A case of when, not if

The threat of a terrorist attack hangs over us all – and this was brought
sharply into focus by events last September. We must all be prepared since we
can never know when or how the next attack might come, by Greta Thornbory

Following the events of 11 September, President Bush said that things would
never be the same again and that it was now a question of "when, and not
if". In the UK, the more controlled approach is that the risk is now
"somewhat higher".

Some occupational health practitioners have commented that the events have
made no difference to them or their practice, while others have experienced a
variety of problems. It was no surprise therefore to see an advertisement in
the March issue of Occupational Health for a conference to be held by the
Faculty of Occupational Medicine on this very topic entitled Chemical,
biological, radiological and nuclear terrorism. This conference was asking some
pertinent questions of OH practitioners such as:

– What plans do you need to put into place to deal with suspicious packages
in your mailroom?

– What advice do you give to the MD of your company when he asks you for
prophylactic antibiotic cover in case he is exposed to anthrax while travelling
in the USA?

– What role has immunisation in preventing anthrax infection?

– How would you deal with an unusual pattern of sickness absence that you
suspect might be sinister? And so on.

Psychological effects

The threat of terrorism comes in many forms and is used by terrorists for
its psychological effects. Leon Trotsky said that terrorism kills individuals
and intimidates thousands, a view that is backed up by the panic buying of gas
masks in the US and the large quantities of expensive prophylactic antibiotics
taken during the anthrax scare.

After the devastating events of last year it is horrific to discover that
the emergency workers were ill prepared to deal with the event and were
therefore exposed to a variety of chemical and biological hazards1. Now that
they have received the accolades and had their work praised and recognised they
have to deal with the aftermath of detrimental physical and psychological

For the emergency services, including hospital-based personnel, the
psychological risks are now well documented and following tragic events it is
not unusual for counsellors to be available for debriefing almost immediately.
Some emergency services have even been proactive in preparing their workers for
psychological trauma2, but little has been documented or appears to have been
done about the physical risks of such events.

Physical effects

Dr Virginia Murray, Director of the Chemical Incident Response Service,
highlighted the fact that following the Sarin gas attack on the Tokyo
underground in 1995 there were no decontamination procedures in place for
patients, let alone the emergency workers and 4,000 of the 5,500 casualties
made their own way to emergency services, thus contaminating the environment on
the way. Almost 10 per cent of the emergency personnel at the incident showed
acute symptoms of Sarin poisoning and required medical treatment.

The contaminants present at the World Trade Centre site post-September 11
are listed in Table 1. Who would have expected the emergency and other services
to be exposed to all these at once and in such unknown quantities?

Dr Murray also identified a variety of occupational groups vulnerable to
terrorism, both organisations and workers. A selection, which is by no means
comprehensive, is shown in Table 2.

One has to remember that if there is a deliberate release of a chemical or
biological agent this may be far from pure or stable as it may have been made
by an amateur in a garage or garden shed. Terrorists are not interested in the
purity or safety of the substance. Dr Richard Stott from Porton Down highlights
the fact that many "recipes" for chemicals can be downloaded easily
from the Internet.

Tests on the deliberate release and spread of micro-organisms have been
carried out in the UK and in the late 1960s tests with Bacillus globigii were
undertaken on London Underground. A ladies’ powder compact containing 16g of
the bacillus was dropped from a train window near Tooting Broadway station,
south-west London on the northbound train. Spores were found all the way up to
the end of the line at Highgate, north London, 30 minutes after the release.

The implications for such a deliberate release are frightening. One only has
to consider the outbreak of Legionnaires disease in London in the 1980s
attributed to a BBC air conditioning unit to realise just how fast and easily
toxins can spread.

So the threat exists and the impact on the population is enormous but what
has it to do with occupational health practice? The American Medical News3 said
that the US attacks have made the workplace the frontline in the war on
terrorism and the UK Government has identified that to learn from the US
experience is vital for the protection of the British workforce.

It highlighted the fact the four countries of the UK have different
standards, policies and practices and that there is a need to standardise these
together with the different agencies involved. The chief medical officer has
published a strategy for infectious diseases and other aspects of health
protection, Getting ahead of the curve4, and part of this strategy is the
setting up of a new Health Protection Agency, which pulls together the
following organisations:

– Public Health Laboratory Service

– National Radiological protection Board

– Centre for Applied Microbiological Research

– National Focus on Chemical Incidents

– Faculty of Public Health Medicine

– Community Infection Control Nurses Network

– Department of Health

– Welsh Assembly

– Scottish Executive Health Department

– Department of Health and Social Services Northern Ireland

Note there is no mention of the HSE or occupational health professionals.
There is a need for OH practitioners to make sure they are included and
consulted for the benefit of the UK workforce. A steering group has set up a
liaison group with the TUC. Workers will be concerned about what they will be
exposed to in the event of an act of terrorism. With an increasingly
enlightened public logging onto the Internet a great deal of information is available.
Much of this is very useful and sensible, but for every good and responsible
website there is one that may cause panic.

Although not caused by a deliberate release or an act of terrorism, the foot
and mouth outbreak in the UK in 2001 highlighted the devastating socio-economic
effects such an incident can have. If this had been a biological problem that
affected humans one can imagine the devastation. Dr Martin Whale, consultant
epidemiologist, suggested that we would have run out of food within two to
three days as delivery drivers refused to go into infected areas and shoppers
started panic buying. And this is just the tip of the iceberg.

The role of occupational health

It is obvious that the OH practitioner is well placed to play a significant
part in ensuring that suitable risk assessments are undertaken and preventative
measures put in place because, according to Dr Whale, the key word is
infrastructure. There is a need to identify who is at risk, and that includes
the family unit not just the individual worker, in the event of a terrorist
attack or a deliberate release.

There is a need to ensure that those at risk are appropriately trained and
have suitable equipment to hand to deal with the situation. Chemical releases
require that decontamination equipment is available otherwise others, such as
healthcare workers, and the environment also become contaminated and at risk.

Above all policies should be developed, not in isolation, but in
collaboration with other agencies in order to protect those at risk. However,
none of this is possible if the infrastructure is not in place at local and
national levels. One company cannot go it alone and needs the direction and
support of the newly formed Health Protection Agency as outlined in the chief
medical officer’s strategy.

Dr Jill Meara of the National Radiological Protection Board says that the
vital factors are:

– Planning: emergency plans should be linked both within and between

– Policy: there should be clear emergency intervention levels

– Practice: attempts should be made to anticipate at least some of the

– Clarity of role: it should be made clear what needs to be decided and by

– Communication: there should be effective lines of communication both
within and between organisations.

The message that came across from all the speakers at this excellent
conference was that the unthinkable is not unthinkable; that it is a case of
not if but when; and that we should not underestimate how easy it would be for
a terrorist to mount an effective attack. You have been warned.


1. Jackson BA et al (2001) Protecting Emergency Responders: Lessons learnt
from terrorist attacks. Conference proceedings. www.rand.org/publications

2. Carmel L, Cook J, Peerby M (2000) Calming Force. Occupational Health 52:

3. American Medical News 25 February 2002.

4. Chief Medical Officer (2002) Getting Ahead of the Curve: A strategy for
infectious diseases. Department of Health. www.doh.gov.uk

useful websites

www.apic.org//bioterror  www.nrpb.org
 www.newscientist.com/hottopics/bioterrorism  www.phls.co.uk  www.who.int  www.icn.org


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