Terrorism in the homeland — the attacks in New York and Washington and the flurry of anthrax-tainted letters that killed five people, infected 18 and forced 30,000 Americans onto a regimen of prophylactic antibiotics — occurred thousands of miles from Los Angeles. But as the nation’s attention was fixed on the East Coast and the sobering threat of biological assault, UCLA was actively engaged on the Western Front.
In those anxious days and weeks, UCLA’s Office of Environment, Health and Safety responded to about 100 incidents of suspected anthrax on campus. The calls, says Rick Greenwood M.P.H. ’75, Ph.D. ’78, director of the office, ranged from sightings of white powder to suspicious letters. None of them amounted to anything — nor did the large number of cases of UCLA patients who feared that their rashes were cutaneous anthrax. But it was enough to make one think: If a concentrated outbreak thousands of miles away can keep the campus and hospital that busy, what would it be like if a more potent biological or chemical attack were focused on the West Coast — or West Los Angeles?
As a Level-1 trauma facility, UCLA Medical Center is open to any and all medical emergencies, and it is anticipated the hospital would receive a large number of cases in any regional disaster. As a leader in the delivery of primary care — at the campus hospital and through satellite hospitals and outpatient clinics — UCLA physicians and nurses could be on the front lines of a bioterrorist act. That understanding of this past fall’s events prompted UCLA to create a 30-member Bioterrorism Preparedness Task Force to ensure that the campus and its medical community are as prepared as can be for what had been, to most people, an unthinkable event. And with its share of faculty among those who have thought about such things, the campus is playing a prominent role in prepping the state’s physicians and public-health professionals, as well as informing legislators and educating the public.
One of the problems facing the task force is the near impossibility of predicting the shape of a future bioterrorist attack. Before Sept. 11, no one considered that commercial airliners might be used as missiles to blow up buildings — nor did anyone imagine that the U.S. Postal Service could serve as a workable and efficient vector for the spread of a lethal disease on a large scale.
“There’s no way to predict exactly how it’s going to happen,” says David Pegues, an infectious-disease epidemiologist and chair of the task force. But the list of agents the Centers for Disease Control and Prevention and the World Health Organization consider to be particularly worrisome is not that long. At the top are anthrax and smallpox, along with plague, botulism, tularemia and a class of hemorrhagic fevers, including Ebola.
UCLA, in a land so prone to earthquakes and other natural disasters, didn’t start its planning from scratch. On the other hand, much of this was uncharted territory. “We’ve long had very strong disaster-response planning in the medical center, but that has been related to an earthquake or some defined catastrophic event,” says Frances Ridlehoover, chief operating officer of the UCLA Hospital System. “Bioterrorism could display itself that way, or in a way that unfolds over a period of days or weeks.”
Rather than pondering how to respond to every possible contingency, the task force grouped its plans into categories: Is the event catastrophic or evolving? Does it involve trauma or illnesses? If it is illness, is it contagious? Planning for a noncommunicable outbreak such as anthrax is one thing; a communicable disease like smallpox or plague opens up issues of respiratory isolation, quarantines and immunization of those placed at risk. “It’s a very different kind of response,” says Ridlehoover. “Everyone’s recent experience has been with traumatic events. This has forced us to put an enormous amount of thought and planning into how to protect our own staff so that we can confidently meet the public’s needs in such a case.”
At the top of the task force’s to-do list was a resource assessment. The medical center increased its supplies of protective equipment and antibiotics such as ciprofloxacin and doxycycline, which can treat anthrax as well as some of the other high-risk agents. Additional breathing tubes and mechanical ventilator bags will enable the hospital to, if necessary, triage and manually treat patients with respiratory failure if there were a sudden influx that exceeded the capacity of the intensive-care units.
“It would take some work, but we’ve now developed contingencies to allow us to bend without breaking, at least in the short term, if we saw 100 people with respiratory failure,” says Pegues. “When you get much more than that, it reaches beyond the individual institution and you need a coordinated county or statewide response.”
Among UCLA’s richest resources are its microbiology laboratories. The campus is capable of testing several thousand specimens a day. Still, a few letters containing anthrax spores generated the need for tens of thousands of laboratory tests on the East Coast, both for possibly infected individuals and for environmental sampling to ensure that buildings were safe. At a certain point, whether due to the quantity or the nature of the pathogen in question, UCLA would refer to the county health department’s reference laboratory, which is investing in high-throughput machines for rapid diagnosis.
Then there are the human resources. UCLA is educating its primary-care providers to recognize and report when patients present with symptoms that raise red flags — a particularly severe respiratory illness, an acute gastrointestinal illness with internal bleeding or hemorrhaging, a severe rash-like illness with fever that might suggest smallpox, a spike in out-of-season cases of flu.
“In traditional disaster planning, first responders are the firefighters and paramedics who arrive on the scene or the physicians in the emergency room,” notes Ridlehoover. “In an unfolding bioterrorist event, the first responder might be a primary-care doctor or nurse practitioner in a clinic.”
That has necessitated a crash course in agents and illnesses that haven’t been seen in the United States in decades, if ever. “Before the anthrax outbreak, most physicians had very limited knowledge of these things,” says Farhad Melamed ’90, an internal-medicine specialist who represents the UCLA Primary Care Network on the task force. Along with educating themselves, the network’s providers were encouraged to work with office staff who take patient phone calls, and to educate their patients. “At the height of the scare, people who had a runny nose and cough thought it was anthrax,” Melamed says. In December, the task force produced a pamphlet for UCLA physicians to distribute.
For the institution as a whole, the aftermath of Sept. 11 also has led to serious thinking about ways to use computer technology to identify unusual patterns in the cases seen by UCLA providers — statistical blips that might signify a bioterrorist agent is at work. “Obviously if someone is diagnosed with a case of smallpox or anthrax, a whole system of notification starts spinning up to the highest levels of the federal public-health system,” says Pegues. “But there might be something lurking more insidiously beneath the surface.”
It’s an enormous technological and logistic undertaking that local public-health systems are also exploring. “With our size, and with the satellite clinics that we have geographically distributed throughout Los Angeles, we’d like to lead the effort in applying this kind of public-health model,” says Pegues.
In responding to any disaster — intentional or not — the ability of the key players on campus to communicate with each other, and with the appropriate responders outside the university, is critical. Operation Topoff, a federal exercise in Denver two years ago that simulated a bioterrorist attack, pointed out the need for a system in which members of the emergency-management and operations team can be easily reached, notes Peter Katona, a UCLA infectious-disease and bioterrorism expert on the task force.
Besides working on ways to ensure that officials can reliably and quickly contact each other, UCLA has paid close attention to other forms of communication. Plans for accommodating a large media contingent have been developed, and medical center spokespeople have been identified. “Good communication includes presenting accurate information in a timely and organized manner,” says Katona. “If you look disorganized, that can instill panic.”
Now that the initial work in education, resource assessment and protocol development is complete, much of the focus has shifted to ongoing training to ensure that the hospital and campus can respond seamlessly to a bioterrorist act. Prophetically, the campus’s Office of Environment, Health and Safety, in conjunction with the Los Angeles Police Department and local FBI office, had a practice drill in August that simulated a response to a device containing anthrax. A statewide bioterrorism drill held last November had been planned well before Sept. 11. Other training initiatives and dry runs are scheduled.
UCLA’s efforts in bioterrorism preparedness extend beyond campus boundaries. Linda Rosenstock, dean of the School of Public Health, has been a leading national voice in calling for a renewed investment in the country’s public-health infrastructure. “That investment has been inadequate for at least a few decades,” she says. “It’s getting better, but we still need enormous support for our local health departments.” (In his FY 2003 budget, President Bush proposed $4.3 billion in new bioterrorism spending, including an expansion of early-warning systems to detect infectious outbreaks.)
Meanwhile, the individual with the ultimate responsibility for L.A. County’s response plan is a UCLA School of Public Health professor. Jonathan Fielding, director of public health for the county’s Department of Health Services, has overseen efforts not unlike those at UCLA, though on a larger scale: enhanced disease surveillance, increased laboratory capacity, beefed-up communication systems and considerable physician and public education, including a bioterrorism Web site.
Some of that education has taken place in Westwood. Fielding has sent several members of his staff to audit a two-unit course, “Terrorism and Mass Destruction,” taught by School of Public Health epidemiologist Scott P. Layne and featuring lectures by other bioterrorism experts from UCLA and elsewhere. Layne and Katona are among several UCLA faculty who have participated on the county’s bioterrorism advisory group, and Pegues and others have assisted the county’s acute-communicable-disease staff.
“Certainly there is great expertise at UCLA, and we’re using that to the degree that it can help us,” Fielding says.
Among the hubs of expertise on campus is the 5-year-old Center for Public Health and Disasters, which promotes interdisciplinary efforts to reduce the health impacts of natural and man-made disasters.
The center was already providing consultations and educating public-health graduate students in bioterrorism, but those efforts were turned up several notches after the events of the fall. A bioterrorism training program for emergency and primary-care physicians was put on the center’s Web site, ph.ucla.edu/cphdr. With funding from Sacramento, the center will soon begin to offer two-day workshops on bioterrorism preparedness for leaders of the state’s local health departments.
“This issue has ratcheted up at a time when the health-care system is already overtaxed,” says Steven Rottman, the center’s director. “How long can you sustain a surge capacity before your personnel and your facilities become overwhelmed? We’re trying to help these public-health leaders to prioritize.”
Like many of the others interviewed for this story, Rottman’s own life has become considerably busier since Sept. 11. After the attacks on the World Trade Center and the Pentagon, his group was flooded with media calls asking about everything from the likelihood of survivors to public-health risks from contamination of the surrounding areas, along with what-if scenarios as future terrorist threats were pondered. The initial wave had barely subsided when the anthrax issue emerged, prompting a new round of interviews. That’s to say nothing of the increased demands for education and training that Rottman’s group is helping to meet.
“We’re running as fast as we can,” he says. In February, his unit was designated by the U.S. Department of Health and Human Services as a federal center for public-health preparedness and will receive funding to recruit additional experts in natural and human-generated disasters.
Rottman has not been alone in thinking about the response to a chemical or biological attack. The U.S. government started viewing bioterrorism as a serious threat after Iraq’s increased bioweapons activity following the Persian Gulf War, Rottman notes. In the years since the war, the government has established a system in which “push packs” of vaccines, antibiotics and other equipment could be deployed into a metropolitan area within hours after an attack.
“Five years ago, a lot of people said this was totally paranoid and that it could never happen,” Rottman says. “Today, many of those same people are stockpiling Cipro in their closets.”
