree in Physics from Carnegie-Mellon University.

A native of Schenectady, New York, Dr. Moriarty came to Auburn University from the University of Georgia where he was Associate Vice President for Research and a Professor of Physiology and Pharmacology. He also was Assistant Provost and Dean of the Graduate School and Executive Assistant to the President at the University of Nebraska. At the University of Nebraska Medical Center, Dr. Moriarty served as Department Head, Physiology and Biophysics; Associate Dean for Research and Graduate Studies; and as Professor of Physiology and Biophysics.

At Auburn, Dr. Moriarty is chief administrator of a research program exceeding $100 million annually in research expenditures. He serves as President for the Auburn University Research Foundation and also holds a Professorship in the Department of Physiology and Pharmacology in the College of Veterinary Medicine.

Among professional societies to which Dr. Moriarty belongs are the American Association for the Advancement of Science; American Association of Cancer Research; American Physiological Society; American Society for Cell Biology; European Histamine Research Society; National Council of University Research Administrators; and Sigma Xi.

Dr. Moriarty has presented invited lectures and seminars at such institutions as the Universities of British Columbia, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Malaga (Spain), Maryland, Michigan, Minnesota, Missouri, Pittsburgh, Toledo, Virginia, Creighton University, Louisiana State University, Texas Tech University, Utah State University, Georgia Tech, and Virginia Tech.

Dr. Moriarty has obtained more than $2 million in individual competitive research grants. He continues to pursue his personal research interests in the areas of toxicity of heavy metals and blood markers for detection of malignant tumors and has published more than 60 research papers and articles on those topics.

Dr. Moriarty and his wife, Donna, are the parents of three children: Megan, David and Brent.

Dr. Tara O'Toole

Dr. O'Toole is currently the Deputy Director of the Johns Hopkins University Center for Cilvilian Biodefense Studies and a member of the faculty of the School of Hygiene and Public Health. The Center, sponsored by the Hopkins Schools of Public Health and Medicine, is dedicated to informing policy decisions and promoting practices that would help prevent the use of biological weapons.

She is a member of the Defense Science Board summer panel on biodefense technologies, and the Maryland Department of Health and Mental Hygiene steering group on public health response to WMD events, among other advisory and consultative positions related to bioterrorism preparedness. In 1993, Dr. O'Toole was nominated by President Clinton to be Assistant Secretary of Energy for Environment Safety and Health and served in this position until 1997.

As Assistant Secretary, Dr. O'Toole managed a staff of 400 professionals and an annual budget of approximately $200 million. She served as principal advisor to the Secretary of Energy on matters pertaining to protecting the environment and worker and public health from DOE operations.

From 1989-1993, Dr. O'Toole was a Senior Analyst at the Congressional Office of Technology Assessment (OTA) where she directed and participated in studies of health impacts on workers and the public due to environmental pollution resulting from nuclear weapons production, among other projects. She has served as a consultant to industry and government in matters related to occupational and environmental health, worker participation in workplace safety protection, and organizational change. She is a Board-certified internist and occupational medicine physician with clinical experience in academic settings and community health centers.

Dr. O'Toole received her Bachelors degree from Vassar College; her MD from the George Washington University and a Master of Public Health degree from Johns Hopkins. She completed a residency in internal medicine at Yale, and a fellowship in occupational and environmental medicine at Johns Hopkins University.

She was also a member of the “exercise staff” of “Dark Winter”

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This white paper was cited in the footnotes of the 2005 CSIS "Model Operational Guidelines for Disease Exposure Control"

CRS Report for Congress
Received through the CRS Web
Order Code RL31333

Federal and State
Isolation and
Quarantine Authority

Updated January 18, 2005
Angie A. Welborn
Legislative Attorney
American Law Division

In the wake of recent terrorist attacks and increasing fears about the spread of
highly contagious diseases, such as severe acute respiratory syndrome (SARS),
federal, state and local governments have become increasingly aware of the need for
an effective public health response to such events. An effective response could
include the isolation of persons exposed to infectious biological agents released
during an attack or infected with a communicable disease, as well as the quarantine
of certain states, cities, or neighborhoods.
Currently, state and local governments have the primary authority to control the
spread of dangerous diseases within their jurisdiction, with the federal government’s
role limited to interstate and foreign quarantine. However, many states have
inadequate procedures in place for isolating individuals who are infected or believed
to be infected and quarantining areas that are or may be infected. Generally, the laws
currently in effect do not address the spread of disease resulting from a biological
attack, and for the most part only address specific diseases that were the cause of past
epidemics, not newly emerging diseases such as SARS. In light of recent events,
many states are reevaluating their public health emergency response plans and are
expected to enact more comprehensive regulations relating to isolation and
quarantine. Public health experts have developed a Model State Emergency Health
Powers Act to guide states as they reevaluate their emergency response plans.
This report provides an overview of federal and state quarantine laws as they
relate to the isolation or quarantine of individuals, as well as a discussion of the
relevant case law. The Model State Emergency Health Powers Act is also discussed.

In the event of a biological attack or the introduction of a highly contagious
disease into a population, the public health system may respond by taking measures
to prevent those infected with or exposed to a disease or a disease-causing biological
agent from infecting others. The terms used to describe these measures generally
apply to distinct groups of persons, but are often used interchangeably. Isolation
typically refers to “the separation of a known infected person or animal from others
during the period of contagiousness in order to prevent the direct or indirect
conveyance of the infectious agent.”1 Quarantine refers to “the restriction of
movement of a healthy person who has been exposed to a communicable disease in
order to prevent contact with unexposed persons.”2 There are varying degrees of
quarantine and the authority to order quarantine or isolation is generally very broad.
First, both complete quarantine and isolation usually involve the confinement of
contagious individuals to their residences pursuant to orders from the state health
department. Health officials post a public notice forbidding anyone from
entering or exiting the dwelling. Alternatively, health authorities may confine
an infected person to either a hospital or a prison. Second, health authorities may
order a modified quarantine, which selectively restricts an individual from
participation in certain activities, e.g. jobs involving food preparation, school
attendance, or particularly hazardous activities. The quarantine power also
includes the authority to place a contagious individual under surveillance to
insure strict compliance with quarantine orders. Finally, the health department
may issue segregation orders which require the separation of an entire group of
people from the general population. Quarantine orders may extend to any
persons who come into contact with the infected individual.3
State health departments or health officials typically have primary quarantine
authority, though the federal government does have jurisdiction over interstate and
foreign quarantine. Both federal and state statutes and regulations will be discussed

Federal Quarantine Authority
Under the Public Health Service Act, the Secretary of Health and Human
Services has the authority to make and enforce regulations necessary “to prevent the
introduction, transmission, or spread of communicable diseases from foreign
countries into the States or possessions, or from one State or possession into any
other State or possession.”4 While providing the Secretary with broad authority to
promulgate regulations “as in his judgement may be necessary,” the law places
limitations on the Secretary’s authority to enact regulations providing for the
“apprehension, detention, or conditional release of individuals.”5 Such apprehension,
detention, or conditional release may be authorized for the purpose of “preventing the
introduction, transmission, or spread of such communicable diseases as may be
specified from time to time in Executive orders of the President upon the
recommendation of the Secretary, in consultation with the Surgeon General.”6
Generally, regulations authorizing the apprehension, detention, examination, or
conditional release of individuals are applicable only to individuals coming into a
State or possession from a foreign country or a possession.7 However, the regulations
may provide for the apprehension and examination of “any individual reasonably
believed to be infected with a communicable disease in a qualifying stage8 and (A)
to be moving or about to move from a State to another State; or (B) to be a probable
source of infection to individuals who, while infected with such disease in a
qualifying stage, will be moving from a State to another State.”9 If found to be
infected, such individuals may be detained for such time and in such manner as may
be reasonably necessary.10 During times of war, the authority to apprehend and
examine individuals extends to any individual “reasonably believed (1) to be infected
with such disease [as specified in an Executive order of the President] and (2) to be
a probable source of infection to members of the armed forces of the United States”
or to individuals engaged in the production or transportation of supplies for the
armed forces.11

Regulations promulgated pursuant to the Public Health Service Act addressing
interstate quarantine primarily restrict travel for persons infected with a
communicable disease.12 Following a transfer of authority from the Secretary of
Health and Human Services to the Director of the Centers for Disease Control and
Prevention (CDC) in 2000, the Director of the CDC is authorized to take measures
as may be necessary to prevent the spread of a communicable disease from one state
or possession to any other state or possession if he or she determines that measures
taken by local health authorities are inadequate to prevent the spread of the disease.13
In an effort to prevent the spread of diseases between states, the regulations prohibit
infected persons from traveling from one state to another state without a permit from
the health officer of the state, possession, or locality of destination, if such permit is
required under the law applicable to the place of destination.14 Additional
requirements apply to persons who are in the “communicable period of cholera,
plague, smallpox, typhus or yellow fever, or who having been exposed to any such
disease, is in the incubation period thereof.”15

State Police Powers and Quarantine Authority
The preservation of the public health has historically been the responsibility of
state and local governments.16 While the federal government has the authority to
authorize quarantine under certain circumstances, the primary authority exists at the
state level as an exercise of the state’s police power.17 The Supreme Court alluded
to a state’s authority to enact quarantine laws in 1824, Gibbons v. Ogden.18 In
Gibbons, the Court noted that while quarantine laws may affect commerce, they are,
by nature, health laws, and thus under the authority of state and local governments.
Courts have noted that the duty to insure that the public health is preserved is
inherent to the police power of a state and cannot be surrendered.19
While every state has acknowledged the authority to pass and enforce quarantine
laws, these laws vary widely by state. Generally, quarantine is authorized through
public health orders, though some states may require a court order before an
individual is detained.20 For example, in Louisiana, the state health officer is not
authorized to “confine any person in any institution unless directed or authorized to
do so by the judge of the parish in which the person is located.”21 Diseases subject
to quarantine may be defined by statute, with some statutes addressing only a single
disease, or the state health department may be granted the authority to decide which
diseases are communicable and therefore subject to quarantine.22 States also employ
different methods for determining when the quarantine or isolation period shall end.
Generally, “release is accomplished when a determination is made that the person is
no longer a threat to the public health, or no longer infectious.”23
One common characteristic of most state quarantine laws is their “overall
antiquity,” with many statutes being between forty and one hundred years old.24 The
more antiquated laws “often do not reflect contemporary scientific understandings
of disease, [or] current treatments of choice.”25 State laws were often enacted with
a focus on a particular disease, such as tuberculosis or typhoid fever, leading to
inconsistent approaches in addressing other diseases.26
Despite the inconsistencies and perceived problems with such laws, state
legislatures have not been forced to reevaluate their quarantine and isolation laws due
to a decline in infectious diseases and advances in medicine.27 However, in light of
recent threats, many states have begun to reconsider their emergency response
systems, including the state’s authority to quarantine.28 A review of quarantine
authority was also listed as priority for state governments in the President’s 2002
National Strategy for Homeland Security.29

Model State Emergency Health Powers Act
The Model State Emergency Health Powers Act was drafted by The Center for
Law and the Public’s Health at Georgetown and Johns Hopkins Universities.30 The
Model Act seeks to “grant public health powers to state and local public health
authorities to ensure a strong, effective, and timely planning, prevention, and
response mechanisms to public health emergencies (including bioterrorism) while
also respecting individual rights.”31 It is important to note that this is intended to be
a model for states to use in evaluating their emergency response plans, and passage
of the Model Act in its entirety is not required. Many states will likely use parts of
the Model Act, but tailor their statutes and regulations to respond to unique or novel
situations that may arise in their jurisdiction.32
The Model Act provides a comprehensive framework for state emergency health
powers, including statutory authority for isolation33 and quarantine.34 Section 604 of
the model act authorizes the isolation or quarantine of an individual or groups of
individuals during a public health emergency.35 The Model encourages the public
health authority to adhere to specific conditions and principles when exercising
isolation or quarantine authority. These conditions and principles include insuring
that the measures taken are the least restrictive means necessary to prevent the spread
of the disease; monitoring the condition of isolated and quarantined individuals; and
providing for the immediate release of individuals when they no longer pose a
substantial risk of transmitting the disease to others.36 The Model Act provides that
a failure to obey the rules and orders concerning isolation and quarantine shall be
treated as a misdemeanor.37
The Model State Emergency Health Powers Act sets forth procedures for
isolation and quarantine under two different sets of circumstances. Section 605(a)
addresses procedures for temporary isolation and quarantine without notice if a
“delay in imposing the isolation or quarantine would significantly jeopardize the
public health authority’s ability to prevent or limit the transmission of a contagious
or possibly contagious disease to others.” The isolation or quarantine must be
ordered through a written directive specifying the identity of the individuals subject
to the order, the premises subject to the order, the date and time at which the isolation
or quarantine are to commence, the suspected contagious disease, and a copy of the
provisions set forth in the act relating to isolation and quarantine.38 The public health
authority is required to petition within ten days after issuing the directive for a court
order authorizing the continued isolation or quarantine if needed.39
Apart from the emergency procedures outlined above, the public health authority
may petition a court for an order authorizing the isolation or quarantine of an
individual or groups of individuals, with notice of the petition given to the
individuals or groups of individuals in question within twenty-four hours.40 The
public health authority’s petition must include the same information as required in
the emergency directive discussed above, in addition to “a statement of the basis
upon which isolation and quarantine is justified in compliance with this Article.”41
A hearing must be held within five days of the petition being filed, and the court
“shall grant the petition if, by a preponderance of the evidence, isolation or
quarantine is shown to be reasonably necessary to prevent or limit the transmission
of a contagious or possibly contagious disease to others.”42 An order authorizing
isolation or quarantine may not do so for a period exceeding thirty days, though the
public health authority may move to continue isolation or quarantine for additional
periods not exceeding thirty days.43
The Model Act provides procedures which allow individuals subject to isolation
or quarantine to challenge their detention and obtain release, and provide remedies
where established conditions were not met.44 Individuals subject to isolation or
quarantine would be appointed counsel if they are not otherwise represented in their
The Model Act has been challenged by groups asserting that model legislation
is unnecessary and that this particular legislation is “unjustifiably broad.”46 Others
have expressed concern that the Model Act “grants unprecedented and . . . .
unconstitutional power.”47 Courts will likely be asked to review any version of the
act passed by the states.

Legal Challenges to State Quarantine Authority
As noted above, the Supreme Court in Gibbons v. Ogden alluded to a state’s
authority to quarantine under the police powers. In 1902, the Court directly
addressed a state’s power to quarantine an entire geographic area in Compagnie
Francaise de Navigation a Vapeur v. Louisiana State Board of Health, where both
the law and its implementation were upheld as valid exercises of the state’s police
power.48 The petitioners in the case - a shipping company - challenged an
interpretation of a state statute that conferred upon the state Board of Health the
authority to exclude healthy persons, whether they came from without or within the
state, from a geographic area infested with a disease.49 The petitioner alleged that the
statute as interpreted interfered with interstate commerce, and thus was an
unconstitutional violation of the commerce clause. The Court rejected this argument,
holding that although the statute may have had an affect on commerce, it was not

Courts have recognized an individual’s right to challenge his or her isolation or
quarantine by petitioning for writ of habeas corpus.51 While the primary function of
a writ of habeas corpus is to test the legality of the detention,52 petitioners often seek
a declaration that the statute under which they were quarantined is unconstitutional
or violative of due process. Due process is a concern, though courts are reluctant to
interfere with a state’s exercise of police powers with regard to public health matters
“except where the regulations adopted for the protection of the public health are
arbitrary, oppressive and unreasonable.”53 The courts appear to give deference to the
determinations of state boards of health and generally uphold such detentions as valid
exercises of a state’s duty to preserve the public health and not violative of due
process. However, some courts have refused to uphold the quarantine of an
individual where the state is unable to meet its burden of proof concerning that
individual’s potential danger to others.54

In People ex rel. Barmore v. Robertson, the court refused to grant the petition
for writ of habeas corpus of a woman who ran a boarding house where a person
infected with typhoid fever had boarded.55 The woman was not herself infected with
the disease, but she was a carrier and had been quarantined in her home. She argued
that her quarantine was unwarranted because she was not “actually sick,” though the
court noted that “t is not necessary that one be actually sick, as that term is usually
applied, in order that the health authorities have the right to restrain his liberties by
quarantine regulations.”56 In providing justification for quarantine under these
circumstances, the court explained that since disease germs are carried by human
beings, and as the purpose of an effective quarantine is to prevent the spread of the
disease to those who are not infected, anyone who carries the germs must be
isolated.57 The court found that in the case of a person infected with typhoid fever,
anyone who had come into contact with that person must be isolated in order to
prevent the spread of the disease to others.58

The Florida Supreme Court upheld a quarantine statute that was challenged on
due process grounds, denying the petitioners petition for writ of habeas corpus. In
Moore v. Draper, the court stated that, “[t]he constitutional guarantees of life, liberty
and property, of which a person cannot be deprived without due process of law, do
not limit the exercise of the police power of the State to preserve the public health
so long as that power is reasonably and fairly exercised and not abused.”59 In
addition to the due process claim, the petitioner had challenged the statute as
discriminatory against “all persons other than those of a certain religious faith and
belief.”60 The court rejected both arguments finding that the statute was a proper
exercise of the state’s police power and not violative of the petitioner’s constitutional

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This white paper was cited in the footnotes of the 2005 CSIS "Model Operational Guidelines for Disease Exposure Control"

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From my research, and I am asking you guys to use a search engine and confirm it on your own, that the "software/systems engineering firm developing supply-chain management systems" that David Heyman worked for was RGTI Systems Software based in New York, NY.  RTGI was bought out by BDM International Inc based out of McLean, VA, (BDM is right DOWN THE STREET/WALKING DISTANCE to Booz Allen Hamilton's HQ!!!)  BDM uses Enterprise Architecture software to manage their supply chain systems!!!

Supply Chain Coordination and Influenza Vaccination

Billions of dollars are being allocated for influenza pandemic preparedness, and vaccination is a
primary weapon for fighting influenza outbreaks. The influenza vaccine supply chain has characteristics
that resemble the news vendor problem, but possesses several characteristics that distinguish it from typical
supply chains. Differences include a nonlinear value of sales (caused by the nonlinear health benefits of
vaccination due to infection dynamics) and vaccine production yield issues. We show that production
risks, taken currently by the vaccine manufacturer, lead to insufficient supply of vaccine. Unfortunately,
several supply contracts that coordinate buyer (governmental public health service) and supplier (vaccine
manufacturer) incentives in industrial supply chains can not fully coordinate the influenza vaccine supply
chain. We design a variant of the cost sharing contract and show that it provides incentives to both parties
so that the supply chain achieves global optimization and hence guarantees sufficient supply of vaccine.

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Emergency response to a smallpox attack: The case for mass vaccination


In the event of a smallpox bioterrorist attack in a large U.S. city, the interim response policy is to isolate symptomatic cases, trace and vaccinate their contacts, quarantine febrile contacts, but vaccinate more broadly if the outbreak cannot be contained by these measures. We embed this traced vaccination policy in a smallpox disease transmission model to estimate the number of cases and deaths that would result from an attack in a large urban area. Comparing the results to mass vaccination from the moment an attack is recognized, we find that mass vaccination results in both far fewer deaths and much faster epidemic eradication over a wide range of disease and intervention policy parameters, including those believed most likely, and that mass vaccination similarly outperforms the existing policy of starting with traced vaccination and switching to mass vaccination only if required.

Although smallpox was eradicated in 1979 by the World Health Organization campaign (1), it remains a feared bioterrorist threat (2). In the aftermath of the September 11 terrorist attacks, the U.S. is stockpiling 286 million doses of smallpox vaccine (3). The Centers for Disease Control and Prevention (CDC) interim response plan (4) calls for targeted vaccination and quarantine: symptomatic smallpox cases would be isolated, contacts of cases vaccinated, asymptomatic contacts monitored but not isolated, and febrile contacts quarantined for 5 days. These guidelines also recommend a broader vaccination strategy if the initial number of cases or outbreak locations is “sufficiently large,” or if new cases fail to decline after two or more generations of cases have developed from those initially identified, or 30% of vaccine stores have been used. An expert panel has also recommended a targeted vaccination strategy (ref. 5;

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Lessons Learned from a Full-Scale Bioterrorism Exercise

Richard E. Hoffman and Jane E. Norton
Colorado Department of Public Health and Environment, Denver, Colorado, USA

During May 20-23, 2000, local, state, and federal officials, and the staff of three hospitals in metropolitan Denver, participated in a bioterrorism exercise called Operation Topoff. As a simulated bioterrorist attack unfolded, participants learned that a Yersinia pestis aerosol had been covertly released 3 days earlier at the city’s center for the performing arts, leading to >2,000 cases of pneumonic plague, many deaths, and hundreds of secondary cases. The exercise provided an opportunity to practice working with an infectious agent and to address issues related to antimicrobial prophylaxis and infection control that would also be applicable to smallpox or pandemic influenza.

The sequence of events and the exact date of the exercise were not specified. However, the probable weekend and possible bioagents were suggested, which enabled us to begin preparations approximately 8 weeks ahead. Preparations included temporary appointments to the governor’s 19-person Expert Emergency Epidemic Response Committee, which was created by enactment of a bioterrorism and pandemic influenza response law on March 15, 2000; recruitment of 25 epidemiologic and emergency management personnel from the 1,050 employees of our department and assignment to disaster response teams (e.g., surveillance, field investigation, and emergency management coordination); and establishment of a command center by reserving conference rooms and installing telephone, computer, and television equipment. Colorado’s bioterrorism and pandemic influenza response law was not enacted to prepare for the exercise, but proved extremely useful. We recommend that state health agencies review their statutory authority and evaluate whether these laws would be adequate to deal with the threats of bioterrorism and pandemic influenza.

During the exercise, we were provided information either from other participating agencies or from exercise controllers, and it was our task to investigate and respond. The staff reviewed mock medical records, analyzed laboratory specimens, interviewed patients, conducted meetings and group conference calls to assess surveillance data and decide on the next steps, drafted public health and executive orders, made written requests to federal officials for specific assistance, participated in news conferences, and packaged mock antibiotics for distribution at a prophylaxis clinic. By the end of day one, 783 cases and 123 deaths from plague had been reported from 16 hospitals (three participating hospitals and 13 simulated facilities). By the end of day two, 1,871 cases and 389 deaths were attributed to pneumonic plague, with 307 patients requiring ventilatory support. Cases were reported from six states outside Colorado. By the end of day three, 3,700 cases and 950 deaths were reported, including at least 780 secondary cases.

The exercise required state health department personnel to develop new working relationships. Although hospitals and local and state health agencies often collaborate with the Centers for Disease Control and Prevention in controlling an epidemic, we were unaccustomed to working closely with the Federal Bureau of Investigation, the U.S. Attorney for the District of Colorado, the Federal Emergency Management Agency, the Regional Office of the U.S. Public Health Service, and the Colorado Office of Emergency Management. Although lines of authority were clear, much time was spent in consultation and debate through scheduled bridge calls. Many persons joined these calls, and decision-making became inefficient, although not impossible. In a true incident, a central location for face-to-face meetings should be large enough to accommodate representatives from all agencies involved, but one difficulty encountered with arranging such meetings was that each agency seemed most comfortable in its own command center.

Another lesson we learned concerned our own organization. In addition to the surveillance, field investigation, and emergency management coordination teams, we needed teams to address laboratory testing, mass fatalities, legal problems, information technology, infection control, public and professional communications, and antibiotic and vaccine administration. During a disaster, no routine agency business can be conducted, as all employees are involved in the public health response. Finally, activities cannot depend on the direction of one or two key persons, such as the executive director and the state epidemiologist; other skilled, informed persons must be able to assume leadership roles. An electronic database documenting events, decisions, and requests for resources should be maintained. These logs enable staff to monitor the epidemic and the public health response rapidly.

In Colorado, where plague is endemic, we are familiar with the public health management of single plague cases, but the magnitude of the simulated epidemic and the fact that infection was spreading from person to person after a short (2- to 3-day) incubation period quickly overwhelmed the available resources. The challenge to our surveillance system was not in detecting the outbreak but rather in maintaining surveillance at each of the 22 acute-care hospitals in metropolitan Denver. Our hospital surveillance system usually relies on reporting by infection control practitioners, but during the exercise these practitioners had many additional responsibilities. In a true bioterrorist attack, emergency response teams of state or local health department employees should be set up and sent to each hospital to monitor cases and provide information to a central command center.

As more cases were identified, an anticipated issue emerged: who should receive antimicrobial prophylaxis? The governor’s committee debated whether to limit prophylaxis to close contacts of infectious cases or offer it more widely (e.g., to all health-care workers, first responders, and public safety workers and their families) to gain the support and participation of key workers. The committee decided on the latter approach, but not unanimously.

The process of isolating plague patients until they are no longer contagious and identifying close contacts is typically straightforward. Isolation, however, was not possible during this exercise. The hospitals had too many patients and worried-well persons and too few health-care workers and empty rooms to permit isolation of pneumonic plague patients. Case reporting was delayed, and there were too few trained public health workers to conduct interviews and locate contacts in a timely manner. As a result, an executive order was issued quarantining all persons in metropolitan Denver in their homes. With infection control in the general population supposedly managed by the order, we could turn our attention to securing additional supplies, staff, beds, and equipment for the hospitals.

However, quarantining two million persons is not simple. Essential workers must be identified, be given prophylaxis and protective barriers, and be permitted to do their jobs. Other members of the community can stay in their homes only a few days before they need fresh supplies of food. Therefore, a one-time, blanket quarantine order is unlikely to be successful and cannot be enforced unless these and many other issues are addressed. The hospitals were quite demanding in their requests for reinforcements, and we made great efforts to assist them. However, by day three of the exercise it became clear that unless controlling the spread of the disease and triage and treatment of ill persons in hospitals receive equal effort, the demand for health-care services will not diminish. This was the single most important lesson we learned by participating in the exercise.

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Reposted from

EID Volume 2 * Number 1                              January-March 1996


Surveillance for Pneumonic Plague in the United States During an International Emergency: A Model for Control of Imported Emerging Diseases

Curtis L. Fritz, D.V.M., Ph.D., David T. Dennis, M.D., M.P.H.,
Margaret A. Tipple, M.D., Grant L. Campbell, M.D., Ph.D.,
Charles R. McCance, B.A., and Duane J. Gubler, Sc.D.
Centers for Disease Control and Prevention,
Fort Collins, Colorado, and Atlanta, Georgia, USA


In September 1994, in response to a reported epidemic of plague in India, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States for imported pneumonic plague. Plague information materials were rapidly developed and distributed to U.S. public health officials by electronic mail, facsimile, and expedited publication. Information was also provided to medical practitioners and the public by recorded telephone messages and facsimile transmission. Existing quarantine protocols were modified to effect active surveillance for imported plague cases at U.S. airports. Private physicians and state and local health departments were relied on in a passive surveillance system to identify travelers with suspected plague not detected at airports. From September 27 to October 27, the surveillance system identified 13 persons with suspected plague; no case was confirmed. This coordinated response to an international health emergency may serve as a model for detecting other emerging diseases and preventing their importation.

In the past 50 years, the speed of international travel, as well as the number of travelers, has accelerated, providing a mechanism for the rapid dissemination of disease agents from one country to another. For this reason, vigilant surveillance is needed to prevent the importation and spread of emergent infections. The United States needs a response plan that involves international and domestic public health officials, physicians and hospitals, and the public and can be implemented at the first indication of an international health threat.

In 1994, in response to an epidemic of pneumonic plague in India, the Centers for Disease Control and Prevention (CDC) developed and implemented an enhanced surveillance system to supplement the existing regulations concerning imported plague. The protocol described here may serve as a model for detection and control of emerging diseases imported into the United States or other countries with frequent and diverse international traffic.
In September 1994, India reported cases of plague for the first time in 28 years. Plague is caused by infection with the bacterium Yersinia pestis. Bubonic plague is typically acquired by the bite of fleas from infected rodents and is characterized by inguinal, axillary, and/or cervical lymphadenitis. Pneumonic plague may occur as a secondary development to the bubonic form or can be contracted by inhaling respiratory droplets from humans or other animals with plague pneumonia (1).

Bubonic plague cases were first identified by Indian health officials in the Beed District of Maharashtra State in late August. By September 24, more than 300 unconfirmed cases of pneumonic plague and 36 deaths had been reported from the city of Surat, Gujurat State, approximately 300 km west of the Beed District (3). After these reports, hundreds of thousands of Surat's two million residents fled, some to the major cities of Bombay, Calcutta, and New Delhi (4). Unconfirmed pneumonic plague cases and plague-related deaths were subsequently reported from several areas throughout India (5,6).

With the reported epidemic of plague in India, the potential for spread of the disease by infected travelers became a concern. Several countries closed their borders to Indian travelers and cargo and discontinued all flights of their air carriers to and from India (7). Because of its epidemic potential, plague is listed as a Class 1 internationally quarantinable disease in the International Health Regulations of the World Health Organization (WHO) (2). These regulations authorize the detention and inspection of any vehicle or passenger originating in an area where a plague epidemic is in progress.
Response to the Epidemic
CDC's domestic response to the apparent plague epidemic in India involved two simultaneous and complementary components: 1) information dissemination and education, and 2) intensified active and passive surveillance to identify and treat suspected plague patients and their contacts.
Information Dissemination

After the initial reports from India, information on plague and the epidemic in India was urgently sought by the media, the public, medical practitioners, and public health officials throughout the United States. To meet this need, CDC circulated detailed and timely information to persons concerned with the potential plague crisis. From September 26 to 29, CDC produced six documents for distribution to public health officials and agencies: 1) a general plague outbreak notice, 2) a plague alert notice for international travelers from India, 3) a plague advisory for persons traveling to India, 4) plague treatment and prophylaxis guidelines for physicians, 5) guidelines for diagnosis and biosafety for persons handling samples from patients with suspected plague, and 6) an article on the Indian outbreak that appeared in CDC's widely circulated Morbidity and Mortality Weekly Report (MMWR)(8).

CDC pursued several avenues to convey information to medical practitioners and the public. Three articles on the epidemic were published in MMWR (September 30, October 7, and October 21) (8-10). Information on plague in general and the Indian epidemic in particular was made available on CDC's Voice Information Service, Fax Information Service, and a special plague hotline telephone number. A message intended for travelers to India concerning the perceived risks and appropriate prophylactic measures was added to the plague selections on the Voice Information Service menu. Finally, all airline passengers disembarking in the United States from India were given a plague alert notice that described the symptoms of plague and advised them to seek medical attention and notify state and federal public health authorities if they had any febrile illness within the next 7 days. The standard Health Alert Notice (yellow card) of the Division of Quarantine, CDC, was made available to all other international arriving passengers and advised them of appropriate measures in the event of illness.
The second component of CDC's response was to intensify active and passive surveillance for persons entering the United States who potentially had plague. Both the active (Figure 1) and passive (Figure 2) surveillance systems identified not only persons suspected of having plague but also those who might have been exposed to a patient with plague during the contagious period.

Figure 1. Active surveillance system: patient with suspected plague identified on arrival at U.S. international airport.

Active Surveillance System

CDC's Division of Quarantine maintains staff at major international airports in seven U.S. cities: Honolulu, Hawaii; Seattle, Washington; San Francisco and Los Angeles, California; Chicago, Illinois; Miami, Florida; and New York, New York. At airports where the division does not have staff, officials of the Immigration and Naturalization Service (INS), Division of Quarantine contract physicians, or both, serve as Quarantine Officers.

During the plague epidemic, crews on all commercial aircraft originating in or continuing from India were reminded of the regulations requiring them to notify the Quarantine Officer at the destination airport of any ill passengers and were instructed to be especially alert for passengers with fever, cough, or chills. When the aircraft landed, before passengers disembarked, a Quarantine Officer and a Division of Quarantine contract physician, in telephone consultation with the medical officer on call at CDC's Division of Vector-Borne Infectious Diseases, examined any passenger who reported illness and determined whether the suspicion of plague was sufficient to warrant the passenger's hospitalization and further evaluation. If deemed not likely to have plague, the passenger was placed under the surveillance of the local health department and released with instructions to consult a physician and to monitor his or her temperature for the next 7 days, the maximal incubation period for pneumonic plague after exposure (1). All other passengers were permitted to deplane and were given a copy of the plague alert notice.

If plague had not beeen ruled out as a possible cause of the passenger's illness, the passenger would have been considered a patient with suspected plague and would have been placed in isolation at the airport until he or she could be safely transported to a predetermined hospital. In the hospital, the patient would have been placed under respiratory isolation conditions, diagnostic specimens would have been obtained for testing in the CDC plague laboratory, and appropriate antibiotic treatment for plague would have been begun.

If the patient had been hospitalized, other passengers on the flight would have been informed that they were under surveillance in accordance with federal quarantine regulations. Locating information would have been obtained from all passengers, who would have been instructed to monitor their body temperature for 7 days and to report any illness to their county or state health department. Because pneumonic plague is transmitted from person to person through respiratory droplets (11) and air flow on passenger airlines is directed toward the floor (12), only passengers seated within 2 m of the patient (proximal passengers) and others with close personal contact would have been considered at reasonable risk for secondary transmission. Those proximal passengers would have been identified and advised to begin antibiotic prophylaxis and to continue it for 7 days. Had a suspected plague case been laboratory-confirmed, the state health departments and state epidemiologists would have contacted all proximal passengers and monitored completion of the antibiotic prophylaxis. All other passengers would have also been contacted to ensure that they continued to monitor themselves for febrile illness.

Figure 2. Passive surveillance system: patient with suspected plague identified a few hours to 7 days afer arrival in U.S.

Passive Surveillance System

Private physicians, hospitals, and local public health officials were relied on to identify international air travelers from India who became ill within a short period (from hours to 7 days) after disembarkation and report the illness to the appropriate state and federal public health officials. The attending physician, in consultation with the CDC medical officers on call, then determined on the basis of clinical and epidemiologic evidence whether the ill person had a reasonable likelihood of having plague. If so, the patient would have been placed under respiratory isolation in a hospital, diagnostic specimens would have been obtained, and antibiotic treatment would have been initiated. Close contacts of the suspected plague patient during the putative contagious period would have been identified and advised to begin antibiotic prophylaxis.

A concerted effort would have been made to determine the time the suspected plague patient became symptomatic, and thereby contagious (13), relative to the person's arrival in the United States. If the patient had been symptomatic at the time of the flight, a passenger list would have been obtained from the airline and the U. S. Customs Service. State epidemiologists in the states of residence of all passengers would have been informed of the need to contact and maintain surveillance of passengers within their jurisdiction who were possibly secondarily exposed. If seating assignments for the flight could be obtained, passengers seated within 2 m of the patient would have been advised to begin antibiotic prophylaxis; all other passengers would have been instructed to monitor their temperature for 7 days and to report any illness to state health officials.
On September 29, plague information documents were sent by electronic mail or fax to four Executive Committee members and 50 members of the Council of State and Territorial Epidemiologists, 60 members of the Association of State and Territorial Public Health Laboratory Directors, 40 Executive Board members and 50 state representatives of the National Association of County and City Health Officials, 132 officers in CDC's Epidemic Intelligence Service (EIS), 15 field supervisors of CDC's Field Epidemiology Training Program, and one representative each in the U. S. Department of State and the Quarantine Health Services in Canada. Although an exact count is not available, more than 3,000 persons probably received these documents directly from CDC or secondarily through other agencies.

From September 27 to October 31, the CDC Voice Information Service received 6,665 calls accessing information about plague; 2,692 of these calls were received through the special plague hotline number. During this same period, 5,589 documents about plague were requested and sent by the CDC Fax Information Service.

On October 25, 1994, after an on-site investigation in India, a WHO team of scientists that included four CDC staff members, determined that the plague epidemic was of more limited scope than previously believed, and recommended the lifting of travel restrictions. On October 27, 1994, CDC authorized a stand-down of the heightened surveillance system at all ports of entry and a return to normal operations. During the 30 days that the surveillance system was in place, 13 airline travelers arriving in the United States were evaluated. Six patients with suspected plague were identified and evaluated in airports — JFK and La Guardia in New York City (four), Dallas-Fort Worth (one), Chicago-O'Hare (one) — and seven by private physicians in New York City (five), Albany, New York (one), and St Louis, Missouri (one). All 13 had a history of recent travel in India. None was found to have plague. Symptoms of illness included fever (eight), cough (six), vomiting (four), and malaise (three). The final diagnoses of persons evaluated were viral syndrome (four), malaria (two), concurrent malaria and dengue (one), typhoid (one), end-stage liver failure (one), and no illness (one) (14). The final diagnosis was unspecified in three patients.
Plague pandemics have occurred throughout history (15). In the European epidemic known as Black Death, from 1345 to 1360, an estimated quarter of the world's known population of 24 million died. Originating in central Asia and carried by ship to Sicily, the disease spread east to China, south to Africa, north to Russia and Scandinavia, and west to Greenland in only a few years. Plague in North America can be traced historically to infected rats aboard ships from the Far East that docked in California during the early 20th century (16). Today, air travel that can transport a person anywhere in the world within 24 hours expands the opportunity for rapid spread of a transmissible disease like pneumonic plague. The potential for pneumonic plague to spread by air travel to the United States during the recent Indian epidemic elicited considerable public concern (7).

Although rare, plague is enzootic in the United States, and 10 to 15 human cases are reported each year; typically only one or two of these are pneumonic plague cases (17). Thus, most public health officials and medical practitioners in this country have limited experience with plague (18). When the Indian epidemic began, detailed and reliable information from India was sparse; therefore, CDC disseminated factual and comprehensive information regarding pneumonic plague and the Indian epidemic to public health officials, physicians, and private citizens. The development and distribution of the e-mail, voice, fax, and printed documents were coordinated through a single branch within CDC, which ensured the accuracy and timeliness of the information conveyed. By serving as the central clearing house for international and domestic reports, CDC was able to gather and redistribute information rapidly and efficiently. Updates in MMWR contained data obtained within hours of publication. Most public health officials and agencies were accessible immediately by electronic mail or fax, and group mailing codes were constructed to facilitate simultaneous communication. These timely updates of information, which included periodic results of the enhanced surveillance system, heightened awareness of the public health threat and encouraged participation by health practitioners in the passive component of the surveillance system.

Like the information network, the surveillance system was centrally coordinated at CDC, but it relied on the contributions of many agencies and individuals to function effectively. Federal, state, and local health officials, the Immigration and Naturalization Service, The U.S. Customs Service, commercial businesses (passenger airlines), medical practitioners, hospital personnel, and the public played key roles in the successful implementation of the system. Many state and local health departments made additional efforts to alert the medical community to the potential for imported plague cases, to reiterate the surveillance protocol, and to emphasize the importance of obtaining a travel history from any patient with unexplained fever (14). This distribution of responsibility through the established public health network was essential to effective surveillance.

In 1992, the Institute of Medicine's Committee on Emerging Microbial Threats to Health recommended that surveillance of international infectious diseases be implemented and coordinated by a single government agency, ideally CDC (19); subsequently, CDC developed a comprehensive strategy for preventing emerging infectious diseases in the United States (20). In its response to the Indian plague epidemic, rather than constructing a new system specific to this emergency, CDC used a surveillance protocol that built on the existing quarantine framework to utilize trained staff in a position to readily respond. Future responses to the threat of importation of communicable diseases with epidemic potential will require a similar network of individuals and agencies, with specific roles and responsibilities but sufficiently flexible to adapt to the particular epidemiologic circumstances. A system similar to the one described here was put in place in response to the Ebola outbreak in Zaire in April and May 1995 (21).

A surveillance system must be effective without becoming overly burdensome to either those conducting the surveillance or those under surveillance; it must safeguard the public health without inhibiting commerce or interfering with individual freedoms. In the 1370s, during the latter years of Black Death, nautical travelers to the Republic of Ragusa, now part of Italy, were detained for 40 days (from which the word "quarantine" [quaranti giorni] derives) (15), a detention period inappropriately long in light of the current knowledge of plague's incubation period of 2 to 7 days (1). In the recent outbreak, closure of airports to all flights from India, compulsory quarantine of all international travelers, and an embargo of trade with India were extreme measures given the epidemiology of plague and the risk of importing a case (18). Primary surveillance efforts were focused at critical control points, i.e., international airports, where personnel resources for identification and control of imported plague cases are maximally efficient. The secondary system, utilizing private physicians and state and local health departments, permitted continued surveillance that was less intensive, but geographically expansive, without placing an unnecessary burden on international air travelers.

If a case of plague had been confirmed in an airline passenger, tracing passengers at risk would have been a substantial undertaking. Depending on the interval between disembarkation and diagnosis, hundreds of persons might have had to be located across the country. In addition to 39 of CDC's Epidemic Intelligence Service (EIS) Officers stationed in state and local health departments, 10 EIS Officers in CDC centers in Atlanta, Georgia, Cincinnati, Ohio, Washington D.C., and Fort Collins, Colorado, were recruited to assist state and local health departments in tracing contacts if necessary. EIS Officers have often been called to assist in public health crises in which a large complement of epidemiologists was required; in 1993, 13 EIS Officers were among the scientists and public health officials assembled during the outbreak of hantavirus pulmonary syndrome in the southwestern United States (22). Because a rapid response to importation of a disease with epidemic potential often requires a national team of epidemiologists to assist local public health agencies, the Institute of Medicine and others have recommended the expansion and continued support of CDC's EIS program (19,20,23).

The surveillance system's first line of detection for plague cases depended on airline personnel, Immigration and Naturalization Service and U.S. Customs officials for the active component, and private physicians and health care providers for the passive component. Since the former are not trained medical personnel and may not detect an ill traveler in the absence of obvious signs and symptoms, and the latter may not be sufficiently alerted to the possibility of plague, diagnosis of some plague cases could have been delayed and not been efficiently detected by the surveillance system. It is unrealistic to expect any system to effectively screen all travelers returning from areas of recognized disease outbreaks. It is impossible to assess the sensitivity of the described surveillance system since no cases of pneumonic plague were identified either within or outside the system. In retrospect, the risk for an imported plague case was quite small, since the epidemic in India was limited in time and space and had far fewer cases than originally suspected (24). The WHO investigative team found no evidence of transmission in metropolitan areas other than Surat. Most of the patients with suspected plague in Surat came from poor neighborhoods, residents of which would be unlikely to travel internationally. In addition, the short incubation period and severe symptoms of pneumonic plague and the rapid deterioration of the patient's condition, substantially limited the contagious period and the opportunity for secondary transmission.

Although the epidemic potential for plague makes it a good model for developing emerging disease response capabilities, the direct applicability of this program for other emerging diseases may not be straightforward. The above protocol was developed in response to a regionally limited outbreak that occurred during a relatively brief period, similar to the recent Ebola outbreak in Zaire (21). To detect emerging diseases in the absence of a recognized outbreak, surveillance would need to be maintained at some baseline level for an indefinite period. Compliance with the enhanced plague surveillance protocol during the short period it was in effect appears to have been excellent, but how compliance might have waned over weeks to months is unknown. In addition, the protocol was specific to plague, a well-characterized disease with well-described pathogenesis and clinical features. The severe manifestations of pneumonic plague, the short incubation and contagion periods, and the availability of reliable diagnostic tests allowed for a focused protocol that could confidently identify cases. Other emerging diseases may be less well characterized, or even entirely unknown, and may require surveillance protocols of lesser specificity. Nevertheless, the plague surveillance system was broad enough (and consistent with the Institute of Medicine's recommendation that a global infectious disease surveillance system implement broad reporting criteria for detection of emerging diseases [19]) to identify four persons who had other potentially fatal notifiable infectious diseases.
The authors thank Dr. May C. Chu, Dr. Robert B. Craven, Mr. Thomas A. DeMarcus, Ms. Rosamond R. Dewart, Dr. Kenneth L. Gage, Dr. Kathleen A. Orloski, Mr. Tony D. Perez, Dr. Jack D. Poland, Dr. Martin E. Schriefer, Mr. Thomas W. Skinner, Dr. Ofelia C. Tablan, and Dr. Theodore F. Tsai, (CDC), and Dr. Brian Gushulak, (Health Canada), for expert consultation and direct assistance; Ms. Mary Ellen Fernandez and Ms. Edwarda O. Lee, (CDC), for administrative support; Ms. Kathy A. Bruce, Ms. Rebecca L. Deavours, Ms. Anna M. Jimenez, and Ms. Karen A. Peterson (CDC), for secretarial support; Mr. Jerome R. Cordts (Association of State and Territorial Public Health Laboratory Directors), Mr. David E. Custer and Ms. Nancy Rawding, (National Association of County and City Health Officials), Mr. Willis R. Forrester and Ms. Kathy F. Getz (Council of State and Territorial Epidemiologists), Dr. Martin Wolfe, (U.S. Department of State), and Ms. Patsy R. Bellamy, Ms. Pamela K. Eberhardt, and Mr. Clyde S. Furney, Jr. (CDC), for assistance with rapid dissemination of information; Mr. Richard Heffernan, and Dr. Marcelle Layton, (New York City Department of Health), and Dr. Rosalind J. Carter (New York City Department of Health and CDC), for assistance in conducting surveillance.
Address for correspondence:
Curtis L. Fritz
Division of Vector-Borne Infectious Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
P.O. Box 2087
Fort Collins, CO 80522
Fax: 970-221-6476
E-Mail: [email protected]

   1. Benenson AS, editor. Control of Communicable Diseases in Man, 15th ed. Washington, DC: American Public Health Association, 1990.
   2. World Health Organization. International Health Regulations. 3rd ed. Geneva, Switzerland: WHO, 1983:26-9.
   3. Desai D, Samuel I. Surat flounders against medical crisis. The Indian Express 24 September 1994.
   4. Gupta S. 600,000 have fled Surat. The Statesman 25 September 1994.
   5. World Health Organization, Regional Office for Europe. Plague in India. Communicable Disease Report (CD News) Issue 4; 3 October 1994.
   6. Friese K, Mahurka U, Rattanani L, Kattyar A, Rai S. The plague peril. Are you at risk? India Today 15 October 1994.
   7. Post T, Clifton T, Mazumdar S, Cowley G, Raghavan S. The plague of panic. Newsweek 10 October 1994:40-1.
   8. Centers for Disease Control and Prevention. Human plague—India, 1994. MMWR 1994;43:689-91.
   9. Centers for Disease Control and Prevention. Update: Human plague—India, 1994. MMWR 1994;43:722-3.
  10. Centers for Disease Control and Prevention. Update: Human plague—India, 1994. MMWR 1994;43:761-2.
  11. Craven RB. Plague. In: Hoeprich PD, Jorday MC, Ronald AR, editors. Infectious diseases: a treatise of infectious processes. 5th ed. Philadelphia: Lippincott, 1994:1302-12.
  12. National Research Council. The airliner cabin environment: air quality and safety. Washington, DC: National Academy Press; 1986.
  13. Poland JD, Barnes AM. Plague. In: Steele JH, editor. CRC handbook series in zoonoses: section A: bacterial, rickettsial, and mycotic diseases. Boca Raton, FL: CRC Press; 1979:515-58.
  14. Centers for Disease Control and Prevention. Detection of notifiable diseases through surveillance for imported plague—New York, September-October 1994. MMWR 1994;44:805-7.
  15. Cartwright FF. Disease and history. New York: Dorset Press, 1972.
  16. Craven RB, Barnes AM. Plague and tularemia. Infect Dis Clin North Am 1991;5:165-75.
  17. Centers for Disease Control and Prevention. Summary of notifiable diseases, United States. 1993. MMWR 1993;42:45.
  18. Campbell GL, Hughes JM. Plague in India: a new warning from an old nemesis. Ann Intern Med 1995;122:151-3.
  19. Lederberg J, Shope RE, Oaks SC, editors. Emerging infections: microbial threats to health in the United States. Washington, DC: National Academy Press, 1992.
  20. Centers for Disease Control and Prevention. Addressing emerging infectious disease threats: a prevention strategy for the United States. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, 1994.
  21. Centers for Disease Control and Prevention. Outbreak of Ebola viral hemorrhagic fever—Zaire, 1995. MMWR 1995;44:381-2.
  22. Centers for Disease Control and Prevention. Update: outbreak of hantavirus infection—southwestern United States, 1993. MMWR 1993;42:441-3.
  23. Henderson DA. Surveillance systems and intergovernmental cooperation. In: Morse SS, editor. Emerging viruses. New York: Oxford University Press, 1993:283-9.
  24. World Health Organization, South-East Asia Regional Office. Plague in India: World Health Organization team executive report. Geneva, Switzerland: WHO, December 1994.

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Am J Psychiatry 156:1500-1505, October 1999

Domestic Terrorism With Chemical or Biological Agents: Psychiatric Aspects
Cleto DiGiovanni, Jr., M.D.

OBJECTIVE: This article highlights the mental health consequences of a domestic terrorist incident involving chemical or biological weapons. METHOD: The author reviews the literature on the neuropsychiatric effects of selected chemical and biological weapon agents, on the psychological sequelae of mass disasters, and on approaches to crisis intervention. RESULTS: Disturbances of behavior, affect, and cognition can result directly from the pharmacological actions of some chemical and biological weapon agents. In addition, an incident involving these agents can have considerable psychological effects on individuals and the community. In either case, some disorders are acute and others are prolonged or delayed in onset. Effective therapeutic intervention involves a broad range of clinical, social, and administrative actions. CONCLUSIONS: Psychiatrists have an important role in the management of a chemical or biological terrorist incident and, along with their other medical colleagues, should train and prepare for it.

No significant criminal (including terrorist) use of chemical or biological weapons has yet occurred in the United States. However, acquisition, delivery, and targeting of these weapons are within the grasp of any determined and skilled individual or group. During the winter of 1995–1996, federal law enforcement authorities arrested a man in Arkansas who had produced ricin (a potent toxin from the bean of the castor plant); they also arrested members of a group in New York City who were acquiring ingredients to manufacture sarin, a nerve agent. In March 1995 the Aum Shinrikyo cult used sarin in the Tokyo subway system to kill 12 people and cause 5,510 people to seek medical care. In preparation for this attack, the same group field-tested its manufactured sarin in central Japan a year earlier, killing seven and injuring 200.

In all likelihood, any incident involving a chemical or biological device will be handled initially by local personnel and institutions at the site. Medical preparations for this event, if made at all by hospitals, may not involve psychiatrists or may rely on assumed but untested "psychiatric assistance." Yet disorders of mood, cognition, and behavior will be among the more common findings in the exposed, or possibly exposed, population because of the uncertainty, fear, and panic that may accompany the incident and the pharmacology of the agents themselves. Persons with altered behaviors may be so numerous that they overwhelm available medical resources, whether the incident involves a high concentration of an effectively delivered agent, an attack that is ineffective because of low concentration and/or poor delivery (as was the case in the Tokyo attack), or just a hoax that takes on a momentum and life of its own.

Psychiatrists who are called on to assist in a chemical or biological incident will encounter anxiety, fear, panic, somatization, and grief at the individual and community levels. They may be expected to advise local civil defense officials about the management of a panicked population and to offer guidance to the suddenly swamped staffs of their hospitals' emergency rooms. They will have to provide crisis intervention to health care workers and first responders who sustain "battle" fatigue while performing their duties. They may also be asked to assist in the mental status evaluations of persons who have been exposed to certain chemical or biological agents in order to perform triage to differentiate those whose psychiatric symptoms are the result of somatization or anxiety from those with agent-induced alterations. And they will be expected to treat, immediately and over the long term, persons with psychiatric disorders of whatever etiology that result from this incident. In this article I will examine these various issues and offer suggestions to help psychiatrists prepare to assume these responsibilities.


Whether from a biological or chemical agent attack, many people, exposed or not, who seek treatment in emergency rooms will exhibit tension, tachycardia, increased respiratory rate, tremors, and other non­specific signs and symptoms that could result from the agent or from anxiety associated with the incident. In the absence of clearly pathognomonic features, ­patients run the risk of either a delay in important ­therapy or administration of unnecessary medications, e.g., atropine in the absence of exposure to a nerve agent, that could create serious side effects. When physical signs and symptoms are ambiguous, mental status findings, especially the finding of delirium and the distinction between the anxieties seen in delirium and the anxieties seen in panic, may be crucial in the differential diagnosis.

Nerve agents have the greatest potential among chemical weapons for causing confusion in diagnosis. These are organophosphorus compounds that, through phosphorylation of acetylcholinesterase, produce enzyme inhibition and the accumulation of acetylcholine at the terminal endings of all postganglionic parasympathetic nerves, at neuromuscular junctions, and in the autonomic sympathetic and parasympathetic ganglia. The principal nerve agents are sarin, tabun, soman, and VX.

In the 1950s and 1960s, studies with human volunteers documented effects of nerve agents or similar organophosphate compounds on mental status. In some studies the volunteers were not told what to expect. In one study (1) the degree of reduction in acetylcholinesterase blood levels correlated with the number of subjects who experienced intellectual impairment, anxiety, psychomotor retardation, and disturbed sleep patterns. Psychological disturbances were more prominent than physical signs and symptoms even when acetylcholinesterase levels were reduced 60%–90% (1).

In four persons accidentally exposed to sarin and one person exposed to soman while working in a military laboratory (2), depressed mood, social withdrawal, insomnia with unpleasant dreams, and "antisocial thoughts" persisted for several weeks in the two most severely intoxicated. Early neuropsychological testing revealed deficits in visual retention, word association, and proverb interpretation, with improvement 6 months later. In a less intoxicated person, emotional lability developed during the first 2 days after exposure; at 4 months he was easily fatigued and had nonspecific pain, depressed mood, and restlessness (2).

Following intravenous administration of VX to volunteers, investigators noted diminished ability to perform mathematical tests at 1 hour postinjection, with rapid recovery thereafter (3). A person exposed percutaneously to VX during an attempt to murder him had persistent anterograde and retrograde amnesia when discharged from the hospital 15 days after the incident (4).

Acute effects of exposure to organophosphate pesticides by persons who attempted suicide and among accidentally exposed livestock workers and farmers included impaired vigilance and concentration, memory deficits, slowing of information processing and psychomotor speed, slowing of speech, word-finding difficulties, depression, anxiety, and irritability (3, 5–8). The degree of depression, measured on depression symptom rating scales, and the degree of diminished memory correlated with the degree of acetylcholinesterase inhibition.

Persistent long-term neuropsychiatric effects of acute intoxication with this class of pesticides include drowsiness, memory impairment, depression, fatigue, and increased irritability, and the symptoms last weeks to years after the exposure. In some persons, long-term changes in auditory attention, visual memory, motor speed, and problem-solving ability may be missed on routine clinical examinations but are detectable by neuropsychological testing (9, 10).

Of the drugs associated with the management of nerve agent exposure, atropine has the most potential for serious alterations in mental status. Most civilian physicians are accustomed to using atropine in doses under 2 mg, but treatment of patients exposed to acetylcholinesterase inhibitors may require 60–100 mg just in the first 24 hours. Given in excess of the patient's needs, atropine can produce psychiatric side effects ranging from drowsiness to hyperactivity, hallucinations, and coma (11–13).

Blister agents (nitrogen or sulfur mustards), another class of chemical weapons, can produce delirium (14, 15) and psychological distress resulting from highly disfiguring lesions that cover the skin, including genitalia, and from long-lasting oligospermia (16, 17).

Potential biological weapon agents include anthrax, botulinum, tularemia, plague, brucellosis, Q fever, smallpox, the viral encephalitides, viral hemorrhagic fevers, and staphylococcal B enterotoxin. Delirium is possible with all these agents. The viral encephalitides can also produce long-term cognitive impairment and alterations in mood. Anthrax spores can produce rapidly progressive meningitis. Depression, irritability, and headaches occur in persons with brucellosis, and nearly all fatalities from this infection involve either the endocardium or the central nervous system. About one-third of patients with Q fever complain of malaise and easy fatigue, and in more advanced disease they can develop encephalitis with hallucinations (18). Botulinum toxins result in a progressive paralysis, with delayed recovery of muscle power; survivors may require months of care with a ventilator and may become demoralized and depressed.


A chemical or biological incident will produce psychological impairment at the individual and community levels and may generate numbers of casualties that overwhelm local medical resources.

An incident with these weapons will be unlike any disaster known to most Americans. Usually, disasters do not produce panic because they involve familiar phenomena that are time limited and discernible to those involved in them. People in fires, for example, generally act responsibly, even altruistically, because they know about fires and receive sensory cues that enable them to assess the threat and to plan their escape (19). However, a chemical or, even more so, biological incident poses a sudden, unanticipated, and unfamiliar threat to health that lacks sensory cues, is prolonged or recurrent, perhaps is contagious, and produces casualties that are observed by others. These are the factors that, historically, have spawned fear, panic, and contagious somatization.

A chemical or biological attack is psychological warfare, whether that attack is real or a cleverly designed hoax and whether it is initiated by a lone sociopath, by a group of domestic or foreign terrorists, or by a nation. How others have responded to such attacks may predict how Americans might react. After the first missile attack on Israel by Iraq during the Persian Gulf war, nearly 40% of the civilians in the immediate vicinity of the attack had breathing difficulties, tremors, sweating, anxiety, and labile mood; subsequent attacks produced fewer symptoms (20). In a World War I incident, of 281 soldiers admitted to a referral center field hospital, 90 were true gas casualties and the rest were victims of "gas mania" (21). Of the 5,510 persons who sought medical treatment from the 1995 sarin attack in Tokyo, 12 died, 17 were critically injured, 1,370 had mild to moderate injuries, and the other 4,000 had no or minimal injuries.

Similar reactions have followed toxic spills and even rumors of "something bad" in the air.

In February 1973 a ship containing 50 drums of a relatively harmless organophosphate defoliant encountered rough seas and docked at Auckland, New Zealand, where several drums were unloaded. During the unloading, a wharf foreman noted a "sickly" odor coming from somewhere aboard the vessel and also noted the word "poison" on one of the drums. Over the next several hours, a mixture of misinformation and garbled translations contributed to a declaration of a state of civil emergency by the government and the evacuation of the area downwind from the incident. By the time the incident ended, 643 patients had sought medical care. Postincident analyses showed that the offending agent was relatively low in toxicity and, at most, had affected 241 workers who had come in direct contact with it, none of whom had sufficient exposure to reduce their acetylcholinesterase levels. The other 400 persons "were treated for symptoms suggestive of either their own anxiety or that of someone else" (22).

Somatization disorders affecting 784 schoolchildren in separate incidents in the continental United States and Alaska (23–26) and 949 people over three districts in the West Bank (27) all resulted from reports of "gas." Operations were curtailed at a Midwestern U.S. university data processing center (28) and at a U.S. electronics assembly plant (29) because of epidemics of somatization produced by fears of "gas poisoning." "Psychological stress reaction" was suspected, but not established, as the cause of collapse of six workers at a California hospital who complained of "ammonia-like fumes" after blood was drawn from a patient they were attending (30). Fear of "toxic gas" produced psychogenic symptoms in approximately 1,000 male U.S. military recruits in California in 1988 (31). Many of these episodes were halted with reassurance and dispersal of the affected populations.

Other psychological reactions to a disaster can affect anyone involved: acute stress disorder, grief, anger, scapegoating (anger directed at people perceived to have contributed to, or profited from, the disaster), and guilt at having done too little to have helped others. Longer-term effects include phobias, sleep disorders, posttraumatic stress disorder, substance abuse, and major depression (32, 33). When a disaster destroys a community, with dislocation and relocation of its members, additional stresses result from the loss of dignity as residents are forced into public shelters and experience the anxiety of strange environments and the disruption of their social networks (34).

There is little reason to believe that medical personnel (including ancillary staff, e.g., housekeepers, central supply workers), inexperienced and perhaps untrained in chemical and biological incidents, will be spared from the anxiety and other psychological distresses that will afflict the rest of the community, particularly if the offending agent threatens their own families. As Raphael noted, as victims and helpers emerge from a disaster, their "roles and experiences may be changed and interwoven so that the distinction between [them] has little meaning" (34, p. 222). Medical and rescue workers may not seek and may even resist therapeutic intervention for themselves (35)

Survivors of any disaster may need prolonged care. Of 111 patients hospitalized at one Tokyo hospital after their exposure to sarin during the subway attack, one-third reported anxiety, fear, nightmares, insomnia, and irritability to their physicians. At 1 month after the incident, 32% of the patients treated at that hospital after the incident reported a fear of subways, 29% noted continuing sleep disturbances, and 16% reported flashbacks and depression. These symptoms persisted at 3- and 6-month follow-up visits to their physicians (36).

Two weeks after the 1979 partial meltdown of the reactor core at the Three Mile Island nuclear power plant, which released a half-mile-wide plume of radioactive steam into the atmosphere, 26% of the local population showed severe demoralization. Eighteen months later the residents reported significantly greater emotional stress, more global symptoms and somatic complaints, and higher levels of anxiety and alienation than control groups (37). Long-lasting psychological effects have also followed transportation accidents (38) and natural disasters (39).

Tyhurst (40) noted three phases in the course of a community's response to disaster. The first, or "impact," stage is the time from the onset of the acute stressors until they are no longer operant. During this period, 12%–25% of disaster victims are able to analyze the dangers, formulate a plan, and act on it. About 75% are stunned and bewildered, and the remaining 10%–25% become confused, paralyzed by fear or anxiety, or hysterical (34). During the second stage, a "period of recoil," which begins when the initial stresses have ceased or when the person has escaped, those involved have a great need to be with others and talk (40, 41). It is during this stage that one form of crisis intervention, the critical incident debriefing (discussed later), may be initiated. During the final posttrauma stage, survivors realize what they have lost and the trauma they have experienced. Promises of aid and assistance that are made to a disaster-hit community by various agencies may lead to additional stress because of disappointment over unfilled or misunderstood promises and frustration with delays in receipt of aid (42).


To help victims reduce their likelihood of developing postdisaster psychiatric disorders, therapists have developed several crisis intervention techniques, including psychological debriefing, for implementation within hours or days after the incident. Although some investigators question the value of these debriefings (43), others believe they are effective in reducing later posttraumatic symptoms (38, 44, 45).

All crisis intervention incorporates certain principles. The therapist should be flexible in addressing the broad spectrum of reactions that may be encountered. Injured and frightened survivors should not be left alone, and parents should be reunited with their children. Providing survivors with blankets and food helps reassure them that someone is concerned about them. Survivors should be encouraged to verbalize their experiences; they may be able to do this better in a group setting than one-on-one (46). Persons with significant psychiatric disorders should be referred for hospitalization. As soon as possible, disaster survivors should be encouraged to participate in simple but useful tasks (32).

Many psychological debriefing techniques follow the reconstructive historical debriefing model developed by Marshall during World War II (47). In general, they allow the survivors to discuss what they experienced and what they felt. In the process, misperceptions may be clarified. Education on the range of expected emotional responses to a traumatic event is provided, and continuing help is offered. These debriefings are provided to anyone directly or indirectly exposed to the critical incident, including their relatives (48–50).

Some therapists have used a mini-marathon model that takes about 3 hours, can involve as many as 300 participants at one time (with enough therapists and microphones), and includes story and symptom sharing (51). Another debriefing technique currently being taught at seminars around the United States, particularly to nonpsychiatrists, is eye movement desensitization and reprocessing, which combines the recollection of painful events and their emotional charge with directed eye movements (52).

The psychiatrist should review his or her hospital's mass disaster response plan to ensure that the mental health component is more than token. It should include the establishment of a command-and-control center that will coordinate the services of mental health staff and volunteers to use their varied skills, ensure quality control, avoid disagreements among service providers, and reduce the possibility of overlapping services (35, 53, 54). The center could also assign service providers to areas where they are needed within the hospital, at the crisis site, and at shelters and community agencies (where injured victims are) and avoid congestion elsewhere. Community mental health centers could also serve as control points for care delivery (55).

The disaster plan should anticipate alternative forms of communication, including runners if telephone systems malfunction or become overcrowded. In a mass disaster the media may be scanning cellular telephone frequencies, and sensitive information should be transmitted by other means, such as hard-wired telephones.

Any disaster response plan should be coordinated with regional medical facilities and local law enforcement and civil defense agencies. This coordination process could serve as a vehicle by which the psychiatrist can educate others about the potential impact of psychological casualties on the community, the spectrum of normal-to-abnormal emotional reactions that may occur, and crisis intervention techniques.

Communication with the public by print media and by television and radio is crucial in a disaster (56). There should be a policy for handling media requests for interviews with local psychiatrists, whose messages must be consistent with ongoing events. It would not be helpful, for example, to tell the public that the danger is minimal if, at the same time, they are watching television footage of armed security forces in full chemical or biological protective clothing. Trust and credibility are key components of communication regarding environmental risk (57).

Thought should be given before a disaster strikes on how to keep adequate psychiatric patient records during the crisis (35) and how to implement an efficient institutional review board procedure for quickly reviewing and approving research projects to capture the experiences learned from the incident.

Whether through self-study or attendance at courses, psychiatrists should become familiar with the effects of, and treatment for, the chemical and biological agents that may be used in a terrorist incident. They should also familiarize themselves with decontamination procedures. In the crisis atmosphere that would be likely in the event of a chemical or biological incident, cohesive teamwork among all members of the medical staff is essential for both efficiency and safety. That quality of teamwork will result only from group training, and psychiatrists should be included in that training.

Psychiatrists will be consultants in a chemical or biological incident, but their environment may be hazardous. Medical personnel who come into initial contact with victims who have not been thoroughly decontaminated will need to wear protective clothing, including a "gas mask." Working effectively while wearing this clothing requires training and considerable practice. Military personnel, including medical, who were observed while in protective clothing without adequate prior practice experienced altered cognition, apprehension, hyperventilation, and claustrophobia that interfered with duty performance (58, 59). Even with experience, personnel who work in this type of protective clothing find their reaction times slowed. Fatigue, dehydration, and even heat exhaustion are risks. Therefore, shortened shift work, frequent rest periods, and duty rotations should be anticipated.


Remote though the possibility of a terrorist-authored chemical or biological incident in an American community may be, we must prepare for one. The agents are too easy to acquire or manufacture and too easy to disperse for us to ignore that possibility. Even the relatively more likely hoax or attack with an agent of low concentration that is ineffectively delivered will still generate mass casualties that will threaten civil order and inundate community medical facilities. The creation of this chaos is as much within the grasp of a lone, skilled, and determined person with his or her own warped agenda as it is of state-sponsored terrorists.

Many, perhaps most, persons involved in such an incident will exhibit fear, anxiety, or more serious disorders of mood, behavior, or cognition, especially if the perceived threat is a biological weapon that can spread silently from person to person. Local psychiatrists have a multifaceted role in their communities' disaster response plans. That role includes immediate treatment of individual patients and groups of patients who are experiencing the psychological impact of a mass disaster, organizing and managing the delivery of mental health care by others to the community, and assisting local medical facilities and community leaders in the control of widespread anxiety, fear, and perhaps even panic.

Should the weapon agent produce mental status changes that overlap those of psychiatric disorders, the psychiatrist's carefully done mental status examination may be crucial to triage and the prompt delivery of medical treatment to those who need it. Beyond the immediate crisis, any chemical or biological incident will likely produce delayed and chronic psychiatric disorders, as psychological effects of the disaster or as sequelae of the pharmacology of the agent itself.

In the absence of experience, confidence in handling this crisis will come from training and solid planning.


Received March 5, 1998; revisions received Aug. 3 and Oct. 14, 1998; accepted Jan. 20, 1999. From the Department of Neurology, National Naval Medical Center. Address reprint requests to Dr. DiGiovanni, Box 137, National Naval Medical Center, Bethesda, MD 20889-5000; [email protected] (e-mail). The author thanks Drs. L. Cantilena, P. Dickinson, A.J. Dutka, J. Hagmann, M. Kaminsky, and J.D. Malone and Mr. J. Vayer for their comments and suggestions. The opinions expressed are those of the author and do not necessarily reflect the policies or positions of the Department of the Navy, the Department of Defense, or the U.S. government.


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Large-Scale Quarantine Following
Biological Terrorism in the United States
Scientific Examination, Logistic and Legal Limits,
and Possible Consequences

December 5, 2001—Vol 286, No. 21

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Special Issue
Aftermath of a Hypothetical Smallpox Disaster

Jason Bardi
Johns Hopkins University, Baltimore, Maryland, USA

The second day of the symposium featured a discussion of a scenario in which a medium-sized American city is attacked with smallpox. Four panels represented various time milestones after the attack, from a few weeks to several months. Panelists discussed what they and their colleagues might be doing at each of these milestones. The goal of the responses was to communicate the complexity of the issues and to explore the diverse problems that might arise beyond the care and treatment of patients.

The scenario itself was a step-by-step account of a smallpox epidemic in the fictional city of Northeast. Tara O'Toole, the scenario's lead author, read the narrative account before each panel.

The panelists responded to the events as if the epidemic were real and they were actually trying to identify, contain, communicate, and otherwise deal with it. Panel members included experts on hospital, city, state, federal, and media responses. Representing the hospitals were John Bartlett and Trish Perl, Johns Hopkins Hospital; Julie Gerberding, Hospital Infections Program, Centers for Disease Control and Prevention; and Gregory Moran, Emergency Medicine, University of California at Los Angeles. Jerome Hauer represented New York City's response. Representing the state were Michael Ascher, California Department of Health Services Laboratory; Arne Carlson, former governor of Minnesota; Terry O'Brien, a Minnesota State Assistant Attorney General; and Michael Osterholm, Minnesota Department of Public Health. The federal representatives on the panels were Robert Blitzer, former counterterrorism chief with the Federal Bureau of Investigation; Robert DeMartino, Substance Abuse and Mental Health Services Administration; Robert Knouss, Office of Emergency Preparedness, Department of Health and Human Services; and Scott Lillibridge, Centers for Disease Control and Prevention. Joanne Rodgers, Johns Hopkins Medical Institutions Public Affairs, spoke to the response of the media. George Strait, the medical news director for ABC News, acted as moderator for each of the panels scheduled on day two. D.A. Henderson also helped to moderate.
Identifying the Agent

At the start of the epidemic, 2 weeks after the bioterrorist attack, confusion reigns. There is uncertainty as to what the infection is and reluctance to diagnose smallpox even when it is suspected. It is unclear who is in charge of investigating and containing the epidemic. Outside, reporters are knocking on the hospital doors. The question of what took so long to identify the agent opens the panel. Smallpox, a nonspecific flulike illness, is hard to diagnose, replies an emergency medicine physician. The disease is not suspected because it was eradicated in the late 1970s. Any laboratory work on the first cases would initially be testing for a battery of other causes, such as other viral infections (e.g., monkeypox) or reactions to recent vaccinations. A window of 2 weeks before positive identification of smallpox may even be optimistic. The diagnosis would probably take much longer because of physicians' lack of familiarity with the disease.

When all the tests for other infections turn up negative and smallpox is strongly suspected, suggests a state laboratory chief, a conclusive result from the laboratories at the Centers for Disease Control and Prevention (CDC) or the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) would still be needed. These are the only two places in the United States equipped to identify smallpox virus in tissue samples. This part of the diagnosis is fairly straightforward but it would take at least 1 day before the definitive results could be obtained.
Responding at the Hospital Level

Hospitals would probably isolate the early cases presumptively, even if smallpox was not suspected, since the symptoms would appear infectious. This is the opinion of a hospital infections expert. In the city, argues a state health department professional, several hospitals would each see one or two of the first few cases. The city health department would quickly become aware of the similarity of the cases in the various hospitals, recognize a potential outbreak (probably measles) and mobilize early to contain it.

Once smallpox is identified, the following organizations within city government would be notified: the police department, the local emergency management office, the city health commissioner's office, and, ultimately, the mayor's office. This process may be difficult since it requires integrating the health department into emergency management plans, an event with little precedent, notes a city emergency official.
Coordinating Response Efforts

Who is in charge, agree panelists, is one of the most important questions yearly in the epidemic, because any large-scale relief effort would require good management. Complicating the answer, however, are various levels of government, each with its own responsibilities and perspective on response, as reflected in panelists' remarks.

Acts of domestic terrorism are under the jurisdiction of the federal government, so several federal agencies become involved, starting with FBI. FBI is involved from the very beginning since any cases of smallpox would indicate a deliberate terrorist attack. A criminal investigation begins immediately. CDC is involved as soon as samples are sent for laboratory diagnosis.

The state government becomes involved at the outset, since major threats to public health are dealt with on the state level. The state health department starts its own investigation, and to reassure the public, the governor may act as a spokesperson for the management of the epidemic.

The city is involved from the outset, explains the city emergency management official, understanding that "bioterrorism is a local issue," which escalates very rapidly to state and federal levels. The local police and emergency management teams, as well as the city health commissioner, the city health department, and the mayor, are involved.

The problems of the city become state problems immediately, counters the former governor, because the news media treat any potential infectious disease outbreak as a regional problem. This forces the governor's hand. The governor has to move in because there is a need for one person to be in charge.

The most difficult situation is how to deal with the hospital patients. One danger in the early days is losing control of the crisis through panic. Once rumors about smallpox start to spread, many workers within the hospital walk off the job. Understaffing also leads to increased stress and confusion for patients and providers alike.

Even before federal and state command structures are in place, suggests a hospital infections control expert, hospital epidemiologists would already be addressing infection control issues. She notes that hospital infection control specialists would be on the phone to colleagues in other city hospitals alerting one another. Hospital epidemiologists, adds a state health official, would have a contact list of state, local, and federal public-health authorities who also would be notified.

Another problem in coordination becomes clear to panelists: the difficulty in sharing classified risk information among agencies and various levels of government. Any early warning, which could have contributed to a more effective response, was missing in the scenario. Even though the FBI had some early intelligence of the attack, the alerting of health care workers was nonexistent. The problem lies in the fact, assesses a state health department official, that health departments have never been seen as intelligence communities, nor has there ever been a precedent for passing such information to them.

On the federal level, CDC addresses the public health issues of the epidemic, and FBI addresses the law enforcement issues. These aims are not necessarily exclusive of one another, and the possibility of linking efforts is raised. Everyone interviewed as a part of the epidemiologic investigation may have to be interviewed as part of the criminal investigation as well. Perhaps the most effective way to accomplish this is to conduct both interviews simultaneously.

Some aspects of the two federal agencies may overlap, perhaps even conflict, in agendas. Specimens that are sent to CDC for positive identification of the smallpox virus may be needed by FBI as evidence for any eventual prosecution. In many ways, it may appear as if FBI is running the investigation. However, dealing with the sick, obtaining vaccine, and mobilizing the epidemiologic investigation at the local, state, and federal levels are outside the scope of FBI. CDC takes the lead on these public health issues, and together with FBI, coordinates the management of federal resources.

However, who is coordinating activities at the hospitals is still unclear, and the question of authority on that level is unresolved. Can outsiders come into a hospital and wield power, and if so, who are they? Federal responders may have ambiguous authority within a hospital and may add to the chaos. An FBI offical notes that his agency's role in the hospitals will simply be to inform the doctors and administrators of what the hospital needs to do to assist in the criminal investigationkeeping evidence and coordinating interviews with patients. However, this may still leave gaps of authority within the hospital.

In the scenario under consideration, the state identifies one hospital as the smallpox hospital, and this also presents a problem of coordination. The hospital itself has to work out the details of local quarantine and the distribution of medicine to the patients, and there is a need to protect the health-care workers and other hospital staff. Vaccine should be immediately available to these workers, and its distribution will have to be coordinated with CDC.

Outside the hospitals, an epidemiologic investigation will be taking place that will need to be coordinated with CDC. A CDC official points out the need for surveillance in the early days of the epidemic. To assist in collecting data necessary to identify the release source and people at risk, he recommends that CDC provide additional staff for much of the epidemiologic work, including mid- and senior-level investigators. Bringing in these outside experts should not represent a problem for local officials, he suggests, since CDC already has strong ties with state epidemiologists.
Informing the Public

How to control the message going to the public weighs heavily upon the minds of all panelists. Reporters on the hospital scene will quickly become aware of any rumors and will demand answers of any worker or official who is handy. Official channels will not be the only source of information during the epidemic, argues the public affairs specialist.

First responders, such as the police or fire officials, might show up with full biohazard protection; such an image immediately raises questions. The media will digest information from day one, whether or not there is an official statement from the city, state, or federal level.

Controlling the message that goes out over the airwaves could be extremely difficult, especially since there may not even be any consensus on what the message should be in the first place. Several panelists point out the need to ensure that information presented to the media is consistent and credible. The city emergency manager suggests that the mayor will work with federal and state officials to get consistent and credible information out to the public. One viable alternative to speculation and misinformation, proposes an FBI official, is to have a centralized joint information center, such as the one his agency set up in Oklahoma City after the bombing, with several experts answering all the questions that arise.

Regardless of how information is disseminated, the message must be carefully considered. If the flulike symptoms of smallpox are identified on the evening news, a flood of noninfected persons with stuffy noses or headaches could swell emergency rooms across the state. Other reports, such as upcoming quarantine efforts, may also spread panic and should be handled carefully. The types of stories the media choose to write present a challenge. The press will not only cover the crisis but the managers of the crisis. Plans for responding to questions about crisis management must be in place. Whether or not the message that goes out to the public includes mention of terrorism should be weighed.

The hospital infections expert pursues a different angle to the issue of information exchange. The difficulties in interviewing the public have not been solved, she points out. Who will do the interviews? How they will be coordinated with criminal investigations? Who will receive vaccine? And how will health-care workers be protected? Will the system be overwhelmed by false casespeople who think they have smallpox? Moreover, a basic problem in the early days of the epidemic is the need for an infrastructure to handle the large volume of calls flooding the hospitals.
Handling Logistics

What will be the plan of action? Hundreds of people will have to be mobilized to interview the public, and hundreds more will be needed to administer vaccine. The distribution of antibiotics and vaccines represents a logistical problem that must be overcome.

As the epidemic grows and spreads to several states, friction between the levels of government grows. Governors are demanding vaccine supplies, fueling a larger debate of how vaccination should be handled. Tens of thousands of people are vaccinated, but many more still need vaccine. Media reports begin to be critical of the government's handling of the crisis.

What still needs to be done? With a growing number of deaths, the rise in the number of patients in quarantine, the loss of critical health-care workers and city emergency workers, within the city things are beginning to get out of focus, notes a city official. Asking how leadership will function inside the hospital, the hospital epidemiologist identifies a need for official responses that are well thought out, strong, and based on hard science.

The vaccine campaign poses significant issues. The limited supply of vaccine must be divided up and distributed according to greatest riskpersons who may have been infected or who care for those infected, argues an official in federal emergency management. Political leaders and essential city workers are other priority groups. A consensus must be reached as to how to proceed with the vaccinations. CDC is best suited to coordinate vaccine efforts, but the public health community must work towards an emergency. The governor, warns the city emergency manager, may step in and call the shots. There is a need for a public health emergency plan. Did the outbreak start from a single source or from multiple sources? This determination would help with vaccine management and allocation, but there is no answer. Moreover, testing facilities at CDC and USAMRIID are overwhelmed at this point in the epidemic.

Hospitals must deal with quarantine. Restrictions are imposed in the first days or weeks of an epidemic. Workers' fear of being sequestered causes them to leave hospitals understaffed. Many people are likely to stay at their posts if they feel they have reliable information and support, argues a mental health provider. Some, however, may leave the front lines to go home to their own families.
Legal Ramifications

According to a 1905 Massachusetts case, cites a state's assistant attorney general, compulsory vaccinations are not a violation of due process and are therefore legal. So the local, state, and federal levels of government have no obstacle to vaccinating those designated at risk.

A more difficult legal question is that of quarantining smallpox patients. Many of the public health codes used to allocate powers to government officials are old and may not be valid or useful. Also, court precedents from HIV cases may have heavily weighted matters in favor of due process. Minnesota, for example, requires a separate court hearing for each case of quarantine. Thus, quarantine may be possible in a hospital but not in the community.

Another basic legal question is whether the lines of legal support are clear to all officials, such as hospital guards and police officers. How far can police go to detain quarantined patients? The limits of emergency powers should be clearly delineated in any predisaster planning.

The epidemic is threatening to expand beyond the city into the rest of the country and even beyond. The World Health Organization (WHO) will probably become involved, and travel notifications have to be introduced.
Vaccine Supply

Even without adequate supplies of vaccine, much can be done with the existing stocks. Prevaccinating some health-care workers is a proactive approach. Having a sizable pool of prevaccinated professionals who can mobilize and act as emergency responders takes much of the pressure off local hospitals. One way to reduce secondary transmission (outside of vaccinating the contacts of the infected person), instructs the hospital epidemiologist, is good infection controlwearing filter masks and washing hands well. Another way of controlling the epidemic is through quarantine. While these measures are not a substitute for adequate vaccine supply, they can slow the epidemic.

One problem with the vaccine supply is that many more people want to be vaccinated than limited stores permit. There are not even enough stores of vaccine to prevent the spread of the epidemic. The existing 6 to 7 million doses of smallpox vaccine will not last forever, and the 36 months it takes for additional large-scale preparations is prohibitive, argues a vaccine campaign expert. Health officials will likely not have the time or resources to target precisely those people who have an actual need for vaccine. The need for vaccine will overwhelm the supply.

The cost of vaccine development may inhibit stockpiling, proposes a CDC official. Since an attack with smallpox is of low probability, large-scale production may be difficult to justify. A partnership between private industry and the government would help, however. Also, the cost of getting caught without an adequate supply could be disastrous.

Possible emergency measures to stretch the vaccine supply, proposes a smallpox expert, include arm-to-arm vaccination as pustules form on the arms of vaccinated people; vaccinia could be grown in massive amounts in tissue culture; and 30 million doses of vaccine could be contracted from South Africa.
The Final Stage

The smallpox epidemic has become a major public health emergency affecting several cities in many states and at least four other countries. The event is identified as a terrorist attack, because no other source of smallpox outside a deliberate release exists. For those who have already contracted smallpox, antiviral drugs, such as cydolfivir, may be useful but these medicines may be just as scarce as the vaccines.

Secondary transmission got out of hand, vaccine use did not contain the epidemic, and standard planning did not work. Thus a state health official sums up the deficiencies of response. Hospital resources have been overwhelmed, with people flooding emergency rooms in the belief they have smallpox. These cases are added to hospitalized cases before and during the epidemic; yet there are not even enough beds for all the sick. The hospital staff have become physically and emotionally exhausted from the long hours and from seeing about a third of infected patients die.

Failure of containment has turned the outbreak from local to national and international. However, the epidemic would have been much worse, had it gone unchecked, notes a state health official. Containment was significant. The 15,000 smallpox cases could have easily been more than 100,000.

No perpetrators have yet been identified, despite combining the criminal and the epidemiologic investigations. Such methodical work, however, is important because, unless the intelligence community comes up with information or a tip, there is no other way to identify the source of the epidemic, explains an FBI offical.

Many of the problems in the epidemic could have been avoided or controlled if extensive plans had existed, panelists agree. The panelist speaking from a governor's perspective identifies leadership as the most pressing void. Should the city have been placed under immediate quarantine? Should martial law have been implemented? Is the designation of a single smallpox hospital a reasonable thing for any city to do? These are difficult questions to face in the wake of a disaster. Such issues must be addressed long before trouble strikes.

Who Will Pay for the Smallpox Epidemic?

The significant cost of curtailing the epidemic is debated. How will a smallpox hospital be financed, inquires a physician. The money might come from the federal government as emergency management funding, suggests a city emergency manager. The infrastructure and linkages within the public health community could be improved, the capacity for laboratory testing of samples could be increased, surveillance methods could be enhanced, and a health information strategy could be developed.

While the smallpox scenario is certainly frightening, experience with earlier epidemics (smallpox among them), knowledge of the issues, and expertise to deal with them show that in a crisis people from all disciplines pull together.