BIOTERRORISM AND THE PUBLIC HEALTH SECTOR

Richard McCluskey MD, PhD

Center for Disaster Management and Humanitarian Assistance

College of Public Health

University of South Florida

WHY PUBLIC HEALTH ?

CHEMICAL effects immediate and

obvious victims localized by

time and place overt illicit immediate

response first responders are

police, fire, EMS

BIOLOGICAL effects delayed and

not obvious victims dispersed in

time and place no first responders unless announced,

attack identified by medical and public health personnel

WHY PUBLIC HEALTH ?

Tokyo subway 1995 / Sarin Effects within minutes Victims self-reported to authorities, self-

transported to hospitals First responders

fire, police, EMS

Agent identified: 3 hrs Event over: 12-24 hrs

WHY PUBLIC HEALTH ?Oregon USA 1984 / Salmonella

County Health Departmentfirst reports of foodborne illness: several daystwo waves of illness over 5 weeks

County Health Department and CDC751 victims and 10 restaurants identified:

weeks - months

Criminal investigation source identified: 12 monthscriminal charges: 18 months

PUBLIC HEALTH

Examples of biological assaults:note: all incidents were discovered by public health officials and initially presented as an unusual cluster in time and

place of an uncommon disease

1996 Shigella dysenteriae USA 1984 Salmonella USA 1970 Ascaris suum Canada 1966 Typhoid Japan 1965 Hepatitis USA

PUBLIC HEALTH

Announced attack Primary response: law enforcement, EMS

Hoax Variation on announced attack Increasing occurrence

1992: 1 event affecting 20 people1998: 37 events affecting 5529 people

PUBLIC HEALTH

Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management -- United States, 1998

MMWR February 5, 1999 48(04);69-74 http://www.cdc.gov/epo/mmwr/preview/

mmwrhtml/rr4904a1.htm

PUBLIC HEALTH

Preparedness and preventionDetection and surveillanceDiagnosis and characterization of agentsResponse Communication

PUBLIC HEALTH

Preparedness and prevention Coordinated preparedness plans Coordinated response protocols Performance standards

self-assessment, simulations, exercises

PUBLIC HEALTH

Detection and surveillance Develop mechanisms for detecting,

evaluating, and reporting suspicious events Integrate surveillance for illness and injury

resulting from WMD terrorism into disease surveillance system

PUBLIC HEALTH

Diagnosis and characterization of agents Multilevel laboratory response network

link clinical labs and public health agencies in all states, districts, territories, and selected cities and counties to CDC and other labs

Transfer diagnostic technology from federal to state level

CDC Rapid Response and Technology Lab

PUBLIC HEALTH

Response Epidemiologic investigation

if requested by state health agency, CDC will deploy response teams to investigate unexplained or suspicious illness

Medical treatment and prophylaxisvaccine / antibiotic stockpile and transportation

Environmental decontamination

PUBLIC HEALTH

Communication Effective communication with the public

use news media to limit panic and disruption of daily life

Effective communication with health care and public health personnelcoordination of activitiesaccess emergency informationrapid notification and information exchange

PUBLIC HEALTH

Effective planning and response to a biological terrorist incident will require collaboration with federal, state, and local groups and agencies including:

-public health organizations-medical research centers-health-care providers and their networks-professional societies-medical examiners

-emergency response units and organizations-safety and medical equipment manufacturers-US Office of Emergency Management-other federal agencies

CRITICAL BIOLOGICAL AGENTSCATEGORY A

High priority agents that pose a threat to national security because they: can be easily disseminated or transmitted

person-to-person cause high mortality, with potential for major

public health impact might cause panic and social disruption require special public health preparedness

CRITICAL BIOLOGICAL AGENTSCATEGORY A

Variola major (smallpox) Bacillus anthracis (anthrax) Yersinia pestis (plague) Clostridium botulinum toxin (botulism) Francisella tularensis (tularemia) Filoviruses

Ebola hemorrhagic fever Marburg hemorrhagic fever

Arenaviruses Lassa (Lassa fever) Junin (Argentine hemorrhagic fever) and related viruses

CRITICAL BIOLOGICAL AGENTSCATEGORY B

Second highest priority agents that include those that: are moderately easy to disseminate cause moderate morbidity and low mortality require specific enhancements of CDC’s

diagnostic capacity and enhanced disease surveillance

CRITICAL BIOLOGICAL AGENTSCATEGORY B

Coxiella burnetti (Q fever)Brucella species (brucellosis)Burkholderia mallei (glanders)Alphaviruses

Venezuelan encephalomyelitis eastern / western equine encephalomyelitis

Ricin toxin from Ricinus communis (castor bean)Epsilon toxin of Clostridium perfringensStaphylococcus enterotoxin B

CRITICAL BIOLOGICAL AGENTSCATEGORY B

Subset of Category B agents that include pathogens that are food- or waterborne

Salmonella speciesShigella dysenteriaeEscherichia coli O157:H7Vibrio choleraeCryptosporidium parvum

CRITICAL BIOLOGICAL AGENTSCATEGORY C

Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of: availability ease of production and dissemination potential for high morbidity and mortality and

major health impactPreparedness for Category C agents requires

ongoing research to improve detection, diagnosis, treatment, and prevention

CRITICAL BIOLOGICAL AGENTSCATEGORY C

Nipah virusHantavirusesTickborne hemorrhagic fever virusesTickborne encephalitis viruses

Yellow feverMultidrug-resistant tuberculosis

ISSUES

Existing local, regional, and national surveillance systems Adequate to detect traditional agents Inadequate to detect potential biowarfare

agents

Specific training for health care professionals clinical personnel will be “first responders”

ISSUES

Civilian biodefense plans are usually based on HAZMAT models Assumes responders enter a high exposure

environment near the source Assumes site of exposure is separate from

the health care facility Assumes no time pressure for

decontamination Maximum protection is provided for a

minimum number of workers / rescuers

ISSUES

HAZMAT OSHA mandates use of PPE based on site

hazard, but site hazards are more easily defined at the point of release

Traditional HAZMAT products are expensive, take time to set up, and are inadequate for large numbers of patients

Difficult to train and maintain proficiency in a civilian work force with high turnover

BIOTERRORISM AND THE PUBLIC HEALTH SECTOR

CONCLUSIONS Preparation for a biological mass disaster

requires coordination of diverse groups of medical and non-medical personnel

Preparation can not occur without support and participation by all levels of government

Preparation must be a sustained and evolutionary process