Enhancing Public Health Response to Emerging Infectious Diseases

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Enhancing Public Health Response
to Emerging Infectious Diseases

• 2009HAVE WE ELIMINATED THE
  THREAT?

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A Reason for Optimism?
Summer 2007
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THE EID THREAT IS A GLOBAL ONE
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Enhancing Public Health Response
to Emerging Infectious Diseases

• 2009WHY DOES THE THREAT
  STILL EXIST?

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WHAT IS PUBLIC HEALTH?

• The art and science of preventing
• disease and disability, prolonging life,
• promoting health of populations, and
• ensuring a healthful environment
• through organized community effort

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Factors in Infectious Disease Emergence

• Human demographics and behavior
• International travel and commerce
• Technology and industry
• Human susceptibility to infection
• War and famine
• Lack of political will
• Poverty and social inequality
• Intent to harm

• Breakdown in
• public health

• Microbial
• adaptation
• and change

Emergence

• Ecological factors
• Zoonotic diseases
• Economic development and land use
• Climate and weather

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ADDRESSING THE THREAT OF
EMERGING INFECTIOUS DISEASES

• The Publics Role in Public Health

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• Bioterrorism
• A Threat to National Security
• or
• Public Health-Defining Issue?
• MMI 554
• September 10, 2009

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BIOTERRORISM

• The intentional or threatened use of
  microorganisms or biologic toxins to kill or
  incapacitate people, animals or crops.
• Everything you want to know
• www.bt.cdc.gov

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Terrorism Why?

• Create terror, panic, uncertainty/uneasiness
• Advance political/religious/apocalyptic beliefs
• Asymmetrical response a.k.a. even the playing
  field
• Doable and affordable
• Effective

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Terrorism
Methods of Choice
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Advantages of Biologics as Weapons

• Easy to obtain
• Inexpensive to produce
• Potential for dissemination over large geographic
  area
• Creates panic
• Can overwhelm medical services
• Perpetrators escape easily

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Bioterrorism Is
this the real deal?

• U.S. vulnerability
• Is the countrys emergency response and public
  health infrastructure adequate?
• Historical precedence
• Capabilities exist worldwide
• Actual BT Events

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BIOLOGICAL AND CHEMICAL
TERRORISM AND WARFARE
A Historical
Perspectivehttp//www.cns.miis.edu/research/cbw/
pastuse.htm

• Early Attempts
• 429 BC - Spartans ignite pitch and sulfur to
  create toxic fumes in the Peloponnesian war.
• 1346-47 - Mongols catapult corpses contaminated
  with plague over the walls into Kaffa.
• 1763 - During the French and Indian wars, the
  British give small pox - contaminated blankets to
  hostile Indian tribes.

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BIOLOGICAL AND CHEMICAL TERRORISM
AND WARFARE A Historical Perspective

• Modern Era (I)
• 1914-1918 - Widespread use of BW and CW during
  WWI
• June 17, 1925 - Geneva Protocol for the
  Prohibition of the Use in War of Asphyxiating,
  Poisonous or Other Gases and of Bacteriological
  Methods of Warfare.
• 1932-1945 - Japan conducts BW research
• 1940 - Japan uses BW on China and Manchuria
• 1942 - U.S. begins offensive BW program

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BIOLOGICAL AND CHEMICAL TERRORISM
AND WARFARE A Historical
Perspective

• Modern Era (II)
• 1969-70 - President Nixon unilaterally dismantles
  U.S. offensive BW and CW programs
• April 10, 1972 - Convention on the Prohibition
  of the Development, Production and Stockpiling of
  Biological and Toxin Weapons and on Their
  Destruction. , The BWC is developed
• 1972 to present - Suspected or proven violations
  of the BWC

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An Opportunity for the Soviet Union
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For some sleepless nightswww.nlm.nih.gov/nichsr/
esmallpox/biohazard_alibek.pdf
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Believe it or not, there was reason for concern
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Actual BT Events An
awakening to the threat
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Past U.S. Incidents of
Food Bioterrorism

• When November, 1996
• Where Texas
• What Contamination of muffins with Shigella
  dysenteriae, medical center lab - staff breakroom
• Who Disgruntled employee
• Why ?
• Outcome 12/45 staff ill, 4 hospitalized, 0
  deaths

• When Sept. Oct., 1984
• Where The Dalles, Oregon
• What Contamination of salad bars with Salmonella
  
• Who Members of the Rajneeshi religious commune
• Why Incapacitate voters in upcoming election
• Outcome 751 ill, 45 hospitalized, 0 deaths

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President Clintons Awakening?
-1998-
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Anthrax 2001
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Anthrax 2001 The Outcome

• 4-5 letters containing anthrax spores sent in
  mail
• 4 regions initially affected in US
• Florida
• New York City / New Jersey
• Washington Metro
• Connecticut

• Mild contamination of other US postal facilities
• 22 human cases in US
• 11 inhalation
• (5 deaths)
• 11 cutaneous
• 10,000 people prophylaxed
• Nationwide Effects
• Concerns/panic

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Anthrax 2001 What We
Really Learned!

• THE POWER
• OF
• PANIC

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Anthrax 2001 The rest
of the story

• Who was responsible for the attack?
• www.promedmail.org
• http//pubs.acs.org/journals/ancham/news/2008/09/1
  8/cp_anthrax.html
• www.washingtonpost.com/wp-dyn/content/
• article/2008/10/26/AR2008102602522_pf.html
• A new science is born
• Microbial Forensic Analysis

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Priority Bioterrorism Agents
http//www.bt.cdc.gov/bioterrorism/

• Category A Agents
• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers (e.g., Ebola, Marburg,
  Lassa)

• Category B Agents
• Brucellosis (Brucella)
• Epsilon toxin of C. perfringens
• Food Threats (e.g., Salmonella, E. coli O157H7,
  Shigella)
• Glanders (Burkholderia mallei)
• Melioidosis (B. pseudomallei)
• Psittacosis (C. psittaci)
• Q Fever (Coxiella burnetii)
• Ricin toxin from castor beans
• Staphylococcal enterotoxin B
• Typhus fever (R. prowazekii)
• Viral encephalitis (e.g., EEE)
• Water threats

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A headline in follow-up to the anthrax
event...

• Smallpox offensive Vaccinations now
• - HEADLINE, WISCONSIN STATE
  JOURNAL, SEPTEMBER 2002 -
• ...whod a thunk it!

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SMALLPOX -Why is it a threat?
www.bt.cdc.gov/agent/smallpox/index.asp

• Potential clandestine stockpiles
• Satisfy most criteria of a good BW
• Aerosol infectivity highly infectious
• Communicability
• Long incubation period
• Potential for large scale production
• Highly pathogenic high mortality
• Lack of population immunity
• Induce panic

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SMALLPOX
Prevention and Control - 2007

• Vaccination
• Pre-exposure Preventive Vaccination
• Post-release Vaccination
• Ring Vaccination and mass vaccination
• Community Containment Strategy
• Identify cases
• Isolate cases (to break chain of transmission)
• Isolate at home if possible
• Institutional isolation
• Designated hospitals
• Hotels, old nursing homes, etc.
• Observation of close contacts for 17 day
• Fever (gt 101) watch
• Is forced quarantine acceptable, doable?

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Bioterrorism

• This is the real deal!
• VS
• This is an unlikely threat

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Biological Terrorism
An Unlikely threat?

• Infrequent use of CBW
• Technical difficulties
• Need for a weapons system
• Moral and social constraints
• Hazard to perpetrator
• Unpredictability
• Fear of retribution
• but dont forget Autumn of 2001!

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BIOLOGICAL TERRORISM

• The bottom line circa 2009
• The threat is very real!
• A low probability, high consequence threat
• It will happen somewhere, sometimeagain!
• BT preparedness and response planning is no
  longer a national priority, however
• preparedness should continue, following an
  all-hazards philosophy.

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Recent EID Threats and the list
continues to grow

• Pandemic Influenza swine flu
• E.coli O157H7/Salmonella
• Norovirus
• MDR, XDR tuberculosis
• Community-acquired MRSA/ Epidemic C. difficile
• Mumps, Measles, Rubella
• Pertussis (Whooping Cough)
• Monkeypox
• SARS
• West Nile Virus
• Anthrax, ricin and other bioterrorism agents

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CDC Program Announcement
99051Public Health Preparedness Response to
Bioterrorism EMERGENCY SUPPLEMENTAL
2002-200-

• Preparedness Planning and Readiness Assessment
• Surveillance Epidemiology Capacity
• Laboratory Capacity - Biological Agents
• Laboratory Capacity - Chemical Agents
• Health Alert Network
• Communication and
• Health Info Dissemination
• Education and Training