NEWS & NOTES 6. Centers for Disease Control and Preven- munications, and medical therapeu- intelligence experts, and law enforce- tion. Update: interim recommendations for tics stockpiling (1). To focus these ment officials1 met to review and antimicrobial prophylaxis for children and preparedness efforts, however, the comment on the threat potential of breastfeeding mothers and treatment of children with anthrax. MMWR Morb Mor- biological agents towards which the various agents to civilian populations. tal Wkly Rep 2001;50:1014-6. efforts should be targeted had to first The following general areas were used 7. Henderson DW, Peacock S, Belton FC. be formally identified and placed in as criteria: 1) public health impact Observations on the prophylaxis of experi- priority order. Many biological agents based on illness and death; 2) delivery mental pulmonary anthrax in the monkey. J can cause illness in humans, but not all potential to large populations based on Hyg 1956;54:28-36. 8. Langmuir A, Popova I, Shelokov A, are capable of affecting public health stability of the agent, ability to mass Meselson M, Guillemin J, Hugh-Jones M, and medical infrastructures on a large produce and distribute a virulent et al. The Sverdlovsk anthrax outbreak of scale. agent, and potential for person-to-per- 1979. Science 1994;266:1202-8. The military has formally assessed son transmission of the agent; 3) pub- 9. Centers for Disease Control and Preven- multiple agents for their strategic use- lic perception as related to public fear tion. Additional options for preventive treatment for persons exposed to inhala- fulness on the battlefield (2). In addi- and potential civil disruption; and 4) tional anthrax. MMWR Morb Mortal Wkly tion, the Working Group on Civilian special public health preparedness Rep 2001;50:1142,1151. Biodefense, using an expert panel con- needs based on stockpile require- 10. Centers for Disease Control and Preven- sensus-based process, has identified ments, enhanced surveillance, or diag- tion. Interim guidelines for investigation of several biological agents as potential nostic needs. Participants reviewed and response to Bacillus anthracis expo- sures. MMWR Morb Mortal Wkly Rep high-impact agents against civilian lists of biological warfare or potential 2001;50:987-90. populations (3-7). To guide national biological threat agents and selected 11. Omenaca C, Topiel MS, Galbraith M, public health bioterrorism prepared- those they felt posed the greatest Jernigan JA, Stephens DS, Ashford DA, et ness and response efforts, a method threat to civilian populations. al. Bioterrorism-related inhalational anth- was sought for assessing potential bio- The following unclassified docu- rax: the first 10 cases reported in the United States. Emerg Infect Dis 2001;7:933-44. logical threat agents that would pro- ments containing potential biological 12. Centers for Disease Control and Preven- vide a reviewable, reproducible means threat agents were reviewed: 1) the tion. Update: investigation of bioterrorism- for standardized evaluations of these Select Agent Rule list, 2) the Austra- related anthrax and interim guidelines for threats. lian Group List for Biological Agents exposure management and antimicrobial In June 1999, a meeting of for Export Control, 3) the unclassified therapy. MMWR Morb Mortal Wkly Rep 2001;50:909-19. national experts was convened to 1) military list of biological warfare 13. Dixon TC, Meselson M, Guillemin J, review potential general criteria for agents, 4) the Biological Weapons Hanna PC. Anthrax. N Engl J Med selecting the biological agents that Convention list, and 5) the World 1999:341:815-26. pose the greatest threats to civilians Health Organization Biological Weap- and 2) review lists of previously iden- ons list (8-12). Participants with tified biological threat agents and appropriate clearance levels reviewed Report Summary apply these criteria to identify which intelligence information regarding should be evaluated further and priori- classified suspected biological agent Public Health tized for public health preparedness threats to civilian populations. Geneti- Assessment of efforts. This report outlines the overall cally engineered or recombinant bio- Potential Biological selection and prioritization process logical agents were considered but not Terrorism Agents used to determine the biological included for final prioritization agents for public health preparedness because of the inability to predict the As part of a Congressional initia- activities. Identifying these priority nature of these agents and thus iden- tive begun in 1999 to upgrade national agents will help facilitate coordinated tify specific preparedness activities for public health capabilities for response planning efforts among federal agen- public health and medical response to to acts of biological terrorism, the cies, state and local emergency them. In addition, no information was Centers for Disease Control and Pre- response and public health agencies, available about the likelihood for use vention (CDC) was designated the and the medical community. of one biological agent over another. lead agency for overall public health This aspect, therefore, could not be planning. A Bioterrorism Prepared- Overview of Agent Selection considered in the final evaluation of ness and Response Office has been and Prioritization Process the potential biological threat agents. formed to help target several areas for On June 3-4, 1999, academic Participants discussed and identi- initial preparedness activities, includ- infectious disease experts, national fied agents they felt had the potential ing planning, improved surveillance public health experts, Department of and epidemiologic capabilities, rapid Health and Human Services agency 1Participants are listed in Acknowledg- laboratory diagnostics, enhanced com- representatives, civilian and military ments. Emerging Infectious Diseases • Vol. 8, No. 2, February 2002 225 NEWS & NOTES for high impact based on subjective Table 1. Critical biological agent assessments in the four general cate- categories for public health preparedness gories. After the meeting, CDC per- Biological agent(s) Disease sonnel then attempted to identify Category A objective indicators in each category Variola major Smallpox that could be used to further define and prioritize the identified high- Bacillus anthracis Anthrax impact agents and provide a frame- Yersinia pestis Plague work for an objective risk-matrix anal- Clostridium botulinum (botulinum toxins) Botulism ysis process for any potential agent. Francisella tularensis Tularemia The agents were evaluated in each of the general areas according to the Filoviruses and Arenaviruses (e.g., Ebola virus, Lassa virus)Viral hemorrhagic fevers objective parameters and were charac- terized by the rating schemes outlined Category B in the Appendix. Final category Coxiella burnetii Q fever assignments (A, B, or C) of agents for Brucella spp. Brucellosis public health preparedness efforts Burkholderia mallei Glanders were then based on an overall evalua- tion of the ratings the agents received Burkholderia pseudomallei Melioidosis in each of the four areas. Alphaviruses (VEE, EEE, WEEa) Encephalitis Rickettsia prowazekii Typhus fever Results Toxins (e.g., Ricin, Staphylococcal enterotoxin B) Toxic syndromes Based on the overall criteria and weighting, agents were placed in one Chlamydia psittaci Psittacosis of three priority categories for initial Food safety threats (e.g., Salmonella spp., Escherichia coli O157:H7) public health preparedness efforts: A, Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum) B, or C (Table 1). Agents in Category Category C A have the greatest potential for adverse public health impact with Emerging threat agents (e.g., Nipah virus, hantavirus) mass casualties, and most require aVenezuelan equine (VEE), eastern equine (EEE), and western equine encephalomyelitis (WEE) viruses broad-based public health prepared- ness efforts (e.g., improved surveil- beyond those identified for Category areas considered. Table 2 shows the lance and laboratory diagnosis and A agents. Biological agents that have evaluation schemes as applied to stockpiling of specific medications). undergone some development for agents in Categories A and B. For Category A agents also have a moder- widespread dissemination but do not example, smallpox would rank higher ate to high potential for large-scale otherwise meet the criteria for Cate- than brucellosis in the public health dissemination or a heightened general gory A, as well as several biological impact criterion because of its higher public awareness that could cause agents of concern for food and water untreated mortality (approximately mass public fear and civil disruption. safety, are included in this category. 30% for smallpox and <2% for brucel- Most Category B agents also have Biological agents that are cur- losis); smallpox has a higher dissemi- some potential for large-scale dissemi- rently not believed to present a high nation potential because of its nation with resultant illness, but gen- bioterrorism risk to public health but capability for person-to-person trans- erally cause less illness and death and which could emerge as future threats mission. Smallpox also ranks higher therefore would be expected to have (as scientific understanding of these for special public health preparedness lower medical and public health agents improves) were placed in Cate- needs, as additional vaccine must be impact.