Public Health and Terrorism: Rising to the Challenge

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Public Health and Terrorism Rising to the
Challenge
Marcelle Layton, MD (EIS 92) New York City
Department of Health
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Terrorism Today

• gt 14,000 terrorist acts worldwide between
  1968-2001, resulting in gt 13,000 deaths
• While overall number of acts decreasing, trend
  toward more violent and destructive attacks
• State sponsored terrorism now less common than
  loosely affiliated groups of extremists
• Move away from terrorism as a means to an end
  to terrorism as an end in itself

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Public Heath Response to Previous Major Terrorist
Events in US

• 1993 World Trade Center bombing
• NYCDOH was not considered a 1st responder
• Limited injury epidemiologic studies (1o done by
  CDC)
• 1995 Oklahoma City bombing
• Provided some clinical services on-site (tetanus)
• Injury surveillance DOH made bomb-related
  injuries or health conditions reportable
• Developed registry of survivors for longterm
  follow-up
• Helped coordinate mental health services

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NYCDOH Transition to a First Responder Agency
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All Hazards Preparedness Planning at New York
City DOH, 1995-Present

• Instituted emergency response command system
• Coordination with emerg mgmt, law enforcement,
  NYC hospitals and regional public health agencies
• Enhanced surveillance systems
• Pre-planning for large-scale surveillance/epi
  response
• Level B Laboratory
• Pre-planning for mass antibiotic distribution
• Emergency communications (MD alerts, hotlines,
  2-way radios)
• Frequent tabletop exercises and drills

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September 11, 2001
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New York City TimelineSeptember 11, 2001

• 846 AM Boeing 767 flew into 1 WTC
• 903 AM 2nd plane hits 2 WTC
• 920 AM NYCDOH EOC activated
• 959 AM 2 WTC collapses
• 1029 AM 1 WTC collapses
• 5 PM 7 WTC collapses (NYCs EOC)
• Overall impact 3000 dead, 25,000
  residents temporarily displaced, 17 acres of
  total destruction

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NYCDOHs Emergency Operations Center Activation
in Response to 9/11

• Modified Incident Command System with 7 emergency
  response committees
• Environmental Operations Laboratory MIS
• Sheltering Clinical Surveillance
• EOC senior staff meetings twice a day
• 24-hour on-site EOC coverage with call schedule
  maintained for gt 2 weeks after attack
• Full time DOH liaisons at Citys EOC to ensure
  inter-agency coordination

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Challenges faced by NYCDOH in Response to
September 11th

• Communication challenges
• Mayors EOC in 7 WTC had collapsed
• Lost our phones when hub near 7 WTC flooded
• Completely dependent on 2-way radios and email
• Unable to contact many of our own employees
• Public provider community could not easily
  reach us
• Needed to evacuate our main building on Sept.
  12th, and relocate to our laboratory uptown

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New York City Department of HealthEmergency
Response to WTC Disaster

• Surveillance ER surveillance for acute injuries
  Hospital needs assessments Rescue worker
  injuries
• Environmental Monitored air, water, food
  safety Rodent and vector control
• Clinical issues Provided first aid in DOH lobby
• Oversaw worker
  safety at site
• Communication Media advisories Medical alerts
  
• Public hotlines,
  Websites
• Sheltering DOH nurses staffed 12 shelters
• Mental health Crisis hotline Referral
  Debriefings

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Enhanced Bioterrorism Surveillance in Response to
9/11

• Sept 12 Enhanced surveillance for any BT event
  
• Active surveillance at 15 sentinel E.R.s
• Frequent broadcast alerts to prompt reporting of
  unusual clusters or disease manifestations
• Oct 4 Began active surveillance for
  inhalational anthrax after index case in Florida
  reported
• Outreach to all ICUs, micro labs, ICP and ID MDs
  

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Friday, October 12, 2001

• 12 AM CDC reports (-) PCR on biopsy/letter
• 3 AM CDC reports () tissue stain on biopsy
• 6 AM NYCDOHs EOC activated
• 9 AM NBC informed. Start epi investigation
• 12 PM Press conference at NBC
• 3 PM Open antibiotic distribution clinic
• 4 PM A 2nd threat letter is found
• 11 PM 2nd letter postmarked 9/18 tests ()

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When it rains it pours.

• By the evening of October 12th, 3 additional
  highly suspect cutaneous cases were reported
  (all associated with major media outlets)
• As each case confirmed, multidisciplinary teams
  mobilized for on-site investigations and response

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NYCDOH Response at Media Sites

• Epidemiologic Active surveillance for other
  cases and interviews for suspicious letters
  (conducted with NYPD/FBI)
• Environmental testing Focused on cases work
  area and mail trail
• Clinical Decision re NP swabs for epi
  purposes and antibiotic prophylaxis for those
  at-risk
• Educational outreach and mental health counseling

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Worksite Investigations
Site Date Started Interviews Nasal swabs Prophylaxis initiated
NBC Oct 12 1283 1360 1283
ABC Oct 15 732 757 None
CBS Oct 18 357 352 None
NY Post Oct 19 175 111 23
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NYCDOH Citywide Response to Anthrax Threat

• Enhanced/Active surveillance for additional cases
• Rapid development of clinical guidelines
• Laboratory testing (gt3000 powder events)
• Prioritized communication
• Targeting providers Broadcast alerts, MD
  hotline, Speakers Bureau, Website
• Targeting public Public Hotline, Website,
  Speakers Bureau, Press conferences
• Environmental testing/clean-up at affected sites

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NYCDOH Anthrax Surveillance

• Enhanced citywide surveillance
• Modified efforts to detect cutaneous cases
• Targeted outreach to dermatologists
• Set up dermatology referral system (digital
  cameras)
• Continued to send frequent broadcast alerts
• Expanded ER syndromic system to 29 hospitals
• Employee health surveillance (USPS and MTA)
• Alerts sent to veterinarians re suspect animal
  cases

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Case Management of Suspect Cases

• Suspect cases reported to Provider hotline (24-7
  coverage)
• Determined if met criteria for further testing
• Highly suspect cutaneous cases met at MD office
  to facilitate collection of specimens and to take
  digital photos
• Lab testing arranged at DOH/CDC with same day
  transports to Atlanta for priority cases

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Response to Inhalational Case

• Unknown source of exposure -- ? Contaminated
  letter vs sentinel case of an aerosolized release
• Close coordination with law enforcement
• Lowered threshold for our response to any
  statistical alarm in ED syndromic system
• Intensive epidemiologic and environmental
  investigation at home, worksite, postal
  facilities, and subways

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We can now conclude that the New York City subway
system is not a sterile environment.

• Neal Cohen, MD
• Commissioner of Health, NYC
• November 21, 2001

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Summary of NYC Anthrax Investigations

• gt 600 potential cases reported by MDs
• What we found
• 8 confirmed cases 7 cutaneous and 1 inhalational
• None of gt2,500 nasal swabs positive
• Only 2 contaminated threat letters found
• 1o focal environmental contamination
• Source for the inhalational case remains unknown
• 30 media and 1700 postal workers recommended to
  take long-term (60-100 d) antibiotic prophylaxis

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Public Health Response to Bioterrorism

• Detection of a potential outbreak
• Rapid investigation to confirm that outbreak has
  occurred and identify etiology (natural vv
  intentional)
• Notification of key partners (esp medical
  community)
• Epidemiologic and criminal investigation
• Maintain active surveillance to track morbidity
• Implement control measures, as indicated
• Pro-active communication with public and
  providers, that also addresses mental health
  concerns

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So How Did We Do??

• What went well
• Emerg. response struc
• MD Health Alerts
• Provider reporting
• Mayoral briefings
• Hotline mobilization
• Working with FBI/PD

• What did not go so well
• Reaching 1o care MDs
• Lab was overwhelmed
• Environmental issues
• Mental health response
• Communication with and efficient use of our staff

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Surge Capacity and Sustaining a Response

• 24/7 response from Sept 11th through mid-Dec.
• Required 6 separate investigations
• Many staff worked gt 12 hour days 7 days a week
• Required reassigning staff from other programs
  gt 80 CDC staff deployed
• Core public health activities still needed to be
  maintained

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Lessons Learned

• Disclaimer The following slides reflect the
  opinion of the speaker only
• and are not the official position of the NYC
  Department of Health

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Risk of Inhalation Anthrax from Letters was
Underappreciated

• because energy is required to aerosolize
  anthrax spores, opening a letter, even if it
  contained anthrax, would be unlikely to place a
  person at substantial risk. For these reasons,
  postexposure prophylaxis may not be necessary in
  many cases of threatened anthrax dissemination.
• From Clinical and Epidemiologic Principles of
  Anthrax in Emerg Infect Dis 1999 vol. 5, p. 554.

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Decision Making without Data

• We knew less than we thought about the
  epidemiology of bioterrorism
• Needed to make decisions rapidly in midst of
  crisis
• Interim control measures developed in absence of
  data
• Few subject matter experts available
• Understanding of risk evolved as outbreak
  unfolded
• Public trust requires consistent approach to
  decisions
• Need rapid, adaptive decision making process
  involving both government academic experts

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Lessons LearnedDetection and Surveillance

• Detection
• For small outbreaks, MD reporting is KEY
  (MD awareness of BT diseases and
  when/how to report)
• For larger outbreak, potential value of syndromic
  surveillance for early detection
• Ongoing surveillance
• Prioritize active communication with providers
• Need clear consistent reporting criteria
• Need surge capacity to rapidly ramp up
  surveillance, including provider hotlines to
  triage calls

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West Nile Virus 1999The Power of Physician
Reporting
Epi investigation started
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EMS calls
Employee health- flu
ED flu syndrome visits
ED respiratory visits
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Lessons LearnedData Management

• Try to solve problems before the outbreak
• Prioritize management of data
• Need flexible, ready-to-go database that
  relates lab and epi data
• Systems should be used routinely, not ramped up
  in emergency conditions

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Multi-Jurisdictional Issues? One vs Separate
Investigations

• Continuity between states was inadequate with
  insufficient sharing of key information
• Multi-state conference calls not implemented
  immediately and not attended by all key states
• Interpretation of data at each site required
  understanding of the comprehensive picture
• It was not always clear who was in charge at the
  national level

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Lessons LearnedMulti-jurisdictional Outbreaks

• Value of centralized coordination
• Need secure and efficient means for communication
• Well moderated conference calls
• Earlier use of Epi-X and HAN
• Consistent case definitions and surveillance
  methods
• Consistent approach to public health decision
  making

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Working with New Partners
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Lessons LearnedWorking with New Partners

• Understand the different professional cultures of
  law enforcement and emergency mgmt
• Get to know each other ahead of time
• Adapt an Incident Command system to ensure
  effective interagency response
• Designate liaisons to ensure regular
  communication before and during acute events
• Respect security and confidentiality concerns

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The Ideal NYC Terrorism Preparedness Planning
Meeting
NYPD
Emerg Mgmt
Me
FBI
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National Pharmaceutical Stockpile
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NYCS Point of Distribution Clinics
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Lessons LearnedMass Prophylaxis

• If public perceives that government is not able
  to protect them, they will try to protect
  themselves
• Pre-planning is KEY Pre-trained staff and
  pre-prepared materials (fact sheets, protocols)
• We cant do it alone! - Need to educate involve
  the public/providers in our preparedness planning
  

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Planning for Mass Casualties
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What Can Hospitals Do To Prepare for BT?

• Have an active emergency response system
• Maintain BT awareness among staff and ensure that
  triage protocols are in place for suspect cases
• Anticipate/plan for surge capacity needs
• Ensure ability to rapidly communicate with staff
• Train and exercise staff regularly
• Work with public health agencies to develop a
  regional mass casualty care plan

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Lessons LearnedCommunication

• NYCDOH Many of our staff felt left out of the
  loop
• Public health There were no unaffected states
• Medical community Needs to get information from
  us in a timely fashion, otherwise they will get
  it elsewhere and may get it wrong
• Public Need pro-active and early PH media
  presence
• Ensure that key officials are informed and on
  message
• Develop expertise in risk communication

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Improving Communication in Response to Public
Health Disasters

• Media Prioritize time for talking with
  reporters
• Public Establish hotlines using well-trained
  staff
• Providers Ensure mechanisms to provide MDs with
  up-to-date information (hotlines, broadcast
  alerts)
• Politicians Educate them to the issues ahead of
  time
• Everyone Use the Web

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Powders, Powders Everywhere
The Impact of the Worried Well on the Public
Health and Medical Systems
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Target of Terrorism is Publics Mental Health
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Weapons of Mass Disruption
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Acute Mental Health Impact of World Trade Center,
2001

• Manhattan residents
• 7.5-40 with PTSD
• National telephone survey
• Conducted 3-5 days after September 11th
• 44 adults and 35 children had one or more
  stress symptoms

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Be Alert!! Go shopping!!
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Approaching Mental Health Preparedness for
Terrorism

• Prior to event
• Educate public on risk and government response
  plans
• Involve the community in planning efforts
• Pre-train public health officials in risk
  communication
• Post event
• Early pro-active public messages explaining what
  is known and what public can do to protect
  themselves
• Rapidly establish crisis hotlines and referral
  sites
• Mobilize mental health reserve corp to counsel
  victims/families/rescue workers and ID those
  at-risk

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  HHS ANNOUNCES 1.1 BILLION IN FUNDING TO STATES
FOR BIOTERRORISM PREPAREDNESS
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Improving Local\State Capacityto Respond to
Terrorism

• Enhance BT awareness and foster relationships
  with MDs
• Improve hospital preparedness with regional mass
  care plan
• Build public health resources and expertise
• Emergency planning and response
• Surveillance and epi capacity
• Reference laboratory services
• Planning for mass antibiotic/vaccine prophylaxis
• Environmental expertise (chemical and radiation)
• Secure electronic communication links with key
  partners
• Communication with public (Call Center, media
  training)
• Mental health preparedness planning
• Ongoing staff training and interagency exercises

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Bioterrorism Preparedness may be a Disastrous
Detour for Public Health

• The magnitude of government support for domestic
  terrorism initiatives may be disproportionate to
  the probability of terrorist incidents occurring,
  particularly in comparison to government support
  for .(other) public health problems that impact
  large segments of the population

Victor Sidel, Hillel Cohen, and Robert Gould,
AJPH May 2001
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Dual Use or Double Green Stamps Value of
Terrorism Funding forOverall Public Health
Preparedness
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Those who forget historyNYC Smallpox Outbreak
of 1947

• 12 smallpox cases in NYC
• Most New Yorkers had not been vaccinated (500,000
  doses of vaccine on hand)
• NYC recommends vaccination for all 7.5 million
  New Yorkers
• Hospitals, schools, police stations, businesses,
  union halls designated as vaccination sites
  (n179)
• 1000 physicians and nurses staffed the clinics

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Last Smallpox Outbreak in NYC - 1947
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Prevention

• The best way to prevent a terrorist event from
  being an overwhelming disaster is to prevent it
  from happening in the first place
• Address the global health and human rights issues
  (social/political/economic factors) that foster
  terrorism
• Strengthen and enforce the UNs Biologic and
  Chemical Weapons Conventions
• Restrict sale of BT organisms from lab
  repositories worldwide, as well as safeguard
  research stocks
• Enhance international intelligence capacity to
  identify terrorists working with WMD agents

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