BIOTERRORISM AND THE PUBLIC HEALTH SECTOR

1. BIOTERRORISM AND THE PUBLIC HEALTH SECTOR Richard McCluskey MD, PhD Center for Disaster Management and Humanitarian Assistance College of Public Health University of South Florida

2. CHEMICAL effects immediate and obvious victims localized by time and place overt illicit immediate response first responders are police, fire, EMS BIOLOGICAL effects delayed and not obvious victims dispersed in time and place no first responders unless announced, attack identified by medical and public health personnel WHY PUBLIC HEALTH ?

3. WHY PUBLIC HEALTH ? • Tokyo subway 1995 / Sarin • Effects within minutes • Victims self-reported to authorities, self- transported to hospitals • First responders • fire, police, EMS • Agent identified: 3 hrs • Event over: 12-24 hrs

4. WHY PUBLIC HEALTH ? • Oregon USA 1984 / Salmonella • County Health Department • first reports of foodborne illness: several days • two waves of illness over 5 weeks • County Health Department and CDC • 751 victims and 10 restaurants identified: weeks - months • Criminal investigation • source identified: 12 months • criminal charges: 18 months

5. PUBLIC HEALTH • Examples of biological assaults: note: all incidents were discovered by public health officials and initially presented as an unusual cluster in time and place of an uncommon disease • 1996 Shigella dysenteriae USA • 1984 Salmonella USA • 1970 Ascaris suum Canada • 1966 Typhoid Japan • 1965 Hepatitis USA

6. PUBLIC HEALTH • Announced attack • Primary response: law enforcement, EMS • Hoax • Variation on announced attack • Increasing occurrence • 1992: 1 event affecting 20 people • 1998: 37 events affecting 5529 people

7. PUBLIC HEALTH • Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management -- United States, 1998 • MMWR February 5, 1999 48(04);69-74 • http://www.cdc.gov/epo/mmwr/preview/ mmwrhtml/rr4904a1.htm

8. PUBLIC HEALTH • Preparedness and prevention • Detection and surveillance • Diagnosis and characterization of agents • Response • Communication

9. PUBLIC HEALTH • Preparedness and prevention • Coordinated preparedness plans • Coordinated response protocols • Performance standards • self-assessment, simulations, exercises

10. PUBLIC HEALTH • Detection and surveillance • Develop mechanisms for detecting, evaluating, and reporting suspicious events • Integrate surveillance for illness and injury resulting from WMD terrorism into disease surveillance system

11. PUBLIC HEALTH • Diagnosis and characterization of agents • Multilevel laboratory response network • link clinical labs and public health agencies in all states, districts, territories, and selected cities and counties to CDC and other labs • Transfer diagnostic technology from federal to state level • CDC Rapid Response and Technology Lab

12. PUBLIC HEALTH • Response • Epidemiologic investigation • if requested by state health agency, CDC will deploy response teams to investigate unexplained or suspicious illness • Medical treatment and prophylaxis • vaccine / antibiotic stockpile and transportation • Environmental decontamination

13. PUBLIC HEALTH • Communication • Effective communication with the public • use news media to limit panic and disruption of daily life • Effective communication with health care and public health personnel • coordination of activities • access emergency information • rapid notification and information exchange

14. PUBLIC HEALTH • Effective planning and response to a biological terrorist incident will require collaboration with federal, state, and local groups and agencies including: -emergency response units and organizations -safety and medical equipment manufacturers -US Office of Emergency Management -other federal agencies -public health organizations -medical research centers -health-care providers and their networks -professional societies -medical examiners

15. CRITICAL BIOLOGICAL AGENTSCATEGORY A • High priority agents that pose a threat to national security because they: • can be easily disseminated or transmitted person-to-person • cause high mortality, with potential for major public health impact • might cause panic and social disruption • require special public health preparedness

16. CRITICAL BIOLOGICAL AGENTSCATEGORY A • Variola major (smallpox) • Bacillus anthracis (anthrax) • Yersinia pestis (plague) • Clostridium botulinum toxin (botulism) • Francisella tularensis (tularemia) • Filoviruses • Ebola hemorrhagic fever • Marburg hemorrhagic fever • Arenaviruses • Lassa (Lassa fever) • Junin (Argentine hemorrhagic fever) and related viruses

17. CRITICAL BIOLOGICAL AGENTSCATEGORY B • Second highest priority agents that include those that: • are moderately easy to disseminate • cause moderate morbidity and low mortality • require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance

18. CRITICAL BIOLOGICAL AGENTSCATEGORY B • Coxiella burnetti (Q fever) • Brucella species (brucellosis) • Burkholderia mallei (glanders) • Alphaviruses • Venezuelan encephalomyelitis • eastern / western equine encephalomyelitis • Ricin toxin from Ricinus communis (castor bean) • Epsilon toxin of Clostridium perfringens • Staphylococcus enterotoxin B

19. CRITICAL BIOLOGICAL AGENTSCATEGORY B • Subset of Category B agents that include pathogens that are food- or waterborne • Salmonella species • Shigella dysenteriae • Escherichia coli O157:H7 • Vibrio cholerae • Cryptosporidium parvum

20. CRITICAL BIOLOGICAL AGENTSCATEGORY C • Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of: • availability • ease of production and dissemination • potential for high morbidity and mortality and major health impact • Preparedness for Category C agents requires ongoing research to improve detection, diagnosis, treatment, and prevention

21. CRITICAL BIOLOGICAL AGENTSCATEGORY C • Nipah virus • Hantaviruses • Tickborne hemorrhagic fever viruses • Tickborne encephalitis viruses • Yellow fever • Multidrug-resistant tuberculosis

22. ISSUES • Existing local, regional, and national surveillance systems • Adequate to detect traditional agents • Inadequate to detect potential biowarfare agents • Specific training for health care professionals • clinical personnel will be “first responders”

23. ISSUES • Civilian biodefense plans are usually based on HAZMAT models • Assumes responders enter a high exposure environment near the source • Assumes site of exposure is separate from the health care facility • Assumes no time pressure for decontamination • Maximum protection is provided for a minimum number of workers / rescuers

24. ISSUES • HAZMAT • OSHA mandates use of PPE based on site hazard, but site hazards are more easily defined at the point of release • Traditional HAZMAT products are expensive, take time to set up, and are inadequate for large numbers of patients • Difficult to train and maintain proficiency in a civilian work force with high turnover

25. BIOTERRORISM AND THE PUBLIC HEALTH SECTOR • CONCLUSIONS • Preparation for a biological mass disaster requires coordination of diverse groups of medical and non-medical personnel • Preparation can not occur without support and participation by all levels of government • Preparation must be a sustained and evolutionary process