Response to Public Health Emergencies: The Role of Public Health and Laboratories MM

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Response to Public Health EmergenciesThe Role
of Public Health and LaboratoriesMMI 554

• December 1, 2009

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Response to Public Health EmergenciesThe Role
of Public Health and Laboratories

• You should be able to discuss
• The expansion of the number of partners
  participating in response to a public health
  emergency and what led to this expansion
• The key laboratory elements of the Laboratory
  Response Network (LRN) for bioterrorism
• What is meant by an All Hazards preparedness
  and response philosophy when dealing with public
  health threats
• Non-traditional laboratory response capabilities
  that can be deployed during public health or
  environmental emergencies
• Current challenges in laboratory response to
  public health threats

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Emerging Infectious Diseases Not really
About Emergency Response

• Targets
• Surveillance and Response
• Applied Research
• Infrastructure and Training
• Prevention and Control
• The Outcomes
• Raised awareness of public health deficiencies
• We understood what needed to be done however,
  minimal funding to do it

http//www.cdc.gov/ncidod/diseases/eid/index.htm
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Traditional Federal Partners in Public Health
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Traditional State Partners in Public Health
The WSLH Serves Them All
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(No Transcript)
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MMWR
Recommendations and Reports April
21, 2000 /Vol. 49 / No. RR-4

• Biological and Chemical Terrorism
• Strategic Plan for Preparedness
• and Response
• Recommendations of the CDC Strategic
• Planning Workgroup

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Development of Advanced Testing Capability
Bioterrorism Agents

• 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 (Chlamydia psittaci)
• Q Fever (Coxiella burnetii)
• Ricin toxin from castor beans
• Typhus fever (R. prowazekii)
• Viral encephalitis (e.g., VEE, EEE)
• Staphylococcal enterotoxin B
• Water threats

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Overt vs. Covert EventsRecognition
Overt Event
Responder Community
Public Health Community
Health Care Community
Covert Event
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Federal Partners in Emergency Preparedness and
Response

• DHHS
• CDC (PH response)
• EPA
• USDA
• FDA
• DHS
• FBI (Crisis Mgmt)
• FEMA (Consequence Mgmt)
• DOD
• DOJ

• USPIS
• Secret Service
• Treasury
• NSC
• SBCCOM
• USAMRIID
• OEP

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State Partners in EmergencyPreparedness and
Response

• WI Division of Public Health
• Local health departments
• DNR - Environmental concerns
• Health care providers
• Public Health Laboratories The WSLH
• DATCP - Food chain/agricultural issues
• WVDL Animal issues
• WEM Local emergency management agencies
• FBI
• Local law enforcement
• Fire/HAZMAT
• Local clinical laboratories

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The National Lab Response Network (LRN)
for Bioterrorism

• Coordination by the CDC
• Comprised of public and private labs
• Timely and accurate diagnostic testing
• Consensus protocols using CDC-approved methods
• Site-appropriate testing
• Secure reference testing protocols and reagents
• Timely and secure results reporting
• NEDSS and HIPAA compliant
• Linkage with local, state and federal agencies
• Central role for the state public health
  laboratory

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The Laboratory Response Network (LRN)
for Bioterrorism-2009

• An integrated network of state local public
  health, clinical, federal, military,
  international laboratories to respond to
  bioterrorism, chemical terrorism and other public
  health emergencies.
• National Labs - CDC USAMRIID
• Reference Labs - State local PHLs, state agency
  labs
• Sentinel Labs Hospital community clinical labs

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RESPONSE TO PUBLIC HEALTH THREATS

• Bioterrorist (BT) events are unnaturally
  occurring emerging infectious diseases (EIDs)
• Laboratory capacity and capability and
  epidemiologic surveillance needed for recognition
  of BT events are the same as for naturally
  occurring EIDs All Hazards

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CDC Program Announcement 99051Public Health
Preparedness Response to BioterrorismEMERGENCY
SUPPLEMENTAL 2002-2009

• CDC Focus Areas 2002-06
• Preparedness Planning and Readiness Assessment
• Surveillance Epidemiology Capacity
• Laboratory Capacity - Biological
• Laboratory Capacity - Chemical
• Health Alert Network
• Communication and Health Information
  Dissemination
• Education and Training

• CDC Goals 2006-09
• Prevent
• Detect/Report
• Investigate
• Control
• Recover

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Why is the WSLH the Lead in Emergency Laboratory
Response?

• Statutory authority within the state
• Historical precedence
• PHLs are reference labs within the state
• PHLs serve as states laboratory liaison to CDC
  and EPA
• State PHL provides link between local
  laboratories and CDC /federal agencies
• Experience with biological agents of public
  health concern, with outbreak investigations and
  supporting response to environmental emergencies

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WSLH Microbiological Testing Capability Non-BT
Agents (All-Hazards)

• Real-Time PCR at WSLH
• SARS
• Monkeypox
• Varicella (Chickenpox)
• Herpes Simplex
• Enterovirus
• Influenza A B Avian Influenza
• Respiratory pathogens battery
• Norovirus
• Pertussis, mumps, measles
• Enteric pathogens

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Chemical Laboratory Response Network 2009
Level 3 Labs
Level 2 Labs
Level 3 American Samoa Chicago Guam Micronesia Ma
rshall Is. N. Mariana Is. New York
City Palau Puerto Rico US Virgin Islands Level
2 District of Columbia Los Angeles
Level 1 Labs
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The Chemical Laboratory Response Network
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WSLH Emergency Laboratory Response All
Hazards Analytical Capabilities

• All Hazards
• Biological
• Chemical
• Radiological

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The Wisconsin Clinical Laboratory Network
Bayfield
Douglas
Ashland
Iron
Vilas
Sawyer
Washburn
Burnett
Price
Oneida
Florence
Forest
Barron
Rusk
Marinette
Polk
Lincoln
Taylor
Oconto
Langlade
Chippewa
St. Croix
Dunn
Menominee
Marathon
Clark
Pierce
Shawano
Eau Claire
Door
Pepin
Waupaca
Wood
Portage
Kewaunee
Buffalo
Outagamie
Trempealeau
Jackson
Brown
Manitowoc
Waushara
Winnebago
Juneau
Adams
Monroe
Calumet
LaCrosse
Marquette
Fond du Lac
Sheboygan
Vernon
Green Lake
Sauk
Columbia
Dodge
Richland
Ozaukee
Washington
Crawford
WCLN Sentinel Labs
Dane
Milwaukee
Jefferson
Waukesha
Iowa
Grant
WCLN Reference Labs
Green
Walworth
Racine
LaFayette
Rock
Kenosha
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What REAL Difference Does the WCLN Make?
Influenza 2004-07
Salmonella 2007
Measles 2008
Powders 2001
Pertussis 2003-05
SARS 2003
Mumps 2006
E.coli 2006
Monkeypox 2003
2009 H1N1

• Capabilities Developed
• ?Enhanced PHL testing capabilities ? Shipper
  repositories
• WSLH 24/7 Emergency Response ?Emergency
  Response guidelines
• Surge capacity for PHLs ?
  Specimen courier
• Rapid reporting
  ? Messaging
• Collaboration/Communication ?Training
  for clinical labs
• with other labs
  ? Response exercises
• Testing and shipping exercises ?
  Lab-based surveillance

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Beyond the LRN

• Emergency Laboratory Response
• Beyond the Traditional Laboratory

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Emergency Laboratory Response Beyond the
Traditional LaboratoryRapid POC Diagnostic
Testing Sites

• Influenza as an example
• Surveyed 1,996 labs POLs, clinics and LTCF
• 1257 (63) returned
• Responses
• Perform rapid influenza tests
• 367 (30)
• Considering performing rapid influenza tests
• 76 (6)
• Perform rapid influenza tests year-round
• 318/464 (69)

Douglas
Bayfield
Ashland
Iron
Washburn
Sawyer
Vilas
Burnett
Florence
Price
Oneida
Rusk
Polk
Marinette
Forest
Lincoln
Barron
Taylor
Oconto
Langlade
Chippewa
Dunn
St. Croix
Menominee
Clark
Marathon
Pierce
Shawano
Eau Claire
Door
Pepin
Portage
Waupaca
Wood
Buffalo
Outagamie
Kewaunee
Jackson
Brown
Trempealeau
Manitowoc
Juneau
Waushara
Monroe
Adams
La Crosse
Calumet
Winnebago
Marquette
Sheboygan
Fond du Lac
Green Lake
Vernon
Columbia
Sauk
Richland
Ozaukee
Crawford
Dodge
Washington
Dane
Iowa
Grant
Jefferson
Waukesha
Milwaukee
Green
Racine
Lafayette
Rock
Walworth
Kenosha
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Emergency Laboratory Response Beyond the
Traditional LaboratoryBiohazard Detection
System-USPIS

• USPS program
• Anthrax detection
• Continuous air sample collection from pinch
  points
• Automated PCR
• Once per hour
• All major processing facilities

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Emergency Laboratory Response Beyond the
Traditional LaboratoryBioWatch-EPA/CDC

• Air filters on EPA air quality monitors
• Located in most major US cities
• Tested daily by Lab Response Network laboratories
• PCR for anthrax, plague, smallpox and tularemia

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Emergency Laboratory Response Beyond the
Traditional Laboratory BioShield-BARDA

• BioShield One
• 5.6B over 10 years for vaccine and
  pharmaceutical RD for the SNS
• Participation issues
• BioShield Two
• Created BARDA Biomedical Advanced RD Agency,
  1B budget
• Provides additional protections and guarantees to
  participants

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Emergency Laboratory Response Beyond the
Traditional LaboratoryNational Guard Civil
Support Teams (WMD)

• WIs 54th CST (WMD)
• Field identification of CBRNE agents following
  intentional release
• On alert 24/7/365
• Federally funded, state controlled
• Activated by Governor
• Employs a mobile analytical lab with full suite
  of biological, chemical and radiological
  detection equipment
• Coordination with WSLH

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Emergency Laboratory Response Beyond the
Traditional LaboratoryHAZMAT

• Civilian response to non-intentional chemical,
  radiological, nuclear events (e.g. spills,
  accidental releases, result of fire, etc.)
• Primary response, detection, containment
• Has became a player in acts of terrorism

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Emergency Laboratory Response CapabilitiesAn
expanding list of partners
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The Response to Public Health and Environmental
Emergencies

• The key to public health
• preparedness and response is
• PARTNERSHIP COMMUNICATION!

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LABORATORY NETWORK RESPONSE TO PUBLIC
HEALTH THREATS
Current Challenges

• Maintaining communications
• New environmental sensing technologies
• Understanding the technologies and limitations
• Coordination with laboratory
• Rapid kit tests for BT and other EID agents
• Understanding the limitations
• Lab testing in the hands of the non-laboratorian
• Threats to water and food the challenges in
  detection and interpretation
• Fast tracking diagnostic methods in the lab
• Biosafety and biosecurity

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WSLH Capabilities, Laboratory Networks and
Emergency Response in General

• The Critical Challenge
• as We Move Forward?
• Sustainability!