Dallas County Bioterrorism Program: Overview and Highlights David Buhner MD MS Epidemiologist Dallas County Department of Health and Human Services

OVERVIEW OVERVIEW

Large-scale terrorism in the US is a reality  1993—World Trade Center bombing  1996—Alfred P. Murrah Federal Building bombing in Oklahoma City  2001—Destruction of the World Trade Center

Chemical and biological attacks are a reality  1978—Deliberate contamination of Israeli citrus exports with mercury  1982—Deliberate contamination of Tylenol with cyanide  1984—Deliberate contamination of salad bars with Salmonella in Oregon  1995—Tokyo Sarin gas attack  2001—The US anthrax attacks

The Scope of the Threat  Office of Technology Assessment: Used under optimal conditions biological weapons could have an impact similar to a small nuclear device. Used under optimal conditions biological weapons could have an impact similar to a small nuclear device.

The Toxin of C. botulinum  C. botulinum lives in the soil.  Evenly dispersed and inhaled 1 gram of botulinum toxin could kill 1 million people.  After the 1991 war, Iraq admitted to the possession of 19,000 liters of concentrated toxin, 10,000 liters loaded into military weapons.

Potential Agents of Bioterrorism

Toronto SARS Epidemic  361 cases reported between 2/23/03 and 6/7/03, with 33 (9%) deaths  Some control measures used: -over 18,000 people quarantined -over 18,000 people quarantined -closure of businesses -closure of businesses -closure of schools -closure of schools  Economic losses projected at 1,000,000,000 dollars

The Latest in Feline Fashion

Historical Epidemics  The European Black Death (bubonic plague) of the 1300’s is estimated to have killed 1/3 of the European populace within 2 years.  Epidemics due to Old World diseases introduced into the New World with the arrival of Europeans are estimated to have killed 90% of the native inhabitants.

Public Health: Epidemic Disease Defense  Traditional role: control of infectious, communicable diseases of “natural” origin in the local populace.  There is little debate about the decades-long deterioration that has been allowed to take place in the local public health infrastructure in the US.

Unique Features of Bioterrorism Unlike other forms of terrorism:  Public health system is THE crucial factor in an effective response.  Bioterrorism may be covert, with a delay, due to the incubation period of the illness, in the appearance of the problem.  Bioterrorism can be self-propagating due to person-to-person spread; early identification and institution of effective public health measures can limit what otherwise might be a catastrophic outbreak of disease.

New Role for Public Health: Watchdog for Bioterrorism  Good news: the skill set, personnel, and physical resources required for this role are little different from those required for traditional public health functions  Bad news: public health infrastructure deterioration and failure to keep up with the modern pace of technological change critically compromise local public health’s ability to respond with the speed and efficacy required to limit the damage from a large-scale attack of bioterrorism

Federal Response  In 1999 The Centers for Disease Control and Prevention (CDC) first received congressionally appropriated funds to enter into multi-year cooperative agreements aimed at upgrading state and local health department preparedness and response capabilities relative to bioterrorism.

1. Preparedness Planning and Readiness Assessment  The worst time to determine how to respond to an emergency situation is during the emergency.  Need adequate planning and preparation  Need training exercises to assess the adequacy of the plans and preparation

2. Surveillance and Epidemiologic Capacity  Rapid disease detection requires a sensitive surveillance system.  Detected cases must be investigated by epidemiologists to: 1) discriminate sporadic cases from outbreaks of disease 2) discriminate natural from intentional 3) identify the population at risk so they may be treated 4) identify appropriate control measures to limit spread to the unaffected

3. Laboratory Capacity  Rapid and correct identification of the particular biological agent in an outbreak is of fundamental importance because 1) public health consequences differ 2) control measures differ  A well-equipped lab with highly trained personnel is a critical necessity.

4. Communications and Information Technology  Public health surveillance and outbreak response require that large amounts of real-time data must be collected, stored, sorted, integrated, analyzed, and interpreted and the results communicated to the appropriate person(s).  Effective communications systems must link public health officials, first responders, government officials, physicians, and all other agencies and organizations likely to be involved in a large-scale outbreak of illness.

5. Risk Communication and Health Information Dissemination  The importance of informed, timely, and effective communication with the public and the media, especially during a public health crisis, cannot be overstressed.

6. Education and Training  All individuals involved in a response to bioterrorism must possess the up-to-date skills and knowledge necessary to carry out their responsibilities.

Highlights of the Dallas County Bioterrorism Program

Highlight I Regional and Regional and Organizational Organizational Cooperation Cooperation

The Importance of a Regional Approach  Substantial population flow takes place daily between Collin, Dallas, Denton, and Tarrant counties, as well as to and from more distant counties.  The effects of bioterrorism are unlikely to respect jurisdictional boundaries.

The Problem of Caring for Victims of Bioterrorism  Hospitals lack the empty beds and staff to manage a sudden influx of large numbers of patients (no surge capacity). This is a nationwide problem.  No hospital wishes to accept the role of epidemic disease hospital in the event of an outbreak.  Where will large numbers of suddenly ill patients be cared for in the event of an outbreak?

A Regional Quarantine and Treatment Facility  Representatives of the four counties (public health and government), DFWHC, PMH, JPS, the VA, NTCOG, local medical societies, and others have been meeting regularly for more than a year to address this problem.

Highlight II Dallas County Dallas County Laboratory Laboratory

DCHHS Bioterrorism Preparedness and Response Laboratory  A state-of-the-art, CDC-sanctioned, LRN laboratory (operating at BSL-3) capable of conducting CDC-validated confirmatory testing for a wide variety of organisms (a Confirmatory lab)  Provides services to all of North Texas including Collin, Dallas, Denton, Tarrant counties, and TDH Region 2/3  Provides critical training and support to local hospital and clinical laboratories (Sentinel labs)

Highlight III Epidemiologic Epidemiologic Response Teams Response Teams

The Benefits of Public Health  Institution of effective treatment as soon as possible after exposure can save the lives of individuals epidemiologically identified as having been exposed to infectious diseases and/or toxins.  Implementation of effective control measures can prevent the spread of communicable illnesses from exposed, infected individuals to the previously unexposed and uninfected.

Epidemiologic Response Teams  Rapid investigation of reported cases can take maximum advantage of the lag time (incubation period) between exposure and the onset of illness.  Dallas County has provided for a rapid and flexible response to outbreaks of illness by forming response teams consisting of, as necessary, physicians, epidemiologists, nurses, laboratorians, and the appropriate equipment and supplies.  These teams are available 24/7 and capable of managing multiple, simultaneous outbreak investigations.