1. 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

2. WHY PUBLIC HEALTH ? CHEMICAL BIOLOGICAL 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

3. 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: hrs

4. 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

5. 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

6. PUBLIC HEALTH Announced attack Hoax
Primary response: law enforcement, EMS
Hoax
Variation on announced attack
Increasing occurrence
1992: 1 event affecting 20 people
1998: 37 events affecting 5529 people

7. PUBLIC HEALTH
Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management -- United States, 1998
MMWR February 5, (04);69-74
mmwrhtml/rr4904a1.htm

8. PUBLIC HEALTH Preparedness and prevention Detection and surveillance
Diagnosis and characterization of agents
Response
Communication

9. PUBLIC HEALTH Preparedness and prevention
Coordinated preparedness plans
Coordinated response protocols
Performance standards
self-assessment, simulations, exercises

10. 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

11. 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

12. 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

13. 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

14. 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

15. CRITICAL BIOLOGICAL AGENTS CATEGORY 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

16. CRITICAL BIOLOGICAL AGENTS CATEGORY 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

17. CRITICAL BIOLOGICAL AGENTS CATEGORY B
Second highest priority agents that include those that:
are moderately easy to disseminate
cause moderate morbidity and low mortality
require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance

18. CRITICAL BIOLOGICAL AGENTS CATEGORY 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

19. CRITICAL BIOLOGICAL AGENTS CATEGORY B
Subset of Category B agents that include pathogens that are food- or waterborne
Salmonella species
Shigella dysenteriae
Escherichia coli O157:H7
Vibrio cholerae
Cryptosporidium parvum

20. CRITICAL BIOLOGICAL AGENTS CATEGORY 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

21. CRITICAL BIOLOGICAL AGENTS CATEGORY C
Nipah virus
Hantaviruses
Tickborne hemorrhagic fever viruses
Tickborne encephalitis viruses
Yellow fever
Multidrug-resistant tuberculosis

22. 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”

23. 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

24. 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

25. 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