The following was an Assignment for my Homeland Security Organizations Class.  I am proud to say I received a 100% for this Critique and some very nice comments from my instructor.

 

A CRITIQUE OF JOURNAL ARTICLE

“PATHOGEN’S FOR KNUCKLEHEADS”:

INVISIBLE AND INFECTIOUS

 

 

Richard G. Hildreth

HLSS 301 Homeland Security Organization

Professor Michael Thornal – Instructor

December 18, 2012

 

As Christina Flowers stated in her article “Pathogen’s for Knuckleheads” Invisible and Infectious ¹, “the Nation’s collective ignorance of Pathogen 101 basics can no longer be acceptable.”  Many gaps exist in our nation’s ability to recognize, respond to and mitigate against a natural or terrorist caused biological incident. The gaps in training of our first responders and of policy leaders about pathogens and the bio terrorism threat could lead to confusion, slow response and unnecessary loss of life.

Many articles in the November 2012 edition of DomPrep Journal (Domestic Preparedness Journal) addressed the current level of Bio-preparedness in the United States and where we need to improve.  Christina M Flowers, MPH (Master of Public Health) describes how little training and information is available to our responders and the gaps in our national preparedness this issue creates. Her intent of this article is not to point fingers at first responders or an unwillingness to learn but to point out this complex topic is very frustrating to prepare for and deal with.

First responders in the United States are often well versed and trained in dealing with incidents involving Chemical, Radiological and Nuclear weapons.  Awareness Level Trainings often include information on IED’s (Improvised Explosive Devices), WMD’s (Weapons of Mass Destruction) and TIC’s (Toxic Industrial Chemicals); the author contends that training should also include information on pathogens, recognition of Bio-Terrorism and the unique response and  communication challenges that bio-terrorism events create. The threat from pathogens is complicated by the fact it is invisible to the human eye, has the ability to modify itself; adapting to both the host (patient or victim) and response attempts (becoming drug resistant). Additionally, because of the time required for incubation periods, responders are often not aware of the threat for days after the outbreak or release of potentially dangerous substances has occurred.  By the time the threat is recognized it is more difficult to properly isolate the victims or control its spread. This is why it is so critical that Public Health Officials and the CDC (Center for Disease Control) be integrated into local emergency planning, training and exercises.

In her description of what a pathogen is, the author defines the word as “an infectious agent that results in and causes disease. “ Its roots are from the Greek words “gen” which means “giving birth to” and “pathos” which means “suffering”. Pathogens are often living organisms themselves or at least derived from organic processes. Because of this, pathogens often have well defined habitats and life cycles that can tip off responders if they know what to look for.  Although the natural defense of the human immune system does limit infection of some traditional pathogens, less typical pathogens might require specialized antibiotics such as Cipro (ciprofloxacin) or streptomycin.  The author notes that some biological toxins such as Ricin, developed from castor beans, currently have no known antitoxins.

The article then goes on to discuss the different processes used to transmit infectious pathogens. Pathogens can be transmitted by contamination of food or water (ingestion), airborne droplets (inhalation) or trans-dermally (absorption).  As we learned with viruses such as AIDS (Acute Immune Deficiency Syndrome) some are transmitted by bodily fluids such as blood or saliva.  Some pathogens such as Staph naturally occur in the host body but become dangerous when something happens to upset the natural balance.  The variety of methods of transmission only makes the subject of pathogens more complex.

Bioterrorism has been used or attempted many times throughout history. The author points out that corpses infected with the plague were catapulted over the walls by the Tartars in their siege of Crimea.  One of the most well-known instances of a bioterrorism attack inside the United States was a 1984 attack by followers of the Bhagwan Shree Rajneesh. In this attack these followers sprayed salmonella on the salad bars of Dalles, Oregon area restaurants. The intent was to sicken area voters so they could take control of local elections.  Another example of an attack inside the US was the 2001 Anthrax laced letters that were mailed to Members of Congress and members of the press.  The author points out that many of these pathogens are easily obtained on the open market and as living organisms can be easily replicated or grown by terrorist.

Ms. Flowers then defines the differences between the three categories of pathogens defined by the CDC. “Category A” agents such as anthrax, smallpox, plague and botulism pose a significant risk to national security because of their ease of transmission and how rapidly an outbreak could spread creating a large number of casualties. “Category B” pathogens including salmonella and ricin are still easy to spread; however they result in more moderate illness and a reduced death rate than Category A agents.  “Category C” are emergent diseases that as of yet have not been classified as A or B.

There are many challenges in identification or recognition of a Bio-Terrorism attack. In addition to the complexities of technologies required to accurately identify specific pathogens, the incubation time required between exposure to a pathogen and visible signs of disease delay response. This is where an understanding of public health monitoring is needed. Unexpected spikes in flu like symptoms, high fever, rash and gastrointestinal illness are closely watched and evaluated by epidemiologists. In the event of an outbreak these spikes might be the earliest warning that an attack has happened.  Unfortunately, it is often days or weeks after the attack was actually made and the terrorist have long since left the area.

After identification of a pathogen has been made there are several methods for response.  Although specific response plans might be different depending on the type of pathogen, the first task is to limit the spread of disease. This might include quarantine for a pathogen that can easily spread person to person or social distancing measures such as closing of schools, daycares and public gathering locations. Responders need to be not only aware of what PPE’s (Personal Protective Equipment) is needed but also what the limitations of those PPE’s are.

The final challenge the author describes is public communication.  In the event of a potentially deadly pathogen, it is critical that responders provide the public with accurate and reliable information.  These communications need to be simple, straightforward and include specific instructions as to what to watch for and where to find additional information.  These communications need to be repeated on a regular basis and be structured so they inform the public with the seriousness of the incident without creating undue alarm of fear.  Effective communications will not only help in mitigating fears and restoring confidence; they may also benefit by providing responders with additional information that might assist in tracking or investigating an incident.

Although I find the topic and thesis of this article of critical importance, I am not sure the author really showed a complete or scholarly review of information or presented her findings in a unique way.  I agree that our first responders need better training on awareness and response to biological pathogens; however I found the article rushed, disjointed and lacking in originality.  I have also identified areas that were not addressed.  I feel that adding these issues would add to the value of this article.

One of the most obvious points I feel was overlooked is how we can address this issue.  I have long been a supporter of cross training between responder disciplines and would have liked to see comments on both existing programs available and training programs that should be developed for the future.  Louisiana State University operates the National Center of Biomedical Research and Training (NCBRT) ² which is an existing DHS training partner providing awareness and responder level training to emergency responders.  Training is available online and field delivered classrooms and is 100% funded by the Department of Homeland Security. This is an effective way for local government agencies to build the capacity needed and address some of the gaps presented in the author’s thesis.

I also believe there should be more distinction between the challenges of facing a naturally occurring outbreak and one caused or aggravated by an act of terrorism.  Although many of the preventative and response measures might be similar; in the response to a terrorist event evidence preservation and law enforcement also play a role.

 I know that many health departments and healthcare facilities have well developed planning guides for various pathogens and threats.  The author could have at least referred the reader to guides or plans that represent best practices.  One example that I have found is an exceptionally well written and complete plan that would have supported the thesis by addressing the gaps is the 2002 California Hospital Bioterrorism Response Guide ³. Although it was designed for the Healthcare industry it visually describes the extent of the threat and provides best practice response tactics for Bioterrorism as a whole and for individual pathogens. 

A final area that I felt should have been at least broached was the legal and policy impacts of Quarantine and Social Distancing Measures.  Although  responders themselves might not need to understand these impacts, it does provide them information they might need to pass on in order to gain policy support for training.  As a practitioner the more information that the author can provide me to use in convincing my superiors of the need and value of training the more value it has for me.

 

As a whole, I did not find that the article was poorly written, it just didn’t include new information that was of value to me as a practitioner. I know that the author might have been constrained by a word limit; however elimination of some more irrelevant information (at least as to supporting her thesis) and inclusion of the information that I referred to would have, in my opinion, made it a much stronger article.  I agree that the gaps the author identified in our responder’s ability to respond to Bio-events are valid concerns.  I know some communities and individual responders have worked to close this gap themselves, but they seem to be the exception and not the rule. The author missed a great opportunity to reach out to emergency management/ homeland security professionals and promote what I feel is an important point.

 

1-     Flowers, Christina M. "Pathogens for Knuckleheads: Invisible and Infectious."
Domestic Preparedness Journal 6, no. 11 (November 2010).

 

2-     National Center of Biomedical Research and Training. http://www.ncbrt.lsu.edu/.

 

3-     Department of Health Services. California Hospital Bioterrorism Response Guide.
N.p.: California Department of Health Services, 2002.
Can be found at http://www.emsa.ca.gov/disaster/files/ca_hosp_guide.pdf