1. Public Health Issues David S. Perlin, Ph.D.
Public Health Research Institute
at the International Center for Public Health
Newark, NJ 07103

3. October 2001 Anthrax Outbreak What went wrong?
Lead agency was unclear
Federal authorities appeared confused
Sloppy scientific thinking underestimated spore threat through mail system
First responders were inadequately trained for hazard
Public health Labs were poorly prepared to receive pathogens, provide timely diagnostics, or perform high volume sample evaluations
Federal and state priorities were unclear, and often conflicted.
Physicians were uneducated about disease
So-called “textbook” knowledge was often misleading or incomplete
Decontamination was difficult

4. Threat Assessment Preparedness Response
Essential Elements of a Public Health Strategy
Threat Assessment
Preparedness
Response

5. Potential Bioterrorism Agents
Viruses
Smallpox
VEE
VHF
Bacterial Agents
Anthrax
Brucellosis
Cholera
Plague, Pneumonic
Tularemia
Q Fever
Source: U.S. A.M.R.I.I.D.
Biological Toxins
Botulinum
Staph Entero-B
Ricin
T-2 Mycotoxins
When CDC started it’s bioterrorism program, it developed a potential list of agents or diseases that could be used against a population. A national group of disease experts created a critical agents list for biologicals. Bacteria, viruses, and toxins are included.

6. Deliberate v. Naturally-Occurring Outbreak
Does it matter?

7. Bioterrorism preparedness should be an extension of our current medical and public health infrastructure.

8. Epidemic Diseases are all around us
WHO: Mortality Trends (1997)
Infectious and Parasitic
Circulatory
33.1% 5
Infectious and Parasitic
Diseases
29.3%
Other 4
13.2%
Deaths,
millions 3
Cancer
Perinatal
6.9% 2
11.9%
Respiratory 1
5.6%
HIV/
AIDS
Acute
Respiratory TB
Malaria
Diarrhea

10. Influenza kills more than 35,000 Americans each year
The 1918 Spanish Flu pandemic killed over 40 million
people worldwide with 450,000 deaths in the USA.

12. Emerging and Re-emerging Diseases

13. West Nile Virus
4156 Cases and 284 Deaths (1/1/03)

14. SARS Coronavirus

15. People are potent vectors of disease

16. PRERAREDNESS
and
RESPONSE

17. Linking of Response Systems
First Responders
Fire/EMS
Medical & Mental
Health Services
Law
Enforcement
Public
Health
Emergency Management

18. Relationship Between Crisis and Consequence Management
The Department of Justice assigns lead responsibility for operational response to the FBI, which operates as the on-scene manager for the Federal Government
FEMA is the lead agency for consequence management and can use FRP structures to coordinate all Federal assistance to State and local governments.

19. The National Pharmaceutical Stockpile Program
National Electronic Data Surveillance System (NEDSS)
The Global Outbreak Alert and Response Network
Epidemic Information Exchange (Epi-X)
Laboratory Response Network
Metropolitan Medical Response System (MMRS)

20. Structure of the LRN
CDC and USAMRIID. Expertise with unusual organisms Specimen repository.
Level D Federal Labs BSL-4
Rapid identification using molecular methods. Test evaluation.
Level C Labs * BSL-3
Isolation and presumptive ID. Antimicrobial susceptibility testing. 24/7 response.
Level B Public Health Labs BSL-2 + or 3
* Level A Labs - Enhanced medical lab protocol.
* Level B Labs - Work at BSL-2 with BSL-3 Practices.
* Level C: Probe, type, identify subspecies, perform toxigenicity testing, etc.
* Need to make sure you are using best practices all the time. Refine practices outside of the cabinet.
OPPORTUNITY TO EXPOUND.
Level A Clinical Labs
BSC (Class II-B)
Early detection, rule out and refer.
*State, research, federal

21. Metropolitan Medical Response System (MMRS)
An operational system at the local level to respond to a terrorist incident and other public health emergencies that create mass casualties
This system enables a Metropolitan Area to manage the event until State or Federal response resources are mobilized
MMRS is a locally developed, owned, and operated mass casualty response system

22. Metropolitan Medical Response Systems
Original MMRS
Boston, New York, Baltimore, Philadelphia, Washington DC, Atlanta, Miami, Memphis, Jacksonville, Detroit, Chicago, Milwaukee, Indianapolis, Columbus, San Antonio, Houston, Dallas, Kansas City, Denver, Phoenix, San Jose, Honolulu, Los Angeles, San Diego, San Francisco, Anchorage, Seattle
MMRS 1999
Hampton Roads (Virginia Beach)Area, Pittsburgh, Nashville, Charlotte, Cleveland, El Paso, New Orleans, Austin, Fort Worth, Oklahoma City, Albuquerque, St. Louis, Salt Lake City, Long Beach, Tucson, Oakland, Portland (OR), Twin Cities (Minneapolis), Tulsa, Sacramento
MMRS 2000
Twin Cities (St. Paul), Hampton Roads (Norfolk),Cincinnati, Fresno, Omaha, Toledo, Buffalo, Wichita,Santa Ana, Mesa, Aurora , Tampa, Newark, Louisville, Anaheim, Birmingham, Arlington, Las Vegas,Corpus Christi, St. Petersburg, Rochester, Jersey City,Riverside, Lexington-Fayette, Akron
MMRS 2001
Colorado Springs, Baton Rouge, Raleigh, Stockton, Richmond (VA), Shreveport, Jackson, Mobile, Des Moines, Lincoln, Madison, Grand Rapids, Yonkers, Hialeah, Montgomery, Lubbock, Greensboro, Dayton, Huntington Beach, Garland, Glendale (CA), Columbus (GA), Spokane, Tacoma, Little Rock
MMRS 2002
Bakersfield, Fremont, Ft. Wayne, Hampton Roads (Newport News, Chesapeake), Arlington, Worcester, Knoxville, Modesto, Orlando, San Bernardino, Syracuse, Providence, Huntsville, Amarillo, Springfield, Irving, Chattanooga, Kansas City, Jefferson Parish, Ft. Lauderdale, Glendale, Warren, Hartford, Columbia

23. Strategic use of vaccines

24. Challenges

25. Contagious Outbreaks
Identification of clinical symptoms
Rapid and accurate diagnostics
Accurate reporting and open communication
Willingness to isolate and quarantine all infected populations
Mobilization of scientists to develop vaccines, therapeutics, new diagnostics, and determine the source of the outbreak

26. Drug Resistance
what if the organism is drug resistant and we can’t treat?
Molecular engineering is easy
What would have happened during the anthrax outbreak?
What good is the National Pharmaceutical Stockpile in this event? ”

27. Role of Healthcare Professionals
First line of defense.
But what if they are early victims of the outbreak (e.g. Toronto)?

28. Hospitals as an amplifier of infection
SARS Cases in Toronto

29. What about mass casualties?
What would a plume of anthrax spores do in our area?
The 1918 Spanish Flu pandemic hospitalized millions of Americans
Can we handle the patients? Do we have enough lab capacity?

30. CONCLUSION
Bioterrorism preparedness must be an extension of our current medical and public health infrastructure.
Our ability to respond effectively to a new outbreak will depend on the robustness of the prevailing system.