Learning to Identify Suspicious Outbreaks

By Deborah Cohen, Biodefense Certificate Student

The Medical Management of Chemical and Biological Casualties (MMCBC) course is densely packed with usable and actionable training for battlefield incidents caused by chemical and biological attacks. The strategies for assessing events and responding could well extend to civilian situations, which may occur adjacent to military operations or even on the home front far from the typical war zone. 

I was compelled to take the course for a few reasons. As a longtime resident of Maryland, I have always had a curiosity about the activities of the two Army facilities in my state – Fort Detrick and Aberdeen Proving Ground (APG). My interest in geopolitical affairs has coincided with the progression of the institutional missions of the US Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick and the US Army Medical Research Institute of Chemical Defense (USAMRICD) at APG. Through the MMCBC practicum, I hoped to gain further insight into the culture and structure of our programs to prepare for and respond to chemical and biological threats. This training promised to be highly relevant and serve as a reinforcement to my studies in the Biodefense Graduate Program at the Schar School as well. It certainly delivered on that promise.

Normally, the chemical instruction portion of the course is held at APG and the biological portion is held at Fort Detrick. However, due to COVID-19 restrictions, my enthusiastic classmates from the Biodefense program and I attended all of the sessions virtually. That was the only disappointment during the week-long course. Though it would have been preferable to meet instructors and military personnel in-person at the facilities and we were not able to gain the hands-on experience with supplies like antidote kits and protective gear, these drawbacks were partially compensated for by video simulations and demonstrations. Army flexibility showed through under these special circumstances caused by the pandemic. That said, if given the chance, I would really like to practice donning and doffing protective gear.

The MMCBC training is very comprehensive and well organized. A cross section of topics included identifying the causative agents that can affect warriors in the field, nerve agents, the how-to’s of triage and evacuation, and foodborne incidents. All of the topics were fascinating as the instructors made each topic thematically overlap with the next. One of the most interesting units was “Epidemiology of Biological Terrorism” presented by Captain Benjamin Pierson.  Many of the MMCBC presentations elucidated the use of “clues” to diagnose an illness or injury in the context of the subject being a victim of an intentional biological or chemical attack. CPT Pierson’s presentation tied a lot of these clues together for me.   

CPT Pierson demonstrated how an 11-point BW assessment tool integrated with a commonly used public health 10-step epidemiological outbreak investigation could help differentiate between natural and deliberate disease outbreaks.  Among the clues used in this type of investigation are the time frame of the outbreak, locations of the cases, and the size of the outbreak.  Clues pointing to a deliberate outbreak are a higher than expected number of cases or highly unusual circumstances such as a higher fatality rate or the emergence of unexpected diseases.  Simultaneous outbreaks of the same disease in different locations or a rapid succession of outbreaks can also point to deliberate schemes.  Many biological warfare agents of concern are zoonotic agents that can cause disease in humans and animals. The presence of dead animals, simultaneous infections of humans or animals, reverse zoonosis in which humans infect animals, or the rapid spread of an infection during a very condensed time period could indicate a suspicious outbreak. Finally, of course, there can be direct evidence of a deliberate attack such as a letter filled with Bacillus anthracis spores.

I learned from CPT Pierson that the key to a successful investigation to characterize an outbreak as either naturally-occurring or deliberately caused is for the investigators to maintain an “Index of Suspicion” throughout the process.  The “Index of Suspicion” refers to the likelihood that a patient’s symptoms and circumstances will lead to a particular disease diagnosis.  To be on the lookout for intentional attacks, investigators or clinicians would be well served to have a heightened level of awareness of the signs and symptoms associated with the effects of a biological or chemical attack. Approaching an epidemiological investigation with a “BW Index of Suspicion” tuned to the possibility of deliberately caused events can result in a more rapid assessment and response.       

While we can debate the probabilities of a biological or chemical attack occurring on the battlefield or in a civilian setting, what is not debatable are the consequences of such an attack.  A chemical or biological attack on military or civilian personnel could inflict a horrible toll.  These weapons present practitioners of chemical and biological defense with a constellation of problems.  While the MMCBC training is focused on providing insights into pragmatic military tactical solutions to these threats, sharing these solutions with civilian responders reinforces the need for all stakeholders to participate in rapid detection and response should an attack occur.  The Army’s commitment to chemical and biological defense is exemplary and I am highly appreciative that they offer this practical training to civilian biodefense practitioners.

Deborah Cohen will complete the Graduate Certificate program in Biodefense at George Mason University in 2021. In her current role at SGS North America, she provides assessments and lab testing services for biological, chemical and environmental hazards to customers in agri-food, consumer products and infrastructure businesses across the globe.  Her focus includes biothreats risk analysis and management and technological innovations for threat detection and prevention.

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