Harmful biological agents can be released by way of the air, food, water, or insects. Their release may not be recognized for several days, during which time a communicable disease—such as smallpox—can spread to others who were not initially exposed. Some biological agents—such as anthrax and plague—produce symptoms that can easily be confused with influenza or other, less virulent illnesses, leading to a delay in diagnosis or identification. For example, the recent outbreak of the new infectious disease, SARS, whose onset includes common symptoms such as high fever, coughing, and difficulty in breathing, was not recognized until about 4 months after the first known case. Initial response to a public health emergency, including an act of bioterrorism, is generally a local responsibility that could involve multiple jurisdictions in a region, with states providing additional support when needed. Since clinicians at the local level are most likely to be the first ones to detect an incident, they and local public health officials are expected to report incidents or symptoms of suspicious illness to the state health department and other designated parties. States can provide supporting personnel, financial resources, laboratory capacity, and other assistance to local responders. Because of the many participants involved, the identification and management of bioterrorism and other public health emergencies call for effective communication and collaboration across all levels of government and the private sector. Figure 1 presents the probable series of responses to the release of a biological agent by the various players. Prior to the anthrax incidents in October 2001, a number of threats and hoaxes involving biological agents, and at least one successful bioterrorist act, had occurred domestically. Since that time, health care and public health officials at the federal, state, tribal, local, and international levels, as well as the private sector—part of a complex network of people, systems, and organizations—have examined their readiness to respond to acts of bioterrorism and have found weaknesses. Among others, these weaknesses include (1) vulnerable and outdated health information systems and technologies, (2) lack of real-time surveillance and epidemiological systems, (3) ineffective and fragmented communications networks, (4) incomplete domestic preparedness and emergency response capability, and (5) communities without access to essential public health services. These reported deficiencies at local, state, and federal levels may hinder the effective detection and identification of a potentially harmful biological agent. The broad scope of bioterrorism activities brings together different professional communities with very diverse areas of expertise—the public health and medical community, the scientific community, and the intelligence and law enforcement community. The public health and medical community—consisting of public health officials, clinicians, traditional first responders, and veterinary and agricultural communities— is responsible for protecting the health of people, animals, and agricultural products. The scientific community—consisting of human, microbial, animal, plant, and environmental researchers, among others— characterizes, develops detection systems for, and creates vaccines and treatments for diseases caused by biological agents. The intelligence and law enforcement community—consisting of intelligence analysts, law enforcement officers, diplomatic officials, and military officers—monitor and deter terrorist movement and activity. In addition, other professions, such as drug store pharmacists and school administrators, are being identified as new players in bioterrorism preparedness and response. Public health and private laboratories are another vital part of the surveillance network because only laboratory results can definitively identify pathogens. Every state has at least one public health laboratory to support its disease surveillance activities and other public health programs. State laboratories conduct testing for routine surveillance or as part of special clinical or epidemiological studies. Independent commercial and hospital laboratories may also share with public health agencies information they have gathered through their private surveillance efforts, such as studies of patterns of antibiotic resistance or of the spread of diseases within a hospital. In addition, commercial and hospital laboratories may be required by state law or regulation to report certain findings for public health surveillance. Federal agencies have key responsibilities for bioterrorism preparedness and response. HHS has primary responsibility for coordinating the nation’s response to public health emergencies, including bioterrorism. HHS divisions responsible for bioterrorism preparedness and response, and their primary responsibilities include: The Office of the Assistant Secretary for Public Health Emergency Preparedness coordinates the department’s work to oversee and protect public health, including cooperative agreements with states and local governments. States and local governments can apply for funding to upgrade public health infrastructure and health care systems to better prepare for and respond to bioterrorism and other public health emergencies. On May 9, 2003, HHS announced that guidelines have been released for the use of $1.4 billion allocated for bioterrorism cooperative agreements. It maintains a recently built command center, where it can coordinate the response to public health emergencies from one centralized location. This center is equipped with satellite teleconferencing capacity, broadband Internet hookups, and analysis and tracking software. CDC has primary responsibility for nationwide disease surveillance for specific biological agents, and it also provides an array of scientific and financial support for state infectious disease surveillance, prevention, and control. For example, CDC administers cooperative agreements for public health preparedness totaling $870 million for fiscal year 2003. CDC has been addressing bioterrorism preparedness and response explicitly since 1998. In April 2003, CDC opened a new emergency operations center to organize and manage all emergency operations at CDC, allowing for immediate communication between CDC, HHS, DHS, as well as federal intelligence and emergency response officials, and state and local public health officials. CDC also provides testing services and consultation that are not available at the state level; training on infectious diseases and laboratory topics, such as testing methods and outbreak investigations; and grants to help states conduct disease surveillance. In addition, CDC provides state and local health departments with a wide range of technical, financial, and staff resources to help maintain or improve their ability to detect and respond to disease threats. CDC laboratories provide highly specialized tests that are not always available in state public health or commercial laboratories, and they assist states with testing during outbreaks. These laboratories help diagnose life-threatening, unusual, or exotic infectious diseases, including those that may be caused by bioterrorist attacks, such as smallpox. CDC also conducts research to develop improved diagnostic methods, and it trains laboratory staff to use them. The Agency for Healthcare Research and Quality (AHRQ) is responsible for supporting research designed to improve the outcomes and quality of health care, reduce its costs, address safety and medical errors, and broaden access to effective services, including anti- bioterrorism research. AHRQ has initiated several major projects and activities designed to assess and enhance the linkages between the clinical care delivery system and the public health infrastructure. AHRQ-supported research focuses on emergency preparedness of hospitals and health care systems for bioterrorism and other public health events; technologies and methods to improve the linkages between the personal health care system, emergency response networks, and public health agencies; and training and information needed to prepare clinicians to recognize the symptoms of bioterrorist agents and manage patients appropriately. The Food and Drug Administration (FDA) is responsible for safeguarding the food supply, ensuring that new vaccines and drugs are safe and effective, and conducting research on diagnostic tools and treatment of disease outbreaks. It is increasing its food safety responsibilities by improving its laboratory preparedness and food monitoring inspections in accordance with the Public Health Security and Bioterrorism Preparedness and Response Act of 2002. The National Institutes of Health (NIH) is responsible for conducting medical research in its own laboratories and for supporting the research of nonfederal scientists in universities, medical schools, hospitals, and research institutions throughout the United States and abroad. Its National Institute of Allergy and Infectious Diseases has a program to support research related to organisms that are likely to be used as biological weapons. NIH is planning to implement a strategic plan for research on CDC’s category A, B, and C biological agents. A complete list of these agents is included in appendix II. The Health Resources Services Administration (HRSA) is responsible for improving the nation’s health by ensuring equal access to comprehensive, culturally competent, quality health care. Its Bioterrorism Hospital Preparedness program administers cooperative agreements, totaling $498 million, to state and local governments to support hospitals’ efforts toward bioterrorism preparedness and response. Besides HHS, other federal departments and agencies are involved in bioterrorism preparedness and response efforts, including the following: DOD, while primarily responsible for the health and protection of its service members on the battlefield, conducts research on bioterrorism preparedness and response through agencies such as the Defense Advanced Research Projects Agency. This research supports force protection and is shared with other agencies when it may benefit the civilian population. It also has civil support responsibilities through the Joint Task Force for Civil Support, the National Guard, and the Army. DOE’s national laboratories are developing new capabilities for countering chemical and biological threats, including biological detection, modeling, and prediction. EPA is responsible for protecting the nation’s water supply from terrorist attack. In January 2003, it established a new homeland security research center. The center is assessing threat management for the water supply and environmental detectors for potential use in protecting the water supply. USDA has become involved in bioterrorism preparedness and response because of the increasing realization that the food supply may become a vehicle for a biological attack. Biological attacks on the health of animals and plants are important because animals and plants can spread diseases and toxins that may be harmful to humans. VA manages one of the nation’s largest health care systems and is the nation’s largest drug purchaser. The department purchases pharmaceuticals and medical supplies for the Strategic National Stockpile and the National Medical Response Team stockpile.