key: cord-017621-pyn1enz2 authors: Zaras, Nikolaos V. title: Case Study – Greece date: 2012-08-31 journal: Biopreparedness and Public Health DOI: 10.1007/978-94-007-5273-3_11 sha: doc_id: 17621 cord_uid: pyn1enz2 Biological terrorism and the need for biological defence is a relatively new concept for Greece. Although defence against weaponized pathogens was part of CBRN training in the military, it was the 9/11 massacre followed by the anthrax letters horror that triggered a more active involvement of the Greek public health sector. In that historical moment a third bullet was added to the already existing disease outbreak classification – naturally, accidental and now deliberate. These incidents and the subsequent 2004 Olympic Games in Athens drove the Greek government to focus on biodefence and revise existing civil emergency planning by inclusion of new emerging threats. Naturally occurring or accidental outbreaks of a disease usually take place in both urban and country environments. Big cities are usually the targets of bioterrorism due to the high density of population resulting in both physical and psychological casualties. If the disease does not start from one's own country then early warning might be possible, leading to preventive measures all the way from the borders into the community. The H1N1 virus pandemic is an example of this globalization of medical information that is useful to both countries and citizens. One important parameter of the epidemiology of infectious diseases is the movement of the populace either for professional, recreational or immigration reasons. In the past, moving from one location to another, even within the same country borders, took considerable time. In modern times, usually less than 24 h is needed to cross the world. We witnessed the contribution of faster travel to the spread of disease recently during the 2010 fl u pandemic. Apart from the legal movement of a population, mass illegal immigration also poses a signi fi cant problem in certain parts of the world -e.g. in Greece -in relation to the spread of a disease or reemergence of old diseases like malaria or tuberculosis. The geographical location of Greece and its porous borders due to the signi fi cant coastline make it an attractive destination for those seeking a better living environment or as a way to enter other EU countries as a fi nal destination. Greece receives a considerable number of tourists annually that exceeds its own population. Greeks also travel globally for the reasons mentioned above. This constant movement of a populace makes epidemiologic surveillance and disease prevention extremely dif fi cult. The reality of disease transmission as a result of immigration and travel is re fl ected below in the results from the Hellenic Centre for Disease Control and Prevention (CDCP) [ 2 ] and various relevant NGOs addressing the health status of immigrants and transmission of old and new infectious diseases. The percentage of declared cases of speci fi c diseases attributed to Greek citizens and immigrants is shown in Table 11 .1 . Timely information is crucial when it comes to a natural or accidental outbreak of a disease. This information might be bene fi cial to laboratory or institution workers or the population that needs to be protected. Of course, in most cases, basic hygiene measures (personal or collective, at home or in a wider infrastructure such as schools) can prevent these diseases. Defence against a deliberate outbreak of a disease requires intelligence. This type of medical intelligence is attributed to national intelligence service both civilian and military. Usually international collaboration is mandatory when weaponized pathogens are the problem. Risk identi fi cation and assessment contribute to national defence as well. It is a continuous process dealing with both the deliberate and non-deliberate forms of disease outbreaks. Internal (sanitary institutions, police reports, etc.) and external (neighboring countries, World Health Organization, EU public health surveillance systems, etc.) hints can assist experts to perform a risk assessment leading to an alert of the public health system. Current geopolitical instability and turmoil in our own region combined with the existing direct and indirect, overt and covert threats against Western societies make bioterrorism attacks a potential risk. Production of biological weapons is both easy and cost effective. Of course we must discriminate between the production and weaponization of pathogens that is not as easy and needs specialized equipment. Pathogen production does not require large factories and existing facilities in commercial infrastructure (food industry, drug industry) can be used for this purpose. On a smaller scale, pathogens can be cultivated in small laboratories or mobile caravans similar to those used to produce illegal drugs. Identi fi cation of such illegal laboratories is very dif fi cult. Viral pathogens are more dif fi cult to produce as compared to bacteria and also need some extra precautions and equipment. Large quantities of biological weapons can still be produced in a short period of time (days or weeks) in small laboratories. According to Kathleen C. Bailey, former Assistant Director, Of fi ce for Disarmament and Armaments Control, who visited many biotechnology and pharmacology companies, a complete biolab requires no more than a room of 4.5 m × 4.5 m and a budget of USD 15,000 for supplies [ 1 ] . In such a room, trillions of bacteria can be quickly produced with low risk and with minimum personal protection equipment such as a gas mask and a plastic suit over clothing. Dif fi culties relevant to the production of biological weapons include: Dif fi culties in the protection of workers at all levels of production, transportation, • and fi nal dispersal of biological weapons; Low level of training and expertise can lead to accidents and exposure to • pathogens; Vaccination of those involved is not always protective/effective; • Controlling the quality and quantity of produced material is dif fi cult; • Dispersion is not without problems since dispersal device explosives, UV expo-• sure, or weather conditions such as rain or drying may have negative effects on pathogens or spores; Storage of pathogens poses additional problems; speci fi c conditions are required • to maintain the ef fi cacy, and it is dif fi cult to maintain them in a form ready for dispersion over long periods of time. Key stakeholders in public health preparedness and response systems are: Epidemiologic monitoring is the systematic and continuous collection, analysis and interpretation of sanitary/medical information relevant to public health. The objectives of epidemiologic monitoring are: Follow-up of tendencies (estimate the impact of a disease or health problem The system of mandatory reporting of diseases represents the basis of epidemiologic monitoring in most countries; usually it is supplemented by more specialized systems, networks or studies with speci fi c objectives. The objectives of this system are: Speci fi c (for the system of mandatory reporting of diseases) -detection of spo-• radic cases; Detection of epidemic cases Generic (for every system of epidemiologic monitoring) -estimation of reper- The reporting process can start from the clinical or laboratory doctor or the hospital's infectious diseases nurse but has to be sent immediately (by fax) to the Regional Health Directorates and CDCP. The reporting form includes the following data: After reporting, evaluation of the validity/completeness of the reported elements will follow along with a thorough investigation of the case that will lead to a systematic/ rapid analysis and interpretation/export of the conclusions. Brie fi ng of public health/ sanitary/medical/nursing services will follow a complete evaluation of the system. 1836: elementary mandatory reporting of diseases (Newspaper of Government, No. 83, 31/12/1836 ). 1911 -1915 : legislation on systematic mandatory reporting of diseases (cholera 1911, smallpox 1911, plague 1915) . 1950: "Measures taken against infectious diseases justifying their reporting as mandatory", Art. 1: mandatory reporting of diseases (RD 7/9-11-1950) . 1998: Essential improvement of mandatory reporting system (National Centre of Epidemiologic Surveillance and Intervention). 2003: "Organization and modernization of public health services and other provisions", Art. 8, Law 3172/6-8-2003: epidemiologic monitoring of pestiferous diseases is practiced and coordinated by CDCP. 2003: "Regulations applied for regional systems of health and providence", Art. 44, Law 3204/23-12-2003: CDCP -each private or public medical institution or individual doctor, operating legally, is obliged to inform CDCP of each case of pestiferous disease that comes to his/her attention. Hellenic Personal Data Protection Authority: 1997: "Protection of individuals from the manipulation/exposure of data of per-• sonal character", Art. 7, Law 2472/1997: Exceptionally, it is allowed: If it concerns subjects of health; -If it is executed by a health professional in duty of secrecy; -If it is essential for medical prevention. This system was set in operation in 1999 and revised in September 2004. It deals with common diseases with minor indications (usually). Its scope is to support the health system through data gathering and processing, to make a clear estimate of diachronic trends and detect a possible epidemic elevation in an area or region. A large number of selected primary care doctors participate in this system/ programme. These doctors are distributed all over the country in the following networks: Private doctors network (86 physicians); • Regional health care centres/clinics (98 physicians); • Social security institute health units network (44 physicians). • The diseases included in the system of illness observers at the fi rst degree health care centres are: whooping cough, measles, mumps, rubella, varicella, in fl uenza of infective etiology, respiratory infection with fever (>37.5 °C). A weekly report is done of the number of cases and patients. The report is done according to the clinical fi ndings and de fi nitions. All public sector services, in the case of a suspected or con fi rmed biological incident -deliberate or not -that needs to be treated, alert the Civil Protection Operations' Centre of GSCP. GSCP then activates the Crisis Management Team (CMT) which consists of representatives from Police, Fire Service, First Aid National Center (FANC) [ 7 ] , National Defence General Staff, Centre for Disease Control and Prevention (CDCP) and the GSCP itself. GSCP's representative coordinates the functions of the CMT through telephone or video conference. After the thorough evaluation of the severity of the incident and the classi fi cation with different color codes if necessary, CMT will conduct a meeting at the GSCP building for better coordination of the operation. When an initial estimation has been made, medical directorates in various/all regions of the country are informed and guidelines are issued. Medical directorates are obliged to report immediately to the GSCP about any laboratory result following citizens' examinations and inform the public according to the guidelines of GSCP. Different missions are given to Police and Fire Service depending on the incident's nature. If needed, National Defence General Staff contributes resources through its military hospitals, laboratories, mobile laboratories, medical personnel, services (mass vaccination) and equipment (direct supply of masks with fi lters against biological agents, personal protective suits, decontaminants, antidotes, drugs, mobile toilets, and decontamination facilities) or other supportive units (e.g. to clear or secure an area, for quick transportation or relocation of people, etc.). In case of a CBRN agent release, Hellenic National Defence General Staff activates its Special Joint CBRN Company which has the capability to be airborne and deploy anywhere in Greece within 4 h (maximum), to conduct a CBRN search, survey, identi fi cation, sampling, decontamination, and provide specialized fi rst aid. For bioterrorism agents, this company has the capability to operate portable biological detectors that can identify pathogens of special interest, such as those causing anthrax or plague, within 30 min (up to 28 biological samples can be processed simultaneously). The Platoon was established after the 2004 Olympic Games by merging the two specialized units (one fi eld unit operating in both hot and warm zones and one hospital-based unit deployed at the Army General Hospital of Athens) that were created and deployed during the Games in support of fi rst responders. the optimal function of the system include: Systematic weekly reporting • Sharing small amounts of information with constant fl ow from the laboratories Syndromic Surveillance (Special Systems) This system is activated in special conditions or when there is a speci fi c objective. It applies to the reporting of predetermined clinical conditions ("syndromes") and not diagnosed diseases (e.g. "respiratory infection with fever" instead of Syndromic surveillance applies to the system of illness observers, early detection of epidemic elevations or individual incidents with public health importance Hepatitis A (syndrome compatible with acute hepatitis) • Septic/unexplained shock monitoring of hospital infections) and studies with speci fi c objectives also exist. These are clinical-laboratory networks for special pathogens, such as hospital bio-pathology laboratories, reference laboratories, specialized laboratories, and special clinical units • Contagious spongiform encephalopathy (centres for spongiform encephalopathy • reporting) Poliomyelitis (centres for poliovirus reporting) • Meningitis (centres for meningitis reporting) Weapons of mass destruction: costs versus bene fi ts Supplement to the general plan for civil protection "XENOKRATES" with the specialized plan for the Management of Human Casualties" 5. Ministry of Citizen Protection