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Featured Report:
Medical Preparedness for Terrorism and Other Disasters (I-00) Full Text

Types of Terrorism, Analogous Natural Disasters, and the Medical Response
Biological Terrorism or Disasters Chemical Terrorism or Disasters
Conventional Explosives
Nuclear and Radiological Terrorism

Critical Needs in Preparing the Medical Response: Physician Preparedness
Biological Terrorism
Chemical Terrorism or Disasters
Conventional Explosives

Health Care Facility and Community Preparedness

Role of the Federation of Medicine
Local and County Medical Societies
State Medical Societies
Specialty Medical Societies
American Medical Association

Role of Academic Medicine

Role of Federal Agencies

Funding and Starting the Programs

Conclusions/Recommendations (Directives Adopted by the AMA)

References

Table 1. Likely Agents of Biological Terrorism as Identified by the CDC
Table 2. Principles of Immediate Care for Hazardous Chemical Exposure Patients
Table 3. Essential Procedures and Equipment
Table 4. Physician-Specific Issues in Community Planning
Table 5. Activities of Federal Agencies in Preparing for Terrorism and Other Disasters

NOTE: This is a revised version of Council on Scientific Affairs Report 11, which was presented at the 2000 Interim Meeting of the AMA. This report represents information on this subject as of May 2001.

Introduction

In recent years public awareness of the threat of terrorism in the United States has grown dramatically. Government response plans have focused on developing resources in local, state, and federal government agencies including health departments, emergency responders (eg, police and fire departments, hazardous materials units, and emergency medical systems), and federal and military response units. However, the need remains to prepare the civilian medical community,¹ as medical responders in a community affected by a terrorist disaster likely will need to function unassisted until outside resources arrive at least 6 to 8 hours after the onset.² In all forms of terrorism, whether involving biological weapons, toxic chemicals, or conventional explosives, local physicians will provide acute and follow-up care to the victims. Hospitals and clinics will be flooded with affected patients and the "worried well."

This report focuses on preparedness and response issues for physicians and medical societies and identifies the following points: (1) community responses to disasters, including terrorism, require physician participation; (2) for some disasters, including biological terrorism and other infectious disease outbreaks, the public health response cannot begin unless clinicians report unusual disease cases; (3) physicians will be more effective in their community response if they are prepared with appropriate education and training; and (4) although various military, federal, and civilian groups have developed physician educational materials, organized medical societies and medical educators are needed to address physician-specific issues, promote learning in this area, and disseminate educational materials.

Background

The urgent need for medical planning for terrorism is illustrated by the experience of Tokyo physicians on March 20, 1995. The Aum Shinrikyo cult released the military nerve weapon sarin in Tokyo subway cars during the height of rush hour by puncturing packages containing sarin. Although there was no device for active dispersion of the sarin, 12 deaths occurred and over 5,000 people sought medical care. At 8:28 am the first patients arrived at nearby St. Luke's hospital complaining of eye pain and dimmed vision. Only 12 minutes after the initial report, this was long before any decontamination stations could have been set up at the scene. Thus the first arriving patients were contaminated, although their relatively mild symptoms suggest their degree of contamination was less than that of more severely affected patients. Not until 8:43 am did the first patients arrive by ambulance. In all, 500 patients arrived in the first hour. St. Luke's Hospital had 3 entrances that were rushed by patients, families, and the news media. As a result, the interior became "chaotic." There was no area dedicated for decontamination, and the hospital did not have enough facilities to treat the patients it received. Treatment was based on symptoms and the military experience of some of the physicians, as the first laboratory reports of acetylcholinesterase levels, which indicated organophosphate poisoning, were not received until 9:40 am. Hospital staff did not use effective personal protective equipment; surgical masks and latex gloves do not protect against sarin contamination. As a result, intoxication symptoms occurred in 39% of nursing assistants, 27% of nurses, 26% of volunteers, 22% of physicians, and 18% of clerks. Fortunately, none required drug therapy.³ In a nearby academic hospital emergency room where more severely affected patients were treated, 13 of 15 physicians became symptomatic and 6 required treatment with atropine or pralidoxime.⁴

The Tokyo experience poses many of the issues confronting physicians preparing for acts of terrorism, including physician awareness of the signs and symptoms of exposures, availability of resources to decontaminate patients, personal protective equipment for health care workers caring for contaminated patients, and plans to control hospital access and crowds.Back to Top

Types of Terrorism, Analogous Natural Disasters and the Medical Response

The Council on Scientific Affairs (CSA) believes that many medical challenges identified with acts of terrorism are similar to those posed by more conventional disasters. We examine different terrorism scenarios, the types of "unintentional" disasters they resemble, and the similar medical consequences of each.

Biological Terrorism or Disasters

Although some authorities suggest biological weapons can be produced with ease, in fact it can be difficult to concentrate cultured organisms and prepare them in a form that can be widely disseminated. Indeed, the Aum Shinrikyo cult tried to use anthrax as a weapon of terror and was not able to successfully disseminate the organism despite several attempts.⁵ However, the consequences of a successful release, especially if the infection is easily communicated from infected patients, could far exceed those of a localized chemical or conventional explosive event. Thus, some authorities consider the risk of release of a biological weapon the most dangerous terrorist threat today, although others suggest that the costs and consequences of such an act will deter all but the most extreme groups.^6,7

The consequences of successful biological terrorism could be devastating. One hypothetical scenario considered the release of smallpox in a major American city. The postulated event resulted in the spread of smallpox across 20 states and 4 countries with 15,000 cases, 2,000 deaths, and the prospect that smallpox would become re-established in the world.⁸ A World Health Organization study estimated that 50 kg of anthrax spores, if released in a 2-km line upwind of a city of 500,000 population, would result in 125,000 infections resulting in 95,000 deaths.⁹

The first critical role of community physicians in a biological terrorism event will be their early recognition of the disease. In any disease outbreak, the local health department must confirm the identification of the infectious agent, define the extent of the disease, identify the source of infection, and take measures to control its further spread. The Centers for Disease Control and Prevention (CDC) supports a major program to improve the capacity of health departments to perform this role in a biological terrorism event.¹⁰ Limited international experience suggests the clinician's role will be crucial for identifying biological terrorism events. In 1979 an anthrax outbreak occurred in Sverdlosk, Russia, following an apparent accidental release of anthrax spores from a military production facility. The earliest patients initially presented on April 4, 1979, with fever, chills, headache, and dizziness, and community physicians assumed the cause was influenza or another flu-like illness. Then 3 patients presented on April 7-8 with severe symptoms and died. At that point, physicians contacted local health departments. Even though the diagnosis had not yet been made, these reports from community physicians stimulated the ensuing investigations and response.¹¹

In 1999 a CDC-sponsored working group considered which diseases are most likely to be used as weapons of biological terrorism (Table 1). Many of these have subtle initial presentations with nonspecific symptoms such as fever, chills, headache, or cough. It is likely, therefore, that a patient with these symptoms initially will present to a community physician, clinic, or emergency department. As the disease progresses and its unusual nature becomes apparent, the alert clinician who notifies the health department will begin the cascade of responses essential to controlling the outbreak. If the initial cases are reported early, it may be possible to save many exposed patients who have not yet developed clinical illness, and early recognition also will enable health care workers to institute appropriate infection control measures to protect themselves.

Table 1. Likely Agents of Biological Terrorism as Identified by the Centers for Disease Control and Prevention¹⁰

Criteria for Inclusion

(1) Can be easily disseminated or transmitted person-to-person
(2) Causes high mortality, with potential for major public health impact
(3) Might cause public panic and social disruption
(4) Requires special action for public health preparedness

Agent

Variola major (smallpox)
Bacillus anthracis (anthrax)
Yersinia pestis (plague)
Clostridium botulinum toxin (botulism)
Francisella tularensis (tularemia)
Filoviruses (Ebola and Marburg hemorrhagic fevers)
Arenaviruses (fevers caused by Lassa and Junin viruses)

As the outbreak progresses, patients with clinical disease will need care, and in a large incident patient numbers will rapidly exceed hospital capacity. Physicians, nurses, and other health care workers who normally practice in the community may be called on to supplement hospital staff. In addition, exposed citizens who are not yet ill may need immunization or prophylactic medications, which may be provided at emergency departments, hospitals, clinics, or designated distribution centers. Although physicians are not needed to distribute medications, they may be needed to answer questions for recipients with coexisting diseases or who are receiving other medications.

Although an act of biological terrorism may seem a disaster without parallel, naturally occurring infectious disease outbreaks can be equally devastating. The influenza outbreak of 1918 was a global pandemic affecting a fifth of the world's population. In the United States, 28% of the population became ill. The case fatality rate was 2.5%, rather than the 0.1% rate typical of influenza, and estimates suggest that over 20 million people died worldwide.¹² Influenza experts believe the rapid appearance of new influenza strains makes the occurrence of another pandemic very possible.¹³ Such a pandemic would tax hospital and health care resources and require a rapid and massive immunization campaign, much as would occur in a biological terrorism event. The key to preventing or controlling that pandemic would be identifying the new strain and implementing appropriate public health measures as quickly as possible. Strategies include global surveillance that relies on both physicians and health departments to report the earliest cases and submit specimens for viral isolation and identification. Preparations for biological terrorism, therefore, are also preparations for natural disease outbreaks.¹³ Other examples of disease outbreaks that were identified and halted after physicians reported suspect cases include hemolytic-uremic syndrome caused by Escherichia coli O157:H7 from contaminated hamburger meat and salmonellosis from contaminated ice cream.¹⁴

Chemical Terrorism or Disasters

Chemical terrorism could employ any of several military chemical weapons, including nerve agents such as sarin, vesicant ("blister") agents such as sulphur mustard, choking agents such as chlorine or phosgene, and "blood agents" such as hydrogen cyanide. Most of these require significant investments in chemical production capability and resources to produce quantities that could be used in a terrorist attack. Indeed, the Aum Shinrikyo cult spent an estimated $30 million and a year's effort by 80 personnel to produce its sarin.⁵ However, terrorists also could use toxic industrial chemicals that are widely produced, shipped by rail and truck tanks, and stored in both urban and rural manufacturing sites. A terrorist could use a conventional explosive to rupture a transport or storage tank, creating a chemical disaster as the contents contaminated the area. Because of the difficulties in obtaining precursor materials and the technical challenges of producing chemical weapons, some experts consider toxic industrial chemicals more likely weapons of terrorism.¹⁵

The consequences of chemical terrorism will be similar to those of an accidental chemical release from a damaged tank or from an industrial explosion. In fact, it is far more likely that a community will confront the effects of an accidental than an intentional toxic chemical release. Roughly 300 million hazardous materials shipments occur in the United States each year. From 1993 through 1998, the annual number of serious hazardous materials incidents reported to the US Department of Transportation averaged 418 per year (serious incident defined as involving a fatality or major injury; closure of a major transportation artery or facility or evacuation of 6 or more persons; or a vehicle accident or derailment resulting in release of hazardous materials). These incidents resulted in an average of 11 deaths per year.¹⁶ Despite this, a recent survey of Level 1 trauma centers across the nation found that most lacked equipment, plans, and personnel training to care for contaminated patients. Given the advanced level of care normally provided at these centers, it may be assumed that other emergency facilities are even less prepared.¹⁷

Whether resulting from accidental or intentional release of toxic chemicals, some exposed victims may die before rescue; others will require medical treatment to survive. The Tokyo experience suggests that, in addition, patients with minimal exposure and mild-to-moderate health effects will also present for care. Health care workers must be able to triage these patients, decontaminate them, and provide appropriate specific or supportive care. Caregivers must know how to provide care without becoming contaminated themselves, and be equipped with appropriate resources to do so.¹⁷

Conventional Explosives

Conventional explosives have been the weapons most frequently used by terrorists because they are the easiest to obtain, create, and use. Recent examples include bombings at the World Trade Center, Oklahoma City, and the 1998 attacks on US embassies in Kenya and Tanzania. Indeed, intelligence agencies believe that terrorists are more likely to use conventional explosives than chemical or biological weapons.¹³

The medical consequences of terrorism using conventional explosives include death and/or acute injury and destruction of critical infrastructure such as buildings, roads, and utilities. Victims trapped in collapsed buildings will require rapid extrication and care. Health care needs include immediate surgical and nonsurgical trauma care, follow-up medical care, forensic disposition of bodies and body parts, and mental health care. Physicians and hospitals must be prepared to treat hundreds or thousands of trauma cases, and their response may be complicated by loss of utilities (eg, electricity, water), difficulty reaching hospitals, or even damage to hospitals in a community. These effects are the same as those of natural disasters such as tornadoes, earthquakes, and industrial or gas main explosions.

Nuclear and Radiological Terrorism

Nuclear and radiological terrorism are very different events. Nuclear terrorism would involve the deliberate detonation of a nuclear weapon; consequences would include fatalities and injuries resulting from the initial explosion and subsequent fires, as well as immediate and long-term effects of radiation exposure. Some assessments suggest that the difficulty of obtaining the materials needed for a nuclear device and the extraordinary technical challenge of building a functioning nuclear weapon make this the least likely form of terrorism.⁵

Radiological terrorism would involve the deliberate contamination of an area using radioactive materials. For example, a terrorist could use conventional explosives to disperse a radiation source such as a spent nuclear reactor fuel rod. The technical challenge is far less than that of nuclear terrorism. However, the consequences would be less, as well, being limited to the longer term effects of radiation exposure and the challenge of decontaminating those exposed and the contaminated area. The medical consequences of radiological terrorism are akin to the effects of accidental radiation incidents, for which emergency guidelines exist.¹⁸Back to Top

Critical Needs in Preparing the Medical Response: Physician Preparedness

Some of the roles required of individual physicians in response to disasters require knowledge or skills that few possess. However, most of the necessary skills and knowledge are simply extensions of the physician's daily working tools, such as forming a differential diagnosis for an infectious process or caring for acute trauma patients. The challenge, therefore, is to "fill in the blanks" for practicing physicians, whose needs will vary depending on their practice specialty and setting.

One hazard common to all disasters is the psychological effects. Patients, caregivers, and the rest of the community will be at risk for acute and lasting mental health effects, including acute stress and anxiety, as well as post-traumatic stress disorder, which can incapacitate health care workers and other responders. In Oklahoma City, an immediate and concerted mental health program was part of the response to the Murrah building bombing to ameliorate or prevent the effects of traumatic stress.¹⁹ In addition, some symptoms of exposure to biological or chemical weapons are similar to those of acute anxiety, posing a diagnostic challenge for caregivers. Physician mental health training, especially for the psychiatric specialties, should include responses to traumatic stress in patients, caregivers, emergency responders, and other community members, and consideration of mental health needs should be part of community disaster response planning.²⁰

If physicians are to master the information needed to prepare for terrorism and other disasters, it must be presented in creative and rewarding ways. Continuing medical education (CME) credit should be offered for any educational program a physician undertakes in this area (eg, attending lectures, reviewing journal articles, participating in accredited distance learning programs, or accessing CD-ROMs, Web sites, or other self-study materials).

Biological Terrorism: The CSA believes that preparing community physicians to recognize and respond to an act of biological terrorism should be among the first priorities in educating physicians about disaster medicine. Because the community physician's prompt report of a suspicious case will be of paramount importance, community physicians should know enough about the diseases of concern to include them in the differential diagnosis. This will be most important for primary care physicians (internists, pediatricians, family practitioners, and obstetrician/gynecologists), emergency medicine specialists and other physicians who staff emergency departments, and infectious disease specialists. Given the unusual presentation of some bioterrorism diseases, especially those resulting from weapons such as botulinum toxin, toxicologists and other poison control center staff should be aware of these diseases.

Physicians also should be familiar with the systems developed by their local and state health departments for immediate reporting of suspicious cases, as well as mechanisms for involving infection control departments in hospital cases. Reporting suspicious cases to the local or state health department generally is a legal requirement, and in most cases the report should be based on suspicion rather than final diagnosis.

Chemical Terrorism or Disasters: Chemical disasters, including chemical terrorism, must be addressed with personal protection for health care workers, patient decontamination, and supportive and specific therapy for the chemical exposure.²¹ The most severely exposed and affected victims will likely receive care in a hospital emergency room. The initial response, therefore, primarily will be that of prehospital care providers and emergency room physicians. However, the Tokyo experience shows that when sufficient numbers of casualties present for care, the victims will overflow the emergency facility and be treated in other parts of the hospital by other physicians.³ Therefore, it is essential that emergency physicians--and optimal that other physicians with hospital privileges--be acquainted with principles of immediate care for victims of hazardous chemical exposure (Table 2).

Table 2. Principles of Immediate Care for Hazardous Chemical Exposure Patients²²

Recognize the acute effects of exposure to the most likely chemical weapons and the most common toxic industrial chemicals;
Understand the basic principles of decontamination;
Recognize when personal protective equipment (protective gloves, respirators [eg, "gas masks"] or impervious clothing) must be used by the health care worker to prevent secondary exposure from the patient; and
Provide supportive and specific therapy for the most likely chemical weapons and the most common toxic industrial chemicals. Back to Top

Conventional Explosives: The major health consequence of an explosion is acute trauma, and most physicians have acquired and maintained skills to care for trauma victims. The experience in Oklahoma City suggests that patients with minor trauma initially may present in a physician's office or urgent care center.²³ Physicians in these environments should be familiar with basic trauma care and the steps needed to rule out occult, more severe effects. Patients with overtly severe injuries will be transported to hospitals, where emergency medicine physicians and surgical specialists are best prepared to treat them. Exposure to explosive blasts can result in unique injuries to internal organs, and emergency and surgical specialists should learn to care for these patients in their specialty training or CME. Back to Top

Health Care Facility and Community Preparedness

In any of the disasters described, health care facilities such as hospitals will bear the brunt of acute care for affected patients. As with routine medical care, disaster care requires specific procedures and equipment. Many of the essentials were recently described (Table 3).²⁴ In addition, a biological terrorism event will require specific infection control measures.²⁵ The health care facility must train staff accordingly and check preparedness through appropriate test exercises.

Table 3. Essential Procedures and Equipment²⁴

Adequate personal protective equipment for hospital staff
Supplies, procedures, and designated external areas for decontaminating patients prior to entry into the treatment area
Procedures for controlling access, patient flow, and holding areas
Adequate supplies of specific antidotes
Access to information resources
Public information

During a major disaster all area hospitals will be involved, perhaps beyond capacity. All will eventually run short of essential medications, supplies, and staff. In addition to their individual planning, all hospitals in the community should participate in area disaster plans to discuss patient allocation and distribution, resource sharing, provisions to expand bed capacity (eg, identifying facilities to house overflow patients) and mechanisms to distribute resources that will be sent to the community in time of need.

Physicians and their staff organizations should be advocates for these measures in their health care facilities. They should be involved in planning and assessing the outcomes of training and practice drills that involve the facility, the local health department, and local emergency response units. They also should participate in hospital purchases of necessary equipment and help ensure that it is adequate for the task and conforms to appropriate recommendations issued by state and local health departments, the CDC, the Occupational Safety and Health Administration, and the Environmental Protection Agency. To ensure that hospitals meet necessary minimum standards for preparation, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and state licensure authorities should include evaluation of hospital plans for terrorism and other disasters as part of the periodic accreditation visits conducted by their representatives. (This goal is greatly facilitated by a new JCAHO standard on emergency planning, released January 2001.²⁶) Hospital laboratories and emergency departments should have mechanisms to ensure prompt reporting of relevant cases to public health authorities.

Every community should have a disaster plan that prepares for the natural and terrorist emergencies most likely for that area. This will involve coordination of diverse agencies including health departments; police, fire, and emergency medical services; utilities; government officials; hospitals; infection control specialists; schools; local military installations; large employers; and others. Physicians should ensure that the health and medical components of these plans include essentials for effective physician participation in disaster response (Table 4).

Table 4. Physician-specific Issues in Community Planning

1. The medical resources of the community must be used effectively. A list should be available with contact information (telephone numbers, fax, pagers, etc), specialty, and location for every physician who could serve. Alternate systems, such as use of broadcast media, should be considered in case of telephone system overload. At least one organization, preferably with a back-up, should have the designated lead for contacting physicians through blast fax, mass e-mail, etc. The local health department should have access to this mass communication system to rapidly disseminate information. If possible, plans should include provision for physician assignments during a disaster, such as to which hospital or other facility each physician would report.

2. The local health department or other appropriate agency should have a mechanism for informing physicians of essential information on a newly recognized outbreak, updated response plans, etc. This will allow physicians to more effectively recognize cases, be able to respond to questions from patients and families, and respond to community needs.

3. Because physician reporting to the health department will be critical to starting a community response, the health department must make reporting as easy as possible. Physicians should be able to report a case 24 hours a day, 7 days a week. The system should encourage early reporting, even on the basis of suspicion before confirmation. The reporting physician should have immediate or rapid access to a reputable authority who can provide additional guidance on confirmation and treatment of the patient. Existing or proposed confidentiality regulations should include provisions to permit such consultation. The medical leadership of the local health department must be knowledgeable and skilled in the management of biologic disasters.Back to Top

Role of the Federation of Medicine

The Federation of Medicine includes the American Medical Association (AMA) and organizations with voting representation in the AMA House of Delegates and their component societies. The CSA believes that each level of the Federation can offer unique contributions in preparing physicians to respond to disasters, including terrorism.

Local and County Medical Societies: Local and county medical societies are the foundation of the Federation. Their members know each other through daily interaction and often know officials in local government, emergency services, and hospitals. The local medical society is thus an important participant in community disaster planning. Each local and county medical society should appoint a staff member or member physician to coordinate the society's participation in disaster preparedness. That person should contact local government and hospital emergency coordinators to learn local emergency plans and discuss areas of need for community medical planning. These include coordinating medical care at standard and emergency care sites; organizing community-based medical resources and supply inventories; planning for receiving and integrating state and federal medical aid (including health care workers) that would be dispatched to the community; and providing public information. The medical society should participate in community disaster drills that test these plans.

The county medical society can work with the local health department to compile and maintain a contact list of physicians (both member and nonmember) in the community. In some communities, the medical society has blast fax or mass e-mail capability; in others, the local health department may be a better repository of the list, as long as appropriate safeguards for privacy are maintained. The medical society and health department should together define when it will be appropriate to contact area physicians. Plans also should identify means for contacting physicians if telephone systems are damaged or overloaded; possible alternatives include using broadcast radio and television.

The medical society also can work with the local health department to ensure that physician-friendly reporting mechanisms are in place, and that a 2-way flow of information exists to provide incentives for physician collaboration. This may include mechanisms for the health department to routinely update area physicians with relevant information about immunization, local patterns of antibiotic resistance, seasonal changes in disease incidence monitored by the department, or information of immediate clinical relevance such as rapid notification of a newly recognized outbreak of foodborne illness. The health officer also has authority to declare quarantine, and physicians involved in community planning should understand the circumstances in which quarantine is appropriate. During a disaster, the health department and the medical society can each carry out complementary, previously determined roles in surveillance, health care, and public information. All of the above should be coordinated with the education, training, and planning underway in the governmental sector, especially in the local and state health departments.

The medical society can be a venue for physician education. Medical societies should include CME on the essential aspects of terrorism and disaster medicine in their educational seminars. The medical society can also work with sponsors of local CME efforts to promote this subject as a topic for hospital grand rounds and other CME programs. Individual members who are particularly interested may become peer leaders and educators.

State Medical Societies: Most disaster responses will escalate to the state level, either because the event spreads across city and county lines or because state resources are needed to augment the local response. The broader geographic scope of the state medical society better equips it to liaise with state-level disaster planners. The state medical society should work with the state health department in these considerations and provide assistance to county medical societies. Like the local medical society, the state society should name a liaison to the state's emergency coordinator to explore medical needs during terrorism and natural disasters, and participate in disaster planning to identify ways to meet those needs. Issues may include devising model plans for the communities in that state, which the state medical society can then promulgate to guide local societies. The state medical society can educate its members on the essential aspects of terrorism and disaster medicine through CME programs at state society meetings and by articles in state society journals and newsletters. The state health department can be a resource for planning CME on this topic.

Most laws regulating physician licensure, practice, and liability are state laws, and state medical societies should explore issues of concern in advance. Physicians will practice under unusual circumstances during a disaster, with potential needs to triage patients, use off-label or unapproved medications or vaccines, and care for victims under less than optimal circumstances. State medical societies should examine state laws governing practice and liability under these circumstances, including "Good Samaritan" laws. If necessary, the society can recommend passage of laws that will allow physicians to respond effectively during a disaster. The state medical society also can ensure that state scope-of-practice laws protect patients while allowing for emergency treatment in a disaster. In some states, nonphysicians such as emergency medical technicians can administer only medications explicitly listed by the state. If that list does not include antidotes such as atropine and pralidoxime, emergency medical technicians will be unable to provide the specific acute care needed to treat victims of severe nerve agent exposure. The state medical society can help regulators find balance when regulating scope-of-practice issues.

Specialty Medical Societies: In recent years, the focus of physician membership has shifted to specialty medical societies, which many physicians believe better represent their specialty-specific concerns.²⁷ Specialty medical societies thus are best positioned for physician education about terrorism and other disasters. Education endorsed by the specialty society is likely to have a higher impact than some other offerings, and the relevant content can be targeted for that specialty. Specialty societies also can be opinion leaders that impress on their members the importance of CME topics and materials. Specialty societies can educate their members by offering courses at specialty society meetings; publishing articles in specialty journals, including tear-out reference sheets; distributing educational materials and references prepared by topic experts and organizations; and co-sponsoring or promoting distance learning programs or other CME opportunities offered by other organizations on responses to terrorism. Because specialty societies may better understand the needs and concerns of their members, they should serve as consultants to federal planners who devise local response plans and training materials.

American Medical Association: The AMA is the largest single medical organization, and effectively is the center of the Federation of Medicine. It has the largest Washington, DC, presence of any medical society and has a long tradition of involvement in federal activities that affect physicians and the practice of medicine. The AMA is therefore the best candidate for a medical society that can act as a liaison to the various federal agencies involved in response planning for terrorism and other disasters. The AMA can form connections between those agencies and the appropriate state and specialty medical societies, and can more easily send representatives to planning meetings. The relationships formed also can support more routine collaborations between public health and medical practitioners for purposes such as disease outbreak prevention and control.

The AMA can also promote disaster and terrorism medical planning through the broad range of its activities. AMA representatives to the JCAHO can promote the need for hospital preparedness. AMA sections such as the Medical School Section and the Specialty and Service Section can provide venues for shared planning and curriculum development or adaptation by their members. Members of the Section on Medical Schools and the Resident and Fellows Section can support the inclusion of disaster medicine in their curricula. The Organized Medical Staff Section, Young Physicians Section, and House of Delegates members can be community leaders advocating physician involvement. AMA staff and elected officials already participate in a variety of federal and private sector activities that regulate or otherwise influence the practice of medicine, and can participate in disaster planning discussions as appropriate. The AMA can also draw on the expertise of specific groups within the House of Delegates that routinely consider terrorism response issues (eg, the Section Council on Preventive Medicine and the Section Council on Federal and Military Medicine). The AMA also has existing liaisons with societies representing other health professionals who would work closely with physicians in responding to acts of terrorism or disasters, such as the American Nurses Association and the American Academy of Physician Assistants. The AMA can encourage them to educate their members, and to work with physicians in developing community response plans.Back to Top

Role of academic medicine

Medical educators at all levels can participate in training physicians in the essentials of disaster and terrorism medicine relevant to their practice and specialty. Medical schools should introduce the basic elements into the undergraduate medical curriculum, including public health management of epidemics and the importance of early detection and reporting of infectious diseases. Organizations such as the Association of American Medical Colleges, the Council on Graduate Medical Education, and the Association of Academic Health Centers should be involved in this process. Residency programs should develop advanced programs appropriate for their particular specialty. Academic medical centers can also include training and education programs in disaster and terrorism medicine among their CME offerings.

It will not be necessary to create completely new curricula. The Uniformed Services University of the Health Sciences developed a curriculum that spans the 4-year medical undergraduate program. While much of it is specific to military physicians in training, elements likely could be adapted for use in a shorter civilian undergraduate course. Other training resources have been or are being developed by military and public health agencies, and can be used when appropriate.Back to Top

Role of federal agencies

Preparation for acts of terrorism is currently a significant initiative in both military and nonmilitary federal programs. In fiscal year 1999, the President requested $6.7 billion for counterterrorism programs, including $160 million in the Department of Health and Human Services.¹⁵ Federal efforts include programs intended to assist in a community medical response (Table 5). Some of these activities will support community physicians' response to a natural disaster or terrorist attack; others may be easily adapted to help civilian physicians prepare for a disaster, and in many cases are already being used for this purpose. The CSA believes it will be most efficient to take advantage of existing resources whenever possible. Emergency preparedness plans developed for use by Major Metropolitan Response System teams²⁸ can be used to develop more generic guides to community medical disaster planning. Educational materials developed by the military and other federal agencies can be adapted for civilian medical education.Back to Top

Funding and Starting the Programs

Like any major initiative, medical preparedness for disasters and terrorism will require financial investments. Funds will be needed to develop (or adapt existing) educational materials and disseminate them to medical societies and individual physicians, and to underwrite the costs of CME lectures at medical society meetings and hospital rounds. Military and federal organizations may require dedicated resources for their contributions to community medical preparedness. Additions to community infrastructure, such as protective equipment and decontamination supplies for hospitals, will also require support if they are not to divert resources from other health care needs. Medical societies can provide their physician members to serve their communities in time of need, but they do not have the financial resources to complete the planning and educational efforts without assistance. Because this is a national priority, national resources should support the effort. Foundations, pharmaceutical firms, and federal agencies should contribute to the effort.

The CSA notes that curricula teaching the medical response to terrorism and other disasters already exist, so it should possible to adapt these to the intended physician audiences. Once curricula are designed, they must be produced, duplicated, and distributed to the appropriate audiences. These tasks will most likely be accomplished if a specific entity has the responsibility for doing so. The CSA proposes that a public-private entity be created to accomplish these tasks. This entity can draw on expertise from military, federal, and public health agencies, as well as medical specialty societies and medical educators. The entity could be as informal as a task force, or as formal as a foundation (such as the National Patient Safety Foundation, which was created by the AMA to support research to promote safer patient care). The CSA does not explicitly define this entity in order to allow the most expeditious options to be considered by the AMA and its potential partners. Indeed, it remains to be determined whether a single entity should perform all these tasks, or whether, for example, it might be more appropriate for one group to design the curricula and another to distribute it.Back to Top

Conclusions

The need exists to prepare the medical community to respond to acts of terrorism on domestic soil. Acts of terrorism are far less likely than other forms of disaster, but most acts of terrorism are analogous to various natural disasters and unintentional manmade disasters. Preparations for disasters, whether from terrorism or other sources, can therefore be viewed as a whole, albeit with distinct components.

Recommendations (Adopted AMA Directives)

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as Directives at the 2000 AMA Interim Meeting: (1) The AMA calls for the creation of a public-private entity (including federal, military, and public health content experts) that will collaborate with medical educators and medical specialty societies to: (a) develop audience-specific medical education curricula on disaster medicine and the medical response to terrorism, with a first charge to develop curricula on bioterrorism, and disseminate these to medical students, physicians in training, and physicians in practice; (b) develop information resources on disaster medicine and the medical response to terrorism for civilian physicians and other health care workers; (c) encourage and work with medical state and specialty societies, the CDC, the Office of Emergency Preparedness, and other appropriate federal, military and private organizations to develop model plans for community medical response to disasters, including terrorism; and (d) address the issue of reliable, timely, and adequate reporting of dangerous diseases by community physicians to public health authorities. (2) The AMA encourages the Federation of Medicine to become involved in planning for the medical component of responses to disasters, including terrorism, at levels appropriate to the Federation component: (a) county/local medical societies are encouraged to become involved in local planning and physician education; (b) state societies are encouraged to become involved in state response planning and physician education; and (c) specialty societies are encouraged to take the lead in conducting and encouraging education of their members in essential components of disaster medicine, as well as encouraging their members to participate in local response planning. (3) The AMA encourages the JCAHO and state licensing authorities to include the evaluation of hospital plans for terrorism and other disasters as part of the periodic accreditation and licensure visits conducted by their representatives.

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Also see the CSA's 2003 Report AMA National Disaster Life Support Program (I-03) Full Text and the AMA Center for Public Health Preparedness and Disaster Response

References

Waeckerle J. Domestic preparedness for events involving weapons of mass destruction. JAMA. 1999;283:252-254.
Tonat K, Anderson M. Federal health and medical requirements for WMD incidents. Presented at Medic WMD 2000, Department of Defense Medical Initiatives Conference and Exhibition; Arlington, Va; April 3-6, 2000.
Okumura T, Suzuki K, Fukuda A, et al: The Tokyo subway sarin attack; disaster management, part 2: hospital response. Acad Emerg Med. 1998;5:618-624.
Nozaki H, Hori S, ShinozawaY, Fujishima S, Takuma K, Sagoh M, et al. Secondary exposure of medical staff to sarin vapor in the emergency room. Intensive Care Med. 1995;21:1032-1035.
Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction. First Annual Report to the President and Congress. Washington, DC: RAND;1999.
Siegrist DW. The threat of biological attack: why concern now? Emerg Infect Dis. 1999;5:505-508.
Stern J. The prospect of domestic bioterrorism. Emerg Infect Dis. 1999;5:517-522.
O'Toole T. Smallpox: an attack scenario. Emerg Infect Dis. 1999;5:540-546.
Report of a WHO group of consultants. Health aspects of chemical and biological weapons. Geneva: World Health Organization; 1970:97-99.
Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. Morbid Mortal Weekly Rev. 2000;49(RR04);1-14.
Guillemin J. Anthrax: the Investigation of a Deadly Outbreak. Berkeley: University of California Press; 1999: 105, 234-235.
Kolata G. Flu. New York: Farrar, Straus and Giroux; 1999; 3-8.
Patriarca P, Strikas R, Gensheimer K, et al. Pandemic influenza: a planning guide for state and local officials (draft 2.1). Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Vaccine Program Office; 2000.
Koo D, Caldwell B. The role of providers and health plans in infectious disease surveillance. Effect Clin Pract. 1999;2:247-252.
US General Accounting Office. Combating terrorism: need for comprehensive threat and risk assessments of chemical and biological attacks. Washington DC: GAO/NSIAD99-163; September, 1999.
Hazardous Materials Program Evaluation Team. Department-wide Program Evaluation of the Hazardous Materials Transportation Programs. Washington DC: Department of Transportation; March 2000.
Ghilarducci DP, Pirrallo RG, Hegmann KT. Hazardous materials readiness of United States Level 1 trauma centers. J Occupat Environ Med. 2000;42:683-692.
Radiation Emergency Assistance Center/Training Site. Managing radiation emergencies: guidance for hospital medical management. Oak Ridge TN: Oak Ridge Institute for Science and Education; 2000. Available at: http://www.orau.gov/reacts/care.htm. Accessed: May 8, 2001.
Tucker P, Pfefferbaum B, Vincent R, et al. Oklahoma City: disaster challenges mental health and medical administrators. J Behav Health Services Research. 1998;25:93-99.
DiGiovanni C. Domestic terrorism with chemical or biological agents: psychiatric aspects. Am J Psychiatry. 1999;156:1500-1505.
Cox R. Decontamination and management of hazardous materials exposure victims in the emergency department. Ann Emerg Med. 1994;23:761-770.
Brennan R, Waeckerle J, Sharp T, et al. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med. 1999;34:191-204.
Gregory JA. Terrorism in Oklahoma. WMD2000: Department of Defense Medical Initiatives Conference and Exhibition, April 2-6, 2000, Arlington, Va (proceedings). Washington: National Defense Industrial Association; 2000:984-1003.
Macintyre A, Christopher G, Eitzen E, et al. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA. 2000;283:242-249.
English J, Cundiff M, Malone J, et al. Bioterrorism Readiness Plan: A Template for Healthcare Facilities. Atlanta: Centers for Disease Control and Prevention; 1999.
Standard EC.14. Emergency management. Chicago: Joint Commission on Accreditation of Healthcare Organizations; 2001. Available at: http://www.jcaho.org/standard/ecer.html. Accessed: May 8, 2001.
American Medical Association: An Environmental Analysis: Trends, Impacts, and Opportunities. June 2000.
Department of Health and Human Services, Office of Emergency Preparedness. Available at: http://www.oep-ndms.dhhs.gov/indext.html. Accessed: August 2, 2000.
Department of Health and Human Services, Centers for Disease Control and Prevention. CDC Recommendations for Civilian Communities Near Chemical Weapons Depots: Guidelines for Medical Preparedness. Federal Register. 1995;60:33307-33312. Available at: http://www.cdc.gov/nceh/demil/medsearches/fedregmed.htm. Accessed: May 8, 2001.
Department of Health and Human Services, Centers for Disease Control and Prevention. Emergency room procedures in chemical hazard emergencies. Available at: http://www.cdc.gov/nceh/demil/articles/initialtreat.htm. Accessed: May 8, 2001.

Table 5. Activities of Federal Agencies in Preparing for Terrorism
and Other Disasters

Office of Emergency Preparedness (OEP) of the Department of Health and Human Services (HHS)

Manages and coordinates federal health, medical, and health-related social and recovery services to major emergencies and federally declared disasters, including natural and technological disasters, major transportation accidents, and terrorism.
Funded the American College of Emergency Physicians to develop an educational curriculum in medical aspects of chemical and biological terrorism, which is targeted at emergency department personnel and prehospital providers but may also be suitable for primary care physicians.
Convened meetings with the American Hospital Association and other groups to discuss hospital preparedness.
Directs and manages the National Disaster Medical System, a cooperative asset-sharing partnership between HHS, the Department of Defense, the Department of Veterans Affairs, the Federal Emergency Management Agency, state and local governments, private businesses, and civilian volunteers.
Responsible for federal health and medical response to terrorist acts. National Disaster Medical System resources include Disaster Medical Assistance Teams, which will travel from their home cities to a disaster site to provide medical care or assist overloaded local health care staff.
Organizes the Major Metropolitan Response System, which pre-organizes specially trained and equipped medical response teams in selected communities.²⁸ The Major Metropolitan Response System team is local and can immediately respond to a disaster in the community.

Centers for Disease Control and Prevention (CDC)

Has undertaken a major effort to strengthen the participation of state and local health departments for acts of terrorism. Includes programs to: strengthen health department laboratories to identify potential chemical and biological warfare agents, working in conjunction with the US Army Medical Research Institute for Infectious Diseases (USAMRIID); prepare health department staff to identify an outbreak, conduct epidemiologic assessments, and begin control measures; and build a national health information system to allow rapid transmission of information between state and local health departments and the CDC.
Is developing a national stockpile of critical antibiotics, vaccines, and other medical supplies that can be delivered rapidly In 1999, the CDC spent $122 million on these efforts.
Developed recommendations for medical preparedness in communities near locations where US military chemical weapons are stored pending destruction, and has developed recommendations for medical care of personnel exposed in an accidental release.²⁹
Developed guidelines to assist emergency departments in preparing for and treating victims of chemical weapons exposures,³⁰ as well as guidelines for hospital infection control during a bioterrorism event.²⁵ All can be used as references for local planning efforts.
Collaborates with national public health agencies such as the Association of State and Territorial Health Officials, the National Association of City and County Health Officials, and the Council of State and Territorial Epidemiologists, which play important roles in preparing state and local health department professionals to respond to acts of terrorism.

Food and Drug Administration (FDA)

Involved in discussions of issues involving vaccine and medications that would be used to respond to a terrorism event. In July 2000, for example, the FDA held a public meeting on an application to add anthrax post-exposure prophylaxis as a new indication for ciprofloxacin. The agency announced its approval of this indication in August 2000.

Department of Defense (DOD)

Funds a variety of response teams for acts of terrorism; these include the National Guard Weapons of Mass Destruction Civil Support teams and the Marine Corps Chemical and Biological Incident Response Force. These teams are equipped to detect and identify some weapons of terrorism, and to decontaminate a limited number of exposed persons if necessary. Such teams will be most effective when they are pre-deployed to potential target area (for example, the 1999 NATO 50^th Anniversary celebrations in Washington, DC).
Produces extensive medical education materials in books, peer-reviewed articles, CD-ROM, and Web page formats on the care of victims of chemical, biological, nuclear, and radiological events. Key sources for these materials include the USAMRIID, the US Army Medical Research Institute for Chemical Diseases (USAMRICD), and the Armed Forces Radiobiology Research Institute. Many of these materials were developed with the civilian medical community in mind and include civilian-specific issues such as pediatric and geriatric patients. Some of the materials, such as military field manuals, primarily target the military health care provider but are useful immediate references. USAMRIID and USAMRICD have also developed satellite educational courses, some with co-sponsorship and participation of the CDC, that provide effective educational outreach to both the military and civilian medical communities.
Under the Domestic Preparedness Program, sponsored terrorism training for first responders in the nation's largest cities. Responsibility for this program is scheduled to be transferred to the Department of Justice in fiscal year 2001.

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Last updated: Feb 21, 2008
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Featured Report:Medical Preparedness for Terrorism and Other Disasters (I-00) Full Text

Featured Report:
Medical Preparedness for Terrorism and Other Disasters (I-00) Full Text