BIOTERRORISM health preparedness

1. BIOTERRORISMhealth preparedness Dr.T.V.Rao MD Dr.T.V.Rao MD

2. Definition of Bioterrorism "Bioterrorism” - The unlawful use, or threatened use, of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The act is intended to create fear and intimidate governments or societies in the pursuit of political, religious, or ideological goals. Dr.T.V.Rao MD Note: There is no single, universally accepted definition of bioterrorism.

3. 1346 Siege of Kaffa; plague 1763 French and Indian War; smallpox WW I German program; anthrax, glanders 1925 Geneva protocol bans biological weapons WW II Japanese program; anthrax, plague, cholera, shigella History of Biological Warfare Dr.T.V.Rao MD

4. 1941 George W. Merck named U.S. civilian head of Chemical Warfare Service later changed to War ResearcService 1946 U.S. announces its involvement in bioweapons research 1969 Nixon eliminates offensive biological warfare program History of Biological Warfare (cont.) Dr.T.V.Rao MD

5. 1972 Biological Weapons Convention 1979 Accidental release of B. anthracis spores at bioweapon research center, Sverdlovsk, U.S.S.R 1989-92 Scientists from the former U.S.S.R. involved in biological weapons research defect to the West History of Biological Warfare (cont.) Dr.T.V.Rao MD

6. Domestic Biological Terrorism • 1984 Rajneesh cult members contaminate salad bar with Salmonella typhimurium in Oregon • 1992 Ricin attack planned by Minnesota militia • 2001 Anthrax releases in FL, DC, NY, NJ Dr.T.V.Rao MD

7. Biological Terrorism The use of biological agents to intentionally produce illness or intoxication in a susceptible population Dr.T.V.Rao MD

8. Public Health impact criteria based on: Morbidity and mortality Delivery potential Public perception (fear, civil disruption) Public health preparedness needs Biological Agents Ranking System Dr.T.V.Rao MD

9. • Bacillus anthracis (spores) • Brucella abortus • Brucella melitensis • Brucella suis • Burkholderia mallei (aka Pseudomonas mallei) • Burkholderia pseudomallei (aka Pseudomonas pseudomallei) CDC Select Agents* – Bacteria • Clostridium (botulinum- producing species) • Coxiella burnetii • Francisella tularensis • Rickettsia prowazekii • Rickettsia rickettsii • Yersinia pestis n = 12 * Not including agents only on USDA lists. Dr.T.V.Rao MD

10. CDC Select Agents* – Fungi • Coccidioides immitis • Coccidioides posadasii n = 2 * Not including agents only on USDA lists. Dr.T.V.Rao MD

11. CDC Select Agents* – Viruses I • Central European Tick-borne encephalitis • Cercopithecine herpesvirus 1 • Crimean-Congo haemorrhagic fever • Eastern Equine encephalitis • Ebola • Far Eastern Tick-borne encephalitis • Flexal South American haemorrhagic fever • Guanarito South American haemorrhagic fever • Hendra • Junin South American haemorrhagic fever • Kyasanur Forest disease • Lassa fever • Marburg * Not including agents only on USDA lists. Dr.T.V.Rao MD

12. CDC Select Agents* – Viruses II • Machupo South American haemorrhagic fever • Monkeypox • Nipah • Omsk haemorrhagic fever • Reconstructed 1918 influenza • Rift Valley fever • Russian Spring and Summer encephalitis • Sabia South American haemorrhagic fever • Variola major (smallpox) • Variola minor (alastrim) • Venezuelan Equine encephalitis n = 24 * Not including agents only on USDA lists. Dr.T.V.Rao MD

13. CDC Select Agents* – Toxins • Abrin • Botulinum neurotoxins • Clostridium perfingens epsilon toxin • Conotoxins • Diacetoxyscirpenol • Ricin • Saxitoxin • Shiga-like ribosome-inactivating proteins • Shigatoxin • Staphylococcal enterotoxins • Tetrodotoxin • T-2 toxin n = 12 * Not including agents only on USDA lists. Dr.T.V.Rao MD

14. anthrax botulism brucellosis cholera food poisoning glanders hemorrhagic fever lassa fever melioidosis plague Bioweapon-related Diseases • psittacosis • Q-fever • salmonellosis • shigellosis • smallpox • tularemia • typhoid fever • typhus • viral encephalitis Dr.T.V.Rao MD

15. Additional Potential Bioterrorism Agents • • Chlamydia psittaci • • Cryptosporidium parvum • • Escherichia coli O157:H7 • • hantavirus • • Salmonella species • • Shigella species • • Vibrio cholerae Dr.T.V.Rao MD

16. Potential Bioterrorism Agents • Potentially thousands • NATO NBC Handbook lists 31 agents • CDC created Category A, B, & C lists • Based on: • Ease of dissemination • Potential for Public Health Impact • Potential for Public Panic and Social Disruption Dr.T.V.Rao MD

17. Bioterrorism agent classification system CDC • The Centers for Disease Control (2004) have placed agents in one of three priority categories for initial public health preparedness efforts: A, B, or C. Agents Dr.T.V.Rao MD

18. CLASSIFYING BIOTERROR AGENTS CLASS A • Contagious • High death rates and high health impact on the public • ANTHRAX, BOTULISM, SMALLPOX, TULAREMIA, PLAGUE CLASS B • Moderately easy to spread • Some illness & death rates • TYPHUS, WATER SAFETY THREATS, SALMONELLA CLASS C • Easily available • Easily produced and spread • Have potential for high death & illness rates • NIPAH VIRUS Hey look, a llama! Never can be too careful… Dr.T.V.Rao MD

19. Critical biological agents Category A • Can be easily disseminated or transmitted person-to-person • Cause high mortality, with potential for major public health impact • Might cause public panic and social disruption • Require special action for public health preparedness • MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

20. Category Aagents include • variola major (smallpox) • Bacillus anthracis (anthrax) • Yersinia pestis (plague) • Clostridium botulinum toxin (botulism) • Francisella tularensis (tularaemia) • filoviruses • Ebola hemorrhagic fever • Marburg hemorrhagic fever • arenaviruses • Lassa (Lassa fever) • Junin (Argentine hemorrhagic fever) and related viruses • MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

21. Category B • Are moderately easy to disseminate • Cause moderate morbidity and low mortality • Require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance • MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

22. Category B agents • Coxiella burnetti (Q fever); • Brucella species (brucellosis) • Burkholderia mallei (glanders) • alpha viruses • Venezuelan encephalomyelitis • eastern and western equine encephalomyelitis • ricin toxin from Ricinus communis (castor beans) • epsilon toxin of Clostridium perfringens • Staphylococcus enterotoxin B. • MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

23. subset of List B agents includes pathogens that are food- or waterborne - these pathogens include • Salmonella species • Shigella dysenteriae • Escherichia coli O157:H7 • Vibrio cholerae • Cryptosporidium parvum Dr.T.V.Rao MD

24. Category C Includes emerging pathogens that could be engineered for mass dissemination in the future • Nipah virus • Hantaviruses • Fick-borne hemorrhagic fever viruses • Tick-borne encephalitis viruses • Yellow fever • Multidrug-resistant tuberculosis Dr.T.V.Rao MD

25. Biological Delivery Methods • Food / Water • Aircraft sprayers • Vehicle sprayers • Hand sprayers • Mail • Air handling systems • Human Vector • Animal Vector Dr.T.V.Rao MD

26. Key Indicators of a Biological TERROR Event • Occurrence of vector-borne disease where there is no vector • Cluster of sick or dead animals • Atypical seasonality • Geographic Pattern of Illness • More respiratory presentation of disease Dr.T.V.Rao MD

27. The Ideal Bioterror Weapon Would Be • contagious • virulent • robust • difficult to detect • drug-resistant • user-controllable No natural agent meets all of these criteria. Thus, sooner or later, terrorists may decide to devise novel weapons using the techniques of synthetic biology to enhance or replace the characteristics of pre-existing organisms or toxins. Countermeasures must be pursued vigorously – in advance. Dr.T.V.Rao MD

28. Familiarize medical staff with BT agents Incorporate into Disaster Planning Decontamination & Infection Control Communications with key agencies Laboratory, Respective health authorities of the Nation. Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc. Security preparations Preparation for BT Attack Dr.T.V.Rao MD

29. What To Do if You Suspect a Bioterrorist Disease IMMEDIATELY NOTIFY: • Hospital Infection Control • Isolation: Smallpox, plague, hemorrhagic fevers • Laboratory • Hospital Administration • Local Public Health Department Dr.T.V.Rao MD

30. Assess health impacts in the community Environmental health assesses water safety and sanitation Public health nurses coordinate with Shelter Operations Acute communicable disease tracks infectious diseases Injury program tracks injuries and fatalities Health Officer coordinates information for the public and health care providers Public Health Laboratories identify agents (either in-house or through referral to State governments or health authorities ) What does Public Health Do in a Bioterrorist Event? Dr.T.V.Rao MD

31. Special Problems with BT • Identifying a covert attack • Social disruption • Prophylaxis for large populations • Decontamination • Secondary transmission Dr.T.V.Rao MD

32. Technology At Work Forensic teams work hard to identify biological agents, their origins and effects Dr.T.V.Rao MD

33. Technology At Work • Labs are working on advanced detection systems to detect early attacks, identify at-risk areas, and to give proper treatment Dr.T.V.Rao MD

34. Technology At Work • Bio surveillance:Real-Time-Outbreak Disease Surveillance system made its debut in 1999. This collects data from labs, hospitals, and environmental studies in order to detect bioterror attacks as early as possible. Dr.T.V.Rao MD

35. bioterrorism bioagent warning systems • Wyatt-Lorenz was founded as a spin-off of Wyatt Technology Corporation ("WTC") with a unique mission: To provide immediate bioterrorism bioagent warning systems for the protection of people and property from biological and chemical threats. These Bioterrorism threats are often directed toward elements of the private sector long ignored by the Department of Defense and Department of Homeland Security Dr.T.V.Rao MD

36. Special Problems with BIOTERRORISM • Specialized labs needed for some agents • Risks to laboratory workers • Limited resources • Communication between agencies Dr.T.V.Rao MD

37. Familiarize medical staff with BT agents Incorporate into Disaster Planning Decontamination & Infection Control Communications with key agencies Laboratory, CDC, Police, FBI, etc. Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc. Security preparations Preparation for BIOTERRORISMAttack Dr.T.V.Rao MD

38. Classification of BioterrorismLaboratories D - High level characterization (seek evidence of molecular chimeras) and secure banking of isolates Safety & proficiency to probe for universe of bio- and chemical agents in non-clinical specimen Level D Lab BSL-4 C - Safety and proficiency sufficient to probe, type, perform toxigenicity testing Level C Lab BSL-3 B - Safety and proficiency adequate to confirm & characterize susceptibility Level B Lab Work at BSL-3 with BT agents A - Adequate safety to rule-out and forward organisms Level-A Labs - Assess Risks for Aerosols and Use Biosafety Cabinet Dr.T.V.Rao MD

39. What To Do if You Suspect a Bioterrorist Disease IMMEDIATELY NOTIFY: • Hospital Infection Control • Isolation: Smallpox, plague, hemorrhagic fevers • Laboratory • Hospital Administration • Local Public Health Department Dr.T.V.Rao MD

40. Public Health’s Role in Bioterrorism Event • Health Officer coordinates information for the public and medical providers • Community Health and PHN’s provide education, information to the public and to community providers • Treatment and prophylaxis • Quarantine Dr.T.V.Rao MD

41. "We refuse to remain idle when modern technology might be turned against us. We will rally the great promise of American science and innovation to confront the greatest danger of our timeFormer President George W. Bush, at the signing of the Project Bio shield Act of 2004 Authorized spending of $5.6 billion over a span of 10 years in order to pay for vaccines and medical facilities in case of national biological emergency Gave the National Institute of Health grants to pursue medical research & technology Emergency Use Authorization – EUA – gave access to best medical responses in case of an emergency as declared by the Secretary of Human Healthy & Services OR Secretary of Homeland Security Project Bioshield Dr.T.V.Rao MD

42. Coordinating with system is priority Coordinating with the Public Health System Dr.T.V.Rao MD

43. What We Need To Prepare for Bioterrorism • More trained epidemiologists to speed detection • Increased laboratory capacity • Health Alert Network • Medical professionals “back to school” • National Pharmaceutical Stockpile Dr.T.V.Rao MD

44. Familiarize medical staff and lab with bioterrorist threat agents Incorporate BT planning into disaster planning Infection control Notification procedures and contact numbers Daily surveillance and reporting Security preparations Media Personal Protective Equipment (PPE) How can Hospitals Prepare? Dr.T.V.Rao MD

45. Is it a True Terrorism ? • Outbreak of rare disease • Seasonal disease at wrong time • Unusual age distribution • Unusual clinical symptoms • Unusual epidemiologic features • Outbreak in region normally not seen Dr.T.V.Rao MD

46. Steps in Preparing Public Health Agencies for Biological Attacks • Enhance epidemiologic capacity to detect and respond to biological attacks. • Supply diagnostic reagents to state and local public health agencies. • Establish communication programs to ensure delivery of accurate information. • Enhance bioterrorism-related education and training for health-care professionals. • MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

47. BIOTERRORISM AND THE PUBLIC HEALTH SECTOR • 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 Dr.T.V.Rao MD

48. Created by Dr.T.V.Rao MD for ‘e” Learning Resources for Medical and Public Personal on Bioterrorism • Email doctortvrao@gmail.com Dr.T.V.Rao MD