BIOTERRORISM & INDIA’S PREPAREDNESS

BIOTERRORISM & INDIA’S PREPAREDNESS

Compiled & shared by-DR. RAJESH KR SINGH, JAMSHEDPUR

What is bioterrorism?

Bioterrorism is a form of terrorism where there is the intentional release of biological agents (bacteria, viruses, or other germs). This is also referred to as germ warfare. Terrorism is defined by the United States government as the “unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.” The term “terrorism” does not imply what weapon is being used. In addition to biological agents, terrorists can also utilize traditional weapons (guns), chemical agents and nuclear bombs. While a biological agent may injure or kill people, animals, or plants, the goal for the terrorist is to further their social and political goals by making their civilian targets feel as if their government cannot protect them. Many biological agents are found in nature; however, they can be modified by the terrorist to make them more dangerous. Some of these agents can be transmitted from person to person, and the infection may take hours or days to become apparent.

What are the biological agents that can be utilized for bioterrorism?

While any germ, bacteria, or virus could potentially be utilized by terrorist, there are a number of biological agents that have been recognized as being more likely to be utilized. The reason for these agents being of concern is based on their availability to terrorists and the ease by which these agents can be disseminated. The U.S. Centers for Disease Control and Prevention (CDC) has developed a classification system for biological terror agents, which is available on their web site (Categories). The classification is based on the likelihood of the agent being used and the risk posed by each agent. The agents (and the diseases they cause) are listed in table 1, including hyperlinks for those wishing to learn more about a specific agent or disease. However, it is almost impossible for most people to memorize all the details about each of these agents. It is more important for the general public to understand the risk of bioterrorism and the appropriate response to a terrorist attack. Continue Reading

There is a general perception that Islamic terrorist organisations in Pakistan like LT could use some advanced technologies against civilian populations in India. The problem of nuclear and biological terrorism deserves special attention from all South Asian states, including India. As nuclear weapons, missile technologies and bio-weapons proliferate, there is a grave danger that some of them might fall into the hands of the Pakistani Taliban (TTP), ISIS, LT terrorist groups.

The Indian government has recognised the threat from bioweapons as real and imminent. Both the ministry of defence and ministry of home affairs placed high priority on this issue. India understands that Pakistan-based terrorist groups may possibly use these weapons in Kashmir in the near future.

Bioterrorism is defined as a planned or destructive use of biological agents such as viruses, bacteria, fungi or toxins produced from living organisms. The main aim of bioterrorism is to harm people, animals and plants by causing death, so as to achieve political or social destruction. The virulence and ability of an agent to cause a disease can be increased through creating mutations in that agent. Also, the agents can be designed in such a way that the current medical treatments are enable to cure and they can be
easily spread through air, water, food, foamites or through infected hosts such as insects, animals, humans and other reservoirs . Biological terrorism resulting in mass destruction or causalities further ensues disturbances or panic among population . Detection of such biological agents may require several hours to weeks. Hence, the rate of mortality by utilizing bioweapons can be excessive, compared to the traditional ways of destruction . Because of these facts, such agents are gaining importance around the world, their nuclear or chemical weapons.
The use of biological agents as bioweapons has its roots in ancient times, when the concepts of bacteria, toxin or virus were not known yet. Over 2,000 years ago, rudimentary techniques of biological warfare resolved the first disputes among people. Hand by hand with the evolution of modern science (especially in the 18th century), the possibility of using biological agents as bioweapons has been refined. In the last few decades, the development of innovative biotechnology techniques has provided the knowledge to create more aggressive bioweapons. These new organisms cause great concern, because they can produce devastating and completely unexpected effects, of the same level or even higher than the most dangerous wild type biological agents. Although international conventions prohibit the use of biological agents for offensive purposes, it is known that many terrorist groups continue their research about the possible use of biological agents as bioweapons. The concerns related to biological agents are aroused, as well as the effects in terms of victims, both from the objective difficulties in the detection of a potential attack. A release of biological agents is difficult to detect with current technology, especially when it comes to a stand-off revelation compared to point detection. Biological agents have a unique feature when compared to other non-conventional weapons (chemical or radiological); with the exception of toxins, they are able to multiply in the host and in turn be transmitted to other individuals. Hence, immediate identification of a biological attack is essential, in order to take appropriate containment measures to contain further dissemination. Therefore, there is a clear need to develop new technologies to detect biological agents from long-range, in order to take immediate action in the event of both intentional and unintentional biological agents releases.

Bioterrorism: Indian scenario———–

The threat of bioterrorism is the most plausible when compared to other weapons of mass destruction (WMDs), considering the riotous advances in biotechnology. The precarious security environment in South Asia, rapid rise in fundamentalism and extremist implosion of Pakistan, the cloud of civil war in Afghanistan and the emergence of the Islamic State of Iraq and Syria (ISIS), Pakistan based terrorist organizations further accentuate this threat. It concludes that bioterrorism is a low-probability, high-impact event. Biological agents are a threat to human, livestock and crop health, as well as to the Indian economy, and their understanding must be considerably improved. Political awareness and public participation are essential for threat mitigation. The preparedness against biological attacks will also prepare our population against natural occurrence of diseases, thus transforming India into a resilient society.

Dense population, poor hygiene and deprived sanitation facilities along with congenial climatic conditions make India vulnerable for the spread of infectious diseases caused by biological agents. Highly infectious and virulent agents occur naturally in India because of easy availability of extended water-locked agricultural fields and animal farms. In addition, India does not have adequate medical facilities, i.e. on an average a single government doctor serves nearly 12,000 people. Hence, most of the people remain untreated and when they move across the country, the release and spread of disease becomes quite easy leading to the outbreak of bioterrorism. Research authorities also need time to differentiate between the nature and type of biological agents, i.e. whether they are natural or man-made and how to deal with them. A number of challenges arise during fight against bioterrorism. The very first challenge is the proper collection of specimens at the site and their identification. It is usually hard to find the site where the original outbreak occurred or from where it was initiated. If samples are not accurately identified, it because difficult to control the bioterrorism crisis. Secondly, it is also a challenge to recognize the occurrence of the attack and quick management of the outbreak. Thus to combat bioterrorism, synchronized and determined efforts of different agencies like Intelligence agency, Indian army, Border Security Force, law enforcement machinery, all health departments and civil administration are needed

Biological Agents That Can Be Used as Bioweapons———-

While there are numerous pathogens (bacteria, viruses and toxins) that cause diseases in humans, animals and plants, only very few possess the characteristics to be a bioweapon. Eitzen (1997) described the characteristics that make a biological agent a potential bioweapon. Ideally, a bioweapon should be easy to find or produce. In order to develop a biological attack towards sensitive targets or the population, large amounts of biological agents are in fact required; it must be considered that it is necessary to have quite a number of biological agents (or a certain amount of toxin) to generate a disease in a target. The ideal bioweapon also must have a high capacity to incapacitate the affected or, alternatively, be highly lethal. It is appropriate to choose an agent with an incubation period depending on whether immediate or delayed effects are required. Other important characteristics for a biological weapon are the route of transmission, and hence, the ease of dissemination with an appropriate method of delivery. Finally, the stability of the agent must be assessed, especially when large quantities must be stored for indefinite periods .

CLASSIFICATION OF BIOLOGICAL WEAPONS——

Category A ——–
• Anthrax (Baccilus anthraxis) • Botulism (C. botulinum Toxin) • Plague (Yersinia pestis) • Smallpox (Variola major) • Tularemia (Francisella tularensis) • Viral Hemorrhagic Fevers (Filoviruses [e.g. Ebola, Marburg] and arenaviruses [e.g. Lassa, Machupo], Others)
Category B ———-
• Brucellosis (Brucella species) • Epsilon toxin of Clostridium perfringens • Food safety Threats (e.g. Salmonella species, E coli O157:H7, Shigella) • Glanders (Burkholderia mallei) • Meliodosis (Burkholderia pseudomallei) • Psittacosis (Chlamydia psittaci) • Q Fever (Coxiella burnetii) • Ricin Toxin from Ricinus communis (Castor Beans) • Staphylococcal enterotoxin B • Typhus fever (Rickettsia prowazekii) • Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern and western equine encephalitis]) • Water safety threats (Vibrio cholera, Cryptosporidium parvum)
Category C ———–
• Emerging infectious diseases such as Nipah virus and Hantavirus
The key features of biologic agents, which may be used as bioweapons, are : • Causes high morbidity and mortality. • Potential for person-to-person spread. • Low infective dose and highly infectious by aerosol. • Lack of rapid diagnostic capability. • Lack of universally available effective vaccine in a short time. • Potential to cause anxiety. • Easy availability of pathogen and feasibility of production. • Environmental stability of the pathogen. • Database of prior research and development. • Potential to be “weaponized”, meaning ability to be modified for greater virulence and ability to be dispersed with available weapon delivery system.

India’s preparedness against bioterrorism————–

Preparedness will focus on risk analysis of biological weapons, medical and public health consequences, medical countermeasures and long-term strategies to combat and prevent future threats. The National Disaster Management Authority (NDMA), Govt. of India (GoI) has proposed a model instrument where participation of both government and private sectors is a pre-requisite to manage the menace of biological disaster. According to NDMA, a sound infrastructure is necessary for both medical countermeasures and for research and development to evolve novel instruments and methods of testing. Biological disasters cause socio-economic upheavals and decline of population. Depending upon vulnerability of the populations to specific biological agents, these may cause mass destruction similar to chemical and nuclear weapons. Epidemics can result in heavy losses due to depletion of crops, domestic animals and natural resources like air, water and productive soil. So, a multi-sector approach has to be adopted, for which judicial involvement of the government is a prerequisite. In India, there are several nodal ministries for dealing with epidemics caused by bioterrorism. Similarly, several acts related to management of environment, human, animal health and crops etc. have been enforced to punish miscreants of such unlawful activities.
NDMA is responsible for laying down the policies on management, approving plans different ministries or departments of GoI in accordance with the national plan and preparing guidelines to be followed by the authorities of different states to prevent any disaster. It also works for the further improvement of development plans and projects and accomplishment of disaster management. The National Crisis Management Committee (NCMC) coordinates and monitor responses in crisis situations especially in disasters. It provides strong co-ordination and implementation of relief measures during disasters. The National Disaster Response Force (NDRF) provides specialized response in a threatening disaster situation. This force is well trained for multitasking in different disciplines. NDRF also provides training to the State Disaster Response Forces personnel, police and civil defence home guards in the field of disaster response.

Recommendations—————
the following recommendations to make India safe from bioterrism:
• Development of rehabilitation centres and financial assistance to affected individuals; • Development of e-learning modules on methods to combat bioterrorism; • Judicial involvement of media and internet for community awareness and preparedness; • Encourage interested citizens to register and get trained to be a part of national disaster management quick response teams in addition to Indian Army; • Environmental and disaster management curriculum should be designed and introduced in engineering, management, humanities, social and material science courses; • Free teaching camps should be organized for community preparedness in border areas where the population is more at risk; • Mass level immunization can offer protection to populations at risk; • Prophylactic measures should be lawfully enforced; otherwise it would cause massive destruction due to rapid spread of infectious agents which usually have very less cell doubling time.

Bacillus anthracis————

This is one of the most serious forms of biological weapons available to terrorists. The very hardy spore can survive years in the environment, although the vegetative form is incapable of surviving outside the host. Anthrax has four known forms, cutaneous, pulmonary, gastrointestinal and oro-pharyngeal. While the first is the commonest the others are rare. However in case of a bio-attack the pulmonary form would be the commonest, with frequent gastro-intestinal features. Cutaneous forms would also be seen.
Bacillus anthracis is a Gram-positive, non-motile, facultative anaerobic endospore forming bacteria, usually surrounded by a capsule. It is the etiological agent of anthrax, which occurs most frequently when an epizootic or enzootic of herbivores becomes infected after acquiring spores from direct contact with contaminated soil. In humans, the disease can occur when exposed to infected animals, tissue from infected animals or high concentrations of anthrax spores. Anthrax endospores have no measurable metabolism, do not divide, and are resistant to drying, heat, ultraviolet and ionising radiation, chemical disinfectant, and other forms of stress, remaining in the environment for years (Bhalla & Warheit, 2004), with survival in soil for up 200 years being reported (Yuen, 2001). The disease is caused by the action of a toxin produced by the vegetative bacillus, which consists of three components; protective antigen (PA), edema factor (EF) and lethal factor (LF). PA binds to cell receptors, mediating the entry of EF and LF into the cell. Another anthrax virulence factor is the D-glutamic acid polypeptide capsule of the vegetative form (WHO, 2004). Three types of anthrax infections can occur; cutaneous, inhalation and gastro intestinal. The cutaneous form is the most common and is characterised by dermal ulcers, painless, non-scarring, pruritic papule progressing to a black depressed eschar with swelling of adjacent lymph glands and oedema (WHO, 2004). Local lymphadenitis and fever can occur, but septicaemia is rare (Moquin & Moquin, 2002). Untreated cutaneous anthrax can become systemic and it is fatal in 5-20% of cases. Gastro-intestinal and inhalation forms are less common. The inhalation form starts with influenza-like symptoms that include fever, fatigue, chills, non-productive cough, vomiting, sweats, myalgia, dyspnoea, confusion, headache and chest and / or abdominal pain, followed by the development of cyanosis, shock, coma and death. The gastro-intestinal form is characterised by fever, nausea, vomiting, abdominal pain and bloody stools. Oropharyngeal infection, on the other hand, is accompanied by oedematous swelling of the neck, often followed by fever and lymphoid involvement (WHO, 2004). There is no evidence of direct person-to-person spread (Yuen, 2001). After exposure, the incubation period is reported to range from 1 to 7 days, possibly extending up to several weeks. Some vaccines are administered to prevent the disease, such as live spore vaccines based on attenuated strains, and cell-free vaccines based on anthrax PA (WHO, 2004). Regarding therapy, there are three types of antibiotics that are effective against B. anthracis; ciprofloxacin, tetracyclines and penicillins (Bhalla & Warheit, 2004). For laboratory diagnosis and research, manipulations involving clinical specimens, Biosafety Level 2 (BSL-2) practices are recommended, while for manipulations involving activities with a significant aerosol production, Biosafety Level 3 (BSL-3) practices are advised (WHO, 2004).

Diagnosis ————

The definitive diagnosis of anthrax is based on isolation of Bacillus anthracis from body fluids and blood by culture. Current recommendations are that once bacillus species is isolated in any case, further confirmation to rule out B anthracis must be done. Chest CT scan may show hyperdense hilar and mediastinal nodes, mediastinal edema, infiltrates and pleural effusion. On thoracocentesis hemorrhagic pleural effusions may be found.
Treatment———-
Anthrax inhalation causes a fulminant systemic infection and treatment must be initiated pending laboratory confirmation. Because even one to two doses of antibiotics interfere with the culture, samples must be taken before initiating therapy.11 Antibiotic therapy is as outlined in Table 3 and it must be emphasized that due to concerns of long surviving spores of B anthracis, treatment/ prophylaxis is to be given for at least 60 days—

Ciprofloxacin, 400 mg IV q12h or Doxycycline, 100 mg IV q12 plus Clindamycin, 900 mg IV q8h and/or rifampin, 300 mg IV q12h; switch to PO when stable for 60 d total

Prophylaxis———Postexposure chemoprophylaxis: Ciprofloxacin, 500 mg, PO bid x 60 days or Doxycycline, 100 mg PO bid x 60 days Amoxicillin, 500 mg PO q8h, likely to be effective if strain penicillin sensitive Anthrax vaccine adsorbed.
Vaccines ——–
Whilst an adsorbed cell-free anthrax vaccine is available, its availability is restricted and in a mass casualty setting chemoprophylaxis is the method of choice. Also the vaccine has to be given in six doses with annual boosters and is known to have side effects.

Recent advances———-

Efforts to develop newer less reactogenic, easily administered vaccines are on. In this regard advantage has been taken of inducing mucosal immunity and vaccines containing recombinant protective antigen (rPA) or protective antigen (PA) have been delivered intranasally with good results in animals.12,13 Full length PA expressed on Salmonella Enterica serovar Typhimurium, administered orally to mice, has been shown to confer immunity as have fusion protein molecules of the domain 1 and 4 of PA. Thus an oral vaccine for anthrax is today a possibility.14 The pathological mechanisms of the anthrax bacillus have also been studied and the lethal (LeTx) and edema (ETx) toxins identified as the key virulence factors. The protective antigen, which has been found to be a component of these toxins, binds to specific cell surface receptors and allows uptake of these toxins. LeTx has the ability to cleave mitogen activated protein kinase kinases, and the evidence indicates that rather than excessive inflammatory response contributing to shock with LeTx, the immunosuppressive effects of LeTx could promote infection; however, direct endothelial dysfunction may have an important role in shock due to LeTx. Edema factor, a potent adenyl cyclase, may have a major role in shock during anthrax and it may also be immunosuppressive.15 In light of this the reports of prophylactic and therapeautic use of recombinant and other immunoglobulins targeting the protective antigen imply that we may be able to improve on prophylaxis and treatment for anthrax soon.

Combating bioterrorist attacks————–

The key element in combating a bio-terrorism strike is rapid identification of a strike and the agent used; so that effective countermeasures may be instituted before the agent disseminates widely. The anthrax attack on the US claimed few victims – thanks to rapid intervention by bio-weapons specialists on the suspicion of an alert physician.5 Identification of bio-attacks however may be expected to pose problems because of: • occurrence of rare hence ill-recognized diseases • many agents of biological warfare also cause naturally occurring disease, • resemblance of biological toxins to chemical agents rather than infectious organisms, and • the concomitant use of more than one agent.5, 9 The Iraqi government used mustard gas, a nerve agent and anthrax or aflatoxin together in their northern provinces. Thus detection of the agent and subsequent decontamination is difficult, symptoms are complicated and mortality much greater

Factors which should arouse suspicion of bio-terrorism are:—–

Clinical Settings
• Suddenness of onset of disease in many people and close clustering of cases • Unusually large numbers of cases of a particular disease • Unusual geographic or demographic distribution. An unusual geographical distribution of persons or animals at the time of their probable exposure could point to deliberate use. Aerosol release resulting in an airborne cloud, for example, would give a distribution consistent with meteorological conditions at the time. Other unusual distributions or association with suspicious objects or activities may also be indicative of deliberate use. • Rareness. The unexplained appearance of an infectious disease of humans or animals that is ordinarily very rare or absent in a region may indicate deliberate use. • Severity of disease following inhalatory infection. Disease initiated by inhalatory infection may follow a course and exhibit symptoms differing from and more severe than those characteristic of other natural, routes of entry

Clinical syndromes
• Acute severe pneumonia or respiratory distress. • Encephalopathy. • Acute onset neuromuscular symptoms. • Otherwise unexplained rash with fever. • Fever with mucous membrane bleeding. • Unexplained acute icteric syndromes. • Massive diarrhea with dehydration and collapse.

Biological weapons are defined as “microorganisms that infect & grow in the target host producing a clinical disease that kills or incapacitates.” Such microbes may be natural, wild- type strains or may be the result of genetically engineered organisms. These may be the products of metabolism (usually of microbial origin) that kill the targeted host & include biological toxins, as well as substances that interfere with normal behavior, such as hormones, neuropeptides & cytokines. It is now possible to design and manufacture substances that mimic the action of biologics e.g. Nerve gases, pesticides etc. “Designer” substances may also be created that can be specifically targeted to a particular cell-type in an enemy (e.g. People with blonde hair and blue eyes). [5] Bioterrorism is the use of BWs as terror attack or threat. Usually terrorists are using the conventional means of destruction but there are chances that unprotected biological weapons may get into their hands and may used to create terror on a vast scale. Anthrax letters were used after 9/11 in the U.S.A. to create terror. Recently ricin letters were used in the U.S.A. by the terrorists.

Bioterrorism agents’ important features of a perfect BW are:
1. Highly infectious and highly effective. 2. Easily produced with a long shelf life. 3. Efficiently dispersible. 4. Readily grown and produced in large quantities. 5. Stable on storage. 6. Resistant enough to environmental conditions. 7. Resistant to treatment

Important Measures & Handling of Such Disasters:———–

Preventive measures: 1. Develop full international cooperation on dealing with this problem. 2. Educate at risk populations 3. Coordinate the monitoring of thc potential producers and users of bw 4. Continue to improve on BW monitoring techniques and apparatus. 5. Stockpile BW fighting supplies
Detection of BW is a big problem unless it is an announced event by the terrorists but this may not be always and it may be a covert incidence; many times there may be hoaxes only.in such situations it may become very important to detect and diagnose such an attack precisely. Such attacks can be tackled only by the awareness. It can be integrated into emergency management or any other mass disaster management. It will involve a multidisciplinary approach involving health departments of the governments, private health care providers, local administration, epidemiologists and media people and there should be effective communication between these groups. There should be proper lab facilities to diagnose and confirm form the samples which should be properly packed to prevent the spread of the disease from the samples. Triple packing is advised and there should be no leakage. Visitors should be strictly prohibited to visit the patients in the hospitals. Decontamination of the patient and environment should be considered in case of gross contamination and removed clothes should be handled minimally & should be put in an impervious bag. Proper arrangements should also be made to handle large number of cadavers. During postmortem on such cases all standard precautions should be taken to prevent the spread of the disease and relatives should be instructed to take precautions while cremating or burying them. Usually there is panic, horror and anger against the state and terrorists. There is fear of infection and social isolation, leading to demoralization of the public. Such an event should be handled carefully by trained psychiatrists, social workers and volunteer religious and NGOs by providing psychological support. At the same time anxiety in the health care providers should also be taken care of and they should be properly educated to protect themselves. This fear can be greatly reduced if they are regularly taking part in the disaster drills held regularly. People should be properly informed through the media about the features of the disease, its mode of spread, precautions to be taken and when & where should they seek medical advice. This will greatly alleviate the anxiety, fear and misunderstanding in the public who usually in such circumstances attribute nonspecific symptoms to an attack of bioterrorism. We should develop and apply biosafety precautions and safeguards in institutions. Dealing with potentially harmful and dangerous organism, which can be used as an agent of bioterrorism. We have to prepare emergency plans to tackle the bioterrorism attack and there should be cohesion between various agencies involved in tackling such situations. We should have good working relations with the media to avoid panic and horror.

Public health emergency preparedness and response to bioterrorist attack———-

The responsibilities of public health agencies are surveillance of infectious diseases, detection and investigation of outbreaks, identification of etiologic agents and their modes of transmission and the development of prevention and control strategies. The measures needed to prevent and control emerging infections are strikingly similar to those needed to check the threat of bioterrorism. Maintaining effective disease surveillance and communication systems are fundamental components of an adequate public health infrastructure. Ensuring adequate epidemiologic and laboratory capacity are prerequisites to effective surveillance systems. One approach to early detection is “syndrome surveillance”, in which electronic symptom data are captured early in the course of illness and analyzed for signals that might indicate an outbreak requiring public health investigation and response. Syndrome surveillance has been used for early detection of outbreaks to follow the size, spread and tempo of outbreaks, to monitor disease trends and to provide reassurance that an outbreak has not occurred. Syndrome surveillance systems seek to use existing health data in real time to provide immediate analysis and feedback to those charged with investigation and follow-up of potential outbreaks. The model of large scale exposure to the agents of bioterrorism (by use of vaccines and antibiotics) has dramatic potential for saving lives and expense . The public health approach to bioterrorism must begin with the development of local and state-level plans. Close collaboration between the clinical and public health communities is also critical. To effectively respond to an emergency or disaster, health departments must engage in preparedness activities. Completion of the following five phases of activities prior to an incident are essential for successful response to a bioterrorist attack
(a) Preparedness phase:
This phase includes actions to be taken by different agencies to ensure required state of preparedness. These include evaluation of the laboratory facilities and upgrading the same, evaluating the hospital preparedness in emergency response and case management in case of an imminent attack, conduct training of health professionals, rapid response team (RRT) and quick response medical team (QRMT) who would be the first responders, work out the legal provision and their implications, ensure that requirement of safe drinking water is met, ensure availability of adequate stocks of medicines and vaccines, coordinate with security organization, organize mock drills for health professionals, government departments, animal husbandry, security, law enforcing and other agencies so as to assess their preparedness levels to act in case of an attack, prepare contact details so that communications is unhampered during an attack. Public should be kept aware about imminent attacks so that voluntary reporting is encouraged. It is important to carry out review of situation based on current information of threat perception.
(b) Early Warning Phase:
The early warning in the surveillance system includes activities like case definitions, notification, compilation and interpretation of epidemiological data. Early detection and rapid investigation by public health epidemiologist is critical in determining the scope and magnitude of the attack and to implement effective interventions.
(c) Notification Phase:
It is mandatory to report any unusual syndrome or usual syndromes in unusual numbers to appropriate authorities. The activities in this phase include rapid epidemiological investigations, quick laboratory support for confirmation of diagnosis, quarantine, isolation, keeping health care facilities geared for impending casualty management and evolving public health facilities for control.
(d) Response Phase:
In this phase the activities include rapid epidemiological investigation, quick laboratory support, mass casualty management and initiation of preventive, curative and specific control measures for containing the further spread of the disease . In order to achieve them, following steps can be followed: (i) Assess the situation: Initiate the response by assessing the situation in terms of time, place and person distribution of those affected, routes of transmission, its impact on critical infrastructure and health facilities, the agencies and organizations involved in responding to the event, communicate to the public health responders, local, state and national level emergency operation centres for event management etc. (ii) Contact key health personnel: Contact and coordinate with personnel within the health department that have emergency response roles and responsibilities. Record all contacts and follow-up actions. (iii) Develop action plan: Develop initial health response objectives that are specific, measurable and achievable. Establish an action plan based on the assessment of the situation. Assign responsibilities and record all actions. (iv) Implementation of the action plan: The RRTs/ QRMTs investigate the outbreak /increase in the disease incidence, collect samples and send it to the identified state/national laboratory for testing. Hospitals are alerted for receiving the patients and their treatment. If necessary tented hospitals are set up. Methods to control the disease and quarantine measures are instituted. Once the disease is identified, treatment protocols are sent to all concerned by the fastest possible means. Standard operating procedures (SOP) for laboratory testing is made by the identified laboratory and the same is sent to all the hospital laboratories and district hospitals for implementation. Laboratory reagents are distributed to the concerned laboratories. Public is taken into confidence to prevent any panic. The list of ‘Do’s and Don’ts’ are circulated thorough the print and electronic media. Hospitals ensure appropriate isolation, quarantine, waste disposal and personal protective measures. All contaminated clothing and equipment are carefully disposed of by incineration. An impact assessment team assesses the impact of the attacks on humans, animals and plants.
(e) Recovery Phase:
The setbacks suffered as a result of the bioterrorist attack are restored and lessons learnt in this phase are incorporated in the future preparedness plans. The damage done to the public health facilities and the essential items utilized during the response phase are replenished. Public advisories are issued regarding restoration of normalcy. The RRTs compile and analyze data to identify the deficiencies experienced in the implementation of the response measures. The necessary modifications are then incorporated in the contingency plan for future.

Bioterrorism remains a legitimate threat both from domestic and international terrorist groups. From a public health perspective, timely surveillance, awareness of syndromes resulting from bioterrorism, epidemiologic investigation capacity, laboratory diagnostic capacity and the ability to rapidly communicate critical information on a need to know basis to manage public communication through the media are vital. Ensuring adequate supply of drugs, laboratory reagents, antitoxins and vaccines is essential. Formulating and putting into practice SOPs/ drills at all levels of health care will go a long way in minimising mortality and morbidity in case of a bioterrorist attack.

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