Bioterrorism Preparedness: Strengthening Nebraska’s Public Health System
BIOTERRORISM AND THE PUBLIC HEALTH SECTOR Richard McCluskey MD, PhD Center for Disaster Management...
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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
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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
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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
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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
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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
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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
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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
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PUBLIC HEALTH
Preparedness and preventionDetection and surveillanceDiagnosis and characterization of agentsResponse Communication
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PUBLIC HEALTH
Preparedness and prevention Coordinated preparedness plans Coordinated response protocols Performance standards
self-assessment, simulations, exercises
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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CRITICAL BIOLOGICAL AGENTSCATEGORY C
Nipah virusHantavirusesTickborne hemorrhagic fever virusesTickborne encephalitis viruses
Yellow feverMultidrug-resistant tuberculosis
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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”
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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
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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
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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