By Mr. Frank Rando, CBRNE Protective & Biomedical Countermeasures SME, University of Arizona and Ms. Dee Ruelas, Clinical Specialist in COVID-19 testing and vaccination services, USA.
Traditionally, the field of public health has been grounded in the prevention of disease and the promotion of health and wellness in communities. In former years, rarely, if ever, public health was a prominent or critical stakeholder in terrorism preparedness and response, let alone taken the shape of a bona fide first response entity. Fairly recently, the role and importance of public health in disaster management has been firmly established at local, state, national and global levels. Indeed, the value of public health in disaster management has been demonstrated time and again as both natural and man-made made adverse events have generated effects impacting healthcare delivery systems, critical infrastructure, supply and distribution chains, environmental health, and the psychosocial aspects of the affected population(s).
Public health emergency management or public health emergency preparedness have become frontline priority areas since the September 11, 2001, terrorist attacks and the October 2001 anthrax attacks via the U.S postal system. Subsequently, public health agencies at all levels of government have been included in emergency planning and preparedness efforts and are of paramount importance in incident management.
In the U.S., public health roles and responsibilities in both natural and man – made events fall under Emergency Support Function # 8 (Health & Medical) of the National Response Framework (NRF) which is a component of the National Incident Management System (NIMS).
In the terrorism context, public health capacity and capabilities become critical to the overall homeland and national security missions as well as the health and medical component of the National Response Framework and its designated roles and responsibilities. For example, the Laboratory Response Network (LRN), was created in 1999 by the U.S. Centers for Disease Control and Prevention (CDC) to expand and link up laboratories that can respond to biological and chemical threats and other public health emergencies such as pandemic threats and natural disasters.
The public health sector strives to address all the complex and multifactorial health, safety and environmental concerns of communities that are subjected to any CBRNE terrorism attack.
In 2002, the U.S Congress passed the Public Health Security and Bioterrorism Act “to improve the ability of United States to prevent, prepare for, and respond to bioterrorism and other public health emergencies”.
The first hints of public health becoming an important front-line function in emergency preparedness and incident response were evident in several acts of terrorism, technological disasters, and catastrophic natural events over the years.
Considered a sentinel event in the US, the contamination of salad bars with Salmonella causing an intentional outbreak of salmonellosis among the population of The Dalles, Oregon brought forth the importance of having a robust bio surveillance capability and a prompt response from the public health sector.
From the intelligence data demonstrating evidence of the weaponization of biological and chemical agents in Iraq to the use of the neurotoxic agent, sarin, in Japan, both Matsumoto in 1994 and the Tokyo subway system in 1995 demonstrated a clear need for involvement of public health resources OCONUS and within the boundaries of the US and its territories.
Additional evolving and existential threats such as the expansive former Soviet bioweapons program known as Biopreparation ,and it’s chemical weapons equivalent , Foulant, and their alleged and covert military- industrial scheme to conduct R& D and to mass produce bioweapons and the ultra- toxic chemical weapons , named as the Novichok ( aka , “ newcomer”) nerve agents, begged that we enhance our public health infrastructure to be able to plan for and respond to these potential threats and contingencies that could affect the U.S. and its allies.
In the aftermath of the 2001 terrorist attacks, public health had marshaled all their resources to respond in a multifaceted fashion to the worst terrorist attack on U.S soil.
Public health emergency operations via the Health Protection Agency (HPA) in the U.K. had a critical role to play in the Novichok nerve agent attacks/attempted assassination events in England, as well as the Polonium -210 (Po-210) radiological poisoning attack on Russian journalist, dissident and former FSB operative, Alexander Litvinenko.
There were several lessons learned from these chemo terrorism and radiological terrorism events with broad implications for planning, preparedness, and response to CBRN events in a civilian urban and suburban environment.
The Litvinenko incident, for example, serves as a “model “for a radiological dispersal device (RDD) scenario, as it created a major public health crisis as radioactive material from the scene of the attack was detected in various environs in London.
As a result, in the U.S., a Health Advisory Network (HAN) notification was transmitted by the CDC to all healthcare and medical personnel, as well as emergency medical services on the event and the health effects and medical management of the radiotoxicity caused by Polonium- 210.
Internationally, the World Health Organization (WHO) disseminated its own briefing on Po-210. Similarly, the Novichok attacks in the U.K. borrowed heavily from public health expertise.
Indeed, public health has become the lead agency in bioterrorism and public health events such as epidemics and pandemics and coordinates their activities with other stakeholders such as local, state emergency management offices and the Federal Emergency Management Agency (FEMA), hospitals and healthcare organizations, first responder agencies and voluntary organizations.
The roles and responsibilities of public health in a terrorism event include:
Epidemiology
Epidemiology is defined as the study of diseases and injuries in human populations, disease patterns, and the frequency of occurrence. It is the fundamental pillar of public health which utilizes the scientific method in problem solving and is applicable to all aspects of public health practice, including public health preparedness and response for terrorism events.
Epidemiology seeks to discover the origins and causes, eg. etiology, of disease and injury in communities/populations.
The critical functions of epidemiology include:
· Conducting epidemiological investigations. In CBRNE events this may involve joint criminal and epidemiological investigations, known as forensic epidemiology, where law enforcement and public health share a symbiotic partnership to simultaneously investigate and prosecute a biocrime or terrorist act as well as act to protect the health, safety, and wellness of the public.
An example would be a joint task force operation in which epidemiologists and law enforcement officials work together to establish contact tracing for exposure to a select agent which may be easily transmissable person to person via droplet infection or airborne transmission. This type of joint effort can also generate investigational leads for law enforcement authorities, as well as bring in exposed individuals for prophylaxis, isolation / quarantine and treatment that would limit spread of contagion and decrease morbidity and mortality.
· Determining risk of exposure for various populations, including vulnerable and susceptible sub-populations such as those with pre- existing co- morbidities (“at risk populations”)
· Identifying populations in need of prophylaxis or therapeutic medical countermeasures
· Providing recommendations to the healthcare community and public to include PPE and other protective countermeasures such as self – quarantine, self- care shelter in place, vaccination, diagnostics, and therapeutics
· Determining criteria to be used for identification of cases and controls
· Monitoring morbidity and mortality associated with the release of CBRNE agents or the use of conventional weapons in a terrorist type of assault (as well as other public health emergencies, eg. pandemic, natural disasters)
· Simultaneously performing and meeting day to day needs and traditional health and wellness promotion and disease prevention activities while engaging in emergency functions
Along with epidemiology, surveillance serves as the second scientific pillar of public health.
The surveillance aspect of public health involves the collection, analysis, interpretation, and dissemination of data on disease or injury occurrence. Surveillance can be passive, in which health systems are collecting and reporting data to a public health department, or active, in which epidemiologists are proactively seeking and gathering data for an investigation, eg. biocrime / bioterrorism or infectious disease outbreak.
Surveillance includes the following:
· Laboratory services, including the national and international partners created by the CDC, Association of Public Health Laboratories, and the Federal Bureau of Investigation (FBI), the Laboratory Response Network (LRN) which includes local “sentinel “laboratories which can provide the initial diagnostic clues in a bioterrorist attack or even a chemical or radiological terrorist attack. “Reference laboratories” are more sophisticated laboratories operating at state and federal levels and include Department of Defense assets such as the US Army Medical Research Institute for Infectious Diseases (USAMRID) at Fort Detrick, Maryland, and the US Army West Desert Testing Grounds in Dugway, Utah.
The LRN is also comprised of food testing laboratories, veterinary diagnostic laboratories, and environmental testing laboratories. In CBRNE/ terroristic events , laboratories become critical not only in medical diagnosis and the application of medical countermeasures for prophylaxis and treatment , but also for proper scientific analysis, confirmatory testing and agent characterization , to provide accurate guidance for decontamination and protective posture , policy decision – making , law enforcement / forensic/ evidentiary , prosecutorial , international security and possible sanctions or military attribution actions against terrorist groups and/ or nation – state – actors .
In bioterrorism events, microbial forensics is an important capability that even define microorganisms and biotoxins at the molecular level and assist in determining whether the agent in question may have been bioengineered to attain enhanced genetic properties or characteristics, eg. novel organism, antimicrobial resistance or increased virulence , transmission or lethality. Public health concepts and techniques are also utilized in ensuring biosafety and biosecurity of laboratories where dangerous pathogens and hazardous materials, including chemicals and radionuclides could be subjected to theft or diversion by internal or external actors and utilized in terrorism attacks.
· Syndromic surveillance, which is the acquisition of data from healthcare providers, including pre- hospital emergency medical services (EMS), in real time, to investigate and analyze potential outbreaks. Originally designed and developed to detect disease clusters in a large-scale bioterrorism attack, the overarching goal is to use real time data to identify illness clusters based on signs and symptomatology.
Syndromic surveillance may also be applied to toxic industrial chemicals and materials (TICs/ TIMs, including heavy metals such as mercury) chemical warfare agents (CWAs), biochemical toxins and radionuclides / ionizing radiation exposure by identifying toxidromes. Syndromic surveillance may also be scrutinized from surrogate data gathered from unexpected veterinary morbidity or mortality, absenteeism at work or schools and even social media posts regarding illness.
· Sentinel surveillance is another method which utilizes an active approach and utilizes data collected by carefully selected sampling of reporting sites and selected healthcare providers usually centered in large population areas. Zoonotic surveillance systems collect data on animals infected with diseases that can be transmitted to humans. Cases involving vector- borne infectious diseases such as West Nile Virus (WNV), dengue fever, Japanese encephalitis, yellow fever, Chikungunya fever and Venezuelan equine encephalitis, and Rocky Mountain spotted fever are examples of such infectious diseases. Warbonnet is a vital surveillance system used to detect these and other vector – borne infectious diseases. Sentinel animals such as various avian species, aquatic organisms and several land animals and insect populations are also essential indicators of a bioterrorist or chemo terrorism event.
Environmental health and the assessment of air, water, soil contamination and potential exposure pathways is of paramount importance along with food and agriculture safety. Providing and maintaining close liaison, communications and coordination with area hospitals and healthcare facilities and emergency services are critically important, as is accurate and evidence – based crisis and risk communications.
The development, storage, distribution, instruction, and technical assistance related to biomedical countermeasures is also a critical function of public health operations as is addressing the psychosocial and mental health needs of a community in the aftermath of a CBRNE event as well as assisting with community reentry assessments and on-going recovery efforts.
Whether natural or man-made events occur, or accidental or intentional acts threaten the health, safety and wellness of communities, public health stands in the forefront of prevention, preparedness, mitigation, response, resiliency, and community recovery.
About the Authors:
Mr. Frank Rando currently serves as an allied health programs educator / lead instructor and healthcare emergency preparedness/medical readiness /public health preparedness and tactical, operational – disaster medicine and homeland security Subject Matter Expert, educator , instructor and curriculum designer. He has served in instructional, guest speaker and consultative roles for DHS-FEMA, various components of the National Domestic Preparedness Consortium, DoD, industry, academia, health, safety and regulatory entities, emergency services organizations and healthcare.
He recently served during the COVID-19 public health emergency as a clinician and clinical researcher and also served in medical and health care support as a clinician for US Customs and Border Protection.
Frank is also an experienced clinician, first responder and an occupational – environmental health scientist with real world experience in hazardous materials management, hazards and pollution control, biosafety, industrial, environmental and inhalation toxicology, environmental epidemiology, exposure and risk assessment and emergency response.
Frank has also received advanced training in Integrated Biological -Chemical Response from the US Army -Dugway West Desert Test Center and the National Ebola and Special Pathogens Training Centers.
Frank’s experience includes public safety roles in law enforcement, pre-hospital medicine/EMS and military duty as a Nuclear, Biological and Chemical/CBRN Specialist ,NBC medical defense instructor Special Forces Medical Sergeant, Dive Medical Technician ,Intelligence Sergeant and Medical Intelligence Analyst.
Ms. Dee Ruelas possesses over 35 years of dedicated professional experience in various roles in public safety/ emergency services, teaching and instruction, healthcare, environmental health and safety, emergency preparedness, community resiliency and Christian ministry. Dee was also a decorated public safety-emergency medical communications specialist for the City of Tucson Fire Department and worked for the Tucson Municipal Court, where one of her roles was serving as the Fire Prevention and General Safety Officer for the municipal courts system.
Currently, Dee has been serving as a clinical specialist in COVID-19 testing and vaccination services and served as a medical and healthcare support specialist for US Customs and Border Protection.
Dee is the former Director of the City of Tucson Community Emergency Response Team (CERT) and is a DHS-Certified CERT Instructor, National Association of Emergency Medical Technician Tactical Emergency Casualty Care (TECC) Instructor and a Certified Stop the Bleed Instructor.
Dee is also trained and serves as an experienced instructor and consultant in hazardous materials, incident command, explosives recognition, medical decontamination, active shooter countermeasures, emerging infectious diseases, mental health first aid, refugee medicine and general health and safety, including roles as a subject matter expert, guest speaker, and instructor for the State of Arizona Division of Occupational Safety and Health.
She has also been trained by the National Ebola Training Center and the Emory University Rollins School of Public Health Dee also is the owner and senior proprietor for Teach 2 Prepare, a consultancy and training entity.
