Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine 1 Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

UW Northwest Center for Public Health Practice 2 AcknowledgementsAcknowledgements This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for the purpose of educating public health employees in the general 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 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 Project Coordinator Centers for Disease Control and Prevention Judith Yarrow Design and Editing Health Policy and Analysis; University of WA Washington State Department of Health Jeff Duchin, MD Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization Section Public Health - Seattle and King County Ed Walker, MD; University of WA Department of Psychiatry

UW Northwest Center for Public Health Practice 3 Health Surveillance and Epidemiologic Investigation

UW Northwest Center for Public Health Practice 4 Health Surveillance and Epidemiologic Investigation Learning Objectives Describe the basic steps in communicable disease case and outbreak investigations Define “syndromic surveillance” and describe how it can be used to identify disease outbreaks Identify potential sources of information for syndromic surveillance systems Describe the basic steps in communicable disease case and outbreak investigations Define “syndromic surveillance” and describe how it can be used to identify disease outbreaks Identify potential sources of information for syndromic surveillance systems

UW Northwest Center for Public Health Practice 5 Health Surveillance and Epidemiologic Investigation Learning Objectives Describe the Laboratory Response Network (LRN) Describe the Laboratory Response Network (LRN) Define and describe its purpose and function in BT response Define and describe its purpose and function in BT response Identify resources available through the LRN for public health Identify resources available through the LRN for public health Describe public health’s participation in the LRN Describe public health’s participation in the LRN Describe the Laboratory Response Network (LRN) Describe the Laboratory Response Network (LRN) Define and describe its purpose and function in BT response Define and describe its purpose and function in BT response Identify resources available through the LRN for public health Identify resources available through the LRN for public health Describe public health’s participation in the LRN Describe public health’s participation in the LRN

UW Northwest Center for Public Health Practice 6 Disease Surveillance and Investigation Legal Basis in Washington RCW gives the local health officer power to “take such measures as he or she deems necessary in order to promote the public health.” RCW requires physicians to report contagious diseases. RCW requires medical examiners to report deaths from contagious diseases. RCW gives the local health officer power to “take such measures as he or she deems necessary in order to promote the public health.” RCW requires physicians to report contagious diseases. RCW requires medical examiners to report deaths from contagious diseases. Notifiable conditions in WA

UW Northwest Center for Public Health Practice 7 Disease Surveillance and Investigation Legal Basis in Washington WAC specifies contagious disease reporting for health care providers, hospitals, laboratories, and local health jurisdictions: Lists of notifiable conditions Time frame for reporting Responsibilities for disease control WAC specifies contagious disease reporting for health care providers, hospitals, laboratories, and local health jurisdictions: Lists of notifiable conditions Time frame for reporting Responsibilities for disease control

UW Northwest Center for Public Health Practice 8 Disease Surveillance and Investigation Legal Basis in WA Effective September 2000, the following are immediately reportable to the local health jurisdiction All suspected illnesses caused by potential bioterrorism agents Unexplained critical illness or death Rare diseases of public health importance Effective September 2000, the following are immediately reportable to the local health jurisdiction All suspected illnesses caused by potential bioterrorism agents Unexplained critical illness or death Rare diseases of public health importance

Recognition of a BT Event Surveillance/Detection Detect unusual medical events sooner rather than later Depends on ability to identify a greater than expected number of “cases” or syndromes Detect unusual medical events sooner rather than later Depends on ability to identify a greater than expected number of “cases” or syndromes More on public health surveillance... 9

UW Northwest Center for Public Health Practice 10 Syndromic Surveillance Sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks Influenza-like illness Invasive bacterial disease Encephalitis/meningitis Unexplained critical illness or death Rash illnesses Sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks Influenza-like illness Invasive bacterial disease Encephalitis/meningitis Unexplained critical illness or death Rash illnesses

UW Northwest Center for Public Health Practice 11 Syndromic Surveillance Potential information sources Primary care clinic visits Emergency room visits Calls to poison control centers Pharmacy visits/requests Nurse hotline calls 911 calls Potential information sources Primary care clinic visits Emergency room visits Calls to poison control centers Pharmacy visits/requests Nurse hotline calls 911 calls

UW Northwest Center for Public Health Practice 12 A CDC-funded Project Syndromic surveillance began in 1999 in King County Traditional Public Health surveillance depends on labs and doctors reporting confirmed diseases (usually laboratory confirmed) Syndromic surveillance identifies disease syndromes prior to confirmation Goal is to identify an increase in disease syndromes, not confirmed case reports Syndromic surveillance began in 1999 in King County Traditional Public Health surveillance depends on labs and doctors reporting confirmed diseases (usually laboratory confirmed) Syndromic surveillance identifies disease syndromes prior to confirmation Goal is to identify an increase in disease syndromes, not confirmed case reports Syndromic Surveillance Project

UW Northwest Center for Public Health Practice 13 Aberration Detection Hospital Emergency Department Discharge Data Primary Care Clinic Discharge Data Seattle Emergency Medical Services Calls (911) Medical Examiner (ME) - Unexplained Deaths Hospital Emergency Department Discharge Data Primary Care Clinic Discharge Data Seattle Emergency Medical Services Calls (911) Medical Examiner (ME) - Unexplained Deaths Syndromic Surveillance Project

UW Northwest Center for Public Health Practice 14 Hospital Emergency Department and Primary Care Clinic Discharge Data Data extracted from clinical discharge diagnosis databases at three hospitals and nine primary care clinics Transmitted electronically to PHSKC Analyzed using CDC aberration detection program Data extracted from clinical discharge diagnosis databases at three hospitals and nine primary care clinics Transmitted electronically to PHSKC Analyzed using CDC aberration detection program Syndromic Surveillance Project

UW Northwest Center for Public Health Practice 15 Seattle Emergency Medical Services Calls (911) The number and type of triage protocols are monitored during each 24-hour period Analyze using CDC Aberration Detection Software The number and type of triage protocols are monitored during each 24-hour period Analyze using CDC Aberration Detection Software Syndromic Surveillance Project

UW Northwest Center for Public Health Practice Triage Protocols Abdominal Pain Sick Unknown Breathing Problems Person Down Convulsions/Seizures Abdominal Pain Sick Unknown Breathing Problems Person Down Convulsions/Seizures HeadacheCVA/StrokeDOA Chest Discomfort Dizzy/Fainting Syndromic Surveillance Project

UW Northwest Center for Public Health Practice 17 Syndromic Surveillance Project Medical Examiner (ME) Unexplained Death Surveillance Data source: Daily Log from the King County ME Definition: Unexplained death in a previously healthy person aged 1-49 years with hallmarks of infectious disease Daily Log is reviewed daily for deaths meeting the definition of unexplained death

UW Northwest Center for Public Health Practice 18 Enhanced Surveillance Activities Number and type of calls from Hospital- Based Consulting Nurse Hotlines Year-Round Influenza Surveillance Number and type of calls from Hospital- Based Consulting Nurse Hotlines Year-Round Influenza Surveillance Syndromic Surveillance Project Infectious Disease Surveillance Systems

UW Northwest Center for Public Health Practice 19 Active Surveillance for School Absenteeism During Influenza Season Syndromic Surveillance Project Ten schools participated in 2000 Schools receive weekly reminders to report when absenteeism exceeds 10%

UW Northwest Center for Public Health Practice 20 Consulting Nurse Hotlines Syndromic Surveillance Project Two hospital-based Consulting Nurse Hotlines participate Total Calls and the proportion of calls for symptoms of influenza-like illness (ILI) are monitored: Flu Sore Throat Colds  Fever  Cough

UW Northwest Center for Public Health Practice 21 Year Round Influenza Surveillance King County Lab participates in CDC’s National Respiratory and Enteric Virus Surveillance System 12 primary care providers submit specimens year-round from persons with ILI Providers receive periodic reminders to submit specimens from persons with ILI King County Lab participates in CDC’s National Respiratory and Enteric Virus Surveillance System 12 primary care providers submit specimens year-round from persons with ILI Providers receive periodic reminders to submit specimens from persons with ILI Syndromic Surveillance Project

UW Northwest Center for Public Health Practice 22 Outbreak Investigation Basic Steps Establish the existence of an outbreak Verify the diagnosis Develop a case definition (confirmed, probable, possible) Identify cases Characterize the outbreak (person, place, time) Develop and test hypotheses Establish the existence of an outbreak Verify the diagnosis Develop a case definition (confirmed, probable, possible) Identify cases Characterize the outbreak (person, place, time) Develop and test hypotheses

UW Northwest Center for Public Health Practice 23 Outbreak Investigation Additional Steps Determining appropriate containment strategies Evaluation of expected and unexpected epi features of the outbreak Identifying the population at risk Prophylaxis (immunization/antibiotics) for exposed, isolation and/or quarantine for suspected/confirmed cases Depends on disease and outbreak characteristics Health officer and/or medical epi decision If person-to-person transmission Contact tracing and identification Determining appropriate containment strategies Evaluation of expected and unexpected epi features of the outbreak Identifying the population at risk Prophylaxis (immunization/antibiotics) for exposed, isolation and/or quarantine for suspected/confirmed cases Depends on disease and outbreak characteristics Health officer and/or medical epi decision If person-to-person transmission Contact tracing and identification

UW Northwest Center for Public Health Practice 24 Post-BT Event Surveillance Active surveillance for suspected, confirmed, probable cases Follow-up on case outcomes Surveillance for vaccine and antibiotic-related adverse events Active surveillance for suspected, confirmed, probable cases Follow-up on case outcomes Surveillance for vaccine and antibiotic-related adverse events VAERS - The Vaccine Adverse Event Reporting System

UW Northwest Center for Public Health Practice 25 Laboratory Response Network Multilevel network of local, state, and federal laboratories Multilevel network of local, state, and federal laboratories Laboratories identified by increasing level of sophistication (A – D) Laboratories identified by increasing level of sophistication (A – D) Facilitates sample collection, transport, testing, and training for laboratory readiness for bioterrorism Facilitates sample collection, transport, testing, and training for laboratory readiness for bioterrorism Multilevel network of local, state, and federal laboratories Multilevel network of local, state, and federal laboratories Laboratories identified by increasing level of sophistication (A – D) Laboratories identified by increasing level of sophistication (A – D) Facilitates sample collection, transport, testing, and training for laboratory readiness for bioterrorism Facilitates sample collection, transport, testing, and training for laboratory readiness for bioterrorism

UW Northwest Center for Public Health Practice 26 Laboratory Response Network For Bioterrorism Level-A Lab Use Class II Biosafety Cabinet A - Rule-out and forward organisms Level B Lab BSL-2 facility + BSL-3 Safety Practices B - Limited confirmation and transport Level C Lab BSL-3 C - Molecular assays, reference capacity D - Highest level characterization (Federal) Level D Lab BSL-4

UW Northwest Center for Public Health Practice 27 Laboratory Diagnosis of Category A Agents Required Bio-safety* Levels *BSL 2/3 - State and some local public health labs BSL 4 - CDC and USAMRIID

UW Northwest Center for Public Health Practice 28 Laboratory Diagnosis of Category A Agents Protocols for Testing and Referral Level A protocols available at: Level A protocols available at: Level B/C protocols available through password-protected Web site for LRN- registered members Level B/C protocols available through password-protected Web site for LRN- registered members Level A protocols available at: Level A protocols available at: Level B/C protocols available through password-protected Web site for LRN- registered members Level B/C protocols available through password-protected Web site for LRN- registered members

UW Northwest Center for Public Health Practice 29 Laboratory Diagnosis of Category A Agents Resources for Testing and Referral LRN members can LRN members can Search for nearest equal or higher-level lab via password-protected Website Search for nearest equal or higher-level lab via password-protected Website Order reagents for B/C testing through password-protected Website Order reagents for B/C testing through password-protected Website Specimen packaging and transport Specimen packaging and transport General information available at: General information available at: Specific information available from public health laboratory Specific information available from public health laboratory LRN members can LRN members can Search for nearest equal or higher-level lab via password-protected Website Search for nearest equal or higher-level lab via password-protected Website Order reagents for B/C testing through password-protected Website Order reagents for B/C testing through password-protected Website Specimen packaging and transport Specimen packaging and transport General information available at: General information available at: Specific information available from public health laboratory Specific information available from public health laboratory

UW Northwest Center for Public Health Practice 30 Summary of Key Points Early detection of a bioterrorism event requires sensitivity to unusual clusters of disease syndromes, in addition to traditional disease reporting. Syndromic surveillance systems integrate data from a variety of sources and alert public health officials to potential outbreaks, prior to the establishment of a diagnosis. Early detection of a bioterrorism event requires sensitivity to unusual clusters of disease syndromes, in addition to traditional disease reporting. Syndromic surveillance systems integrate data from a variety of sources and alert public health officials to potential outbreaks, prior to the establishment of a diagnosis.

UW Northwest Center for Public Health Practice 31 Summary of Key Points The investigation of any disease outbreak follows several basic steps. Post-event surveillance includes systems to monitor for the development of new cases, case outcomes, and adverse events related to treatment and prophylaxis. The Laboratory Response Network is a system of local, state, and federal laboratories identified by increasing levels of proficiency to respond to bioterrorism. The Laboratory Response Network is a system of local, state, and federal laboratories identified by increasing levels of proficiency to respond to bioterrorism. The investigation of any disease outbreak follows several basic steps. Post-event surveillance includes systems to monitor for the development of new cases, case outcomes, and adverse events related to treatment and prophylaxis. The Laboratory Response Network is a system of local, state, and federal laboratories identified by increasing levels of proficiency to respond to bioterrorism. The Laboratory Response Network is a system of local, state, and federal laboratories identified by increasing levels of proficiency to respond to bioterrorism.

UW Northwest Center for Public Health Practice 32 ResourcesResources Centers for Disease Control and Prevention Bioterrorism Web site Epidemiology Program Office Council for State and Territorial Epidemiologists Roundtable on bioterrorism detection – summary of several syndromic surveillance systems in development Centers for Disease Control and Prevention Bioterrorism Web site Epidemiology Program Office Council for State and Territorial Epidemiologists Roundtable on bioterrorism detection – summary of several syndromic surveillance systems in development JAIMIA 2002;9: