1. ERIC K. NOJI, M.D. Bioterrorism Preparedness European Masters in Disaster Medicine Arona, Italy 27 April 2004 Eric K. Noji, MD, MPH Department of Homeland Security Washington, D.C.

2. ERIC K. NOJI, M.D. “A bioterrorism attack anywhere in the world is inevitable in the 21 st century.” Anthony Fauci, Director, NIAID Clinical Infectious Diseases 2001;32:678

3. ERIC K. NOJI, M.D. Increasing Global Travel Increasing Global Travel Rapid access to large populations Rapid access to large populations Poor global security & awareness Poor global security & awareness...create the potential for simultaneous creation of large numbers of casualties

4. ERIC K. NOJI, M.D. Limited prior experience in CBRN type response except for naturally occurring infectious disease outbreaks, for example – Cholera/Lassa fever/Ebola virus. Evacuation only strategy. Limited numbers of adequately trained staff, equipment, procedural knowledge. Global Preparedness

5. ERIC K. NOJI, M.D. History CBRN Agents have been used on unprotected civil populations on many occasions CBRN Agents have been used on unprotected civil populations on many occasions Some of the locations where the local population had no defense were Some of the locations where the local population had no defense were EthiopiaEthiopia IraqIraq AfghanistanAfghanistan LaosLaos JapanJapan

6. ERIC K. NOJI, M.D. CBRNE Agents Conventional (Explosive) Chemical Biological / Radoilogic OnsetInstantRapid Often Delayed SourceObviousObvious Often covert First Victim Encounter PrehospitalPrehospitalHospital ContainmentEasy Relatively Easy Difficult Decon Helpful Usually Not Yes Usually Not*

7. ERIC K. NOJI, M.D. Sources of Agents for Terrorism Use World Directory of Collections of Cultures and Microorganisms World Directory of Collections of Cultures and Microorganisms 453 worldwide repositories in 67 nations453 worldwide repositories in 67 nations 54 ship/sell anthrax 54 ship/sell anthrax 18 ship/sell plague 18 ship/sell plague International black-market sales associated with governmental programs International black-market sales associated with governmental programs

8. ERIC K. NOJI, M.D. Anthrax Threats Reported to FBI Source: M. Lyons, CDC from FBI personal communication

9. ERIC K. NOJI, M.D. Biological Agents CDC/WHO list of high-likelihood potential bio-terrorist agents CDC/WHO list of high-likelihood potential bio-terrorist agents Prioritized according to: Prioritized according to: Ease of disseminationEase of dissemination TransmissibilityTransmissibility MortalityMortality Public health impactPublic health impact Potential to cause fear and social disruptionPotential to cause fear and social disruption Need for special preparednessNeed for special preparedness

10. ERIC K. NOJI, M.D. Biological Agents Category A Category A SmallpoxSmallpox AnthraxAnthrax PlaguePlague BotulismBotulism TularemiaTularemia Viral Hemorrhagic FeversViral Hemorrhagic Fevers Ebola, Marburg, Lassa, Argentine HF Ebola, Marburg, Lassa, Argentine HF

11. ERIC K. NOJI, M.D. Biological Agents Category B: Category B: Q fever, Brucellosis, Glanders, VEE, EEV, WEV, Ricin, … Q fever, Brucellosis, Glanders, VEE, EEV, WEV, Ricin, … Food & water-borne: Salmonella, Shigella, E. coli 0157:H7, ….. Food & water-borne: Salmonella, Shigella, E. coli 0157:H7, ….. Category C: Category C: Nipah virus, Hanta virus, Yellow fever, Tickborne viruses, …. Nipah virus, Hanta virus, Yellow fever, Tickborne viruses, ….

12. ERIC K. NOJI, M.D. Diagnosis - Diagnosis difficult given diseases have been seen by few living clinicians -Abnormal presentations of classical diseases may be present due to super infection -Diagnosis critical for epidemiological monitoring -Accurate data required for potential future prosecution of war crimes -Psychogenic overlay may cloud the diagnostic process

13. ERIC K. NOJI, M.D. Biological Agents Syndrome Recognition Syndrome Recognition Most bio-terrorist agents initially induce an influenza-like prodrome, including fever, chills, myalgias, or malaiseMost bio-terrorist agents initially induce an influenza-like prodrome, including fever, chills, myalgias, or malaise One of four syndromic patterns then follow:One of four syndromic patterns then follow: Rapidly progressive pneumonia Rapidly progressive pneumonia Fever with rash Fever with rash Fever with altered mental status Fever with altered mental status Bloody diarrhea Bloody diarrhea

14. ERIC K. NOJI, M.D. Small Pox (Variola major virus) Transmitted primarily by aerosol route, contaminated clothes & linens Transmitted primarily by aerosol route, contaminated clothes & linens Highly communicable Highly communicable Vaccine can lessen the severity of disease if given within 4 days of exposure Vaccine can lessen the severity of disease if given within 4 days of exposure

15. ERIC K. NOJI, M.D. Small Pox 30% case fatality rate if untreated 30% case fatality rate if untreated One of four biological agents thought to be most likely used by terrorists One of four biological agents thought to be most likely used by terrorists Incubation 7-17 days Incubation 7-17 days Prodrome of high fever, malaise, vomiting, headache, myalgias Prodrome of high fever, malaise, vomiting, headache, myalgias 2-3 days later get rash beginning on face, hands, forearms 2-3 days later get rash beginning on face, hands, forearms

16. ERIC K. NOJI, M.D. Small Pox Patients infectious until all scabs are shed Patients infectious until all scabs are shed No treatment, but animal studies show promise for cidofovir No treatment, but animal studies show promise for cidofovir

17. ERIC K. NOJI, M.D. Anthrax (bacillus Anthracis) Inhalational, gastrointestinal, cutaneous Inhalational, gastrointestinal, cutaneous NOT communicable (except maybe cutaneous) NOT communicable (except maybe cutaneous) Vaccine not available for civilian use Vaccine not available for civilian use 20%-80% mortality 20%-80% mortality

18. ERIC K. NOJI, M.D. Anthrax Resistant to heat, UV, drying, many disinfectants Resistant to heat, UV, drying, many disinfectants Incubation 2-6 days Incubation 2-6 days Biphasic illness Biphasic illness nonspecific flu-like symptomsnonspecific flu-like symptoms High fever, SOB, chest and abdominal painHigh fever, SOB, chest and abdominal pain Sore throat, runny noseSore throat, runny nose NOT associated

19. ERIC K. NOJI, M.D. Anthrax Treatment – multi-drug antibiotics Treatment – multi-drug antibiotics Prophylaxis – single drug for 60 days Prophylaxis – single drug for 60 days

20. ERIC K. NOJI, M.D.

21. Pneumonic Plague Caused by infection with Yersinia Pestis Caused by infection with Yersinia Pestis Pneumonic form will occur after intentional aerosol delivery Pneumonic form will occur after intentional aerosol delivery Incubation period of 1-7 days Incubation period of 1-7 days

22. ERIC K. NOJI, M.D. Pneumonic Plague Symptoms: Symptoms: Fever, malaise, fatigue, cough, SOBFever, malaise, fatigue, cough, SOB Signs: Signs: Classic finding of production of bloody sputum in a previously healthy patientClassic finding of production of bloody sputum in a previously healthy patient Treatment: Antibiotics Treatment: Antibiotics

23.  Detection & surveillance  Rapid laboratory diagnosis  Epidemiologic investigations  Implementation of control measures Public Health Response to Bioterrorism

24. Bioterrorism Surveillance Early, rapid recognition of unusual clinical syndromes or deaths Early, rapid recognition of unusual clinical syndromes or deaths Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death

25. Clues to Possible Bioterrorism I Single case caused by an uncommon agent Single case caused by an uncommon agent Large number of ill persons with similar disease, syndrome, or deaths Large number of ill persons with similar disease, syndrome, or deaths Large number of unexplained disease, syndrome, or death Large number of unexplained disease, syndrome, or death Unusual illness in a population Unusual illness in a population Higher morbidity & mortality than expected with a common disease or syndrome Higher morbidity & mortality than expected with a common disease or syndrome Multiple disease entities coexisting in the same patient Multiple disease entities coexisting in the same patient Disease with an unusual geographic or seasonal distribution Disease with an unusual geographic or seasonal distribution

26. Clues to Possible Bioterrorism II Multiple atypical presentations of disease agents Multiple atypical presentations of disease agents Similar genetic type of agent from distinct sources Similar genetic type of agent from distinct sources Unusual, atypical, genetically engineered, or antiquated strain Unusual, atypical, genetically engineered, or antiquated strain Endemic disease with unexplained increased incidence Endemic disease with unexplained increased incidence Simultaneous clusters of similar illness in con-contiguous areas Simultaneous clusters of similar illness in con-contiguous areas Atypical aerosol, food, or water transmission Atypical aerosol, food, or water transmission Ill persons presenting during the same time Ill persons presenting during the same time Concurrent animal disease Concurrent animal disease

27. ERIC K. NOJI, M.D. Bioterrorism: Potential Data Sources Laboratories Laboratories Infectious disease Infectious disease Specialists Specialists Hospitals Hospitals Physician’s offices Physician’s offices Poison control centers Poison control centers Medical Examiners Medical Examiners Death Certificates Death Certificates Police/Fire departments Police/Fire departments Other “first responders” Other “first responders” Pharmacy data Pharmacy data

28. ERIC K. NOJI, M.D. Syndrome Surveillance The monitoring of illnesses based upon a constellation of symptoms and/or findings The monitoring of illnesses based upon a constellation of symptoms and/or findings Provides an “early warning system” for outbreaks, emerging pathogens Provides an “early warning system” for outbreaks, emerging pathogens Highly sensitive, seasonal specificity varies Highly sensitive, seasonal specificity varies

29. ERIC K. NOJI, M.D. Examples of Syndromes for Surveillance Unexplained death w/ history of fever Unexplained death w/ history of fever Meningitis, encephalitis or unexplained acute encephalopathy/delirium Meningitis, encephalitis or unexplained acute encephalopathy/delirium Botulism-like syndrome (cranial nerve impairment and weakness) Botulism-like syndrome (cranial nerve impairment and weakness) Rash and fever Rash and fever Non-pneumonia respiratory tract infection w/ fever Non-pneumonia respiratory tract infection w/ fever Diarrhea/Gastroenteritis Diarrhea/Gastroenteritis Pneumonia Pneumonia Sepsis or non-traumatic shock Sepsis or non-traumatic shock

30. ERIC K. NOJI, M.D. Information System Functions Needed for Bioterrorism Preparedness and Response PREPAREDNESS REQUIRES THAT ALL PARTNERS--LOCAL, STATE, & FEDERAL ARE PART OF SYSTEMS PREPAREDNESS REQUIRES THAT ALL PARTNERS--LOCAL, STATE, & FEDERAL ARE PART OF SYSTEMS Surveillance data analysis--event detection & management Surveillance data analysis--event detection & management Notification—rapid alerting Notification—rapid alerting Communications –information, not data Communications –information, not data Knowledge management Knowledge management

31. ERIC K. NOJI, M.D. The Immediate Future 2003 – 2010 A Revolution in biotechnology, genomics and proteomics that will affect all human beings

32. ERIC K. NOJI, M.D. TODAY’S SITUATION Many hospitals on trauma diversion with no major incidents going on Many hospitals on trauma diversion with no major incidents going on Not economically viable for hospitals to maintain surge capacity, or even to focus on treating sick and injured (hospitals lose money treating the truly sick) Not economically viable for hospitals to maintain surge capacity, or even to focus on treating sick and injured (hospitals lose money treating the truly sick) Public health infrastructure is beyond simple band-aid fixes Public health infrastructure is beyond simple band-aid fixes Military health system (including VA) is not effectively integrated or used Military health system (including VA) is not effectively integrated or used

33. ERIC K. NOJI, M.D. Provide More Health System Surge Capacity Health care cost control has systematically eliminated reserve capacity from the system. Health care cost control has systematically eliminated reserve capacity from the system. Need to rethink how much surge capacity is needed for emergencies. Need to rethink how much surge capacity is needed for emergencies. Need to re-assess adequacy and geographic extent of mutual aid agreements. Need to re-assess adequacy and geographic extent of mutual aid agreements. What mobile resources can the federal and state governments truly provide? What mobile resources can the federal and state governments truly provide? Also need plans to tap unconventional resources if disasters strike – e.g., sites for emergency care, inventories of health care workers. Also need plans to tap unconventional resources if disasters strike – e.g., sites for emergency care, inventories of health care workers.

34. ERIC K. NOJI, M.D. Summary: Priority Preparedness Activities State & local preparedness planning State & local preparedness planning Surveillance and epidemiology Surveillance and epidemiology Outbreak verification Outbreak verification Laboratory capacity for biologic & chemical agents Laboratory capacity for biologic & chemical agents Health information & communication systems Health information & communication systems Training Training Establish key liaisons Establish key liaisons

35. Bottom Line Early, rapid recognition of unusual clinical syndromes or deaths Early, rapid recognition of unusual clinical syndromes or deaths Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death