Bioterrorism Preparedness Public health CBRN course Bonnie Henry, MD, FRCPC

Goals of session To provide a review of bioterrorism agents and history of BT use (with a focus on anthrax and smallpox) To review potential roles for public health in a BT incident To review principles of laboratory testing of ‘suspicious packages’ and continuity of evidence

Bioterrorism Preparedness

Bioterrorism is the intentional use of microorganisms (bacteria, viruses, and fungi) or toxins to produce death or disease in humans, animals or plants. Electron micrograph of anthrax bacteria Electron micrograph of ebola virus

Category A “Biologic Threat Agents” Can be easily disseminated or transmitted person-to- person; Cause high mortality, w/potential for major public health impact; Might cause public panic and social disruption; and Require special action for public health preparedness.

Biological Agents of Highest Concern Category A Smallpox – variola major Anthrax – Bacillus anthracis Plague – Yersinia pestis Botulism – Clostridium botulinum toxin Tularemia – Francisella tularensis Viral hemorrhagic fevers – arenaviruses, filoviruses (Ebola, Marburg, Lassa, Junin)

Category B: Second Highest Priority Moderately easy to disseminate Cause moderate morbidity and low mortality Require specific enhancements of diagnostic capacity and enhanced disease surveillance Coxiella burnetti (Q fever) Brucella Burkholderia mallei (glanders) Alphaviruses (Venezuelan encephalomyelitis and Eastern and Western equine) Rickettsia prowazekii Toxins (Ricin, Staph enterotoxin B) Chlamydia psittaci Food safety threats (e.g.Salmonella, Shigella. E. coli O157:H7) Water safety threats (Vibrio cholerae, Cryptosporidium parvum)

Category C: Third Highest Priority Pathogens that could be engineered for mass destruction because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact Nipah virus Hantavirus Tickborne hemorrhagic fever viruses Tickborne encephalitis viruses Yellow fever MDR TB

Characteristics of Bioterrorist Agents Mainly inhaled - may be ingested or absorbed Particles may remain suspended for hours May be released silently with no immediate effect Person-to-person spread happens for some agents Long incubation periods mean "first responders” may be primary health care providers Agents may be lethal or incapacitating Vaccines & antitoxins exist for some agents

Recent Examples of Bioterrorism Recent Examples of Bioterrorism 1984: Salad bars contaminated with Salmonella by Rajneeshe cult members to influence local election in The Dalles, Oregon / 751 people affected (8 salad bars) 1995: Sarin nerve gas release by Aum Shinrikyo in Tokyo subway / At least 9 failed attempts to use biological weapons 1996: Pastries contaminated with Shigella by disgruntled lab worker in Dallas

Recent Examples of Bioterrorism Recent Examples of Bioterrorism Former Soviet Union’s extensive biological weapons program thought to have found their way to other nations Iraq acknowledged producing and weaponizing anthrax and botulinum toxin Currently, at least 17 nations believed to have biological weapons programs

Anthrax: Soviet incident An accident at a Soviet military compound in Sverdlovsk (microbiology facility) in 1979 resulted in an estimated 66 deaths downwind.

Smallpox Variola virus Declared eradicated by WHO in 1980 Civilian vaccination stopped 1972, healthcare workers stopped in 1977 and CF stopped 1988 Known stockpiles remain in CDC and Institute for Viral Preparations, Moscow Virus spread by aerosol Incubation period: average 12 days (7-19 days)

Last Case, Variola major Rahmina, 1975 Rahmina Banu, 2001

SMALLPOX RASH EVOLUTION Day 1Day 2Day 3

SMALLPOX RASH EVOLUTION Day 4 Day 5 Day 7

SMALLPOX RASH EVOLUTION Days 8-9 Days Day 20

Smallpox Vaccination –Within 3 days will likely prevent disease –Within 5 days is life-saving (ameliorates) –Canada has about 320,000 doses –?long term immunity –Cell culture and oral vaccine in research –Research on antivirals also ongoing (particularly Cidofovir)

DIFFERENTIAL DIAGNOSIS: VESICULO – PUSTULAR RASHES CHICKEN POX ERYTHEMA MULTIFORME - BULLOUS COWPOX MONKEY POX HERPES ZOSTER (Shingles) - DISSEMINATED DRUG ERUPTIONS HAND FOOT AND MOUTH DISEASE ACNE IMPETIGO INSECT BITES

Today’s Perspective in Canada: Pros vs Cons “Moderately” contagious Virus not robust No natural reservoir Able to vaccinate Able to control Improved medical care Better pop’n health 30% mortality Misdiagnosis Long incubation Low level of “Immunity” Pop’n mobility Immuno- compromised Mass panic, hysteria

Smallpox Isolation, Toronto (1909)

National Smallpox Contingency Plan (v.4) Canada’s ‘search and contain’ strategy highlights: –Early detection, immediate notification –Immediate isolation of cases –Immediate deployment of smallpox responders –Immediately vaccinate all those directly exposed, all known direct contacts, all local personnel… –Intensive contact tracing –Rapid set up of isolation facilities –Rapid set-up of local Smallpox assessment centres Assumption: In the absence of smallpox anywhere in Canada A risk of disease and death from a vaccine, no matter how small, may be unacceptable Especially when pre- attack vaccination is considered

VACCINE ADMINISTRATION

VACCINATION: THE RESPONSE

US Vaccination Experience Plan for ‘first responders” (Phase 1) Estimated 4 million eligible; expected 500K Vaccination in teams by Public Health Actual uptake: about 35,000

US Vaccination Experience Complications: –US Military: 10 cases myopericarditis/240,000 primary vaccinations; 1 cardiac arrest 5 days post vaccine –Civilian: 1case pericarditis, 1 case myocarditis, 5 cardiac ischemic events (3 MIs, 2 angina), 2 deaths (both cardiac arrest) –No cases in 110,000 military re-vacinees but 2/5 civilians were re-vacinees

US Vaccination Experience Stockpile of ~200 million doses of cell culture vaccine + 15 million calf lymph vaccine (from 1978,1958) Threat felt to be diminished post acute phase of the war in Iraq Phase 2 practically is on hold although still not official (almost 4 years later)

Public Health Role Health effects of emergencies recently highlighted In most jurisdictions the Medical Officer of Health is part of the municipal/regional emergency response team Have a mandated lead role in events involving biologic agents

Public Health Role Public Health Role Early Detection Mass Patient Care Mass Immunization/Prophylaxis Epidemiologic investigation Communication Command and Control

Public Health Role Public Health Role Mass Fatality Management Evacuations/sheltering (humans and animals) Environmental Surety Community Recovery (rapid health risk assessment, mental health etc)

Public Health Role ‘Secondary’ responders Key role in communication with the public for biologic emergencies Can be liaison or link between healthcare facilities and first responders, the community Have legal authority for many restrictive actions

Public Health Actions Promptly investigate original case Confirm laboratory results Identify & interview case contacts as needed Initiate active surveillance for additional cases Take immediate public health prevention action as needed Collaborate/notify MOHLTC, Health Canada as indicated Alert local medical community/public Determine need for Rx of contacts/health professionals Mobilize needed assets at local, provincial, federal level Maintain contact with case family & reporting MD

Public Health Incident Manager Liaison Public Information OperationsPlanning Logistics Administration Mass Vaccination/Post Exposure Prophylaxis Hotline Operation Case Management/Contact Tracing Environmental Inspection/ Sampling Situation Assessment Staffing & Resource Needs Resource Deployment Documentation Demobilization & Recovery Facilities Human Resources Nutrition/staff accommodation Claims/ Compensation Costing Procurement Reception Centre/Mass Care Communications Equipment Miscellaneous Supplies Chair, Board of Health Medical Officer of Health Senior Management Team Epidemiological Investigations Recovery Public Health Incident Management System

THE SUSPICIOUS PACKAGE May be reported any time or any place Since 2001 many examples have been letters delivered or packages discovered This is a law enforcement and public health responsibility

Anthrax in the USA 4 known letters 11 cases of inhalational anthrax 11 cases of cutaneous anthrax 5 deaths from inhalational anthrax

The Suspicious Package

Key Messages: Stay calm Remember, there is danger but there is time Leave the package or letter but don't leave the scene

Impact on the public

Toronto Public Health Case Definitions for Biological Events PriorityPublic Health ResponseFirst Responder Action Priority 1 (High): 1.Overt threat such as a letter, note or picture; or 2.Obvious target such as media outlet, political or religious target or large corporation 3.Human exposure has occurred (i.e. package has been opened) 4.A substance is present On-scene response Obtain personal decontamination information Obtain contact information for those exposed Advise CPHL of priority Advise re environmental decontamination Provide counseling to exposed individuals Obtain lab results and communicate to first responders and exposed persons Call Public Health Immediately From 8am-8pm: After 8pm: Priority 2 (medium): 1.Overt threat such as a letter, note or picture; or 2.Obvious target such as media outlet, political or religious target or large corporation 3.No human exposure has occurred (i.e. package has NOT been opened) 4.A substance is present Obtain contact information for relaying lab results Advise CPHL of priority Advise re environmental decontamination Counsel individuals involved as needed Obtain lab results and communicate to first responders and involved persons Call Public Health with contact information and incident number on semi-urgent basis: 8am-8pm: After 8pm: Priority 3 (low): 1.No overt threat, and 2.No obvious target 3.There is human exposure (i.e. a package has been opened) 4.A substance is present Obtain contact information if sample sent to CPHL Advise CPHL of priority Provide personal and environmental decontamination advice if requested If sending sample to the lab, call Public Health with contact information and incident number when practicable Priority 4 (lowest): 1.No overt threat, and 2.No obvious target 3.There is no human exposure (i.e package has not been opened) Provide reassurance and environmental decontamination advice if requested Call Public Health only if involved persons requesting specific advice

Public Health Response 24 hour first responder hotline Coordination with laboratory Developing protocols with police, fire, EMS Links with other Health Units, provinces, Health Canada Info to businesses, hospitals, local physicians, consulates, the public…..

Triage of Suspicious Envelopes/Packages* A general process is outlined below, in some areas public health may play role of onsite assessment and/or transport to lab –Police notified - call 911. –Police contact local Health Unit. –Decision is made re lab testing, management of exposed individuals –Police transport material to lab. *all environmental specimens are tested in the Central Public Health Lab

Testing in the Public Health Lab Open and examine package in a negative pressure containment lab using level 3 protection. Gram stain, +/- spore stains for bacteria on any material (powder, etc.) present. Cultures, motility, biochemicals as required.

Testing in the Public Health Lab Testing performed while maintaining chain of custody procedures and evidence documentation. –Photograph material –preserve DNA, fingerprints, handwriting CPHL does not do chemical analysis or tell the police what the substance is.

Testing in the Public Health Lab Send any suspicious organisms to the NML in Winnipeg for confirmation. All samples must be treated as possible forensic evidence. –maintain chain of custody –preserve DNA, fingerprints, handwriting etc. –alert police of similar incidents from different jurisdictions

Reporting Results Phone results to health unit and to police, within hours of receipt of sample. Written report to health unit (Medical Officer of Health) and police, within weeks. Police contacted re deposition of material –material returned to police –material destroyed by police order

Summary Roles public health will play will vary by health unit Will certainly have a key role in public communication Will most often have lead for follow-up of contacts/people exposed Will have lead role in determining of PEP/vaccination Need to understand roles of other players in your community