Bioterrorism Preparedness and Response A Public Health Perspective

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Bioterrorism Preparedness and Response A Public
Health Perspective

• James M. Hughes, M.D.
• Director, National Center for Infectious Diseases
• Centers for Disease Control and Prevention

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one can think of the middle of the twentieth
century as the end of one of the most important
social revolutions in history, the virtual
elimination of the infectious disease as a
significant factor in social life.
Burnet, 1962
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IOM Definition ofEmerging Infections

• New, reemerging or drug-resistant infections
  whose incidence in humans has increased within
  the past two decades or whose incidence threatens
  to increase in the near future.

Institute of Medicine Report, 1992
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Major Factors Contributing to theEmergence of
Infectious Diseases

• Human demographics and behavior
• Technology and industry
• Economic development and land use
• International travel and commerce
• Microbial adaptation and change
• Breakdown of public health measures

Institute of Medicine Report, 1992
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Goals
I - Surveillance and Response II - Applied
Research III - Infrastructure and Training
IV - Prevention and Control
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Selected Priority Areas

• Antimicrobial Resistance
• Foodborne and Waterborne Diseases
• Vectorborne and Zoonotic Diseases
• Chronic Diseases Caused by Microbial Agents

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Detecting Common Source Outbreaks
1997 - Salmonella Agona with the same PFGE
fingerprint identified in 19 States Investigation
Toasted oats breakfast cereal
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SCIENCE 1998 282219
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New and reemerging infectious diseases will pose
a rising global health threat and will complicate
U.S. and global security over the next 20 years.

• National Intelligence Estimate The Global
  Infectious Disease Threat and Its Implications
  for the United States, 2000

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Bioterrorism Threat Agents

• Little familiarity
• Little or no immunity
• Little research

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Characteristics of Potential Agents of
Bioterrorism

• Category A
• Can be easily disseminated or transmitted from
  person-to-person
• High mortality, with potential for major public
  health impact
• Mass casualties which may overwhelm healthcare
  systems
• May cause public panic and social disruption
• Require special efforts for public health
  preparedness

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Critical Biological Agents

• Category A
• Variola major (Smallpox)
• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Franciscella tularensis (Tularemia)
• Clostridium botulinum toxin (Botulism)
• Hemorrhagic fever viruses (Ebola, Marburg)

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NY Times, Oct 7, 2001
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Anthrax Recognition in Florida

• 63 yo male photo editor employed by AMI
• Onset 9/30/01
• Fever, fatigue, sweats, altered mental status
• Admitted to hospital 10/2/01
• Gram bacilli detected in cerebrospinal fluid
• Cultures from blood and cerebrospinal fluid
  positive
• CDC notification 10/3/01 case confirmed
  10/4/01
• Autopsy consistent with inhalational anthrax on
  10/6/01

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Florida Index Inhalational Anthrax Case CSF
Grams Stain
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NEJM 20013451607
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Laboratory Response Network Concept
D BSL-2, -3, and -4
Level D
C BSL-3
Level C
B BSL-2 with BSL-3 practices
Level B
A - Rule-out and if needed forward
Level A
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NY Times, Oct 13, 2002
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Recognition in New York City

• 38 year old woman NBC TV anchor assistant
• Recalled handling a suspicious letter with
  powder before onset
• Cutaneous lesion onset 9/25/01
• Central necrosis with eschar
• Cultures negative
• Immunohistochemical staining of skin biopsy
  showed B. anthracis on 10/12/01

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Bioterrorism-related Anthrax Cases Reported Date
of Onset
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Post-Exposure Prophylaxis for Prevention of
Inhalational Anthrax

• 22 people with anthrax 5 deaths
• Hundreds evaluated to rule out anthrax
• 30,000 people advised to start antibiotics
• 10,000 people recommended to take at least 60
  days of antibiotic therapy
• Hundreds of thousands more affected by events

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The National Pharmaceutical Stockpile

• 12 push packages ready to arrive anywhere in the
  U.S. within 12 hours of deployment
• Vendor Managed Inventory (VMI) follow-on stores
  of medical supplies to augment push packages that
  arrive within 24-36 hours of activation

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Issues Not Confronted

• Multiple agents
• Multiple drug resistance
• Genetic engineering
• Transmission to animals
• Multiple modes of transmission
• Clinical surge capacity
• Multiple time zones
• Cases in other countries
• Cyberterrorism

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Other Issues Related to Other Agents

• Organism difficult to isolate or identify
• Person-to-person transmission
• Vectorborne transmission

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JAMA 2002287898
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Healthcare Providersand Microbiologists
Local Bioterrorism Preparedness Detection and
Response
Healthcare Organizations
Public Health
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Lessons Learned Emerging Infection /
Bioterrorism Outbreaks

• Importance of
• surveillance
• prompt epidemiologic investigation
• laboratory capacity
• Disruption of travel and commerce
• Global implications of local problems
• Critical linkages and partnerships
• Emergency Operations Center
• Communication

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gt1B for State and Local Preparedness

• Health Departments (CDC) 918 M
• Hospitals (HRSA) 125 M
• Metro Med Resp System (OEP) 15 M

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Public Health PreparednessState and Local
Support
Priorities

• Bioterrorism
• Other infectious disease outbreaks
• Other urgent public health threats

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State and Local SupportFocus Areas

• Preparedness Planning and Readiness Assessment
• Surveillance and Epidemiology Capacity
• Biological Laboratory Capacity
• Communication and Information Technology /
  Health Alert Network
• Communicating Health Risks and Health
  Information Dissemination
• Education and Training

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Washington Post, Sept 23, 2002
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Atlanta Journal-Constitution, October 14, 2002
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NY Times Dec 14, 2002
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Front Line Response Begins at the Local Level

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• MMWR
• Training Broadcasts 500,000 participants
• Health Alert Messages Over 50 sent out
• Public Inquiries
• 500,000

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Terrorism Preparedness Critical Elements

• Plan
• Products
• Personnel
• Practice

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Future Challenges

• Pandemic Influenza
• Antimicrobial Resistance
• International Foodborne Disease Outbreaks
• Urban Yellow Fever in Latin America and Asia
• Microbial Etiologies of Chronic Diseases
• The Unexpected

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www.cdc.govwww.bt.cdc.gov
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www.smallpox.gov
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Looking to the future, we can expect an
increasing array of infectious disease threats.
Our public health system will be challenged to
confront both routine and unexpected outbreaks of
disease, including possible acts of bioterrorism.
We have a chance to defend the nation against its
adversaries and improve the public health system
with the same steps. We must do
it. Margaret A. Hamburg Science
20022951425