Preparedness:
Public Health
With Bruce Clements
Associate Director, Center for the Study
of Bioterrorism
Thursday, July 18, 2002; 3 p.m. EDT

President Bush unveiled his homeland security strategy Tuesday, calling for action by government and private industry to prevent "a new wave of terrorism" in the U.S. The Bush plan urges that security be tightened against "catastrophic threats," such as nuclear, radiological, biological and chemical weapons, as well as cyber-attacks and more conventional weapons.

Bruce Clements is associate director of the Center for the Study of Bioterrorism and Emerging Infections at Saint Louis University School of Public Health. He is responsible for the development of bioterrorism training and quick reference material for healthcare and public health workers. He was online Thursday, July 18 at 3 p.m. EDT, to discuss risks posed by a bioterrorism attack, the probability of such an attack and public policy and preparedness, including national policy on smallpox vaccination.

Clements has served more than 18 years in the Air Force and Air National Guard and continues to serve as a public health officer with the Missouri National Guard. His military experience includes developing and teaching training courses designed to prepare troops and medical personnel for a domestic bioterrorism attack.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Bruce Clements: Hello, this is Bruce Clements at Saint Louis University's Center for the Study of Bioterrorism ready to answer your questions.

Reno, Nev.: Dear Bruce Clements,

Why is the smallpox vaccination not available to the general population?

When the terrorists strike in this way, someone will have to needlessly die before the vaccine is available.

I would take the vaccine willingly if it were available.

Why is it the vaccine is not avilable?

Bruce Clements: This is a very difficult questions facing policy makers today. The challenge is balancing the risk of a smallpox bioterrorism attack against the risk of the vaccine. This vaccine can pose problems. It is especaillay true for individuals with compromised immune systems and we have more people in that status than ever before. At this point details are being worked out to vaccinate a small number of healthcare workers in each region that could respond to an attack and then vaccinate everyone around the first cases identified. Unless the risk of a smallpox attack increases or the risk of the vaccine side effects are reduced, this seems to be the best balance for now.

Washington, D.C. : Do you think another attack against the U.S. will occur?

Bruce Clements: I wish I could say no but unfortunately there is widespread proliferation of dual use equipment that may be used to develop biological weapons combined with the volumes of information available on the topic. At the same time we have seen a shift in the motivation of terrorists. In the 1970s the IRA would call in a bomb threat before they detonated it in order to reduce casualties. They just wanted publicity and political pressure. Today, a variety of terrorist organizations are simply wanting to hurt and kill as many people as possible. This makes the bioterrorism option more likely.

Charlottesville, Va.: Where will additional health care workers be found if there is a malevolent use of smallpox or plague. I know the public health system in most places is rather stretched by "normal" disease outbreaks. If thousands or hundreds of thousands of people start becoming ill, who is going to help care for them and/or see to the quarantining of them?

Bruce Clements: Mass care is one of the greatest planning challenges we are facing. The National Disaster Medical System now has over 10,000 volunteer healthcare workers they can deploy within hours to the scene of an attack. In addition, the National Guard is exploring new ways to deploy DOD resources to support these types of incidents. In spite of all these efforts, the local public health and healthcare workers must shoulder this preparedness responsibility through coordinating their planning and exercises and integrating their resources. If the billions of dollars being spent on our nation's preparedness makes it to the local level, it will make a difference. It is our best hope for community preparedness.

Greensboro, N.C.: Who gets the vaccines first, first responders, old people, kids ... who? I hear that Dr. Kevin Fannin out at the Univ. of Idaho has a plan under consideration which would outline who should be given the antidote to these biological agents first, but it is being kept secret. What do you think should be done?

Bruce Clements: Most states have developed plans that include a priority listing of who gets vaccinated first. You are correct in your assumptions. Usually first responders and healthcare workers are first so they can provide care and stability. The groups listed first also will normally include the family members of these workers since a physician, police officer, etc. is not likely to come to work if they are concerned for the safety and health of family. A bigger challege is in the sheer volume of people we may need to vaccinate or treat. Most major cities have developed plans to address this but a great deal of work needs to be done to identify the most effective approaches so the greatest good can be accomplished for the geatest number of people at risk.

Boston, Mass.: Do you think there is any cause for concern/action in the reports of pinpricks and darts that people are experiencing on the streets (see Washington D.C. news today)?

Bruce Clements: Although these types of reports are usually "urban legends", there was an incident several years ago in London where an individual was stuck with the tip of an umbrella that injected a small pellet containing the toxin ricin into his leg. He later died. However, this was a very specific attack using complex materials provided by the KGB. In general, this type of risk for the average citizen is extremely low.

Reston, Va.: Is there anything we, as individuals, do to protect
ourselves from attacks?

Bruce Clements: Keep in mind that many of the pathogens we are most concerned with spread like influenza. Your mother was right when she told you how important it is to wash your hands. Good hygiene and good health are your best weapons. Very few of these diseases are 100% fatal in a population. Those who are healthier and practice good hygiene are more likely to be among the survivors of a bioterrorism attack. It is not wise to stockpile your own antibiotics.

Boston, Mass.: Hi,
I should know this, but if someone contracts smallpox, what are their chances for survival, if any? Thank you.

Bruce Clements: If our historical trends hold up in a future outbreak, it would be fatal in about 30% of those infected. However, with improvements made in healthcare and new drugs being developed, the mortality may be much lower. We cannot know for sure unless it happens...I hope we never find out.

University Park, Md.: Dr. Clements, my question concerns the implications of widespread smallpox vaccinations. For health reasons, only one member of my family can receive the vaccine (if it's ever offered to the public). Will the rest of us be at risk if she receives it? Or if other members of the public receive it? Thank you.

Bruce Clements: The smallpox vaccine infects those vaccinated with a mild case of vaccinia. This disease is genetically almost identical to smallpox but is missing some of the DNA needed to make it a dangerous disease. However, those vaccinated must avoid spreading the small infection they get from the vaccine to those who have compromised immune systems. In studies done here at Saint Louis University, a large dressing is placed on the vaccine site and the person immunized is taught how to avoid infecting others. Simple precautions like these may be instituted in your home to protect those that cannot be exposed.

Herndon, Va.: You are providing a great service, keep up the good work. I recently attended a seminar in which a speaker, Micheal Forgy, was discussing the importance of local planning to receive the National Pharmaceutical Stockpile. How do you think planning for this is coming along both at the local and federal level?

Bruce Clements: This has been difficult. The stockpile will not do us much good unless we can rapidly identify a problem and deliver what is needed quickly. With recent changes made to the stockpile, the CDC has done an outstanding job making it easier to manage. The problems remain at the local level. First we need surveillance systems in place that can detect an event early. Second, we need mass prophylaxis plans in our communities in which we have some confidence. On both of these issues, much work remains to be done.

Washington, D.C.: From what I've read, most --if not all-- of the diseases that might be spread by bioterrorists are treatable (or can be vaccinated against), and are not easy to spread in a large-scale way. Based on this I've viewed bioterrorism as a significant but small risk. Is this incorrect?

Bruce Clements: You are correct. It is called a low probability/high impact event. It is not very likely to happen in your community on a large scale but the impact would be so great if it did that we must take steps to prepare.

Tampa, Fla.: My concern is about the nation's hospitals. Just as people were afraid to fly after 9/11, imagine the panic that would insue if terrorists actually used hospitals as ground zero for their biological weapons attack. This would cause people to be afraid to seek medical treatment, which would cause a catastrophe of even greater magnitude.

Has this possibility been addressed?

Bruce Clements: Hospitals as primary or secondary targets is a huge concern. A frightening trend that the first responder community has been dealing with is the risk of secondary devices at a scene. These devices specifically target the responders. In a bioterrorism attack, the first reponders include healthcare. If the goal is terror, they are a likely target. Most major healthcare facilities are revisiting their security systems and shoring up vulnerabilities.

Bethesda, Md.: I received a smallpox vaccination 30 years ago. What are the chances it would still be effective today?

Bruce Clements: The short answer is, you may have some immunity but don't count on it. Additional studies are underway to better understand this but you should assume that you have little or no immunity.

FFX: In Konstaty Kaminski's book, "BioWarfare, the Citizens Guide to Health", he says gas masks are useless against a bio-attack. Should I buy a gas-mask to protect myself or no?

Bruce Clements: I wouldn't recommend it. The biggest problem with buying a protective mask is that an attack is likely to be covert. That means you would need to wear your mask constantly to protect yourself. However, if you decide to buy one be sure you understand how to use it safely. In Isreal (where they have a different type of threat including missile attacks), they have a program to provide protective masks to everyone (including babies). In spite of comprehensive training from childhood, they had several people die from using protective masks inappropriately during the Gulf War.

Iowa City, Iowa : Hi, Thanks for doing this great public service. My name is Micheal Forgy and I am a furturist looking at American civilization in the next decade. My profession certainly was taken aback by the events of 9/11. Now I will ask you to do my job. What will our homefront security look like in the next decade?

Bruce Clements: I wish a had good news to report on this but I believe we have entered a new era. If future biological attacks are carried out successfully on a large scale, I believe we may eventually institute programs similar to those of Isreal. We may need to establish safe rooms and protective equipment in every home and have our children in training to identify and respond appropritately to various types of terrorist attacks. I am also concerned that the need for more security may erode our rights, the basis for our society. I hope I am wrong.

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