ERIC K. NOJI, M.D. Bioterrorism Preparedness European Masters in Disaster Medicine Arona, Italy 27 April 2004 Eric K. Noji, MD, MPH Department of Homeland

ERIC K. NOJI, M.D.ERIC K. NOJI, M.D.

Bioterrorism Bioterrorism PreparednessPreparedness

European Masters in Disaster European Masters in Disaster Medicine Medicine

Arona, ItalyArona, Italy27 April 200427 April 2004

Eric K. Noji, MD, MPHDepartment of Homeland Security

Washington, D.C.


““A bioterrorism attack anywhere in the A bioterrorism attack anywhere in the

world is inevitable in the 21world is inevitable in the 21stst century.” century.”

Anthony Fauci, Director, NIAIDAnthony Fauci, Director, NIAID

Clinical Infectious Diseases 2001;32:678Clinical Infectious Diseases 2001;32:678



Increasing Global TravelIncreasing Global Travel Rapid access to large Rapid access to large

populationspopulations Poor global security & Poor global security &

awarenessawareness

...create the potential for simultaneous ...create the potential for simultaneous creation of large numbers of casualtiescreation of large numbers of casualties


• Limited prior experience in CBRN type response except for naturally occurring infectious disease outbreaks, for example – Cholera/Lassa fever/Ebola virus.

• Evacuation only strategy.

• Limited numbers of adequately trained staff, equipment, procedural knowledge.

Global Preparedness


HistoryHistory CBRN Agents have been CBRN Agents have been

used on unprotected civil used on unprotected civil populations on many populations on many occasionsoccasions

Some of the locations Some of the locations where the local population where the local population had no defense werehad no defense were• EthiopiaEthiopia• IraqIraq• AfghanistanAfghanistan• LaosLaos• JapanJapan

CDCCenters for Disease Control

and Prevention


CBRNE AgentsCBRNE AgentsConventional Conventional (Explosive)(Explosive)

ChemicalChemical Biological / Biological / RadoilogicRadoilogic

OnsetOnset InstantInstant RapidRapid Often DelayedOften Delayed

SourceSource ObviousObvious ObviousObvious Often covertOften covert

First Victim First Victim EncounterEncounter

PrehospitalPrehospital PrehospitalPrehospital HospitalHospital

ContainmentContainment EasyEasy Relatively EasyRelatively Easy DifficultDifficult

Decon HelpfulDecon Helpful Usually NotUsually Not YesYes Usually Not*Usually Not*




Sources of Agents for Sources of Agents for Terrorism UseTerrorism Use

World Directory of Collections of World Directory of Collections of Cultures and MicroorganismsCultures and Microorganisms• 453 worldwide repositories in 67 nations453 worldwide repositories in 67 nations• 54 ship/sell anthrax54 ship/sell anthrax• 18 ship/sell plague18 ship/sell plague

International black-market sales International black-market sales associated with governmental associated with governmental programsprograms



Anthrax Threats Reported to Anthrax Threats Reported to FBIFBI

0

50

100

150

200

250

1996 1997 1998 1999*

* first four months of 1999

Source: M. Lyons, CDC from FBI personal communication







Biological AgentsBiological Agents• CDC/WHO list of high-likelihood potential bio-terrorist CDC/WHO list of high-likelihood potential bio-terrorist

agentsagents• Prioritized according to: Prioritized according to:

• Ease of disseminationEase of dissemination• TransmissibilityTransmissibility• MortalityMortality• Public health impactPublic health impact• Potential to cause fear and social disruptionPotential to cause fear and social disruption• Need for special preparednessNeed for special preparedness


Biological AgentsBiological Agents

Category ACategory A• SmallpoxSmallpox• AnthraxAnthrax• PlaguePlague• BotulismBotulism• TularemiaTularemia• Viral Hemorrhagic FeversViral Hemorrhagic Fevers

Ebola, Marburg, Lassa, Argentine HFEbola, Marburg, Lassa, Argentine HF



Category B:Category B: Q fever, Brucellosis, Glanders, VEE, EEV, Q fever, Brucellosis, Glanders, VEE, EEV,

WEV, Ricin, …WEV, Ricin, … Food & water-borne: Salmonella, Shigella, E. Food & water-borne: Salmonella, Shigella, E.

coli 0157:H7, …..coli 0157:H7, …..

Category C:Category C: Nipah virus, Hanta virus, Yellow fever, Nipah virus, Hanta virus, Yellow fever,

Tickborne viruses, ….Tickborne viruses, ….


DiagnosisDiagnosis

-Diagnosis difficult given diseases have been seen by few living clinicians

-Abnormal presentations of classical diseases may be present due to super infection

-Diagnosis critical for epidemiological monitoring

-Accurate data required for potential future prosecution of war crimes

-Psychogenic overlay may cloud the diagnostic process



Syndrome RecognitionSyndrome Recognition• Most bio-terrorist agents initially induce an Most bio-terrorist agents initially induce an

influenza-like prodrome, including fever, influenza-like prodrome, including fever, chills, myalgias, or malaisechills, myalgias, or malaise

• One of four syndromic patterns then follow:One of four syndromic patterns then follow: Rapidly progressive pneumoniaRapidly progressive pneumonia Fever with rashFever with rash Fever with altered mental statusFever with altered mental status Bloody diarrheaBloody diarrhea



Small Pox (Variola major virus)Small Pox (Variola major virus)

Transmitted primarily by aerosol Transmitted primarily by aerosol route, contaminated clothes & linensroute, contaminated clothes & linens

Highly communicableHighly communicable Vaccine can lessen the severity of Vaccine can lessen the severity of

disease if given within 4 days of disease if given within 4 days of exposureexposure


Epidemiological Pattern of Epidemiological Pattern of Smallpox WeaponSmallpox Weapon

New foci of secondary infection

“Contaminated” zone

“Infected” zone

Zone of initialexplosion


Small PoxSmall Pox

30% case fatality rate if untreated30% case fatality rate if untreated One of four biological agents thought One of four biological agents thought

to be most likely used by terroriststo be most likely used by terrorists Incubation 7-17 daysIncubation 7-17 days Prodrome of high fever, malaise, Prodrome of high fever, malaise,

vomiting, headache, myalgiasvomiting, headache, myalgias 2-3 days later get rash beginning on 2-3 days later get rash beginning on

face, hands, forearms face, hands, forearms



Small PoxSmall Pox

Patients infectious until all scabs are Patients infectious until all scabs are shedshed

No treatment, but animal studies No treatment, but animal studies show promise for cidofovirshow promise for cidofovir


Smallpox Infected People Smallpox Infected People DisperseDisperse

Infected board flights to thirty eight US citiesInfected board flights to thirty eight US cities


Anthrax (bacillus Anthracis)Anthrax (bacillus Anthracis)

Inhalational, gastrointestinal, cutaneousInhalational, gastrointestinal, cutaneous NOTNOT communicable communicable (except maybe cutaneous)(except maybe cutaneous)

Vaccine not available for civilian useVaccine not available for civilian use 20%-80% mortality20%-80% mortality


Anthrax: InhalationalAnthrax: Inhalational

Inhalation of sporesInhalation 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, malaiseFever, cough, myalgia, malaise Terminal symptoms (1-2d )Terminal symptoms (1-2d )

• High fever, dyspnea, cyanosisHigh fever, dyspnea, cyanosis• Hemorrhagic Hemorrhagic

mediastinitis/effusionmediastinitis/effusion• Rapid progression shock/deathRapid progression shock/death

Mortality rate in 1957 ~ Mortality rate in 1957 ~ 100% despite Rx 100% despite Rx CDC


Anthrax: CutaneousAnthrax: Cutaneous

Most common form Most common form (95%)(95%)

Inoculation of spores Inoculation of spores under skinunder skin

Incubation: hours to 7 Incubation: hours to 7 daysdays

Small papule --> ulcer Small papule --> ulcer surrounded by vesicles surrounded by vesicles (24-28h)(24-28h)

Painless eschar with Painless eschar with edemaedema

Death 20% untreated; Death 20% untreated; rare treated rare treated USAMRICD


AnthraxAnthrax

Resistant to heat, UV, drying, many Resistant to heat, UV, drying, many disinfectantsdisinfectants

Incubation 2-6 daysIncubation 2-6 days Biphasic illness Biphasic illness

• nonspecific flu-like symptomsnonspecific flu-like symptoms• High fever, SOB, chest and abdominal High fever, SOB, chest and abdominal

painpain• Sore throat, runny noseSore throat, runny noseNOTNOT associated associated


AnthraxAnthrax

Treatment – multi-drug antibioticsTreatment – multi-drug antibiotics Prophylaxis – single drug for 60 daysProphylaxis – single drug for 60 days




Pneumonic PlaguePneumonic Plague

Caused by infection with Yersinia Caused by infection with Yersinia PestisPestis

Pneumonic form will occur after Pneumonic form will occur after intentional aerosol deliveryintentional aerosol delivery

Incubation period of 1-7 daysIncubation period of 1-7 days



Pneumonic PlaguePneumonic Plague

Symptoms:Symptoms:• Fever, malaise, fatigue, cough, SOBFever, malaise, fatigue, cough, SOB

Signs:Signs:• Classic finding of production of bloody Classic finding of production of bloody

sputum in a previously healthy patientsputum in a previously healthy patient

Treatment: AntibioticsTreatment: Antibiotics


Detection & surveillanceDetection & surveillance

Rapid laboratory diagnosisRapid laboratory diagnosis

Epidemiologic investigationsEpidemiologic investigations

Implementation of control Implementation of control measuresmeasures

Public Health ResponsePublic Health Responseto Bioterrorismto Bioterrorism


Bioterrorism SurveillanceBioterrorism Surveillance

Early, rapid recognition of unusual Early, rapid recognition of unusual clinical syndromes or deathsclinical syndromes or deaths

Early rapid recognition of increase Early rapid recognition of increase above “expected levels” of common above “expected levels” of common syndromes, diseases, or deathsyndromes, diseases, or death


Clues to Possible Bioterrorism Clues to Possible Bioterrorism II

Single case caused by an uncommon agentSingle case caused by an uncommon agent Large number of ill persons with similar disease, Large number of ill persons with similar disease,

syndrome, or deathssyndrome, or deaths Large number of unexplained disease, syndrome, or Large number of unexplained disease, syndrome, or

deathdeath Unusual illness in a populationUnusual illness in a population Higher morbidity & mortality than expected with a Higher morbidity & mortality than expected with a

common disease or syndromecommon disease or syndrome Multiple disease entities coexisting in the same patientMultiple disease entities coexisting in the same patient Disease with an unusual geographic or seasonal Disease with an unusual geographic or seasonal

distributiondistribution


Clues to Possible Bioterrorism II Clues to Possible Bioterrorism II

Multiple atypical presentations of disease agentsMultiple atypical presentations of disease agents Similar genetic type of agent from distinct sourcesSimilar genetic type of agent from distinct sources Unusual, atypical, genetically engineered, or Unusual, atypical, genetically engineered, or

antiquated antiquated strainstrain Endemic disease with unexplained increased Endemic disease with unexplained increased

incidenceincidence Simultaneous clusters of similar illness in con-Simultaneous clusters of similar illness in con-

contiguous areascontiguous areas Atypical aerosol, food, or water transmission Atypical aerosol, food, or water transmission Ill persons presenting during the same timeIll persons presenting during the same time Concurrent animal diseaseConcurrent animal disease


Bioterrorism: Bioterrorism: Potential Data SourcesPotential Data Sources

LaboratoriesLaboratories Infectious diseaseInfectious disease SpecialistsSpecialists HospitalsHospitals Physician’s officesPhysician’s offices Poison control Poison control

centerscenters

Medical Medical ExaminersExaminers

Death CertificatesDeath Certificates Police/Fire Police/Fire

departmentsdepartments Other “first Other “first

responders”responders” Pharmacy dataPharmacy data



Syndrome SurveillanceSyndrome Surveillance

• The monitoring of illnesses based upon a The monitoring of illnesses based upon a constellation of symptoms and/or constellation of symptoms and/or findingsfindings

• Provides an “early warning system” for Provides an “early warning system” for outbreaks, emerging pathogensoutbreaks, emerging pathogens

• Highly sensitive, seasonal specificity Highly sensitive, seasonal specificity varies varies


Examples of Syndromes Examples of Syndromes for Surveillancefor Surveillance

• Unexplained death w/ history of feverUnexplained death w/ history of fever• Meningitis, encephalitis or unexplained acute Meningitis, encephalitis or unexplained acute

encephalopathy/deliriumencephalopathy/delirium• Botulism-like syndrome (cranial nerve impairment Botulism-like syndrome (cranial nerve impairment

and weakness)and weakness)• Rash and feverRash and fever• Non-pneumonia respiratory tract infection w/ feverNon-pneumonia respiratory tract infection w/ fever• Diarrhea/GastroenteritisDiarrhea/Gastroenteritis• PneumoniaPneumonia• Sepsis or non-traumatic shockSepsis or non-traumatic shock


Information System Functions Needed for Information System Functions Needed for Bioterrorism Preparedness and ResponseBioterrorism Preparedness and Response PREPAREDNESS REQUIRES THAT ALL PREPAREDNESS REQUIRES THAT ALL

PARTNERS--LOCAL, STATE, & FEDERAL PARTNERS--LOCAL, STATE, & FEDERAL ARE PART OF SYSTEMSARE PART OF SYSTEMS

Surveillance data analysis--event detection Surveillance data analysis--event detection & management& management

Notification—rapid alerting Notification—rapid alerting Communications –information, not dataCommunications –information, not data Knowledge managementKnowledge management


The Immediate Future The Immediate Future 2003 – 20102003 – 2010

A Revolution in A Revolution in biotechnology, genomics biotechnology, genomics and proteomics that will and proteomics that will affect all human beingsaffect all human beings


TODAY’S SITUATIONTODAY’S SITUATION

Many hospitals on trauma diversion with Many hospitals on trauma diversion with nono major incidents going on major incidents going on

Not economically viable for hospitals to Not economically viable for hospitals to maintain surge capacity, or even to focus maintain surge capacity, or even to focus on treating sick and injured (hospitals on treating sick and injured (hospitals lose lose money treating the truly sick)money treating the truly sick)

Public health infrastructure is beyond Public health infrastructure is beyond simple band-aid fixessimple band-aid fixes

Military health system (including VA) is not Military health system (including VA) is not effectively integrated or usedeffectively integrated or used


Provide More Health System Provide More Health System Surge CapacitySurge Capacity

Health care cost control has Health care cost control has systematically eliminated reserve systematically eliminated reserve capacity from the system.capacity from the system.

Need to rethink how much surge Need to rethink how much surge capacity is needed for emergencies.capacity is needed for emergencies.

Need to re-assess adequacy and Need to re-assess adequacy and geographic extent of mutual aid geographic extent of mutual aid agreements.agreements.

What mobile resources can the federal What mobile resources can the federal and state governments and state governments truly truly provide?provide?

Also need plans to tap unconventional Also need plans to tap unconventional resources if disasters strike – e.g., sites resources if disasters strike – e.g., sites for emergency care, inventories of for emergency care, inventories of health care workers.health care workers.


Summary:Summary:Priority Preparedness ActivitiesPriority Preparedness Activities

State & local preparedness planningState & local preparedness planning Surveillance and epidemiologySurveillance and epidemiology Outbreak verificationOutbreak verification Laboratory capacity for biologic & Laboratory capacity for biologic &

chemical agentschemical agents Health information & communication Health information & communication

systemssystems TrainingTraining Establish key liaisonsEstablish key liaisons


Bottom LineBottom Line

Early, rapid recognition of unusual Early, rapid recognition of unusual clinical syndromes or deathsclinical syndromes or deaths

Early rapid recognition of increase Early rapid recognition of increase above “expected levels” of common above “expected levels” of common syndromes, diseases, or deathsyndromes, diseases, or death


… … Life Has Changed for us allLife Has Changed for us all

Documents

ERIC K. NOJI, M.D. Bioterrorism Preparedness European Masters in Disaster Medicine Arona, Italy 27 April 2004 Eric K. Noji, MD, MPH Department of Homeland