1. Placing Bioterrorism in its Context Dr. C. de Ville de Goyet

2. The Anthrax great scare A demonstration of the superiority of informal reporting systemsA demonstration of the superiority of informal reporting systems Six deaths: A society overwhelmed with fearSix deaths: A society overwhelmed with fear Not a new threat!Not a new threat!

3. Anthrax Threats Reported to FBI Source: M. Lyons, CDC from FBI personal communication to Dr. Eric Noji

5. A critical look at some slides from CDC Most of the slides used are from Dr. Eric Noji Presentation at the PAHO Senior Managers Meetings in Nov 2001. Those slides have a blue background

6. Detection & surveillance Rapid laboratory diagnosis Epidemiologic investigations Implementation of control measures Public Health Response to… Bio-terrorism

7. Public Health Role in “Bioterrorism” “Detect and control the epidemic” Comments: Is it not the normal role of the Ministry of Health? Can you detect terrorist outbreaks without detecting first normal epidemics?

8. Early, rapid recognition of unusual clinical syndromes or deaths & of increase above “expected levels” of common syndromes, diseases, or death Rapid etiologic diagnosis Rapid response Bioterrorism Surveillance

9. Key features –Real time data  real time epidemiology –Syndrome-based reporting –Sentinel surveillance sites –Pro-active (high profile potential target events, ongoing surveillance in sentinel sites) –Reactive (monitoring and response) –Aberration Detection

10. Syndrome Surveillance The monitoring of illnesses based upon a constellation of symptoms and/or findings Provides an “early warning system” for outbreaks, emerging pathogens

11. Likely BT Agents: Initial Symptoms Agents –Anthrax –Plague –Q-fever –Tularemia –Smallpox Initial Symptoms –Fever –Cough –Malaise –Headache

12. Current Challenges Identification of localized clusters Sustainability of surveillance system Development of response protocols

13. Unanswered Questions What is the threshold that initiates response What is the sensitivity and specificity of surveillance systems Usefulness and feasibility of aggregate data from hospital admissions, ICD-9 codes on a large scale Do we have an answer to these questions for normal surveillance?

14. The “Unasked” Questions What is the real risk of terrorism act in the Caribbean?What is the real risk of terrorism act in the Caribbean? How much to invest (i.e. divert resources from other health priorities) for terrorism counter- measures?How much to invest (i.e. divert resources from other health priorities) for terrorism counter- measures? Cost-effectiveness?Cost-effectiveness?