The web of measures that comprise the nuclear non-proliferation regime continues to hold at bay the "nuclear-armed crowd" that was part of President John F. Kennedy's alarming vision in 1963. The number of nuclear weapons states in 2004 stands at only eight or nine, and assertive steps may yet keep this number from growing. The proliferation of biological weapons, however, is quite another matter. Biotechnological capacity is increasing and spreading rapidly. This trend seems unstoppable, since the economic, medical, and food-security benefits of genetic manipulation appear so great. As a consequence, thresholds for the artificial enhancement or creation of dangerous pathogens--disease-causing organisms--will steadily drop. Neither Cold War bilateral arms control nor multilateral non-proliferation provide good models for how we are to manage this new challenge. Much more than in the nuclear case, civilization will have to cope with, rather than shape, its biological future.

The third edition has 120 new articles, among them Artificial nutrition and hydration, Bioterrorism, Cloning, Cybernetics, Dementia, Managed care, and Nanotechnology. Some 200 articles have been extensively revised, and 100 additional articles have new bibliographies. The alphabetical entries address a wide range of topics that raise difficult and important questions. Abortion, genetic screening, female genital mutilation, the right to die, health issues of immigration, and corporate responsibility are but a few. The contributors discuss the issues from many points of view. The abortion article includes sections covering medical perspectives, contemporary ethical and legal aspects, and Jewish, Catholic, Protestant, and Islamic religious perspectives. There are also articles about bioethics in Buddhism, eugenics, health policy, women as health-care professionals, whistle-blowing in health care, and veterinary ethics. All of the articles are signed, and all have bibliographies. Ample cross-references help readers find related useful material. A list of all the articles and a topical outline appear in volume 1. A series of appendixes offers codes, oaths, and directives related to bioethics; additional resources; key legal cases; and an annotated bibliography of literary works that have a medical component. A detailed index helps users find material that may be scattered over numerous entries, such as information about surrogate motherhood.

This report describes the results of some calculations on the effectiveness of penetrating nuclear weapons of yield 1 and 10 kilotons against targets containing biological agents. The effectiveness depends in detail on the construction of the bunkers, on how the bio-agents are stored, on the location of the explosions with respect to the bunkers, the bio-agent containers and the surface of the ground, and on the yield of the explosion and the geology of the explosion site. Completeness of sterilization of the bio-agents is crucial in determining effectiveness. For most likely cases, however, complete sterilization cannot be guaranteed. Better calculations and experiments on specific target types would improve the accuracy of such predictions for those targets, but significant uncertainties regarding actual geology, actual target layouts, and knowledge of the position of the explosion with respect to the target would remain. Aboveground effects of the nuclear explosions, all of which would vent to the surface, are estimated. They include intense local radioactivity and significant fallout, air blast, and seismic effects to kilometers distances. It is likely, however, that casualties from those effects would be less than the casualties that would result from the dispersal of large quantities of bio-agents.

One spring morning in 2004, Professor Steven Kurtz of the State University of New York (SUNY), Buffalo campus, woke to the horrid discovery that his wife of twenty years had died overnight from a heart attack. He called 9-1-1 for emergency services. Paramedics arriving at the Kurtz home noticed technical equipment that would normally only be found in a clinical or research laboratory. If the emergency responders had not been suspicious and had not acted on those suspicions, it would have been worrisome. What happened later--the investigation of Kurtz and colleagues by the U.S. Department of Justice and the Federal Bureau of Investigation's (FBI's) Joint Task Force on Terrorism under bioterrorism statues--might have more worrisome implications for both academic research and limiting the threat of bioterrorism.

BACKGROUND: Given the threat of bioterrorism and the increasing availability of electronic data for surveillance, surveillance systems for the early detection of illnesses and syndromes potentially related to bioterrorism have proliferated.

PURPOSE: To critically evaluate the potential utility of existing surveillance systems for illnesses and syndromes related to bioterrorism.

DATA SOURCES: Databases of peer-reviewed articles (for example, MEDLINE for articles published from January 1985 to April 2002) and Web sites of relevant government and nongovernment agencies.

STUDY SELECTION: Reports that described or evaluated systems for collecting, analyzing, or presenting surveillance data for bioterrorism-related illnesses or syndromes.

DATA EXTRACTION: From each included article, the authors abstracted information about the type of surveillance data collected; method of collection, analysis, and presentation of surveillance data; and outcomes of evaluations of the system.

DATA SYNTHESIS: 17 510 article citations and 8088 government and nongovernmental Web sites were reviewed. From these, the authors included 115 systems that collect various surveillance reports, including 9 syndromic surveillance systems, 20 systems collecting bioterrorism detector data, 13 systems collecting influenza-related data, and 23 systems collecting laboratory and antimicrobial resistance data. Only the systems collecting syndromic surveillance data and detection system data were designed, at least in part, for bioterrorism preparedness applications. Syndromic surveillance systems have been deployed for both event-based and continuous bioterrorism surveillance. Few surveillance systems have been comprehensively evaluated. Only 3 systems have had both sensitivity and specificity evaluated.

LIMITATIONS: Data from some existing surveillance systems (particularly those developed by the military) may not be publicly available.

CONCLUSIONS: Few surveillance systems have been specifically designed for collecting and analyzing data for the early detection of a bioterrorist event. Because current evaluations of surveillance systems for detecting bioterrorism and emerging infections are insufficient to characterize the timeliness or sensitivity and specificity, clinical and public health decision making based on these systems may be compromised.

The anthrax attacks of 2001, the outbreak of severe acute respiratory syndrome (SARS), and weapons of mass destruction tabletop exercises have made it clear that no single community can prepare fully, nor respond completely, to a large-scale bioterrorism event. Policymakers recognize the need to forge relationships and coordinate preparedness planning efforts at the local, state, national, and international levels.1 However, there is little consensus about the optimal level of localization or regionalization for each of the resources and services that must be operationalized during a bioterrorism response.

We sought to evaluate the evidence regarding the effectiveness of existing regional systems that facilitate a response to bioterrorism. We sought evidence regarding the tasks that would need to be performed during a bioterrorism response (such as triage, provision of emergency medical care, transportation, and surveillance) and regionalized organizations that would likely contribute personnel, material, and information required to perform these bioterrorism response tasks.

The key questions addressed in this report are:

*What are the key tasks of local responders - such as local public health officials, clinicians, and emergency medical personnel - during a bioterrorism event?

*What resources do local responders require to perform the tasks identified in Key Question 1?

*Which existing regional systems for delivery of goods and services could be relevant to supplying the resources identified in Key Question 2?

*Can regionalization of bioterrorism preparedness planning facilitate supplying needed resources to local responders during a bioterrorism event?

*How do geographic variations in the affected population (e.g., urban as opposed to rural), special populations, and the interplay of private and public sector players affect regionalized systems?