1. Biological Threats and the Importance of Preparedness Thomas Inglesby, MD Center for Biosecurity of UPMC March 3, 2008

2. Major Points  Biological threats remain a top problem before the country - need to keep working toward long-term resilience, the ability to withstand bioattacks or pandemics  Building biopreparedness will help us deal with other catastrophes, make progress on serious health care challenges, and improve U.S. ability to help other countries  Biopreparedness funding has been invaluable in past years and will be critical in years ahead

3. State of H5N1 in the World Bird Cases -- More than 200M killed or culled  59 counties affected  Last 3 months: bird outbreaks in China, Thailand, Laos, Vietnam, Indonesia, Bangladesh, India, Pakistan, Saudi Arabia, Egypt, Nigeria, Ukraine, Hungary, UK, Iran, Turkey, Myanmar, Romania, Benin, Poland, Russia, Israel, Germany  Geographic spread unprecedented: no past avian flu has led to global outbreak Human cases since 2003 -- 360 cases, 226 have died 63% human case fatality ratio; involving 14 countries on 3 continents  2008 so far: 11 human cases in Indonesia, Vietnam– 9 have died  Source of infection unclear in ¼ cases - may be live-poultry market  No sustained human to human transmission yet Never have so many different kinds of animals been infected with same flu virus: e.g. cats, dogs, pigs, ferrets, civets, fish, wide range of birds

4. H5N1 Outbreaks Humans and birds as of February 12, 2007

5. U.S. Government Planning Assumptions for a Severe Pandemic Flu  Proportion of population ill: 25-30%  Duration of community outbreak: 8 weeks  Average duration of illness: 10 days  Case/fatality ratio: 2% ?  90 million ill  9.9 million hospitalized  1.9 million U.S. deaths [http://www.hhs.gov/pandemicflu/implementationplan/pdf/Pandemic.pdf – see pg. 18]

6. Influenza Outbreaks in 1957: August 0 10% 50% Percentage of Counties Reporting Outbreaks

7. Influenza Outbreaks in 1957: September 14 0 10% 50% Percentage of Counties Reporting Outbreaks

8. 0 10% 50% Percentage of Counties Reporting Outbreaks Influenza Outbreaks in 1957: September 28

9. 0 10% 50% Percentage of Counties Reporting Outbreaks Influenza Outbreaks in 1957: October 12

10. 0 10% 50% Percentage of Counties Reporting Outbreaks Influenza Outbreaks in 1957: October 26

11. Source: US CDC Major Transportation Flow: 1960-75

12. Source: US CDC Major Transportation Flow: 1990s

13. Biological Weapons  Cause disease epidemics  Proven to work On smallest of scales: anthrax 2001 attacks, Soviet accidents In past, large-scale field tests: U.S., UK, Former Soviet Union  Knowledge widely dispersed; not easy to detect or deter Materials accessible, inexpensive Dual use, hard to track, easily hidden Attribution difficult  Anthrax leads list, but many other “Material Threats to the Nation”: Smallpox, Botulism, Glanders, Meliodosis, Ebola, Marburg, Plague, Junin Virus, Tularemia, Drug-resistant pathogens  Based on number of analyses: large-scale bioattacks on par with nuclear terrorism in potential to cause fatalities

14. Previously healthy 47 year old man… Develops nausea, pain in his abdomen, “flu” Four days later - Loses consciousness in church Next day - intense abdominal pain  goes to ER, evaluated, then sent home with medicines Becomes confused and unresponsive  ambulance Pt arrives to hosp in shock; placed on ventilator, dies 5 hrs later

15. Rapid deterioration

16. Anthrax in US Postal Worker, 2001

17. Consider thousands of anthrax cases, or more  Discovery of first cases, only tip of the iceberg  Pervasive uncertainties: scale of attack? location? who is at risk?  Potential for “reload”: (repeated attacks over time and in different places); public will understand this, and everyone will feel at risk  Hospitals inundated with sick people and people seeking antibiotics  Need to get antibiotics to hundreds of thousands or millions of people  Social, economic disruption: may be severe  Consequences not over quickly: timeline = weeks or more Public health and medicine central to the response

18. Al Qaeda Seeking Means of Large-scale Attacks  AQ had major bioweapons effort in Afghanistan WMD Commission on Intelligence, 2004 [http://www.wmd.gov/report/wmd_report.pdf] AQ claims “right to kill 4 million Americans, including 2 million children.”  Suliman Abu Ghaith, al Qaeda spokesman  2003: AQ justifies use of WMD on religious grounds in contradiction to mainstream Islam  2006: AQ in Iraq: call for scientists to join jihad, help make WMD 2008: LA Times: AQ has reconstituted WMD program, new R&D efforts and attempts to obtain [See: http://www.upmc-biosecurity.org/website/biosecurity_briefing/archive/international_biosecurity/content/2006-09-29-alqaedalookingforscientists.html ]

19. “Our greatest concern is that terrorists might acquire biological agents, or less likely, a nuclear device, either of which could cause mass casualties.” “Mapping the Global Future”: Report of the National Intelligence Council’s 2020 Project; January 2005

20. Resilience to Biological Threats Goals  Prevention – improve international sentiment toward US, more international collaboration, approbation against bioweapons; dismantle terrorist networks; ensure we can attribute  Highly-informed and broadly prepared public - before and during crises  Info systems for health care & political leaders during crisis  Accelerate research, development, production, stockpiling of vaccines, therapies, diagnostic tests for major biological threats  Public health and medical systems that can cope with big epidemics and catastrophes Rapidly investigate epidemics, communicate with leaders and the public, prophylactic meds for the exposed, medical care for the sick

21. Big successes National smallpox vaccine reserve Large stockpiles of antibiotics & antivirals Substantial pandemic flu funding and program development –Substantial pandemic vaccine development program Stronger health departments (e.g. 2x the number of epidemiologists; all on-call 24/7; better inter-heatlh dept comm.) Improving hospital preparedness PAHPA legislation Federal programs consolidated under HHS ASPR New BARDA office to develop meds, vaccines Community resiliency now explicit policy goal Continued global leadership in bio research and Biopharma industry

22. Serious Challenges Small quantities of anthrax vaccine, no way to make more fast Little funding for BARDA – long lists of unmet med, vaccine needs Few tested means for mass distribution – need private sector to engage Hard to find and retain good public health leaders, investigators – keep building human capital in public health Hospitals can’t cope with top national planning scenario events Set biosurveillance strategy that makes sense Health information systems that provide situational awareness Systems to help communities become more resilient, better cope with disasters Biological knowledge and technology evolving very fast Stop losing ground in Bio research and global Biopharma position Use US successes to help fight infectious disease abroad – humanitarian assistance strongly improves attitudes toward US

23. “What physics was to the 20th century, biology will be to the 21 st …. Many of the big problems facing humanity are biological, or are susceptible to biological intervention…how to deal with an aging population ….climate change…the risk of a new lethal infection becoming pandemic…..the fact that such an infection might itself be the result of synthetic biology only emphasizes the biological nature of future risks…. June 2007 Economist