1. Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine, July 2002 Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians

2. UW Northwest Center for Public Health Practice AcknowledgementsAcknowledgements This presentation, and the accompanying instructor’s manual (current as of 7/02), were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, and Jeff Duchin, MD with Public Health – Seattle & King County and the Division of Allergy & Infectious Diseases, University of WA, for the purpose of educating primary care clinicians in relevant aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH The Centers for Disease Control and Prevention Project Coordinator Judith Yarrow Health Policy & Analysis, University of WA Design and Editing Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization section, Public Health - Seattle & King County Ed Walker, MD; University of WA Department of Psychiatry

3. UW Northwest Center for Public Health Practice Introduction to Bioterrorism

4. UW Northwest Center for Public Health Practice Introduction to Bioterrorism Learning Objectives Define bioterrorism Define bioterrorism Describe the general characteristics of potential agents of biological terrorism Describe the general characteristics of potential agents of biological terrorism List epidemiologic clues that suggest a deliberate, as opposed to spontaneous, source of disease List epidemiologic clues that suggest a deliberate, as opposed to spontaneous, source of disease Know the reporting requirements if an intentional disease source or other reportable condition is suspected Know the reporting requirements if an intentional disease source or other reportable condition is suspected Define bioterrorism Define bioterrorism Describe the general characteristics of potential agents of biological terrorism Describe the general characteristics of potential agents of biological terrorism List epidemiologic clues that suggest a deliberate, as opposed to spontaneous, source of disease List epidemiologic clues that suggest a deliberate, as opposed to spontaneous, source of disease Know the reporting requirements if an intentional disease source or other reportable condition is suspected Know the reporting requirements if an intentional disease source or other reportable condition is suspected

5. UW Northwest Center for Public Health Practice What Is Bioterrorism? Definition Terrorism (FBI definition): "The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment of it, in furtherance of political or social objectives." Terrorism (FBI definition): "The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment of it, in furtherance of political or social objectives."

6. What Is Bioterrorism? Definition The intentional use of micro-organisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The intentional use of micro-organisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The goal of bioterrorism is to produce fear in the population with subsequent disruption of society. The goal of bioterrorism is to produce fear in the population with subsequent disruption of society. The intentional use of micro-organisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The intentional use of micro-organisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The goal of bioterrorism is to produce fear in the population with subsequent disruption of society. The goal of bioterrorism is to produce fear in the population with subsequent disruption of society.

7. What Is Bioterrorism? Potential An overt attack is announced. An overt attack is announced. Resembles the traditional HAZMAT event: explosives, chemical exposures. Resembles the traditional HAZMAT event: explosives, chemical exposures. First responders are likely to be traditional first- responders: fire, HAZMAT, police. First responders are likely to be traditional first- responders: fire, HAZMAT, police. An overt attack is announced. An overt attack is announced. Resembles the traditional HAZMAT event: explosives, chemical exposures. Resembles the traditional HAZMAT event: explosives, chemical exposures. First responders are likely to be traditional first- responders: fire, HAZMAT, police. First responders are likely to be traditional first- responders: fire, HAZMAT, police.

8. What Is Bioterrorism? Definite A “covert attack” is unannounced. A “covert attack” is unannounced. Thought to be likely scenario with bioterrorism. Thought to be likely scenario with bioterrorism. First responders are likely to be health care providers, including emergency departments, primary care physicians, and hospitals. First responders are likely to be health care providers, including emergency departments, primary care physicians, and hospitals. A “covert attack” is unannounced. A “covert attack” is unannounced. Thought to be likely scenario with bioterrorism. Thought to be likely scenario with bioterrorism. First responders are likely to be health care providers, including emergency departments, primary care physicians, and hospitals. First responders are likely to be health care providers, including emergency departments, primary care physicians, and hospitals.

9. UW Northwest Center for Public Health Practice History of Bioterrorism Biological warfare (BW) was used as far back as 6th century BC. Examples of past BW: 14th Century: Mongols catapulted corpses with bubonic plague over walls into Crimea. 15th Century: Pizarro presented native South Americans with smallpox-contaminated clothing. 1940: Japan’s “Unit 731” dropped plague- infected fleas over Manchuria & China. Biological warfare (BW) was used as far back as 6th century BC. Examples of past BW: 14th Century: Mongols catapulted corpses with bubonic plague over walls into Crimea. 15th Century: Pizarro presented native South Americans with smallpox-contaminated clothing. 1940: Japan’s “Unit 731” dropped plague- infected fleas over Manchuria & China.

10. UW Northwest Center for Public Health Practice History of Bioterrorism Recent Examples 1984: Rajneeshee Cult contaminated restaurant salad bars with Salmonella typhimurium. 1995: Aum Shinrikyo cult attempted unsuccessfully to disperse BW agents in aerosol form; sarin gas attack in Tokyo. 2001: Anthrax-contaminated letters to U.S. media and government offices. 1984: Rajneeshee Cult contaminated restaurant salad bars with Salmonella typhimurium. 1995: Aum Shinrikyo cult attempted unsuccessfully to disperse BW agents in aerosol form; sarin gas attack in Tokyo. 2001: Anthrax-contaminated letters to U.S. media and government offices.

11. UW Northwest Center for Public Health Practice History of Bioterrorism State-sponsored Bioweapons Research 1972 Biological Weapons Convention 1972 Biological Weapons Convention Treaty prohibiting stockpiling and research into biological agents for offensive purposes Treaty prohibiting stockpiling and research into biological agents for offensive purposes Ratified by >140 countries Ratified by >140 countries Not adhered to in some countries (former Soviet Union) Not adhered to in some countries (former Soviet Union) United States Bioweapons program United States Bioweapons program Offensive program: 1943-1969 Offensive program: 1943-1969 Defensive program: 1953-today at USAMRIID Defensive program: 1953-today at USAMRIID 1972 Biological Weapons Convention 1972 Biological Weapons Convention Treaty prohibiting stockpiling and research into biological agents for offensive purposes Treaty prohibiting stockpiling and research into biological agents for offensive purposes Ratified by >140 countries Ratified by >140 countries Not adhered to in some countries (former Soviet Union) Not adhered to in some countries (former Soviet Union) United States Bioweapons program United States Bioweapons program Offensive program: 1943-1969 Offensive program: 1943-1969 Defensive program: 1953-today at USAMRIID Defensive program: 1953-today at USAMRIID

12. Recognition of a BT Event Surveillance/Detection Goal: Detect unusual medical events sooner rather than later Goal: Detect unusual medical events sooner rather than later Depends on ability to identify a greater than expected number of “cases” or syndromes Depends on ability to identify a greater than expected number of “cases” or syndromes Requires sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks Requires sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks Goal: Detect unusual medical events sooner rather than later Goal: Detect unusual medical events sooner rather than later Depends on ability to identify a greater than expected number of “cases” or syndromes Depends on ability to identify a greater than expected number of “cases” or syndromes Requires sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks Requires sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks

13. UW Northwest Center for Public Health Practice Recognition of a BT Event Surveillance/Detection Identify local experts to assist with evaluation/diagnosis Identify local experts to assist with evaluation/diagnosis Infectious disease specialists Infectious disease specialists Hospital epidemiology team Hospital epidemiology team Public health Public health Identify local experts to assist with evaluation/diagnosis Identify local experts to assist with evaluation/diagnosis Infectious disease specialists Infectious disease specialists Hospital epidemiology team Hospital epidemiology team Public health Public health

14. UW Northwest Center for Public Health Practice Recognition of a BT Event General Characteristics Many agents initially produce a nonspecific and/or flu-like illness Many agents initially produce a nonspecific and/or flu-like illness Aerosol dissemination Aerosol dissemination Not detectable: odorless, colorless, tasteless Not detectable: odorless, colorless, tasteless Particle size 1-5um Particle size 1-5um Potential wide-spread dissemination Potential wide-spread dissemination May require special treatment approach May require special treatment approach Many agents initially produce a nonspecific and/or flu-like illness Many agents initially produce a nonspecific and/or flu-like illness Aerosol dissemination Aerosol dissemination Not detectable: odorless, colorless, tasteless Not detectable: odorless, colorless, tasteless Particle size 1-5um Particle size 1-5um Potential wide-spread dissemination Potential wide-spread dissemination May require special treatment approach May require special treatment approach

15. Recognition of BT Event Epidemiologic Clues I Increase in persons ill with a similar or unusual syndrome Increase in persons ill with a similar or unusual syndrome Increase in unexplained disease or deaths Increase in unexplained disease or deaths Single case of disease due to an uncommon agent Single case of disease due to an uncommon agent Unexpected geographic or seasonal distribution of disease Unexpected geographic or seasonal distribution of disease Unusual age distribution Unusual age distribution E.g., varicella, measles in adults Increase in persons ill with a similar or unusual syndrome Increase in persons ill with a similar or unusual syndrome Increase in unexplained disease or deaths Increase in unexplained disease or deaths Single case of disease due to an uncommon agent Single case of disease due to an uncommon agent Unexpected geographic or seasonal distribution of disease Unexpected geographic or seasonal distribution of disease Unusual age distribution Unusual age distribution E.g., varicella, measles in adults

16. Recognition of BT Event Epidemiologic Clues II Illness in persons with common ventilation system or other exposure Illness in persons with common ventilation system or other exposure Atypical route of transmission Atypical route of transmission E.g., aerosol botulism Unusual illness among animals preceding or accompanying human illness Unusual illness among animals preceding or accompanying human illness Failure to respond to usual antibiotic therapy Failure to respond to usual antibiotic therapy Illness in persons with common ventilation system or other exposure Illness in persons with common ventilation system or other exposure Atypical route of transmission Atypical route of transmission E.g., aerosol botulism Unusual illness among animals preceding or accompanying human illness Unusual illness among animals preceding or accompanying human illness Failure to respond to usual antibiotic therapy Failure to respond to usual antibiotic therapy

17. UW Northwest Center for Public Health Practice Recognition of BT Event Surveillance/Detection By Washington State statute (RCW 70.05.090), physicians are to report diseases to the local health jurisdiction By Washington State statute (RCW 70.05.090), physicians are to report diseases to the local health jurisdiction Dangerous contagious or infectious diseases Dangerous contagious or infectious diseases Other diseases required by the state Board of Health to be reported Other diseases required by the state Board of Health to be reported Link to current notifiable conditions in Washington State: Link to current notifiable conditions in Washington State: By Washington State statute (RCW 70.05.090), physicians are to report diseases to the local health jurisdiction By Washington State statute (RCW 70.05.090), physicians are to report diseases to the local health jurisdiction Dangerous contagious or infectious diseases Dangerous contagious or infectious diseases Other diseases required by the state Board of Health to be reported Other diseases required by the state Board of Health to be reported Link to current notifiable conditions in Washington State: Link to current notifiable conditions in Washington State: http://www.doh.wa.gov/EHSPHL/Epidemiology/CD/ NotifyCondsPosters/docposter.pdf This link will take you away from the educational site

18. Recognition of BT Event Surveillance/Detection By Washington State statute (RCW 68.50.010), the following criteria are to be used to report deaths to the Medical Examiner… By Washington State statute (RCW 68.50.010), the following criteria are to be used to report deaths to the Medical Examiner… ….when death is due to a suspected contagious disease that may be a public health hazard ….when death is due to a suspected contagious disease that may be a public health hazard By Washington State statute (RCW 68.50.010), the following criteria are to be used to report deaths to the Medical Examiner… By Washington State statute (RCW 68.50.010), the following criteria are to be used to report deaths to the Medical Examiner… ….when death is due to a suspected contagious disease that may be a public health hazard ….when death is due to a suspected contagious disease that may be a public health hazard

19. UW Northwest Center for Public Health Practice Recognition of BT Event Surveillance/Detection Effective September 2000, the following are immediately reportable to the local health jurisdiction Effective September 2000, the following are immediately reportable to the local health jurisdiction All suspected illnesses caused by potential bioterrorism agents All suspected illnesses caused by potential bioterrorism agents Unexplained critical illness or death Unexplained critical illness or death Rare diseases of public health importance Rare diseases of public health importance Effective September 2000, the following are immediately reportable to the local health jurisdiction Effective September 2000, the following are immediately reportable to the local health jurisdiction All suspected illnesses caused by potential bioterrorism agents All suspected illnesses caused by potential bioterrorism agents Unexplained critical illness or death Unexplained critical illness or death Rare diseases of public health importance Rare diseases of public health importance

20. UW Northwest Center for Public Health Practice Introduction to Bioterrorism Summary of Key Points A biological attack is likely to be covert. A biological attack is likely to be covert. Primary care clinicians are likely to be among the first to see affected persons. Primary care clinicians are likely to be among the first to see affected persons. Many agents of BT potential initially produce a nonspecific illness. Many agents of BT potential initially produce a nonspecific illness. A biological attack is likely to be covert. A biological attack is likely to be covert. Primary care clinicians are likely to be among the first to see affected persons. Primary care clinicians are likely to be among the first to see affected persons. Many agents of BT potential initially produce a nonspecific illness. Many agents of BT potential initially produce a nonspecific illness.

21. UW Northwest Center for Public Health Practice Introduction to Bioterrorism Summary of Key Points Patient history and epidemiologic clues are important elements in BT recognition. Patient history and epidemiologic clues are important elements in BT recognition. Clinicians must be alert to unusual clusters of illness and know how to report illness caused by suspected BT agents. Clinicians must be alert to unusual clusters of illness and know how to report illness caused by suspected BT agents. Patient history and epidemiologic clues are important elements in BT recognition. Patient history and epidemiologic clues are important elements in BT recognition. Clinicians must be alert to unusual clusters of illness and know how to report illness caused by suspected BT agents. Clinicians must be alert to unusual clusters of illness and know how to report illness caused by suspected BT agents.

22. UW Northwest Center for Public Health Practice ResourcesResources Centers for Disease Control & Prevention Centers for Disease Control & Prevention Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense USAMRIID USAMRIID Centers for Disease Control & Prevention Centers for Disease Control & Prevention Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense USAMRIID USAMRIID http://www.hopkins-biodefense.org/ http://www.bt.cdc.gov http://www.usamriid.army.mil These links will take you away from the educational site

23. UW Northwest Center for Public Health Practice ResourcesResources St. Louis University Center for the Study of Bioterrorism and Emerging Infections — fact sheets and links St. Louis University Center for the Study of Bioterrorism and Emerging Infections — fact sheets and links Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Washington State Department of Health Washington State Department of Health (877)-539-4344 - 24-hour emergency number St. Louis University Center for the Study of Bioterrorism and Emerging Infections — fact sheets and links St. Louis University Center for the Study of Bioterrorism and Emerging Infections — fact sheets and links Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Washington State Department of Health Washington State Department of Health (877)-539-4344 - 24-hour emergency number http://bioterrorism.slu.edu/ http://www.nbc-med.org http://www.doh.wa.gov These links will take you away from the educational site

24. UW Northwest Center for Public Health Practice ResourcesResources Tucker JB. Historical trends related to bioterrorism: an empirical analysis. Emerging Infect Dis [serial online] 1999 Jul-Aug; 5(4). Other BT-related articles in EID BT-related JAMA articles BT-related JAMA articles Public Health - Seattle & King County Public Health - Seattle & King County Tucker JB. Historical trends related to bioterrorism: an empirical analysis. Emerging Infect Dis [serial online] 1999 Jul-Aug; 5(4). Other BT-related articles in EID BT-related JAMA articles BT-related JAMA articles Public Health - Seattle & King County Public Health - Seattle & King County http://www.metrokc.gov/health http://www.cdc.gov/ncidod/eid/index.htm http://www.cdc.gov/ncidod/eid/bio_links.htm http://pubs.ama-assn.org/bioterr.html These links will take you away from the educational site

25. UW Northwest Center for Public Health Practice In Case of An Event… Web Sites with Up-to-Date Information and Instructions Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EI Saint Louis University, CSB & EI WA State Local Health Departments/Districts WA State Local Health Departments/Districts Level A Lab Protocols: Presumptive Agent ID Level A Lab Protocols: Presumptive Agent ID Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EI Saint Louis University, CSB & EI WA State Local Health Departments/Districts WA State Local Health Departments/Districts Level A Lab Protocols: Presumptive Agent ID Level A Lab Protocols: Presumptive Agent ID http://www.bt.cdc.gov/EmContact/index.asp http://bioterrorism.slu.edu/hotline.htm http://www.bt.cdc.gov/LabIssues/index.asp http://www.doh.wa.gov/LHJMap/LHJMap.htm These links will take you away from the educational site

26. UW Northwest Center for Public Health Practice In Case of An Event… Web Sites with Up-to-Date Information and Instructions FBI Terrorism Web Page FBI Terrorism Web Page WA State Emergency Mgt Division – Hazard Analysis Update WA State Emergency Mgt Division – Hazard Analysis Update Mail Security Mail Security Links to your state health department Links to your state health department NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE FBI Terrorism Web Page FBI Terrorism Web Page WA State Emergency Mgt Division – Hazard Analysis Update WA State Emergency Mgt Division – Hazard Analysis Update Mail Security Mail Security Links to your state health department Links to your state health department NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE http://www.fbi.gov/terrorism/terrorism.htm http://www.usps.com/news/2001/press/serviceupdates.htm http://www.cdc.gov/niosh/emres01.html http://www.wa.gov/wsem http://www.astho.org/state.html These links will take you away from the educational site