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?

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the winter 2004 quarter. It features articles about CHP/PCOR faculty member Mark McClellan's new position as administrator of the federal Centers for Medicare and Medicaid Services; a report by the Stanford-UCSF Evidence-based Practice Center evaluating the regionalization of bioterrorism preparedness and response; the development of a research protocol for a World Health Organization study on the effectiveness of public-private partnerships in health care; a new design for CHP/PCOR's Web site; and a roundup of last quarter's media coverage highlighting the centers' research work.

OBJECTIVES: The authors sought to develop a conceptual framework for evaluating whether existing information technologies and decision support systems (IT/DSSs) would assist the key decisions faced by clinicians and public health officials preparing for and responding to bioterrorism.

METHODS: They reviewed reports of natural and bioterrorism related infectious outbreaks, bioterrorism preparedness exercises, and advice from experts to identify the key decisions, tasks, and information needs of clinicians and public health officials during a bioterrorism response. The authors used task decomposition to identify the subtasks and data requirements of IT/DSSs designed to facilitate a bioterrorism response. They used the results of the task decomposition to develop evaluation criteria for IT/DSSs for bioterrorism preparedness. They then applied these evaluation criteria to 341 reports of 217 existing IT/DSSs that could be used to support a bioterrorism response. Main Results: In response to bioterrorism, clinicians must make decisions in 4 critical domains (diagnosis, management, prevention, and reporting to public health), and public health officials must make decisions in 4 other domains (interpretation of bioterrorism surveillance data, outbreak investigation, outbreak control, and communication). The time horizons and utility functions for these decisions differ. From the task decomposition, the authors identified critical subtasks for each of the 8 decisions. For example, interpretation of diagnostic tests is an important subtask of diagnostic decision making that requires an understanding of the tests' sensitivity and specificity. Therefore, an evaluation criterion applied to reports of diagnostic IT/DSSs for bioterrorism asked whether the reports described the systems' sensitivity and specificity. Of the 217 existing IT/DSSs that could be used to respond to bioterrorism, 79 studies evaluated 58 systems for at least 1 performance metric.

CONCLUSIONS: The authors identified 8 key decisions that clinicians and public health officials must make in response to bioterrorism. When applying the evaluation system to 217 currently available IT/DSSs that could potentially support the decisions of clinicians and public health officials, the authors found that the literature provides little information about the accuracy of these systems.

We evaluated the usefulness of detection systems and diagnostic decision support systems for bioterrorism response. We performed a systematic review by searching relevant databases (e.g., MEDLINE) and Web sites for reports of detection systems and diagnostic decision support systems that could be used during bioterrorism responses. We reviewed over 24,000 citations and identified 55 detection systems and 23 diagnostic decision support systems. Only 35 systems have been evaluated: 4 reported both sensitivity and specificity, 13 were compared to a reference standard, and 31 were evaluated for their timeliness. Most evaluations of detection systems and some evaluations of diagnostic systems for bioterrorism responses are critically deficient. Because false-positive and false-negative rates are unknown for most systems, decision making on the basis of these systems is seriously compromised. We describe a framework for the design of future evaluations of such systems.

In the recent past the issue of covert trade in nuclear material gained public prominence when it was erroneously claimed by British intelligence sources that the former Government of Iraq under Saddam Hussein had tried to obtain uranium from Niger. The far reaching consequences of such assessments for society were clearly demonstrated by U.S. President George W. Bush in his speech on January 28, 2003, using this incorrect information as one of the reasons why terrorists and countries belonging to the "Axis of Evil" posed a potential nuclear threat. In view of the occurrence of such significant errors even in the intelligence community, it is not surprising that information in the media on the topic of illicit trafficking of nuclear material is frequently flawed by errors.

In order to avoid the pitfalls of evaluating important security-related decisions from questionable sources of information, this paper discusses only the most reliable currently available data on illicit trafficking of weapons-usable nuclear material, contained in the Database on Nuclear Smuggling, Theft, and Orphan Radiation Sources.