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July 2003 |
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Expecting the unexpected |  Back to contents | |
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With media-fuelled fears over a major bio-terrorist attack in Britain and the lack of preparedness in parts of the health service in dealing with such an incident1, questions have been raised over how well response teams will cope. Even if the risk of a large scale, deliberate release of chemical or biological materials appears to be low in the foreseeable future, it is clear that an attack is still a possibility, and consequently local authorities, along with other agencies, need to be prepared and able to respond effectively and efficiently.2 The events of September 11 and the "anthrax letters" episode in the US are a potent reminder of the real and potential impact of using high-profile terror tactics, while the discovery of ricin in a flat in north London in January once again emphasises the importance of remaining vigilant and ensuring safeguards are in place. While preparing for all eventualities may seem a daunting task, Dr Robert Spencer, consultant medical microbiologist and deputy director at the Health Protection Agency Southwest Regional Laboratory, argues that future biological and chemical scenarios will fall into four groups:
Speaking at last year's CIEH conference in Harrogate on the level of preparedness and response to bio-terrorism, Dr Spencer said that the use of biological agents would either occur covertly, in which case there would be no warning, overtly, in which case a warning would be given, or the incident would involve the discovery of a suspect device or package. In a covert attack, the first sign that a biological agent had been released into the environment would be when infected members of the public began turning up at the front line of the health care system harbouring unusual illnesses. As these initial cases will most likely be indistinguishable from naturally occurring common diseases, such as a flu-like illness, the laboratories supporting the front line staff will have an essential role to play in terms of early detection. To minimise the impact of a released agent, Dr Spencer says the laboratories must be in a position to:
In terms of the potential types of agents that might be used, the list is fairly long although most reports tend to concentrate on anthrax, plague, smallpox, viral hemorrhagic fevers (VHFs) and botulism. Nevertheless, as Dr Spencer points out, the likelihood of many of these agents being used is slim. To begin with, the plague is extremely difficult to weaponise (perhaps only by the US and the former USSR), and therefore is not a feasible option for bio-terrorists. Likewise, the former USSR is the only known country to have weaponised smallpox, rendering the chances of its usage in a bio-terrorist attack negligible. VHFs, he adds, are "the stuff of Hollywood" - there is no evidence of airborne transmission. And despite the discovery of ricin in a flat in north London, the agent is in fact an assassination rather than a bio-terrorist weapon. That leaves anthrax, which, due to "its history and the availability of the causative organism in the wild", makes it one of the most likely weapons. Dr Spencer adds that the "much talked up scenarios" are airborne attacks on a large scale, but this, he claims, is "quite difficult technically and probably beyond most terrorist capability." Interestingly, of the 50 or so terrorist/criminal acts that have involved the deliberate release of microbiological agents, around 50 per cent have involved the gastro-intestinal route using salmonella, shigella and some gut parasites, he says. Since these agents would most likely be targeted towards the food chain, environmental health has a key role to play in detecting, identifying and managing the deliberate contamination of food. Predicting when and how biological or chemical attacks might take place however, is extremely difficult, which is why a well-planned and co-ordinated response is so essential. Preparations for dealing with the deliberate release of biological and chemical agents had in fact been underway long before the attack on the Twin Towers and the Pentagon in 2001. It was the Aum Shinrikyo sect's use of sarin on the Tokyo underground in 1995, killing 12 people and causing 5,000 casualties, that first prompted the Department of Health (DoH) to take action by distributing confidential guidance on the management of such incidents to directors of public health and the NHS trust chief executives in March 2000. 3,4 While this guidance specifically targeted the health service, the Government recognised that local authorities, alongside other key agencies, would also need to be briefed on the course of action in the event of a biological or chemical incident. As a result, the Cabinet Office drew up guidance for local authorities, which was circulated to all council chief executives in October 2001. In the event of an incident, there are three levels of response - gold (strategy); silver (tactical); and bronze (implementation). The guidance explains that at gold level, a strategic command, headed by the police incident commander (PIC), will be set up in the police main base station (PMBS), which in most cases will be the police headquarters for the force in whose area the incident occurs. Of course, circumstances may result in an alternative site being chosen, for example, the biological or chemical material being dispersed may be so toxic that it affects operations at the original PMBS. To manage the incident, a multi-agency response will be set up, including representatives from key government departments and ministries, as well as members from the Food Standards Agency, the Environment Agency (EA), and others (depending on the nature of the incident). The local authority chief executive (possibly with the emergency planning officer in support) would be expected to attend multi-agency strategic meetings at the PMBS. Central to the multi-agency "gold level" command response is the establishment of a Joint Health Advisory Cell (JHAC), a strategic group, which reports to the director of public health (DPH) for the area affected. The DPH will draw on a wealth of expertise for advice, including a consultant in communicable disease control, representatives from the Department of the Environment, Food and Rural Affairs and the EA, and in many cases an environmental health officer (EHO) from the local authority. The guidance notes that the choice of the EHO will depend on the nature of the incident and the individual's expertise. The main purposes of the JHAC is to:
In addition, the JHAC will, as necessary, need to:
According to Sarah Webb, health emergency planning advisor at the East Midlands Health Protection Agency, JHACs have been set up with flexible structures, reflecting the wide pool of experts that may be called upon to advise on a broad range of incidents (besides biological or chemical scenarios, there is also the possibility of nuclear or a radiological "dirty bomb" to consider). She acknowledges that in some instances, it may not be necessary to call upon an EHO to advise the DPH. However, given that EHOs have key public health skills to offer, it is perhaps advisable that officers grasp a clear understanding of the environmental health role in the JHACs. Ian Hoult, county emergency planning officer for Hampshire CC, suspects that few EHOs will have seen the Cabinet Office's guidance, and therefore officers' knowledge and awareness of how environmental health fits into emergency planning across the UK is decidedly patchy. He says that EHOs can do a number of things to improve their readiness. The first is to approach either their emergency planning officer or emergency planning teams (depending on whether they work in a unitary or district council) to find out exactly how the JHAC operates and discuss how they can contribute their skills and knowledge to the JHAC. He also suggests they ask their emergency planning officer/team for training and the opportunity to participate in emergency planning exercises. In London, arguably the most likely target of a bio-terrorist attack, a number of senior EHOs from the Association of London Environmental Health Managers (ALEHM) have already undergone training for chemical, biological, radiation or nuclear (CBRN) attacks, and participated in emergency planning exercises at the Ministry of Defence's Chemical and Biological Defence (CBD) sector at Porton Down. According to Steve Miller, CIEH trustee and chair of the ALEHM, officers' level of awareness is now very high, and 10 senior EHOs have volunteered to serve on the London JHAC on a rota basis. Last December, the ALEHM held a seminar at Chadwick Court as part of a programme of initiatives to review and raise the profile of environmental health services in dealing with emergency incidents. One of the seminar's aims was to clarify the environmental health response to a pan London emergency and in doing so, improve understanding of the different roles of the emergency partners. The seminar also sought to outline the role of the London JHAC and identify what further action was required to prepare an effective environmental health response. When a major incident occurs, there are four main phases:
As Keith Delaney, former emergency planning officer at the London Borough of Enfield explains, the principal role of the local authority in an emergency is to support the emergency services and to continue normal services to the local community. As the emphasis switches to recovery, the local authority will then take a leading role to facilitate the rehabilitation of the community and restoration of the environment. Mr Delaney acknowledges that the role of environmental health is complex and depends on the position of the service within the local authority, although the EHO's powers in relation to health and safety, environmental protection and food safety will be imperative to dealing with the incident. EHOs will be leading players in the long-term recovery process, notes Ms Webb. In helping to restore normality, their duties will most likely include the immediate and ongoing safety of the area, disposal of contaminated waste, environmental monitoring and sampling, support for business recovery, provision of information and advice, and the restoration of public confidence. Since the Cabinet Office's guidance was first circulated in October 2001, a number of key developments have taken place, which are likely to affect the role of local authorities. One is the establishment of the Health Protection Agency, a new public health organisation set up to provide an integrated approach to protecting public health and reducing the effects of infections, poisons, chemical and radiation hazards on human health. Although, the HPA is still in its infancy, having been launched on 1 April, it is evident that new agency will come to play a significant role in a co-ordinated response. The day after it was launched, HPA chief executive,Dr Pat Troop, said: "...the spectre of the deliberate release of chemical, biological, nuclear and radiological agents means that we will need all the skills and expertise of the Health Protection Agency to ensure a coherent and rapid co-ordinated response, based on sound planning."5 In another development, as EHJ was going to press, the Government was on the verge of publishing the long-awaited Civil Contingencies Bill, which will see a fundamental review of emergency planning.6 A number of proposals have been put forward, including new duties on local organisations, depending on whether they fall into a leadership, planning and response category or a co-operating category. Equally telling, is a decision to withdraw and update the Cabinet Office's guidance to local authorities, with implications for the role of EHOs. Mr Miller notes that although new guidance for local authorities may not mention a specific role for environmental health, as far as London is concerned, "the people on the ground recognise the importance of bringing in EHOs". At last year's ALEHM meeting, responses to the question on environmental health's role in an emergency situation showed that there was a wide range of potential actions that the service could provide, depending on the type, location, and time of the incident, as well as what other services or action had already been undertaken before environmental health had been called. While current developments make it difficult to define a specific role for environmental health, in an emergency its main function will be to protect the community's health, act as a support agency providing specialist advice, and to initiate any actions that are appropriate to protect public health and the environment. To find out more about the ALEHM's activities, contact Steve Miller on 020 8430 4411. References
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