THE ATTACK THAT HIDES

By Jenifer Goodwin

If terrorists struck the United States using explosives or other conventional weapons, word about the attack would spread fast from eyewitnesses calling 9-1-1. But a biological attack could be more insidious, says Dr. Alex Garza, former chief medical officer/assistant secretary for the U.S. Department of Homeland Security (DHS).

“The timeline and the way biological weapons unfold are so different than radiological, nuclear, or chemical attacks,” Garza says. “If you think about a chemical event, you find out about it immediately. In Syria, you had people showing up to the hospital minutes after they were shelled with sarin gas. There was immediate identification that something was wrong and immediate response to it. With radiological or nuclear weapons, you will also realize what happened quickly.

“A covert release of a biological weapon is very different,” Garza continued. “Biological weapons have an incubation period—it takes days before people start feeling sick. The first sign you have something going wrong might be sick people showing up at hospitals, but they aren’t necessarily identified right away. It takes time to figure out what happened, and who was exposed and who wasn’t.”

Yet there are several strategies that can aid in the early detection of biological attacks, Garza says. One is BioWatch, a federal bio-surveillance program that monitors the air in major American cities for dangerous pathogens. Another is by carefully mining 9-1-1 data using FirstWatch, which provides near real-time monitoring of CAD and EMS data for a wide range of purposes, including bio-surveillance, situational awareness, and operational and clinical quality improvement. With FirstWatch, 9-1-1 centers can set up triggers to alert supervisors or other command staff if there’s an unusual spike in a similar type of complaint, such as seizures or trouble breathing. The International Academies of Emergency Dispatch (IAED) has partnered with FirstWatch to ensure ProQA data can be easily mined.

Garza is a member of the IAED’s Chemical/Biological/Radiological/Nuclear (CBRN) committee, along with FirstWatch President Todd Stout and other experts. Greg Scott, IAED’s CBRN committee chair, explains that the group was created after the severe acute respiratory syndrome (SARS) outbreak in 2003, when it became apparent the Academy needed a way to quickly respond to these kinds of threats, to not only communicate information to 9-1-1 centers but if needed, to recommend new protocols. The committee meets occasionally to review current developments and maintain working connections, to be ready to move fast if needed.

Garza began his career as a paramedic in Kansas City, Mo., before going to medical school at the University of Missouri, Columbia. While an emergency medicine resident in 1997, he joined the U.S. Army Reserve and served as a battalion surgeon and public health team chief. He deployed to Iraq in 2003 and was awarded the Bronze Star and a Combat Action Badge. President Barack Obama appointed him to DHS in April 2009. Ready to return to his native St. Louis, Mo., with his wife and three sons, Garza left Washington, D.C., last year to join FirstWatch (based in California), but also to become associate dean for public health practice and an associate professor in epidemiology at St. Louis University’s College of Public Health and Social Justice.

 Garza spoke with Jenifer Goodwin about his years in federal government and the important role of CAD, ProQA, and EMS data in the early detection of threats to U.S. health and safety.

Q: Has there even been a “successful” biological weapon attack in the U.S.?

No, it’s mostly been clumsy terrorists and one sophisticated person in the 2001 anthrax attacks, who used weapons-grade bacteria.

There have been several attempts at using ricin. Ricin has a long but mostly unsuccessful career as a weapon. I wrote a paper about ricin being the poor man’s chemical weapon. You can make trace amounts of it by crushing castor beans. But there is a big difference between primitive ricin preparations and weaponized ricin. To do that, a terrorist would have to produce very large amounts with some degree of sophistication for the toxin to truly be considered a weapon of mass destruction. In early 2013, letters containing ricin were mailed to President Obama, New York City Mayor Michael Bloomberg, and a gun control organization. No one became ill.

But there have been attacks in other countries that we have taken a close look at. The Aum Shinrikyo cult in Japan had a successful chemical attack and an unsuccessful biological attack. In 1995, they released sarin on the Tokyo subway, killing 13 people. They tried to develop biological weapons using anthrax, but their seed culture was vaccine grade and inert, so it can’t cause disease.

The best-known release of weapons-grade anthrax was from a weapons factory in Sverdlovsk in Russia in 1979. About 100 people died. For years, the Soviets denied it was inhalation anthrax and said it was gastrointestinal anthrax from tainted beef. Then they finally fessed up.

It takes skill to develop weapons-grade anthrax—it’s not something a kid in biological class can do. Although anthrax lives out in nature, collecting it, keeping it alive, and milling it is difficult, but not impossible.

So you can do that or make a couple of pressure cooker bombs and put them in a backpack. Boston, Mass., showed it isn’t horribly difficult to do. The Tsarnaev brothers figured out how to do it from the Internet and were able to kill and injure scores of people. The primary motivation of a terrorist is to spread terror. They locked down one of the largest American cities for a couple of days with firecrackers and a pressure cooker.

Q: Are there any lessons to be learned from Boston’s response to the marathon bombing?

Boston has a very good EMS system. Another thing that played in the city’s favor is because it was a sporting event with a lot of people participating, you had a lot of medical assets nearby. That was very fortuitous. They were able to respond really quickly. But a really good takeaway from the marathon bombing was how the public reacted. There were a lot of stories about people assisting at the scene and taking care of people, evacuating people, and even applying tourniquets. I’m impressed that they had the frame of mind to do those things. When I was doing training as a medic and emergency medicine resident, we were taught that you’d do more harm than good with a tourniquet. That dogma has been turned on its head ever since the U.S. went to war.

Q: Still, the general public tends not to take preparedness all that seriously. A few years ago, the Centers for Disease Control and Prevention (CDC) used the interest in all things zombie to get attention to preparedness (The “Are you Prepared for the Zombie Apocalypse” campaign). It generated a lot of attention. In general, why doesn’t the public take preparedness more seriously? 

It’s part of our culture that we don’t deal with things until we have to deal with things. That’s permeated through our business models, where we have just-in-time inventory. Even when we are doing large planning for budgeting and infrastructure we’re very much focused on short-term goals. Preparedness is no different. The Zombie Apocalypse was very entertaining and caught people’s attention. Whether it spurred people to become more proactive in disaster preparedness is another question.

Short of mandating that people have to do certain things, it’s difficult to motivate them. I applaud CDC for trying these different approaches, but you see time after time, whether it’s snowstorms or earthquakes, people are not well prepared.

Q: Are we prepared for a Nairobi (Kenya)-style attack on a shopping center? What should we be doing?

By being prepared, do you mean can we stop random acts of violence? No. But from the response side, we’re definitely much better prepared than they were in Nairobi. The siege took four days. There were multiple victims and criticisms of the police and the military for not moving in faster. I think we would be much better prepared here. All of these mass shootings have brought these sorts of events to the forefront of people’s thinking, even though you can’t secure everything, all the time, nor would you want to.

Q: When it comes to terrorism, we tend to think a lot about risks at mass gatherings or on airplanes. What other types of sites could be at risk that people might not think about? 

The safety of the food supply is one of them. One of the things we did in cooperation with the U.S. Department of Agriculture was look for vulnerabilities in the large food distribution points. For example, what would happen if a terrorist organization decided to focus on infecting the cattle herd in the U.S. with hand, foot, and mouth disease? A large segment of the cattle industry is consolidated into large businesses that operate huge feedlots. If somebody wanted to tamper with that system, how would they go about it?

An electromagnetic pulse is another one. If a nuclear weapon detonated in the stratosphere, it could knock out the power grid and anything with circuitry. Solar flares from the sun can knock out the electrical grid. We’ve gotten very used to dealing with computers for everything and become very dependent on them.

Q: At the 2012 Public Health Preparedness Summit, you were part of a panel discussion about pandemic viruses that included the screenwriter for the movie Contagion, in which a rapidly spreading, lethal virus wipes out large swaths of the world’s population, causing mass panic. How far-fetched is that idea?

It’s difficult to predict. We’ve never seen a virus like that. In 1918, the so-called Spanish flu was as close as we’ve gotten. Is it possible? I don’t think it’s out of the question, however, the risk of that happening is not huge because most of the time viruses don’t mutate to become that easily transmissible or lethal. 

However, even a less lethal virus (than depicted in the movie) could have a significant impact. Influenza circulates around the world and is constantly changing. It can spread rapidly and become a pandemic if you get the right genetic re-assortment. The two big ones we’re keeping an eye on are the Middle East Respiratory Syndrome (MERS) coronavirus, and the highly lethal avian influenzas coming out of southeast Asia. The most recent one is H7N9, an avian influenza with a high mortality rate circulating around China earlier in 2013. They culled their ducks and wild bird population to cut off the chain of transmission. One of the preventive measures we take is making sure nobody is importing birds from southeast Asia. There’s quite a smuggling operation that Customs and Border Protection tries to stop.

Q: How worried should we be about the MERS coronavirus? 

It’s concerning. It’s the same family of virus that caused the SARS epidemic in 2002–2003. At least from what we understand, MERS has a substantial mortality rate. All of those things put together make it something you should have on your radar screen. While there are case reports of it transmitting from person to person, on the plus side, it seems like you have to have significant exposure to catch it. There hasn’t yet been sustained person-to-person transmission. But viruses are notorious for genetic re-arrangement, so we have to keep an eye on it. For EMS and 9-1-1 centers, that translates to making sure we are keeping good track of our data and being aware if you see an uptick in respiratory illnesses or an illness that is not easily explained. Public safety providers also need to be aware of what is going on globally. We live in a global culture. If your patient has a respiratory illness and has been to the hajj to Mecca, Saudi Arabia, you might want to put a mask on.

A virus that has high transmissibility and high lethality can destabilize the security of the country, which is why the Department of Defense has its own vaccine stockpile so it doesn’t have to compete with everybody else for a vaccine.

Q: What else can a public safety agency or 9-1-1 center do to be prepared? 

By using FirstWatch to monitor CAD data, you can look for complaints in the community and compare them against a historical average. It’s similar to what traditional epidemiologists do when they look for flu-like illness in emergency departments and clinics. But when the CDC puts out its data, it’s usually lab confirmed and two weeks later.

With CAD and ProQA data, you can look for people who call 9-1-1 with respiratory complaints analogous to the flu and plot that against historical data. It could serve as an early marker of flu in the community.

Q: After nearly four years in Washington, D.C., you were eager to move on. What drew you to getting back into public health and FirstWatch?

It was a combination of things. I wanted to move to St. Louis to be closer to family and get back to some of the academic work I enjoyed doing. The life span of a political appointee is pretty short, and you can’t stay in these jobs forever. Most political appointees are only in their jobs for two or so years. I was there for more than four years, so I doubled that.

I had known and respected the folks at FirstWatch for some time. I thought it was a natural fit for what my interests were—with data, public health, and particularly, EMS quality improvement issues.

Q: FirstWatch works closely with the IAED to monitor ProQA data for customers. Why is that data source particularly rich? 

We have this tremendous data capture from the time patients call 9-1-1 to the time we deliver them to the hospital, yet 9-1-1 data tends to be overlooked.

One of the benefits of 9-1-1 data is it captures the complaints of the entire geographic community. Anybody and everybody calls 9-1-1. There is some socioeconomic bias, but nonetheless you get a pretty good snapshot of what is going on. For those that use ProQA, the records are all time stamped, valid, and geo-located. The information is captured in a reliable, consistent fashion, whereas a triage nurse at a hospital may ask different questions depending on who is doing the triage. CAD data is also available quickly. To interrogate hospital ER data can take days to weeks.

Q: Even though we haven’t seen a large-scale terrorist attack recently, is there reason to remain vigilant?

There are always going to be threats against the country. In the last decade, we’ve degraded a lot of terrorist capability. But they are a very resilient group as the attacks in Boston and Kenya demonstrated. But how much protection, how vigilant do you need to be? There is a fine line you walk. Before 9/11, you could walk to a gate and get on a plane with minimal security. After 9/11 the world changed. Some people feel inconvenienced by it. There are a lot of things that you have to figure out where the line is, between investing too much and not investing enough. 

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