Overview of Terrorism Research at the CDC Dixie E. Snider, M.D., MPH. Associate Director for Science Presented at 2003 Medical Research Summit March 6, 2003

All Hazards Approach

Major Program Components Preparedness and Response Planning Public Health Interventions Rapid Disease Detection and Investigation Biological and Chemical Laboratory Capacity Application of Information Systems and Technology Public and Media Risk Communications Training Worker Safety Environmental Monitoring Select Agent Monitoring Public Health Law

Public Health’s System of Preparedness, Response, and Recovery Detection Response Recovery Response Planning Command and control Exercising Partnering Training System building Testing Surveillance Clinician training Laboratory diagnostics Reporting Communicating Clinicians Public health General public Responders Intervention Medical therapies Quarantine Contact tracking Coordination Monitoring health impact Community mental health Lessons learned – continuous response improvement

CDC Components Involved in Terrorism Preparedness National Center for Infectious Diseases (NCID)— infectious agents National Center for Environmental Health (NCEH)– chemical and radiologic agents National Institute for Occupational Safety and Health (NIOSH)—worker protection National Immunization Program (NIP) – immunization programs Agency for Toxic Substances and Diseases Registry (ATSDR) – risk assessment and mitigation

All Hazards Preparedness and Response: Chemical / Radiation / Biological Chemical Terrorism Choking agents (phosgene / chlorine) Blood agents (cyanides) Blister agents (mustard gas) Nerve agents (sarin, soman, tabun, etc.) Radiation Terrorism Dirty bombs Food / water supply contamination Power plants

Biological Agents of Highest Concern (Category A Agents) Variola major (Smallpox) Bacillus anthracis (Anthrax) Yersinia pestis (Plague) Francisella tularensis (Tularemia) Botulinum toxin (Botulism) Filoviruses and Arenaviruses (Viral hemorrhagic fevers) These six diseases were chosen because: 1) the potential public health impact if an outbreak occurred is huge; 2) they can be weaponized; 3) public health needs to be ready if such an outbreak occurs; and 4) the high level of perception the public has regarding these diseases

Examples of Priority Areas of Smallpox Research Evaluation of immune response to smallpox vaccination and risk factors for adverse reactions Assessment of duration of immunity Comparison of cellular and humoral immunity in previously vaccinated vs recently vaccinated persons Assessment of vaccination site care regimens Evaluation of VIG and cidofovir for treatment of adverse reactions to vaccination

Examples of Priority Areas of Anthrax Research Development of model for cutaneous anthrax Rapid detection methods, including powder analysis Host response, including infectious dose Integration of human and veterinary surveillance systems Assessment of antitoxin therapy

Examples of Priority Areas of Botulism Research Production of heptavalent antitoxin Production of an immune globulin Rapid assays to detect toxins

Examples of Priority Areas of Plague Research Safety and efficacy of gentamycin vs. streptomycin or doxycycline for treatment Rapid diagnostic methods

National Institute for Occupational Safety and Health (NIOSH) Respiratory protective equipment Recommendations for use Testing & certification of equipment Sampling and analysis Toxic industrial chemicals Biological agents Workforce screening and health tracking Guidance for enhancing building preparedness Related research & surveillance If you can only use ONE SLIDE, this describes our past activities. See last slide in this presentation file for future research needs if you want to limit this to TWO SLIDES. NIOSH provided input on emergency response efforts during 2001-2002 for both the World Trade Center response and for the following anthrax attacks. NIOSH’s mission, to protect workers, met the needs by providing recommendations for personal protective equipment (including respirators), as well as for sampling strategies and methods for toxic chemicals, dusts, and biological agents found at the attack sites. NIOSH also provided valuable input on worker screening efforts for emergency responders.

Medical Screening Program Mt. Sinai & Consortium of Health Clinics Voluntary clinical examination of WTC responders Focus: Respiratory effects Musculoskeletal disorders Chronic effects from injuries Psychological conditions NIOSH is supporting Mt. Sinai School of Medicine and a consortium of occupational health clinics in NY/NJ metro area and around the country to provide baseline clinical exams of workers and volunteers involved in rescue and recovery efforts at the WTC site. This program will determine whether rescue and recovery workers and volunteers who worked at the World Trade Center disaster site are experiencing related illnesses or injuries. The goal of the project is to have a system in place that will help employers and public health professionals identify symptoms, injuries or conditions that may indicate long-term illness as a result of their work at the World Trade Center, so that interventions can be pursued.

Future Work and Research Needs CBRN standards for additional classes of respirators Improved sensors and detectors for protective equipment (service-life indicators) for field sampling instruments Improved worker screening and health tracking tools Working with employers, workers, and responders to address other needs IF YOU ARE LIMITED TO TWO SLIDES – PLEASE USE THIS AS #2. NIOSH is planning additional work to develop new respirator certification standards for first responders. Having completed and begun approving self-contained breathing apparatus, more work is needed to extend the process to include other types of units including air-purifying respirators. This is a critically important need. Another area is to develop rugged direct-reading instruments for rapid field assessment of chemical and biological agents. Finally, NIOSH needs to design and develop systems for health screening and tracking of emergency responders, both from the ranks of professional hazardous incident teams as well as the many volunteers and cross-jurisdictional responders that may arrive at a mass casualty site such as the World Trade Center.

Critical Next Steps to Support The Public Health System of Response CDC: Office of Terrorism Preparedness and Response established Strategic direction Coordination of resources Accountability Priorities: Improve readiness with a focus on critical threats (i.e., Smallpox, VX, Dirty Bomb, Mass Trauma events) Drive to exercise national, state, and local capacities to demonstrate response proficiency Support Public Health Information Network Research new ways to detect and diagnose disease presence in the population and develop new vaccines, antibiotics and other treatments Train, train, train…