Application of Technology to Transportation Operations in Biohazard Situations

May 17, 2005

Submitted to the
Federal Highway Administration
U.S. Department of Transportation

Table of Contents

1. Introduction
2. Biohazard Agents
   1. Definition of Biohazards
   2. Specific Biohazard Agents
3. Biohazard Events
   1. Deliberate Release
   2. Agroterrorism
   3. Accidental Release
   4. Natural Occurrence
4. Role of Transportation in Biohazard Situations
   1. Release and Spread of Bioagents
   2. Detection and Identification
   3. Response – Restricted Mobility and Restricted Access
   4. Response – Delivery of Prophylaxis
   5. Response – Other Transportation Logistics
   6. Response – Decontamination
5. Existing Programs, Plans, and Guidance
   1. Biohazard Response Programs
   2. Federal Response Plans and Guidance
   3. State Emergency Management Plans
   4. Local and Regional Plans
   5. Transit Emergency Response Guidance
   6. Rail Guidelines
6. Overview of Applicable Emergency Response Models and Tools
   1. Information Sharing Tools
   2. Operations Support Tools
   3. Network-Based Transportation Models
   4. Biohazard Emergency Planning Support Tools
7. Conclusions

Appendix A: Bioagents Background Information Table
Appendix B: Biological Agents Treatment Table
Appendix C: Examples of Agroterrorism Agents
Appendix D: Sample of Biohazard Exercise Scenarios
Smallpox (Variola major virus)
Pneumonic Plague (Yersinia pestis)
Anthrax (Bacillus anthracis)
Other Bioagents
Endnotes

1 Introduction

This document summarizes the literature review conducted for our project, Application of Technology to Transportation Operations in Biohazard Situations. We reviewed a wide variety of materials relevant to the project, including background information on biohazards and biohazard events, documents describing the role of transportation during a biohazard event, and current plans, guidance, and analytical tools for transportation response to biohazard events. This literature review is intended to support all the remaining project tasks, including the tabletop exercise, the development of the concept of operations, and the development of an analytical tool or model.

We identified relevant literature through a variety of means. Following are some of the key sources:

• An extensive bibliography of documents pertaining to chemical, biological, and nuclear terrorism/warfare is available from the Dudley Knox Library of the Naval Post Graduate School, online at http://library.nps.navy.mil/home/bibs/chemtoc.htm.
• The Center for Biosecurity at the University of Pittsburgh Medical Center (UPMC) has posted many relevant documents online at http://www.upmc-biosecurity.org/.
• The Radio-Television News Directors Association maintains an online list of relevant internet sites and published material at http://www.rtnda.org/resources/resources.shtml.
• The University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP) includes an extensive list of bioterrorism research resources at http://www.cidrap.umn.edu/cidrap/content/bt/bioprep/readings/.
• Biosecurity And Bioterrorism: Biodefense Strategy, Practice, and Science, a quarterly peer-reviewed journal, provides an international forum for debate and exploration of strategic operational issues posed by biological weapons and bioterrorism. http://www.biosecurityjournal.com/index.asp
• UCLA’s Center for Public Health and Disasters lists useful resource and disaster training materials on its bioterrorism website at http://www.cphd.ucla.edu/bt1.htm.

We also reviewed materials available from many Federal government agencies, including the following:

• Office for Domestic Preparedness, http://www.ojp.usdoj.gov/odp/
• Centers for Disease Control (CDC), http://www.cdc.gov
• Federal Transit Administration (Connecting Communities), http://transit-safety.volpe.dot.gov/training/Archived/EPSSeminarReg/CD/index.htm
• Federal Highway Administration (Emergency Response), http://www.ops.fhwa.dot.gov/program_areas/enhancing-etr.htm
• Department of Agriculture, http://www.usda.gov/homelandsecurity/
• Food and Drug Administration, http://www.fda.gov/cber/cntrbio/cntrbio.htm

The remainder of this document is organized into six chapters and four appendices.

• Chapter 2 discusses the general categories of bioagents and describes key characteristics of specific biohazard agents.
• Chapter 3 discusses four broad categories of biohazard events – deliberate release directed at humans, agroterrorism, accidental release, and natural spread.
• Chapter 4 discusses the role of transportation in biohazard situations, including the release and spread of bioagents, detection and identification, and biohazard response.
• Chapter 5 summarizes programs and guidance that address response to biohazard incidents, including formal guidance and recommendations from government-sponsored studies.
• Chapter 6 reviews a variety of models and automated tools to assist with planning and/or responding to a biohazard event, as well as tools that focus more broadly on transportation operations during emergency situations.
• Chapter 7 contains some conclusions from the literature review.
• Appendix A is a detailed table with characteristics of specific bioagents.
• Appendix B is a detailed table with information on treatment of specific bioagents.
• Appendix C is a list of potential agroterrorism agents.
• Appendix D describes 19 biohazard exercise scenarios.

2 Biohazard Agents

This chapter discusses the general definition of biohazards and describes the broad categories of agents and their environmental characteristics. The chapter then describes key characteristics of specific biohazard agents.

2.1 Definition of Biohazards

A biohazard, as defined by the Centers for Disease Control and Prevention (CDC), is “an agent of biological origin that has the capacity to produce deleterious effects on humans, i.e., microorganisms, toxins and allergens derived from those organisms; and allergens and toxins derived from higher plants and animals.”¹ The term “bioagent” is used interchangeably with “biohazard” and can be associated with naturally occurring or intentional releases in the environment. Bioagents are typically of three main types: bacteria, viruses, and biological toxins.

Biohazards are often colorless, odorless, and are most easily spread undetected as an aerosol. They also can be spread through ingestion, injection, or direct contact. Given their predominately colorless, odorless nature and their ease at being concealed, they are difficult to detect before or during a release. Similarly, biohazards typically elicit nondescript initial symptoms and often require an incubation period of several days to weeks in order to induce illness. Therefore, bioagents are difficult to detect after an attack, as well. Rather than generate an immediate high fatality response, biohazards operate by overwhelming health care facilities, creating panic and chaos.³

Despite biohazards’ undetectable nature and general potency in relatively small quantities, many are not good candidates for biological weapons. To be effective as a weapon, a bioagent should have the potential for human-to-human transmission, high infection and mortality rates, limited vaccination/treatment options or availability, suitable environmental stability, and ability to be produced in mass quantities. The last requirement is particularly cumbersome in that manufacturing weapons grade quantities of bioagents is difficult, and such knowledge is known to be held by few countries (although the knowledge may exist unreported elsewhere).⁴ Based on these characteristics, the CDC has established categories of bioagents. The categories are ranked by level of priority determined by the threat they pose to national security and are shown in Table 2-1 below.

Table 2-1. Bioagent Categories Ranked by Threat Priority

Source: Centers for Disease Control and Prevention (CDC), 2004. “Bioterrorism Agents/Diseases,” November 19. Available at http://www.bt.cdc.gov/agent/agentlist-category.asp.

Due to their high potential for a major public health impact and high fatality rate, we discuss the diseases caused by Category A agents in some detail below. The majority of the information contained in the following bioagent summaries was excerpted from a series of articles from The Journal of American Medical Association (JAMA) that chronicle various bioagents’ historical and potential use as biological weapons. The articles represent consensus statements from the Working Group on Civilian Biodefense, a group of experts trained in public health, emergency management, and clinical medicine.

2.2 Specific Biohazard Agents

This section describes specific Category A biohazard agents and discusses their health effects, behavior in the environment, historic use in accidental or intentional events, and treatment. More detailed information, including infectivity, potential for human-to-human transmission, incubation periods, treatment options, and mortality rates can be found for all classes of biohazards in Appendices A and B.

2.2.1 Anthrax

Anthrax is an animal disease caused by the bacterial spore, Bacillus anthracis (BA). BA spores are found in soil worldwide where they typically cause anthrax cases in herbivore animals that ingest the spores while foraging. The disease is zoonotic, meaning that it can be spread from animal to animal, from animal to human, but not from human to human. Transmission to humans normally occurs through direct contact with an infected animal, but can also be transmitted by eating meat from an infected animal or inhaling BA spores. Human infection is generally limited to those working in specific industry groups, namely goat hair, wool, or tannery workers.⁵ Cutaneous (direct contact) anthrax is the most common naturally occurring form of anthrax, with 2,000 cases reported annually worldwide.⁶ In the United States, 224 cases were reported between 1944 and 1994,⁷ with one additional case reported in 2000.⁸ Gastrointestinal anthrax (ingestion) is uncommon, and inhalational anthrax is even rarer, with not a single reported naturally occurring case in the U.S. since 1976.⁹

Due to the protective, waterproof nature of the spores (which can survive for decades),¹⁰ their small diameter (1 gram can contain 100 billion to 1 trillion spores),¹¹ lack of odor, inability to be seen, and potential to travel many miles before dissipating, anthrax is particularly well-suited for an aerosolized weapons-grade biohazard. Anthrax has been studied as a bioweapon for over 80 years; although, most national offensive bioweapons programs died out after ratification of the Biological Weapons Convention in the early 1970s. Despite military testing of aerosolized BA by the U.S., Iraq, and the former Soviet Union, only two known cases of bioterrorism with BA spores have occurred.¹² Aum Shinrikyo, the cult that released sarin nerve gas in a Tokyo subway station in 1995, experimented with aerosolized anthrax and botulism at least eight times before the successful sarin attack. The anthrax attacks did not produce illness because the strain used is specific to animals and does not pose a significant health threat to humans.¹³

The second reported case is the 2001 attacks in which BA spores in sealed envelopes were sent through the U.S. Postal Service. Twenty-two confirmed or suspected cases of anthrax were reported in Washington, D.C., Florida, Connecticut, and New York. Inhalational anthrax was the culprit in 11 cases, resulting in 5 deaths, and another 11 cases were from cutaneous anthrax.¹⁴

The only known unintentional, non-naturally occurring release of BA came from a Soviet bioweapons factory in Sverdlovsk, Russia, in 1979. The release resulted in an epidemic.¹⁵

Exposure risk to aerosolized BA is greatest during primary aerosolization, when spores are first airborne. The spores may then settle on surfaces in potentially high concentrations and may later be re-suspended in the air. Therefore, area-wide decontamination is necessary to help reduce the chance of re-suspension of spores and potential further spread of the disease.¹⁶

A small stockpile of anthrax vaccine (anthrax vaccine adsorbed [AVA] produced by Bioport Corp) is available in the U.S. for military use only. Antibiotics are also readily available to treat the disease and are listed in Appendix B. Prophylaxis is recommended for at least 60 days following exposure to anthrax. Given the lack of human-to-human transmission of the disease, it is not necessary to provide preventative treatment to patient contacts unless it is determined that they, too, were likely exposed to the BA spores at the time of attack. Humans and animals dying from the anthrax must be properly buried or cremated in order to minimize further exposure.¹⁷

2.2.2 Botulism

Botulism is a paralyzing disease caused by the botulinum toxin, which is produced by the bacterium Clostridium botulinum (C. botulinum) (and in some rare cases, from unique strains of Clostridium baratii and Clostridium butyricum). C. botulinum is naturally found in soil and is not transmittable among humans. Pre-formed botulinum toxin is a foodborne threat that is transmitted to humans by ingestion of foods that are not heated, or are not heated thoroughly (the toxin is susceptible to heat of at least 85°C for five minutes).¹⁸ Almost every type of food has been linked to botulism, with vegetables the most common culprit in the U.S.^{19, 20, 21} Humans are also susceptible to the toxin by direct open wound contact with the bacteria C. botulinum, which can then release botulinum toxin once inside the body. C. botulinum may also be found naturally occurring in the intestines.²² Manmade aerosolized botulinum toxin poses an inhalational threat as a bioweapon. Fewer than 200 cases of all forms of botulism are reported annually in the U.S.²³

As the most poisonous known substance, botulinum toxin is a desirable bioweapon for its potency, lethality, and ability to debilitate infected people for weeks to months as their paralyzed muscle fibers heal. Given the right dispersion factors, a single gram of crystalline toxin could kill more than one million people.²⁴ Ironically, it is also used for therapeutic medicinal treatment of a variety of conditions in the U.S. The toxin is also easy to produce and transport and is virtually undetectable as it is colorless, odorless, and presumably tasteless. Botulinum toxin has been studied as a bioweapon for at least 60 years. The U.S., Japan, Iraq, the former Soviet Union, Iran, North Korea, and Syria are known to have developed or are thought to be currently developing weapons grade botulinum toxin. Iraq has produced thousands of liters of concentrated botulinum toxin, an amount equal to roughly three times the amount needed to kill the entire human population by inhalation, for use in military weapons. In 1990, Iraq filled missiles and bombs with botulinum toxin, among other bioagents, presumably for use during the Gulf War.²⁵

Between 1990 and 1995, Aum Shinrikyo released aerosolized botulinum toxin in downtown Tokyo and U.S. military bases in Japan. The attacks were unsuccessful due to poor microbiological technique, equipment failing to effectively aerosolize the toxin, or internal sabotage.^{26, 27} Bioterrorism could also be used to simulate a naturally occurring outbreak of foodborne botulism, in the form of either a large-scale outbreak from one meal or restaurant or a series of widely scattered outbreaks.

A number of factors were identified by the Working Group on Civilian Biodefense as indicating a possible intentional release of botulinum toxin. The first sign would be a large number of cases with the characteristic paralysis associated with botulism. An outbreak with an unusual botulinum toxin type distinct from the seven naturally occurring types that are currently detectable might also be suspect. Multiple simultaneous outbreaks with no common source might indicate an intentional foodborne attack. Officials also should be suspicious of an outbreak with a common location and time, but no common dietary exposure. This might suggest an aerosol release. However, the Working Group on Civilian Biodefense recognizes that detection “of a covert release of finely aerosolized botulinum toxin would probably occur too late to prevent additional exposures.”²⁸

Exposure to botulinum toxin can be combated with an equine botulinum antitoxin that is effective against the three most common types of botulism, coupled with supportive care. Antitoxin treatment is crucial as soon after clinical diagnosis of botulism as possible. However, antitoxin quantities are limited. The U.S. Army also has access to an investigational antitoxin that treats all seven known types of botulinum toxin. Antibiotics are not effective against the toxin, but can be useful in treating secondary infections that may coexist with botulism.

2.2.3 Plague

Naturally occurring plague is a zoonotic disease spread from rodents to rodents and rodents to humans by the transmission of the bacterium, Yersinia pestis (Y. pestis) via flea and rodent bites. Bubonic plague is the most common form of plague and is usually preceded by a massive rodent die-off. Having lost their primary host, fleas then transfer to humans. In rare cases of naturally occurring plague, secondary pneumonic plague can develop in advanced stages of bubonic or septicemic plague. If this occurs, inhalation of respiratory droplets can spread the disease among humans. Large outbreaks of pneumonic plague have occurred in this manner. An intentional release of plague would likely occur via an aerosolized form of Y. pestis causing primary pneumonic plague, which would then be spread from human to human via inhalation. An average of 1700 cases of plague has been reported annually worldwide for the last 50 years.²⁹

The plague has been used as a bioweapon in the past. Secret Japanese military dispersed plague-infected fleas over populated areas of China during World War II.³⁰ The U.S. and the former Soviet Union later developed methods to aerosolize the plague. In a worst case scenario involving an aerosol release of Y. pestis, the World Health Organization (WHO) estimated the bacteria would remain infectious as an aerosol for one hour for a distance of up to 10 kilometers (roughly 6 miles). They also predicted residents would try to flee the affected areas only to further spread the disease.³¹ While the U.S. stopped its offensive biological weapons program in 1970 as part of the Biological Weapons Convention, the former Soviet Union has manufactured large enough quantities of Y. pestis to use in weapons.³²

Pneumonic plague is considered a high threat potential bioagent due to relatively widespread availability, knowledge of mass production as an aerosol, its undetectable nature, high fatality rate, and likely potential for secondary transmission during an outbreak.³³

There is no longer a U.S. vaccine for the plague, and even when it was manufactured prior to 1999, it did not protect against pneumonic plague. However, research is being conducted for such a vaccine.³⁴ Antibiotics are effective in treating the plague and are listed in Appendix B. Given a strong suspicion or confirmed diagnosis of the plague, treatment should be given to anyone in the affected area with fever or a cough as a precautionary measure. Immediate treatment is crucial to survival of pneumonic plague. Similarly, asymptomatic contacts should be given antibiotics for seven days and be wary of fever or cough.³⁵

Historically, quarantining those infected and their contacts has been the rule for preventing further dissemination of the plague. However, modern experience has not shown widespread dispersion of the disease; therefore, the Working Group on Civilian Biodefense does not recommend isolation of contacts. Rather, they should monitor for fever or cough for the first seven days following exposure. Once the primary aerosol has attenuated, there is no further exposure risk from the environment. Respiratory droplets from infected patients are still of concern. However, Y. pestis is inactivated by sunlight and heating and does not survive long in the environment.³⁶ In fact, in cases of a bioterrorism release, the aerosol powder would dissipate long before the first symptoms appear.³⁷

2.2.4 Smallpox

Smallpox is a highly contagious disease spread by inhalation of respiratory droplets containing the Variola major virus or by direct contact with infected persons or linens. Once a widespread disease, smallpox has been eradicated since 1977. Routine vaccination against the virus was ceased in the U.S. in 1972 and worldwide in 1980.³⁸ Smallpox has the potential to be a particularly devastating bioweapon due to the susceptibility of a largely unimmunized population, its high transmission rate, and lack of treatment options.³⁹

Smallpox is thought to have been first used has a bioweapon during the French and Indian War (1754-1767). British soldiers distributed infected blankets to Native Americans, resulting in epidemics killing more than 50 percent of affected tribes.⁴⁰ The discovery of a smallpox vaccine in 1796 greatly reduced the effectiveness of smallpox as a bioweapon.⁴¹ Now that vaccine is no longer regularly administered and existing supplies are limited, the global population is again at risk of an intentional smallpox release.

The former Soviet Union is known to have manufactured the Variola major virus in mass quantities to be used in bombs and missiles. Russia is reportedly working on developing more deadly and contagious strains of the virus, and it is thought that this knowledge might be spreading to other countries.⁴²

Given the delayed onset of symptoms, by the time smallpox is diagnosed, the original quantity of the virus released in the environment would pose no threat of further contagion. However, due to the high transmission rate of the virus (as many as 10 to 20 second-generation cases can result from one case),⁴³ it is crucial to isolate anyone thought to have the virus and ideally those that have come in contact with them. Because it is impractical to identify and quarantine all associated contacts, the Working Group on Civilian Biodefense recommends they be vaccinated and monitored for any smallpox symptoms. It is preferred that patients be isolated within the home in order to minimize the spread of the disease that can easily occur in the close quarters of a hospital.⁴⁴

Vaccination has proven effective in preventing or minimizing the symptoms of smallpox if administered within three days of exposure. Vaccination four to seven days after exposure may help protect against or lessen the severity of the disease. Currently, the U.S. has enough supply of the vaccine to vaccinate everyone in the United States in the event of a smallpox emergency.⁴⁵ After eradication of smallpox in the 1970s, the WHO initially intended to destroy all remaining stores of the Variola major virus outside of its reference laboratories at the CDC in Atlanta and the Institute of Virus Preparations in Moscow, Russia. However, given recent fears of its use as a bioweapon, the WHO has delayed its destruction to allow for the development of new vaccines.^{46, 47} The WHO currently is working to build a 200 million-dose stockpile of the vaccine for use if a bioterrorist attack were to occur. Member countries, including the U.S. have agreed to make commitments to meeting the dosage goal; however, it may take up to three years to complete the stockpile.⁴⁸

Antibiotics are not effective against smallpox itself, but may treat secondary bacterial infections. Dead bodies should be handled as contagious objects and be cremated to eliminate further exposure to the disease.

2.2.5 Tularemia

Tularemia is a zoonotic disease caused by the bacteria Francisella tularensis (F. tularensis) that is transmitted from animals to humans, but cannot be spread from human to human. Humans can acquire the disease directly from animals if bitten by infected ticks, flies, and mosquitoes or by handling contaminated animal tissues or bodily fluids. F. tularensis is also transmittable via direct contact or ingestion of contaminated food, water, or soil. The bacteria can also be inhaled in aerosol form.⁴⁹

Tularemia is almost exclusively a rural disease found in North America and Eurasia, often associated with farming and close interaction with animals. The first epidemics of tularemia occurred in the 1930s and 1940s via waterborne infection in Europe and the former Soviet Union and from direct contact with infected animals in the U.S. Tularemia also has historically been spread in laboratory settings.⁵⁰

Japan first began studying tularemia as a potential bioweapon between 1932 and 1945,⁵¹ and the former Soviet Union may have been responsible for tularemia outbreaks during World War II. In the 1950s and 1960s, the U.S. began its own research to use F. tularensis as an aerosol and developed stores of the agent. In response, the former Soviet Union developed its own program that continued into the early 1990s with development of antibiotic- and vaccine-resistant strains. As part of the Biological Weapons Convention, the U.S. discontinued its offensive bioweapons development program in 1970 and had destroyed its bioweapons stock by 1973.^{52, 53}

Naturally occurring airborne tularemia outbreaks related to lab exposure and contact with animal carcasses occur. The largest such outbreak occurred in 1966-1967 in rural Sweden when a weaker, less deadly strain of F. tularensis infected more than 600 people from aerosolized bacteria that was stirred up during day-to-day farm work. While F. tularensis is highly infectious (it requires only ten to 50 organisms to show illness),⁵⁴ there were no reported deaths.⁵⁵

The Working Group on Civilian Biodefense concludes that an intentional aerosol release of F. tularensis would cause the greatest public health damage, rather than a foodborne or waterborne attack. According to the Working Group on Civilian Biodefense, public health officials should suspect an intentional release if there are sudden clusters of cases or if any urban outbreak occurs.⁵⁶ While tularemia has a lower fatality rate than other high threat bioagents such as pneumonic plague or anthrax, its generally longer incubation period and slower rate of progression of the disease from general symptoms to more specific, potentially life-threatening symptoms may cause the disease to pass unknowingly to more people prior to being detected and identified. Identification of F. tularensis could take several weeks.

An experimental live attenuated vaccine is available in the U.S. for laboratory and other high risk workers. Another investigational vaccine is currently under review by the U.S. Food and Drug Administration (FDA), but its future availability is uncertain given the extended amount of time (2 weeks) it requires to take effect.⁵⁷ The Working Group on Civilian Biodefense does not recommend vaccination for post-exposure prophylaxis. Antibiotics are effective and available to treat tularemia. See Appendix B for the recommended antibiotics. Exposed people do not need to be isolated, nor do their contacts need to be treated as tularemia is not spread among humans.⁵⁸

2.2.6 Viral Hemorrhagic Fevers

Viral Hemorrhagic Fevers are caused by a suite of viruses belonging to four virus families: Arenaviridae, Bunyaviridae, Filoviridae, and Flaviviridae. The viruses are spread to humans via direct contact with infected animals, through insect bites, or via respiration of aerosolized agents. Outbreaks are commonly limited to rural areas.⁵⁹

The diseases of each virus family and their known or suspected routes of exposure are provided in Table 2-2. More detailed information, including infectivity, potential for human-to-human transmission, incubation periods, treatment options, and mortality rates of the Hemorrhagic Fever Viruses (HFVs) and all potential biohazards can be found in Appendices A and B.

Only certain HFVs possess the characteristics necessary to pose a serious bioweapon threat. The arenaviruses causing Lassa fever, Argentine hemorrhagic fever (HF), Bolivian HF, Brazilian HF, and Venezuelan HF; the bunyavirus causing Rift Valley fever; the filoviruses causing Ebola and Marburg; and the Flaviviruses causing yellow fever, Omsk HF, and Kyasanur Forest disease could be used as bioweapons. However, the viruses causing dengue, Crimean-Congo hemorrhagic fever (CCHF), and hemorrhagic fever with renal syndrome (HFRS) are not considered viable candidates for biowarfare. A covert aerosol attack with one of the HFV bioweapons poses the greatest threat.⁶⁰

The U.S., former Soviet Union, Russia, and possibly North Korea have researched and developed HFVs as bioweapons. The U.S. developed weaponized yellow fever and Rift Valley viruses, and the former Soviet Union and Russia manufactured weapons grade Marburg, Ebola, Lassa fever, Junin (Argentine HF) and Machupo (Bolivian HF) viruses until 1992. North Korea may have developed yellow fever for bioweapon use.⁶¹ Aum Shinrikyo, prior to releasing sarin in the Tokyo subway system in 1995, unsuccessfully attempted to use Ebola virus as a bioweapon.⁶²

Table 2-2. Viral Hemorrhagic Fevers by Family

Sources: Borio, Luciana et al., 2002. “Hemorrhagic Fever Viruses as Biological Weapons, Medical and Public Health Management.” JAMA, Vol. 287, No. 18, May 8.
Jahrling, Peter B. “Chapter 29, Viral Hemorrhagic Fevers,” Medical Aspects of Chemical and Biological Warfare, pp. 591-602. Available at http://www.nbc-med.org/SiteContent/HomePage/WhatsNew/MedAspects/Ch-29electrv699.pdf.

The HFVs exhibit various symptoms and are not quickly confirmed with laboratory testing. Lab results may be further delayed or impossible to obtain during a large attack given current laboratory capacities. Only the CDC in Atlanta or the U.S. Army Medical Research Institute of Infectious Diseases in Frederick, Maryland, is able to even initially diagnose HFVs.⁶³

The only licensed vaccine available for any of the HFVs is the yellow fever vaccine. The supply of the vaccine is limited and would not be sufficient in the case of a large-scale bioattack. Furthermore, yellow fever vaccine is not useful for post-exposure prophylaxis because the virus requires longer to build immunity than it takes the virus to produce illness. Investigational vaccines are available in the U.S. for Junin (causative agent of Argentine HF), Rift Valley fever, Hantaan virus (causative agent of HFRS), and dengue virus. These are not likely to be publicly available in the near future. A vaccine for Lassa fever is under development by the CDC.⁶⁴ In addition, the investigative antiviral drug ribavirin has proven effective in treating some arenaviruses and bunyaviruses, yet it is not approved by the FDA and is available in limited quantities. Passive antibody therapy can be used to treat Argentine and Bolivian hemorrhagic fevers. However, their effectiveness is not conclusively proven, nor is there a national stockpile available for use in a bioterrorist attack. Overall, treatment for HFVs is largely limited to supportive care.^{65, 66}

Because human-to-human transmission is a possibility only in certain HFVs – namely arenaviruses causing Lassa fever, Argentine HF, Bolivian HF, Brazilian HF, Venezuelan HF, and the filoviruses causing Ebola and Marburg – isolation of those potentially exposed and patient contacts may not be needed. They should, however, be watched for signs of fever or other symptoms. Affected dead bodies should be properly handled and buried or cremated.⁶⁷

3 Biohazard Events

This chapter describes four broad categories of biohazard events, focusing primarily on deliberate release directed at humans, but also describing agroterrorism, accidental release, and natural spread.

3.1 Deliberate Release

A deliberate release of a biohazard directed at humans is generally recognized to be the type of biohazard event that poses the greatest risk to human health and national security. Such an event could be overt (immediately recognized) or covert (unrecognized at the time of release). An overt biohazard event might be identified by the following:⁶⁸

• Previous intelligence,
• A threat of action or post-event claim of responsibility, and
• Direct evidence, such as powder residue or equipment used to release the bioagent, gathered at the release site

The response in an overt situation could be immediate, increasing the chances of limiting those exposed. First responders would be those traditionally involved in an emergency – police, firefighters, and Emergency Medical Services (EMS) personnel.

In a covert attack, as is the case in most biological attacks, there is often no forewarning, making the prediction of when and how an attack might occur impossible. Due to the delayed onset of most diseases caused by bioagents, there might be no indication of foul play until days or even weeks after the initial release. Exposed individuals likely would begin to report generic symptoms accompanied by a fever to healthcare personnel at local hospital and medical centers. The patients likely would be diagnosed with a less severe illness at first. Healthcare facilities might become crowded with patients exhibiting similar symptoms as initial patients begin returning with more severe symptoms. Healthcare workers, at this time, would order initial diagnostic tests, and the responsible bioagent might be initially identified within hours to days of the first reported symptoms. However, results would have to be confirmed through a chain of laboratory command. In-house hospital laboratories would send samples to an intermediate state or local public health agency laboratory that can then pass the samples onto the CDC or other higher level agency, Federal facility, or academic research center for official confirmation. Once a confirmatory diagnosis is made, local officials must decide how to respond. If available for the responsible bioagent, the Strategic National Stockpile (SNS) of vaccine and antibiotics likely would be requested. All the while, those initially infected may be spreading the disease to others, leading to a second generation outbreak of the disease. In the case of a covert attack, delay is likely to occur between the following stages:

• Release of the biohazard and first detection,
• First detection and initial diagnosis,
• Initial diagnosis and confirmatory diagnosis/request of SNS supplies, and
• Request of SNS supplies and distribution to those affected.

Given the delay in detection, medical personnel would be the first responders in a covert biohazard event. Employers and schools may note an increase in absenteeism, which also may help trigger a response.

As discussed in Chapter 2, this generic scenario could unfold in the event of an intentional aerosol release, via intentional contamination of food or water supply, or by infecting animals known to transmit the disease to humans. In order to better understand the types of biohazard events that have been the focus of emergency response preparation, and to understand transportation response options to these events, we reviewed 19 past biohazard exercises conducted. In general, most biohazard exercise scenarios are one of two types: (1) aerosolized release of a bioagent in a crowded shopping mall or (2) aerosolized release of a bioagent at a heavily attended sporting event. In these exercise scenarios, air ventilation systems often are assumed to increase dissemination, extending the reach of an aerosolized bioagent to expose as many people as possible within an enclosed building or subway station. Table 3-1 provides an overview of the exercises we reviewed. A full description of the scenarios and their possible transportation response are detailed in Appendix D.

In addition to the exercises summarized in Table 3-1, the Homeland Security Council (HSC) developed fifteen scenarios for use in national, federal, state, and local security preparedness activities, including four scenarios that involve a deliberate bioagent release.⁶⁹ These include the following:

• An anthrax attack delivered in a single aerosol dispersal by a truck using a concealed improvised spraying device in a densely populated urban city. For planning purposes, it is assumed that the attack includes five separate metropolitan areas, attacked in sequence.
• A plague attack in which an adversary releases pneumonic plague into three main areas of a major metropolitan city – in the bathrooms of the city’s major airport, at the city’s main sports arena, and at the city’s major train station.
• Intentional food contamination in which an adversary acquires restricted documents allowing them to contaminate a beef plant and an orange juice factory using liquid anthrax.
• An agroterrorism attack in which an adversary targets several locations with foot and mouth disease. The disease is spread to many locations in the nation through shipping of livestock. This scenarios involves the transportation system most explicitly as a mechanism for spreading disease.

Each of these scenarios addresses the eight (8) mission areas identified by the Department of Homeland Security, Office for Domestic Preparedness, in its terrorism planning, training and exercise materials. These mission areas include the following:

• Prevention and Deterrence,
• Emergency Assessment/Diagnosis,
• Emergency Management/Response,
• Incident/Hazard Mitigation,
• Public Protection,
• Victim Care,
• Investigation/Apprehension, and
• Recovery/Remediation.

Table 3-1. Summary of Biohazard/Bioterrorism Exercise Scenarios

^a Neither disease is transmittable to humans.

3.2 Agroterrorism

Agroterrorism describes the deliberate introduction of an animal or plant disease with the goal of generating fear, causing economic losses, and/or undermining stability.⁷⁰ The results of an agroterror attack can include major economic crises, loss of confidence in food supplies and government protections, and possibly human casualties. Such threats can be countered on four levels:⁷¹

1. at the organism level, by fostering resistance to likely diseases;
2. at the farm level, by practicing techniques designed to prevent disease from being introduced or spread;
3. at the agricultural sector level, by implementing disease detection and response procedures; and
4. at the national level, through policies designed to minimize the social and economic costs of a catastrophic disease outbreak.

Detection sometimes rely on the same mechanisms for identifying, reporting, and tracking natural and accidental disease outbreaks, though specific detection efforts specific to agroterrorism may also be implemented.

The low-density distribution of potential targets represents a major challenge in preventing agroterrorism. An assessment of recent laws related to agroterrorism preparedness and to date can be found in a recent Congressional Research Service report titled, “Agroterrorism: Threats and Preparedness.”⁷² Appendix C lists diseases and agents that are of concern for agroterrorism.

3.3 Accidental Release

An accidental release of biohazards could occur by mishandling of biomedical waste or an accident associated with a laboratory that studies contagious diseases or biological threats. Such accidents may involve accidents during transportation of waste material, damage to laboratory facilities where diseases are studied, or accidental release of laboratory animals infected with diseases. A recent example of a lab-related accidental release occurred last year when three lab workers at a Boston University research facility contracted tularemia after being exposed to the virus through their research. The public was not informed of the accidental release until three months after tularemia was confirmed as the infectious source.⁷³

Some accidental releases have been tied to military bioweapons programs. For example, an ecological research ship passed within nine miles of a smallpox testing site off the coast of the former Soviet Union in 1971. A single crew member became infected, presumably through inhalation of the disease, and carried the virus back to port. The Soviet government has never admitted to aerial smallpox testing; however, a 2002 report prepared by the Monterey Institute of International Studies suggests that an outbreak ensued, killing three people and infecting many, some of whom had been previously vaccinated. Hundreds were quarantined, and nearly 50,000 were vaccinated in response. Travel to and from the port city was banned.⁷⁴

Despite the public hazards of an accidental release of a bioagent, the public health impact is likely to be less severe than for a deliberate release. Therefore, this literature review focuses less on these types of events.

3.4 Natural Occurrence

Bacteria, viruses, and biological toxins that are harmful to humans and animals frequently spread naturally through populations. When large populations are affected or biological responses are sufficiently severe, naturally occurring biohazard events can cause a major public health problem. Widespread natural outbreaks occur for a number of reasons, including the following:

• Natural mutations that make diseases resistant to existing vaccines or naturally occurring antibodies,
• Environmental conditions that favor the development of certain bioagents, and
• Natural cycles of disease agents.

Another naturally occurring biohazard source is the mishandling and improper sanitation of food and water. In the case of food, a single source such as a restaurant that fails to thoroughly cook its meat could be the culprit, causing a localized threat to public health. Contaminated food could also originate from a single feedlot or a cattle-dense region that distributes animal products across the country, potentially resulting in numerous, scattered outbreaks. Leaking septic systems or deficient water sanitation systems could cause water contamination, leading to localized biohazard events.

Overt biological attacks could be confused with naturally occurring outbreaks, especially in foodborne diseases and those spread by animals. The detection and identification process would be the same as described above for a deliberate release. However, in the event of a natural occurrence, the public health impact is likely to be less severe than for a deliberate release. Therefore, this literature review focuses less on these types of events.

The Homeland Security Council (HSC) scenarios⁷⁵ discussed in Section 3.1 also address natural disease occurrence. One scenario deals with influenza pandemics, relating what could happen without an effective preplanned response. In this scenario, at least twenty-five cases occur in a small village in south China and spread to Hong Kong, Singapore, South Korea, and Japan over the following two months. Young adults appear to be the most severely affected with case-fatality rates approaching 5 percent. The virus eventually appears in four major U.S. cities, with ongoing outbreaks as the exercise continues.

4 Role of Transportation in Biohazard Situations

This chapter discusses the role of transportation in biohazard situations. The chapter first discusses the potential role of transportation in the release and spread of bioagents, and in bioagent detection and identification. The chapter then covers transportation during biohazard response, including restricting mobility, delivery of prophylaxis, other transportation logistics roles, and decontamination.

4.1 Release and Spread of Bioagents

Whatever the source or reason for a biohazard situation, transportation systems are likely to play an important role in spreading or preventing the spread of bioagents or disease. The transportation system may spread disease either from a naturally occurring outbreak or from a deliberate attack. Transportation may also cause an accidental release during the transport of biohazard materials. This chapter discusses the role of transportation for several types of biohazard events and then discusses some of the impacts for each mode.

4.1.1 Transportation’s Role in the Release and Spread of Biohazards

Deliberate Release⁷⁶
The transportation system can function to spread a deliberately released bioagent, or the system itself may be the target of a deliberate release. When the transportation system is not the target, but simply the vector for a deliberate bioterror attack, the situation is somewhat similar to transportation’s role in spreading natural disease. The system may carry not only the biological agents, but also the terrorists harboring the bioagents, to the site of an attack on some other venue. The scale of an intentional release, however, is usually different. A deliberate attack may seek to maximize the number of infected individuals, thus increasing the chance that the transportation system will spread the disease to many areas before authorities are aware of the attack and associated infections.

Transportation facilities are attractive targets for bioterror attacks because large numbers of vulnerable passengers congregate in terminals and travel in transit vehicles and airplanes. In addition, most of the nation’s goods are delivered by truck and rail or stored in depots and warehouses served by the transportation system. In cases where the transportation system is the target of a terrorist attack that uses a highly contagious agent, the system simultaneously serves as both the target and disease spreading agent. Such a situation might make the transportation system a particularly attractive target to a terrorist. Finally, in addition to having an immediate impact on people or goods, a terrorist organization that targeted transportation facilities could achieve longer-term disruption by making passengers or shippers fearful of using or unable to use the system.⁷⁷

For non-contagious diseases, transportation systems also may play a purely mechanical role in spreading biohazards. By their very nature, transportation systems involve movement of equipment. In cases where aerosolized bioagents have been released in the environment, the movement of transportation vehicles may be an important mechanism for re-suspending and distributing particles that had already settled out of the air.

Accidental Release
Transportation also can play a role in the accidental release of biohazards when a crash or other mishap occurs during the transport of known biohazard materials. Because highway transportation is sometimes used to carry infectious medical materials, such an accidental release is not inconceivable and might create small scale contamination that would disrupt travel along a specific route. However, well-developed response plans and packaging requirements for such substances (known as Class 6 hazardous materials) make a large scale biohazard event from such accidental releases unlikely.⁷⁸

Natural Occurrence
The transportation system plays a significant role in spreading disease for two primary reasons. First, many places in transportation systems have high concentrations of people allowing for diseases to be exchanged directly between passengers, though ventilation systems, or through surface materials. Second, by transporting the disease carriers themselves, transportation systems can quickly carry naturally occurring diseases to areas and populations that have not yet been infected, turning what would have been an isolated outbreak to geographically broader, sometimes global, events.

4.1.2 Modal Differences Related to Biohazard Release and Spread

Each mode has specific characteristics that affect its potential role in the release and spread of biohazards. These characteristics include the physical characteristics of the system and the way the system typically is used. The most important characteristics relate to the degree to which the system concentrates people, the distance and speed of travel, and mechanisms for controlled access. This section briefly highlights the vulnerabilities of each mode in biohazard incidents. Many of these points are summarized in Table 4-1 below.

Highway
The roadway network is a difficult target for bioterrorism, largely because there are few enclosed spaces with high concentrations of individuals. This limits the potential for persistent contamination, as well as the threat of heating, ventilation, and air conditioning (HVAC) system contamination. There are, however, some components of the highway system, such as rest areas, where biological contamination may be a greater concern. In addition, roadways may play a significant role in the re-suspension of contaminants in the case of an aerial attack. Given the diverse travel patterns and moderate speed of travel, the roadway network can play a substantial role in spreading a biohazard between regions and states. Highway rest areas also merit specific consideration as areas potential targets and as sites where diseases may be transmitted. In addition to these issues, the porous materials used to construct roads may present particular challenges for decontamination.

Transit
The transit system includes enclosed spaces such as passenger compartments and, in some cases, tunnels, stations, and terminals. Naturally, subway systems include the highest proportions of enclosed spaces. With a large number of enclosed spaces, there is high potential for persistent contamination and HVAC contamination. Given the potential of infecting a large number of individuals at once, spread to other modes is a significant threat. The range of many transit systems would generally limit their role to spreading biohazards within a given region. Because transit systems are centrally controlled, their role in disease spread could be limited once authorities are aware of the biohazard situation.

Aviation
Both aircrafts and airport terminals include enclosed concentrated populations that might be attractive bioterror targets. The long duration of many plane flights and re-circulating HVAC systems make the exchange of contagious diseases more likely. In addition, high travel speeds make it possible to carry disease sometimes anywhere on the planet before authorities are aware of contamination. However, the high degree of central control of air travel means that the role of air travel could be eliminated once authorities are aware of a biohazard situation.

Rail
For intercity passenger rail, characteristics are similar to transit, except that the system may carry infectious agents a greater distance before authorities are aware of any problem. Rail also has the potential for spreading biohazards through livestock, agricultural products, and other cargo. Rail lies between highway and aviation in terms of the degree of central control once an incident has been identified.

Maritime
Cruise ships are a significant potential target for bioterror because of the high concentration of people. However, in terms of effectiveness in spreading disease, the slow speed of cruise ships increases the likelihood that the situation will be recognized before significant spread occurs. Like rail, ships present an opportunity for agricultural cargo contamination and also offer some opportunity for centralized control if a biohazard event is recognized.

Table 4-1: Summary of Modal Characteristics Related to Biohazard Release and Spread

Source: Science Applications International Corporation (SAIC), 2004. Draft Report, NCHRP Project 20-59(19)
* Decontamination for highway and rail modes is given a moderate difficulty ranking above. However, there are some unknowns that could make decontamination of such facilities difficult. These unknowns include the degree of absorption of bioagents into porous asphalt, the transport of bioagents into gravel drainage systems, and the challenges associated with bridge decontamination.

4.2 Detection and Identification

Biohazard detection is traditionally conducted by public health and military officials. For a number of reasons, however, detection is also an important consideration for transportation officials. First, since the transportation system is often the last opportunity to catch bioagents before they spread, the transportation network is a logical focus for detection efforts and technology. Second, the point at which a biohazard is detected during the course of an event can drastically affect the appropriate role for transportation response. For example, if bioagents are detected soon after release, the transportation system may have a much larger role in support of specific evacuation and quarantine requirements. In contrast, if detection occurs several days after the presence of bioagents, transportation may play a smaller role in these activities. Thus, the research and planning priorities for transportation officials depend somewhat on likely detection technologies. This section briefly reviews some of the major technologies and programs for detecting and identifying biohazards.

4.2.1 Detection Technology

From a transportation perspective detection can be important at a number of stages. Urgent response would be required for detection of an approaching cloud of potential bioagents (called “standoff” detection). This could merit immediate response and highly coordinated transportation system mobilization. In this case, a detector may simply provide notice of an approaching cloud. Then, depending on the general category of materials in the cloud (e.g., biotic vs. non-biotic), more sensitive detectors could be used and the appropriate authorities notified.

Currently a wide range of technologies are available for detecting and identifying different types of biohazards, but existing technology is not adequate for a widely dispersed network of detectors that could reliably identify the existence of bioagents in developed areas. There is substantial ongoing research in this area and a number of promising technologies.⁷⁹

Distance Detection
For standoff detection, LIDAR (Light Detection and Ranging) equipment is the most promising technology. From many miles, LIDAR can detect the shape of a cloud, which can provide some insight as to whether it was artificially dispersed. From closer range, current LIDAR systems can reliably distinguish whether a cloud is biological in nature, though this may also include benign pollen, molds, and agricultural fertilizers. Current LIDAR systems are not designed for continuous monitoring, but can be used both to track and identify agents once the agent is detected and as an active probe to scan suspect areas. Today’s systems are bulky, relatively complicated, expensive, and require training to operate and maintain. However, current research suggests that LIDAR systems may become much more versatile and practical.⁸⁰

The Department of Energy’s Brookhaven National Laboratory recently received a patent for an advanced portable LIDAR system. The military expects to test another version, the Joint Chemical Spill Detection System, in 2005. Yet another model, the Joint Biological Standoff Detection System (demonstrated in October 2004), uses LIDAR technology to track and ID agents up to five km (3 miles) away. This system uses a combination of LIDAR applications for long-range detection and short-range identification. For domestic use, LIDAR applications research is mainly focused on post-detection missions, such as identification and tracking during biohazard events. However, advances in detection equipment open the possibility of perceiving imminent arrival of bioagents. As one example, implementation of the Autonomous Pathogen Detection System (developed at Lawrence Livermore National Laboratory) would provide continuous monitoring of specific domestic areas. Currently, however, there is no practical technology that can serve as a highly distributed, day-to-day monitoring system for civilian purposes.⁸¹

Point Detection
Point detectors can be used when an actual sample is taken from a cloud of particles. Point detectors may use a variety of mechanisms for assessing the presence of biohazards. For example, an aerosol particle sizer (APS) detects unusual or uniform concentrations of particles that are small enough (0.5 to 20 microns) to embed in alveoli in the human respiratory system. This would suggest artificial weaponization of the subject material and would motivate more specific tests.⁸²

Point detectors that sense a specific bioagent are also available; although, many have significant shortcomings. For example, genetic detection is biologically specific and fairly fast, but requires significant preparation, as well as a clean, liquid sample. Similarly, mass spectrometry is reliable for specific detection, but is too bulky and expensive to be considered for first responders. Traditional Petri dish cultures are accurate and inexpensive, but confirmation is slow.⁸³

These bioagent-specific detectors could be important tools for transportation responders in a biohazard situation. For example, these technologies could flag the presence of a biohazard within a transportation system before passengers leave the enclosed system. Early detection could aid in providing appropriate quarantine until the situation is confirmed. These types of detection tools are not well developed and face some significant problems, including both false positives and false negatives. Given the drastic measures that are required if detectors identify the presence of a dangerous bioagent, false positives (i.e., inaccurately signaling the presence of a specific biohazard agent when there is none) could potentially waste significant economic and human resources.

Although current methods that provide reliable specificity may not provide a signal until a large number of people are infected, regular sampling and identification of bioagents can still play an important in reducing the time between infection and response. A few promising bioagent-specific technologies are described below.

• Surface Acoustical Wave (SAW) Systems – SAW systems use materials that produce electrical current when subjected to slight changes in mass. These materials are coated with antibodies or complimentary nucleic acid sequences that bind with specific target bioagents. The presence of the antibodies or nucleic acid sequences causes a change in mass, which produces a subsequent change in electric current. This change is measured and alerts to the presence and, possibly, the identity of the bioagent. SAW systems can be fairly sensitive, detecting the presence of bioagents in very low concentrations.⁸⁴
• Immunoassays – Immunoassays are available as individual test strips or handheld kits. Immunoassays mimic the immune system by providing specific antibodies that bind selectively with specific biological agents, similar to SAW systems. Fluorescent compounds are then used to detect the presence of chemical binding between the antibodies and bacteria, toxins, or other microbiological organisms. Analysis requires less than twenty minutes for analysis. Though easy-to-use, these quick and disposable immunoassay tests are not currently sensitive enough to capture low concentrations. For example, one of the best test strips for Bacillus anthracis (the causative agent of Anthrax) requires more than 10,000 spores for a positive reading – this is more than the number necessary to cause infection.⁸⁵ In some cases, they also generate unacceptably high false positive rates. This can occur, for example, when closely related but non-pathogenic bacterial species are present. Despite these problems, immunoassays show some promise as research improves their sensitivity and the range of bioagents they can practically detect.⁸⁶

4.2.2 Detection Programs

Biowatch
Biowatch is a joint U.S. Environmental Protection Agency (EPA) and Department of Homeland Security (DHS) program that monitors 500 air filter stations across 31 U.S. cities. The filters are collected every 12 hours and then tested in a lab for agents. In the case of contagious diseases, this system will not provide detection before significant spreading occurs. In many cases, however, it will provide detection much earlier than waiting for symptoms to appear in numerous individuals. It may also allow for treatment earlier in the disease cycle, minimizing victim mortality, as well as the necessary level of ongoing treatment.⁸⁷

Biohazard Detection System (BDS)
Biohazard Detection System units are currently being installed in postal centers around the country. A BDS unit consists of an air-collection hood, a cabinet where the collection and analysis devices are housed, and a local computer network connection. The BDS equipment continuously collects air samples from postage canceling equipment while the canceling operation is underway. The system creates a liquid sample and uses DNA matching to detect the presence of anthrax (Bacillus anthracis).

The system concentrates air samples over the course of a one hour period. While the sample test is performed (requiring 30 minutes), the BDS is simultaneously concentrating particles for the next sample. Thus, the first result requires approximately one and a half hours; subsequent results are obtained every hour. In the future, BDS can be adapted to test for other biological threats and may be applicable to a broader range of settings.⁸⁸

4.3 Response – Restricted Mobility and Restricted Access

Travel restrictions might be a significant component of the response to a biohazard situation. Restrictions would serve two primary objectives: 1) controlling travel to prevent the spread of biohazards beyond already infected areas and 2) rearranging travel routes so that transportation can function efficiently without approaching potentially infected areas. There is limited literature discussing these two roles for transportation as they pertain specifically to biohazard situations. However, some lessons are apparent from a number of documented exercises (discussed in general in Chapter 2 and detailed in Appendix D).

4.3.1 Restricted Mobility to Prevent Disease Spread

Road closures, transit restrictions, and air and sea port closures might play an important role in preventing the spread of disease agents from an exposed area. Generally, local or state public health officials would implement quarantine. When infectious disease could potentially cross state lines, the federal government has the authority to enact quarantine, with specific closure actions taken by the CDC.⁸⁹ Transportation authorities might exercise specific plans for such closures, usually in response to scenarios involving likely bioterror targets such as stadiums or shopping malls. However, because the location of such attacks likely would remain unknown, transportation agencies must also have general approaches for how appropriate closures would be determined and implemented.

The effectiveness of mobility restrictions in preventing the spread of disease depends heavily on early warning. In many plausible scenarios, a contagious disease associated with a bioterror attack may not be discovered until infected individuals have spread throughout the country. Depending on the degree of disease contagiousness, small scale travel restrictions might not provide any certainty of disease containment. Nonetheless, such travel restrictions around the area of the attack might still be useful for limiting the probability of transmission.

In most envisioned biohazard situations, the area of restricted mobility would be much larger than a neighborhood or city and would affect national and, possibly, international transportation considerations. Many of the scenarios summarized in Appendix D involve access restrictions at the state or national scale, such as closure of highways at state or international borders, in order to prevent infected individuals or vehicles from spreading a bioagent.

4.3.2 Restricted Access to Prevent Exposure

In many cases, action would be required in order to maintain transportation systems, while avoiding contaminated areas. If the contaminated area were relatively small (on the scale of a neighborhood), adjustments for typical commute and local transit routes might be necessary. For example, in a case where there is an immediate recognition of contamination at a major event or in a transit system, it might be necessary to address access routes that allow the rest of the city or region to continue basic transportation operations without traveling through the affected area. Local access restrictions also may be needed to route transportation around demonstration and violence points, as described in several exercises in Appendix D.

If the biohazard were to spread throughout a state or the nation, the process for maintaining a functioning transportation system would be entirely different. Such restrictions would require a reorientation of typical freight transportation flows, including modifications of national and global supply chains, to avoid potentially affected states or nations.

4.3.3 Tool for Restricting Mobility and Access

A number of transportation operations tools and technologies can support efforts to restrict mobility and access. Some examples include the freeway and arterial management technologies listed below:

• Ramp controls,
• Variable message signs,
• Phone and internet based traveler information systems,
• Highway Advisory Radio,
• Traffic signals, and
• Emergency operations centers (EOCs) that coordinate a wide range of operations equipment (e.g., cameras, radios, web sites, HOV/Managed lanes, message signs, and other technologies listed above)

Little research exists that specifically addresses how these tools will be employed during a biohazard event. However, several efforts have examined the general use and coordination of traffic management centers toward such ends. Chapter 6 reviews models and other tools that are available or under development for the purpose of addressing transportation response to emergency situations, including biohazards.

4.4 Response – Delivery of Prophylaxis

Delivery of prophylaxis such as vaccines and antibiotics is likely to be a critical component of transportation system response. In simulation models for bioterror attacks, such as an overt anthrax attack on a major population center, failure to deliver sufficient medicines is identified as a factor contributing to tens of thousands of additional deaths.⁹⁰ Maximizing transportation capabilities for prophylaxis delivery requires a high level of operations coordination between Federal agencies, local transportation officials, and public health officials.

4.4.1 Strategic National Stockpile

The CDC’s Strategic National Stockpile (SNS) holds medicine and medical supplies for use during public health emergencies that are severe enough to cause local supplies to run out (e.g., terrorist attacks, flu outbreaks, earthquakes). A system has been established such that, from the time Federal and local authorities agree that the SNS is needed, medicines will be delivered to any state in the U.S. within 12 hours. A range of packages for various response scenarios have been configured at the SNS to be immediately loaded onto either trucks or commercial cargo aircraft for the most rapid transportation.⁹¹

Individual states are responsible for planning how they will receive and distribute SNS medicine and medical supplies to local communities. However, at the same time that SNS supplies are being sent, the SNS Program will deploy its Technical Advisory Response Unit (TARU). TARU staff are trained to coordinate with state and local officials so that the SNS assets can be efficiently received and distributed upon arrival at the site.

4.4.2 Local Distribution

Depending on the nature of a biohazard event, distribution of prophylaxis from locations within each state may be the most significant transportation challenge. A survey in 2003 indicated that only two states have reported that they are prepared to deploy adequate personnel to break down the SNS drugs, antidotes, and medical supplies once they arrive.⁹² However, significant ongoing training and investment have been made in this area. For example, the CDC recently sponsored two web casts:

• Mass Antibiotic Dispensing: A Primer (June, 2004)
• Mass Antibiotic Dispensing-Managing Volunteer Staffing (December, 2004)

Additional programs, such as the Cities Readiness Program described in Chapter 5, also focus on how prophylaxis will be dispensed once it arrives at the target community. However, amidst all these programs, it is not clear whether states and localities have addressed transportation considerations with regard to local distribution in a sufficiently detailed fashion.

Approaches may be considered in three main categories. In one approach, people who are healthy will be asked to go to a designated central location to get medicines that will keep them from getting sick. This approach helps ensure that hospitals are able to continue treating their existing patients and others who get sick as a result of the emergency. Another approach involves delivery of medicines and supplies, most likely by U.S. Postal Service employees. This may be called for if it is desirable to minimize public travel. In the third approach, mechanisms suitable for their own specific situations would be identified and developed by cities and states.

4.5 Response – Other Transportation Logistics

A range of additional considerations come into play for transportation response during a biohazard event. Support for other emergency functions, including additional medical support, transportation during evacuation, and adjustments to transportation operations in response to mode shifts, may be required.

4.5.1 Additional Medical Support

In addition to the distribution of prophylaxis discussed above, transportation support will be needed for a range of medical services. These services may include the following:

• Directing emergency transportation to and from hospitals. (This was addressed in the Mass Casualty Exercise: Plague Outbreak which is summarized in Appendix D, #10);
• Transport of infected patients to an area that has facilities that can handle them;⁹³
• Transport of elderly, handicapped, and others who cannot drive. (This was addressed in the Richmond, Virginia, Bioterrorism Exercise which is summarized in Appendix D, #9); and
• Transport of dead bodies. This can be particularly critical for disease situations and requires special transport considerati