3 October 2001 Anthrax Outbreak What went wrong? Lead agency was unclearFederal authorities appeared confusedSloppy scientific thinking underestimated spore threat through mail systemFirst responders were inadequately trained for hazardPublic health Labs were poorly prepared to receive pathogens, provide timely diagnostics, or perform high volume sample evaluationsFederal and state priorities were unclear, and often conflicted.Physicians were uneducated about diseaseSo-called “textbook” knowledge was often misleading or incompleteDecontamination was difficult
4 Threat Assessment Preparedness Response Essential Elements of a Public Health StrategyThreat AssessmentPreparednessResponse
5 Potential Bioterrorism Agents VirusesSmallpoxVEEVHFBacterial AgentsAnthraxBrucellosisCholeraPlague, PneumonicTularemiaQ FeverSource: U.S. A.M.R.I.I.D.Biological ToxinsBotulinumStaph Entero-BRicinT-2 MycotoxinsWhen CDC started it’s bioterrorism program, it developed a potential list of agents or diseases that could be used against a population. A national group of disease experts created a critical agents list for biologicals. Bacteria, viruses, and toxins are included.
6 Deliberate v. Naturally-Occurring Outbreak Does it matter?
7 Bioterrorism preparedness should be an extension of our current medical and public health infrastructure.
8 Epidemic Diseases are all around us WHO: Mortality Trends (1997)Infectious and ParasiticCirculatory33.1%5Infectious and ParasiticDiseases29.3%Other413.2%Deaths,millions3CancerPerinatal6.9%211.9%Respiratory15.6%HIV/AIDSAcuteRespiratoryTBMalariaDiarrhea
17 Linking of Response Systems First RespondersFire/EMSMedical & MentalHealth ServicesLawEnforcementPublicHealthEmergency Management
18 Relationship Between Crisis and Consequence Management The Department of Justice assigns lead responsibility for operational response to the FBI, which operates as the on-scene manager for the Federal GovernmentFEMA is the lead agency for consequence management and can use FRP structures to coordinate all Federal assistance to State and local governments.
19 The National Pharmaceutical Stockpile Program National Electronic Data Surveillance System (NEDSS)The Global Outbreak Alert and Response NetworkEpidemic Information Exchange (Epi-X)Laboratory Response NetworkMetropolitan Medical Response System (MMRS)
20 Structure of the LRNCDC and USAMRIID. Expertise with unusual organisms Specimen repository.Level D Federal Labs BSL-4Rapid identification using molecular methods. Test evaluation.Level C Labs * BSL-3Isolation and presumptive ID. Antimicrobial susceptibility testing. 24/7 response.Level B Public Health Labs BSL-2 + or 3* Level A Labs - Enhanced medical lab protocol.* Level B Labs - Work at BSL-2 with BSL-3 Practices.* Level C: Probe, type, identify subspecies, perform toxigenicity testing, etc.* Need to make sure you are using best practices all the time. Refine practices outside of the cabinet.OPPORTUNITY TO EXPOUND.Level A Clinical LabsBSC (Class II-B)Early detection, rule out and refer.*State, research, federal
21 Metropolitan Medical Response System (MMRS) An operational system at the local level to respond to a terrorist incident and other public health emergencies that create mass casualtiesThis system enables a Metropolitan Area to manage the event until State or Federal response resources are mobilizedMMRS is a locally developed, owned, and operated mass casualty response system
22 Metropolitan Medical Response Systems Original MMRSBoston, New York, Baltimore, Philadelphia, Washington DC, Atlanta, Miami, Memphis, Jacksonville, Detroit, Chicago, Milwaukee, Indianapolis, Columbus, San Antonio, Houston, Dallas, Kansas City, Denver, Phoenix, San Jose, Honolulu, Los Angeles, San Diego, San Francisco, Anchorage, SeattleMMRS 1999Hampton Roads (Virginia Beach)Area, Pittsburgh, Nashville, Charlotte, Cleveland, El Paso, New Orleans, Austin, Fort Worth, Oklahoma City, Albuquerque, St. Louis, Salt Lake City, Long Beach, Tucson, Oakland, Portland (OR), Twin Cities (Minneapolis), Tulsa, SacramentoMMRS 2000Twin Cities (St. Paul), Hampton Roads (Norfolk),Cincinnati, Fresno, Omaha, Toledo, Buffalo, Wichita,Santa Ana, Mesa, Aurora , Tampa, Newark, Louisville, Anaheim, Birmingham, Arlington, Las Vegas,Corpus Christi, St. Petersburg, Rochester, Jersey City,Riverside, Lexington-Fayette, AkronMMRS 2001Colorado Springs, Baton Rouge, Raleigh, Stockton, Richmond (VA), Shreveport, Jackson, Mobile, Des Moines, Lincoln, Madison, Grand Rapids, Yonkers, Hialeah, Montgomery, Lubbock, Greensboro, Dayton, Huntington Beach, Garland, Glendale (CA), Columbus (GA), Spokane, Tacoma, Little RockMMRS 2002Bakersfield, Fremont, Ft. Wayne, Hampton Roads (Newport News, Chesapeake), Arlington, Worcester, Knoxville, Modesto, Orlando, San Bernardino, Syracuse, Providence, Huntsville, Amarillo, Springfield, Irving, Chattanooga, Kansas City, Jefferson Parish, Ft. Lauderdale, Glendale, Warren, Hartford, Columbia
25 Contagious OutbreaksIdentification of clinical symptomsRapid and accurate diagnosticsAccurate reporting and open communicationWillingness to isolate and quarantine all infected populationsMobilization of scientists to develop vaccines, therapeutics, new diagnostics, and determine the source of the outbreak
26 Drug Resistancewhat if the organism is drug resistant and we can’t treat?Molecular engineering is easyWhat would have happened during the anthrax outbreak?What good is the National Pharmaceutical Stockpile in this event?”
27 Role of Healthcare Professionals First line of defense.But what if they are early victims of the outbreak (e.g. Toronto)?
28 Hospitals as an amplifier of infection SARS Cases in Toronto
29 What about mass casualties? What would a plume of anthrax spores do in our area?The 1918 Spanish Flu pandemic hospitalized millions of AmericansCan we handle the patients? Do we have enough lab capacity?
30 CONCLUSIONBioterrorism preparedness must be an extension of our current medical and public health infrastructure.Our ability to respond effectively to a new outbreak will depend on the robustness of the prevailing system.