1. CDC Centers for Disease Control and Prevention Medical & Public Health to Bioterrorism: Challenges for Decisive Action 13 th World Congress on Disaster and Emergency Medicine World Association for Disaster & Emergency Medicine Melbourne, Australia 6-10 May, 2003 Eric K. Noji, M.D., M.P.H., FACEP Office of the US Surgeon General US Public Health Service Washington, D.C.

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3. CDC Centers for Disease Control 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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5. CDC Centers for Disease Control and Prevention 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)

6. CDC Centers for Disease Control and Prevention 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

7. CDC Centers for Disease Control and Prevention “A bioterrorism attack against Americans anywhere in the world is inevitable in the 21 st century.” Anthony Fauci, Director, NIAID Clinical Infectious Diseases 2001;32:678

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10. Powders, Powders Everywhere… The Impact of the Worried Well on the Public Health System

11. CDC Centers for Disease Control and Prevention 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

12. CDC Centers for Disease Control and Prevention 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

13. Centers for Disease Control and Prevention  Detection & surveillance  Rapid laboratory diagnosis  Epidemiologic investigations  Implementation of control measures Public Health Response to Bioterrorism

14. CDC Centers for Disease Control 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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19. CDC Centers for Disease Control and Prevention 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

20. CDC Centers for Disease Control 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

21. CDC Centers for Disease Control 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

22. CDC Centers for Disease Control and Prevention 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

23. CDC Centers for Disease Control and Prevention 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

24. CDC Centers for Disease Control 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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26. CDC Centers for Disease Control 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

27. CDC Centers for Disease Control and Prevention Release Number of Cases Symptom OnsetSevere Illness Rationale for Syndromic Surveillance

28. CDC Centers for Disease Control and Prevention 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

29. CDC Centers for Disease Control and Prevention 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

30. Lessons Learned from Anthrax Incidents Late 2001 DRAFT

31. CDC Centers for Disease Control and Prevention 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

32. CDC Centers for Disease Control and Prevention Varying Presentations of NYC Cutaneous Lesions

33. CDC Centers for Disease Control and Prevention 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 deaths 18 infected 30,000 treated with antibiotics 10,000 treated for 60 days Many billions of dollars cost + impact

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35. CDC Centers for Disease Control and Prevention Public Awareness Reliable, credible information to the public is key to keeping cooperation and minimizing panic

36. CDC Centers for Disease Control and Prevention 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

37. CDC Centers for Disease Control and Prevention 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

38. CDC Centers for Disease Control and Prevention 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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40. CDC Centers for Disease Control and Prevention 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

41. CDC Centers for Disease Control and Prevention 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

42. CDC Centers for Disease Control and Prevention 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 Langmuir Founder of CDC EIS Program 1952 CDC Epidemiology and Bioterrorism

43. U.S. Department of Health and Human Services Eric K. Noji, M.D., M.P.H. Special Assistant to the US Surgeon General for Emergency Preparedness & Response, US Public Health Service Phone: 202-690-5707 Fax: 202-690-6985 Email: Enoji@cdc.gov For Questions Contact: