CDC Centers for Disease Control and Prevention Public Health &Bioterrorism European Diploma Course in Disaster Medicine Republic of San Marino 12 May, 2003 Eric K. Noji, M.D., M.P.H. Office of the US Surgeon General US Public Health Service Washington, D.C.

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention Sources of Agents for Terrorism Use World Directory of Collections of Cultures and Microorganisms World Directory of Collections of Cultures and Microorganisms 453 worldwide repositories in 67 nations 453 worldwide repositories in 67 nations 54 ship/sell anthrax 54 ship/sell anthrax 18 ship/sell plague 18 ship/sell plague International black-market sales associated with governmental programs International black-market sales associated with governmental programs

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention Critical Agents B. anthracis (anthrax) B. anthracis (anthrax) Y. pestis (plague) Y. pestis (plague) F. tularensis (tularemia) F. tularensis (tularemia) Filo and Arena viruses (viral hemorrhagic fevers) Filo and Arena viruses (viral hemorrhagic fevers) Cl. botulinum toxin (botulism) Cl. botulinum toxin (botulism) V. major (smallpox) V. major (smallpox)

CDC Centers for Disease Control and Prevention Why These Agents? Infectious via aerosol Infectious via aerosol Organisms fairly stable in aerosol Organisms fairly stable in aerosol Susceptible civilian populations Susceptible civilian populations High morbidity and mortality High morbidity and mortality Person-to-person transmission (smallpox, plague, VHF) Person-to-person transmission (smallpox, plague, VHF) Difficult to diagnose and/or treat Difficult to diagnose and/or treat Previous development for BW Previous development for BW

CDC Centers for Disease Control and Prevention “A bioterrorism attack against Americans anywhere in the world is inevitable in the 21 st century.” Anthony Fauci, Director, NIAID Clinical Infectious Diseases 2001;32:678

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

Powders, Powders Everywhere… The Impact of the Worried Well on the Public Health System

CDC Centers for Disease Control and Prevention Anthrax: Cutaneous Most common form (95%) Most common form (95%) Inoculation of spores under skin Inoculation of spores under skin Incubation: hours to 7 days Incubation: hours to 7 days Small papule --> ulcer surrounded by vesicles (24-28h) Small papule --> ulcer surrounded by vesicles (24-28h) Painless eschar with edema Painless eschar with edema Death 20% untreated; rare treated Death 20% untreated; rare treated USAMRICD

CDC Centers for Disease Control and Prevention Anthrax: Inhalational Inhalation of spores Inhalation of spores Incubation: 1 to 43 days Incubation: 1 to 43 days Initial symptoms (2-5 d) Initial symptoms (2-5 d) Fever, cough, myalgia, malaise Fever, cough, myalgia, malaise Terminal symptoms (1-2d ) Terminal symptoms (1-2d ) High fever, dyspnea, cyanosis High fever, dyspnea, cyanosis Hemorrhagic mediastinitis/effusion Hemorrhagic mediastinitis/effusion Rapid progression shock/death Rapid progression shock/death Mortality rate ~ 100% despite Rx Mortality rate ~ 100% despite Rx CDC

Centers for Disease Control and Prevention  Detection & surveillance  Rapid laboratory diagnosis  Epidemiologic investigations  Implementation of control measures Public Health Response to Bioterrorism

CDC Centers for Disease Control and Prevention CDC Plague: Bubonic Incubation: 2-6 days Incubation: 2-6 days Sudden onset HA, malaise, myalgia, fever, tender LNs Sudden onset HA, malaise, myalgia, fever, tender LNs Regional lymphadenitis (Buboes) Regional lymphadenitis (Buboes) Cutaneous findings Cutaneous findings possible papule, vesicle, or pustule at inoculation site possible papule, vesicle, or pustule at inoculation site Purpuric lesions - late Purpuric lesions - late

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention BT: Timeliness is the Key to Success Go to the source Go to the source Increase awareness of BT in medical community to improve rapid reporting of: Increase awareness of BT in medical community to improve rapid reporting of: Suspect cases potentially BT-related unusual clusters of disease, in time or space unusual manifestations of disease or unusual disease or symptoms for the geographic area Suspect cases potentially BT-related unusual clusters of disease, in time or space unusual manifestations of disease or unusual disease or symptoms for the geographic area

CDC Centers for Disease Control and Prevention Close Cooperation with clinicians, healthcare and first responder communities Emergency departments, urgent care centers Emergency departments, urgent care centers Infection control units Infection control units Physician networks, private offices Physician networks, private offices Hospitals, HMOs Hospitals, HMOs Medical examiners Medical examiners Poison control Poison control Law enforcement, fire, other first responders Law enforcement, fire, other first responders

CDC Centers for Disease Control and Prevention Clues to Possible Bioterrorism I Single case caused by an uncommon agent Single case caused by an uncommon agent Large number of ill persons with similar disease, syndrome, or deaths Large number of ill persons with similar disease, syndrome, or deaths Large number of unexplained disease, syndrome, or death Large number of unexplained disease, syndrome, or death Unusual illness in a population Unusual illness in a population Higher morbidity & mortality than expected with a common disease or syndrome Higher morbidity & mortality than expected with a common disease or syndrome Multiple disease entities coexisting in the same patient Multiple disease entities coexisting in the same patient Disease with an unusual geographic or seasonal distribution Disease with an unusual geographic or seasonal distribution

CDC Centers for Disease Control and Prevention Clues to Possible Bioterrorism II Multiple atypical presentations of disease agents Multiple atypical presentations of disease agents Similar genetic type of agent from distinct sources Similar genetic type of agent from distinct sources Unusual, atypical, genetically engineered, or antiquated strain Unusual, atypical, genetically engineered, or antiquated strain Endemic disease with unexplained increased incidence Endemic disease with unexplained increased incidence Simultaneous clusters of similar illness in con- contiguous areas Simultaneous clusters of similar illness in con- contiguous areas Atypical aerosol, food, or water transmission Atypical aerosol, food, or water transmission Ill persons presenting during the same time Ill persons presenting during the same time Concurrent animal disease Concurrent animal disease

CDC Centers for Disease Control and Prevention Bioterrorism Surveillance Early, rapid recognition of unusual clinical syndromes or deaths Early, rapid recognition of unusual clinical syndromes or deaths Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death

CDC Centers for Disease Control and Prevention Bioterrorism: Potential Data Sources Laboratories Laboratories Infectious disease Infectious disease Specialists Specialists Hospitals Hospitals Physician’s offices Physician’s offices Poison control centers Poison control centers Medical Examiners Death Certificates Police/Fire departments Other “first responders” Pharmacy data

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention Syndrome Surveillance The monitoring of illnesses based upon a constellation of symptoms and/or findings The monitoring of illnesses based upon a constellation of symptoms and/or findings Provides an “early warning system” for outbreaks, emerging pathogens Provides an “early warning system” for outbreaks, emerging pathogens Highly sensitive, seasonal specificity varies Highly sensitive, seasonal specificity varies

CDC Centers for Disease Control and Prevention Release Number of Cases Symptom OnsetSevere Illness Rationale for Syndromic Surveillance

CDC Centers for Disease Control and Prevention Examples of Syndromes for Surveillance Unexplained death w/ history of fever Unexplained death w/ history of fever Meningitis, encephalitis or unexplained acute encephalopathy/delirium Meningitis, encephalitis or unexplained acute encephalopathy/delirium Botulism-like syndrome (cranial nerve impairment and weakness) Botulism-like syndrome (cranial nerve impairment and weakness) Rash and fever Rash and fever Non-pneumonia respiratory tract infection w/ fever Non-pneumonia respiratory tract infection w/ fever Diarrhea/Gastroenteritis Diarrhea/Gastroenteritis Pneumonia Pneumonia Sepsis or non-traumatic shock Sepsis or non-traumatic shock

CDC Centers for Disease Control and Prevention Information System Functions Needed for Bioterrorism Preparedness and Response PREPAREDNESS REQUIRES THAT ALL PARTNERS--LOCAL, STATE, & FEDERAL ARE PART OF SYSTEMS PREPAREDNESS REQUIRES THAT ALL PARTNERS--LOCAL, STATE, & FEDERAL ARE PART OF SYSTEMS Surveillance data analysis--event detection & management Surveillance data analysis--event detection & management Notification—rapid alerting Notification—rapid alerting Communications –information, not data Communications –information, not data Knowledge management Knowledge management

Lessons Learned from Anthrax Incidents Late 2001

CDC Centers for Disease Control and Prevention There Were Some Important Surprises Even for Experts Anthrax lethal dose rates appear to have been seriously over-estimated Anthrax lethal dose rates appear to have been seriously over-estimated Re-aerosolization is a greater problem than anticipated Re-aerosolization is a greater problem than anticipated Dispersal characteristics of an envelope in the mail system could be devastating Dispersal characteristics of an envelope in the mail system could be devastating The threshold at which the medical system will be overwhelmed appears to be lower than expected The threshold at which the medical system will be overwhelmed appears to be lower than expected

CDC Centers for Disease Control and Prevention Varying Presentations of NYC Cutaneous Lesions

CDC Centers for Disease Control and Prevention Effects Magnification Do not need large numbers of casualties to incur massive damage - economic, social, political ! E.g. anthrax by mail: 5 deaths 18 infected 30,000 treated with antibiotics 10,000 treated for 60 days Many billions of dollars cost + impact impact

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention Public Awareness Reliable, credible information to the public is key to keeping cooperation and minimizing panic

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention Decision Making without Data Need to make decisions rapidly in the absence of data Need to make decisions rapidly in the absence of data Access to subject matter experts was limited Access to subject matter experts was limited No “textbook” experience to guide response No “textbook” experience to guide response Understanding of “risk” evolved as outbreak unfolded Understanding of “risk” evolved as outbreak unfolded Need coherent, rapid process for addressing scientific issues in midst of crisis Need coherent, rapid process for addressing scientific issues in midst of crisis

CDC Centers for Disease Control and Prevention TODAY’S SITUATION Many hospitals on trauma diversion with no major incidents going on Many hospitals on trauma diversion with no major incidents going on Not economically viable for hospitals to maintain surge capacity, or even to focus on treating sick and injured (hospitals lose money treating the truly sick) Not economically viable for hospitals to maintain surge capacity, or even to focus on treating sick and injured (hospitals lose money treating the truly sick) Public health infrastructure is beyond simple band-aid fixes Public health infrastructure is beyond simple band-aid fixes Military health system (including VA) is not effectively integrated or used Military health system (including VA) is not effectively integrated or used

CDC Centers for Disease Control and Prevention Provide More Health System Surge Capacity Health care cost control has systematically eliminated reserve capacity from the system. Health care cost control has systematically eliminated reserve capacity from the system. Need to rethink how much surge capacity is needed for emergencies. Need to rethink how much surge capacity is needed for emergencies. Need to re-assess adequacy and geographic extent of mutual aid agreements. Need to re-assess adequacy and geographic extent of mutual aid agreements. What mobile resources can the federal and state governments truly provide? What mobile resources can the federal and state governments truly provide? Also need plans to tap unconventional resources if disasters strike – e.g., sites for emergency care, inventories of health care workers. Also need plans to tap unconventional resources if disasters strike – e.g., sites for emergency care, inventories of health care workers.

CDC Centers for Disease Control and Prevention

CDC Centers for Disease Control and Prevention Epidemiological Pattern of Smallpox Weapon New foci of secondary infection “Contaminated” zone “Infected” zone Zone of initial explosion

CDC Centers for Disease Control and Prevention Summary: Priority Preparedness Activities State & local preparedness planning State & local preparedness planning Surveillance and epidemiology Surveillance and epidemiology Outbreak verification Outbreak verification Laboratory capacity for biologic & chemical agents Laboratory capacity for biologic & chemical agents Health information & communication systems Health information & communication systems Training Training Establish key liaisons Establish key liaisons

CDC Centers for Disease Control and Prevention Bottom Line Early, rapid recognition of unusual clinical syndromes or deaths Early, rapid recognition of unusual clinical syndromes or deaths Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death

CDC Centers for Disease Control and Prevention The detection and control of saboteurs are the responsibilities of the FBI, but the recognition of epidemics caused by sabotage is particularly an epidemiologic function…. Therefore, any plan of defense against biological warfare sabotage requires trained epidemiologists, alert to all possibilities and available for call at a moment’s notice anywhere in the country” Alexander Langmuir Founder of CDC EIS Program 1952 CDC Epidemiology and Bioterrorism

U.S. Department of Health and Human Services Eric K. Noji, M.D., M.P.H. Special Assistant to the US Surgeon General for Disaster Medicine, US Public Health Service Phone: Fax: For Questions Contact: