BIOTERRORISM AND THE PUBLIC HEALTH SECTOR

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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

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WHY PUBLIC HEALTH ?

• 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

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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

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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

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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

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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

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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/rr49
  04a1.htm

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PUBLIC HEALTH

• Preparedness and prevention
• Detection and surveillance
• Diagnosis and characterization of agents
• Response
• Communication

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PUBLIC HEALTH

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

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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

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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

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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

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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

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PUBLIC HEALTH

• Effective planning and response to a biological
  terrorist incident will require collaboration
  with federal, state, and local groups and
  agencies including

-public health organizations -medical research
centers -health-care providers and their
networks -professional societies -medical
examiners
-emergency response units and
organizations -safety and medical equipment
manufacturers -US Office of Emergency
Management -other federal agencies
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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

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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

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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 CDCs diagnostic
  capacity and enhanced disease surveillance

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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

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CRITICAL BIOLOGICAL AGENTSCATEGORY B

• Subset of Category B agents that include
  pathogens that are food- or waterborne
• Salmonella species
• Shigella dysenteriae
• Escherichia coli O157H7
• Vibrio cholerae
• Cryptosporidium parvum

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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

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CRITICAL BIOLOGICAL AGENTSCATEGORY C

• Nipah virus
• Hantaviruses
• Tickborne hemorrhagic fever viruses
• Tickborne encephalitis viruses
• Yellow fever
• Multidrug-resistant tuberculosis

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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

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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

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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

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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