cdc centers for disease control and prevention medical & public health to bioterrorism:...

CDCCenters for Disease Control

and Prevention

Medical & Public Health to Bioterrorism: Challenges for

Decisive Action

13th World Congress on Disaster and Emergency MedicineWorld Association for Disaster & Emergency Medicine

Melbourne, Australia6-10 May, 2003

Eric K. Noji, M.D., M.P.H., FACEPOffice of the US Surgeon General

US Public Health ServiceWashington, D.C.


and Prevention


and Prevention

Sources of Agents for Terrorism Use

• World Directory of Collections of Cultures and Microorganisms– 453 worldwide repositories in 67 nations

– 54 ship/sell anthrax

– 18 ship/sell plague

• International black-market sales associated with governmental programs


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Critical Agents

• B. anthracis (anthrax)• Y. pestis (plague)• F. tularensis (tularemia)• Filo and Arena viruses (viral hemorrhagic

fevers)• Cl. botulinum toxin (botulism)• V. major (smallpox)


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Why These Agents?

• Infectious via aerosol• Organisms fairly stable in aerosol• Susceptible civilian populations• High morbidity and mortality • Person-to-person transmission (smallpox,

plague, VHF)• Difficult to diagnose and/or treat• Previous development for BW


and Prevention

“A bioterrorism attack against Americans anywhere in the world is inevitable in the 21st century.”

Anthony Fauci, Director, NIAID

Clinical Infectious Diseases 2001;32:678


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Powders, Powders Everywhere…

The Impact of the Worried Well on the Public Health System


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Anthrax: Cutaneous

• Most common form (95%)• Inoculation of spores

under skin• Incubation: hours to 7

days• Small papule --> ulcer

surrounded by vesicles (24-28h)

• Painless eschar with edema

• Death 20% untreated; rare treated

USAMRICD


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Anthrax: Inhalational

• Inhalation of spores• Incubation: 1 to 43 days • Initial symptoms (2-5 d)

– Fever, cough, myalgia, malaise

• Terminal symptoms (1-2d )– High fever, dyspnea, cyanosis

– Hemorrhagic mediastinitis/effusion

– Rapid progression shock/death

• Mortality rate in 1957 ~ 100% despite Rx

CDC


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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


and Prevention

CDC

Plague: Bubonic

• Incubation: 2-6 days• Sudden onset HA, malaise, myalgia,

fever, tender LNs• Regional lymphadenitis (Buboes)• Cutaneous findings

– possible papule, vesicle, or pustule at inoculation site

– Purpuric lesions - late


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BT: Timeliness is the Key to Success

• Go to the source• Increase awareness of BT in medical

community to improve rapid reporting of:– Suspect cases potentially BT-related unusual

clusters of disease, in time or space unusual manifestations of disease or unusual disease or symptoms for the geographic area


and Prevention

Close Cooperation with clinicians, healthcare and first

responder communities• Emergency departments, primary care

clinics• Infection control units• Physician networks, private offices• Hospitals• Medical examiners, coroners• Poison control• Law enforcement, fire, other first responders


and Prevention

Clues to Possible Bioterrorism I

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

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

death• Unusual illness in a population• Higher morbidity & mortality than expected with a

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

distribution


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Clues to Possible Bioterrorism II

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

strain• Endemic disease with unexplained increased incidence• Simultaneous clusters of similar illness in con-

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


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Bioterrorism Surveillance

• Early, rapid recognition of unusual clinical syndromes or deaths

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


and Prevention

Bioterrorism: Potential Data Sources

• Laboratories• Infectious disease

Specialists• Hospitals• Physician’s

offices• Poison control

centers

• Medical Examiners

• Death Certificates• Police/Fire

departments• Other “first

responders”• Pharmacy data


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and Prevention

Syndrome Surveillance

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

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

• Highly sensitive, seasonal specificity varies


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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Release

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ases

Symptom Onset Severe Illness

Rationale for Syndromic Surveillance


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Examples of Syndromes for Surveillance

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

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

and weakness)• Rash and fever• Non-pneumonia respiratory tract infection w/ fever• Diarrhea/Gastroenteritis• Pneumonia• Sepsis or non-traumatic shock


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Information System Functions Needed for Bioterrorism Preparedness and Response

• PREPAREDNESS REQUIRES THAT ALL PARTNERS--LOCAL, STATE, & FEDERAL ARE PART OF SYSTEMS

• Surveillance data analysis--event detection & management

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

Lessons Learned fromAnthrax Incidents Late

2001

DRAFT


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There Were Some Important Surprises Even for Experts

• Anthrax lethal dose rates appear to have been seriously over-estimated

• Re-aerosolization is a greater problem than anticipated

• Dispersal characteristics of an envelope in the mail system could be devastating

• The threshold at which the medical system will be overwhelmed appears to be lower than expected


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Varying Presentations of NYC Cutaneous Lesions


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Effects Magnification

Do not need large numbers of casualties to incur massive damage - economic, social, psychological political !

E.g. Impact by anthrax via mail:5 deaths18 infected30,000 treated with antibiotics10,000 treated for 60 daysMany billions of dollars cost +

impact


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and Prevention

Public Awareness

• Reliable, credible information to the public is key to keeping cooperation and minimizing panic


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Decision Making without Data

• Need to make decisions rapidly in the absence of data

• Access to subject matter experts was limited• No “textbook” experience to guide response • Understanding of “risk” evolved as outbreak

unfolded• Need coherent, rapid process for

addressing scientific issues in midst of crisis


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TODAY’S SITUATION

• Many hospitals on trauma diversion with no major incidents going on (no inpatient beds, consultants)

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

• Public health infrastructure is beyond simple band-aid fixes

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


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Provide More Health System Surge Capacity

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

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

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

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

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


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Summary:Priority Preparedness

Activities• State & local preparedness planning• Surveillance and epidemiology• Outbreak verification• Laboratory capacity for biologic & chemical

agents• Health information & communication systems• Training• Establish key liaisons


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Bottom Line for Effective Response

• Early, rapid recognition of unusual clinical syndromes or deaths

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


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The detection and control of saboteurs are the responsibilities

of the FBI, but the recognition of epidemics caused by sabotage

is particularly an epidemiologic function…. Therefore, any plan of

defense against biological warfare sabotage requires trained

epidemiologists, alert to all possibilities and available for call

at a moment’s notice anywhere in the country”

Alexander LangmuirFounder of CDC EIS Program1952

CDC Epidemiology and Bioterrorism

U.S. Department of U.S. Department of Health and Human Health and Human

ServicesServices

Eric K. Noji, M.D., M.P.H.Special Assistant to the US Surgeon General for Emergency Preparedness & Response,US Public Health ServicePhone: 202-690-5707 Fax: 202-690-6985Email: [email protected]

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