Post on 15-Jan-2016
Bioterrorism PreparednessBioterrorism Preparedness
Public health CBRN course
Bonnie Henry, MD, FRCPC
Goals of sessionGoals of session
To provide a review of bioterrorism agents and history of BT use (with a focus on anthrax and smallpox)
To review potential roles for public health in a BT incident
To review principles of laboratory testing of ‘suspicious packages’ and continuity of evidence
Bioterrorism PreparednessBioterrorism Preparedness
Bioterrorism is the intentional use of microorganisms (bacteria, viruses, and fungi) or toxins to produce death or disease in humans, animals or plants.
Electron micrograph of anthrax bacteria
Electron micrograph of ebola virus
Category ACategory A
““Biologic Threat Agents”Biologic Threat Agents”
•Can be easily disseminated or transmitted person-to-person;
•Cause high mortality, w/potential for major public health impact;
•Might cause public panic and social disruption; and
•Require special action for public health preparedness.
Biological Agents of Highest ConcernBiological Agents of Highest Concern
Category A Smallpox – variola major Anthrax – Bacillus anthracis Plague – Yersinia pestis Botulism – Clostridium botulinum toxin Tularemia – Francisella tularensis Viral hemorrhagic fevers – arenaviruses,
filoviruses (Ebola, Marburg, Lassa, Junin)
Category B: Second Highest PriorityCategory B: Second Highest Priority
Moderately easy to disseminate
Cause moderate morbidity and low mortality
Require specific enhancements of diagnostic capacity and enhanced disease surveillance
Coxiella burnetti (Q fever) Brucella Burkholderia mallei (glanders) Alphaviruses (Venezuelan
encephalomyelitis and Eastern and Western equine)
Rickettsia prowazekii Toxins (Ricin, Staph enterotoxin
B) Chlamydia psittaci Food safety threats
(e.g.Salmonella, Shigella. E. coli O157:H7)
Water safety threats (Vibrio cholerae, Cryptosporidium parvum)
Category C: Third Highest Category C: Third Highest PriorityPriority
Pathogens that could be engineered for mass destruction because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact
Nipah virus Hantavirus Tickborne
hemorrhagic fever viruses
Tickborne encephalitis viruses
Yellow fever MDR TB
Characteristics of Bioterrorist AgentsCharacteristics of Bioterrorist Agents
Mainly inhaled - may be ingested or absorbed Particles may remain suspended for hours May be released silently with no immediate effect Person-to-person spread happens for some agents Long incubation periods mean "first responders” may
be primary health care providers Agents may be lethal or incapacitating Vaccines & antitoxins exist for some agents
Recent Examples of Recent Examples of BioterrorismBioterrorism
1984: Salad bars contaminated with Salmonella by Rajneeshe cult members to influence local election in The Dalles, Oregon / 751 people affected (8 salad bars)
1995: Sarin nerve gas release by Aum Shinrikyo in Tokyo subway / At least 9 failed attempts to use biological weapons
1996: Pastries contaminated with Shigella by disgruntled lab worker in Dallas
Recent Examples of Recent Examples of BioterrorismBioterrorismFormer Soviet Union’s extensive biological weapons program
thought to have found their way to other nations
Iraq acknowledged producing and weaponizing anthrax and botulinum toxin
Currently, at least 17 nations believed to have biological weapons programs
Anthrax: Soviet incidentAnthrax: Soviet incident
An accident at a Soviet military compound in Sverdlovsk (microbiology facility) in 1979 resulted in an estimated 66 deaths downwind.
SmallpoxSmallpox Variola virus Declared eradicated by WHO in 1980 Civilian vaccination stopped 1972, healthcare
workers stopped in 1977 and CF stopped 1988
Known stockpiles remain in CDC and Institute for Viral Preparations, Moscow
Virus spread by aerosol Incubation period: average 12 days (7-19
days)
Last Case, Variola major Last Case, Variola major
Rahmina, 1975 Rahmina Banu, 2001
SMALLPOX RASH EVOLUTIONSMALLPOX RASH EVOLUTION
Day 1 Day 2 Day 3
SMALLPOX RASH EVOLUTIONSMALLPOX RASH EVOLUTION
Day 4 Day 5 Day 7
SMALLPOX RASH EVOLUTIONSMALLPOX RASH EVOLUTION
Days 8-9 Days 10-14 Day 20
SmallpoxSmallpox
Vaccination– Within 3 days will likely prevent disease– Within 5 days is life-saving (ameliorates)– Canada has about 320,000 doses– ?long term immunity– Cell culture and oral vaccine in research– Research on antivirals also ongoing
(particularly Cidofovir)
DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS: VESICULO – PUSTULARVESICULO – PUSTULAR RASHESRASHES
CHICKEN POX ERYTHEMA MULTIFORME - BULLOUS COWPOX MONKEY POX HERPES ZOSTER (Shingles) - DISSEMINATED DRUG ERUPTIONS HAND FOOT AND MOUTH DISEASE ACNE IMPETIGO INSECT BITES
Today’s Perspective in Canada:Today’s Perspective in Canada:Pros vs ConsPros vs Cons “Moderately”
contagious Virus not robust No natural reservoir Able to vaccinate Able to control Improved medical
care Better pop’n health
30% mortality Misdiagnosis Long incubation Low level of
“Immunity” Pop’n mobility Immuno-
compromised Mass panic, hysteria
Smallpox Isolation, Toronto Smallpox Isolation, Toronto (1909)(1909)
National Smallpox Contingency National Smallpox Contingency Plan (v.4)Plan (v.4) Canada’s ‘search and
contain’ strategy highlights:
– Early detection, immediate notification
– Immediate isolation of cases– Immediate deployment of
smallpox responders– Immediately vaccinate all
those directly exposed, all known direct contacts, all local personnel…
– Intensive contact tracing– Rapid set up of isolation
facilities– Rapid set-up of local
Smallpox assessment centres
Assumption: In the absence of
smallpox anywhere in Canada
A risk of disease and death from a vaccine, no matter how small, may be unacceptable
Especially when pre-attack vaccination is considered
VACCINE ADMINISTRATIONVACCINE ADMINISTRATION
VACCINATION: THE RESPONSEVACCINATION: THE RESPONSE
US Vaccination ExperienceUS Vaccination Experience
Plan for ‘first responders” (Phase 1)Estimated 4 million eligible; expected
500KVaccination in teams by Public
HealthActual uptake: about 35,000
US Vaccination ExperienceUS Vaccination Experience Complications:
– US Military: 10 cases myopericarditis/240,000 primary vaccinations; 1 cardiac arrest 5 days post vaccine
– Civilian: 1case pericarditis, 1 case myocarditis, 5 cardiac ischemic events (3 MIs, 2 angina), 2 deaths (both cardiac arrest)
– No cases in 110,000 military re-vacinees but 2/5 civilians were re-vacinees
US Vaccination ExperienceUS Vaccination Experience
Stockpile of ~200 million doses of cell culture vaccine + 15 million calf lymph vaccine (from 1978,1958)
Threat felt to be diminished post acute phase of the war in Iraq
Phase 2 practically is on hold although still not official (almost 4 years later)
Public Health RolePublic Health Role
Health effects of emergencies recently highlighted
In most jurisdictions the Medical Officer of Health is part of the municipal/regional emergency response team
Have a mandated lead role in events involving biologic agents
Public Health RolePublic Health Role
Early Detection Mass Patient Care Mass Immunization/ProphylaxisEpidemiologic investigationCommunicationCommand and Control
Public Health RolePublic Health Role
Mass Fatality Management Evacuations/sheltering (humans and
animals)Environmental Surety Community Recovery (rapid health
risk assessment, mental health etc)
Public Health RolePublic Health Role ‘Secondary’ responders Key role in
communication with the public for biologic emergencies
Can be liaison or link between healthcare facilities and first responders, the community
Have legal authority for many restrictive actions
Public Health ActionsPublic Health Actions
Promptly investigate original case Confirm laboratory results Identify & interview case contacts as needed Initiate active surveillance for additional cases Take immediate public health prevention action as needed Collaborate/notify MOHLTC, Health Canada as indicated Alert local medical community/public Determine need for Rx of contacts/health professionals
Mobilize needed assets at local, provincial, federal level
Maintain contact with case family & reporting MD
Public Health Incident Manager
Liaison
Public Information
Operations Planning Logistics Administration
Mass Vaccination/Post Exposure Prophylaxis
Hotline Operation
Case Management/Contact Tracing
Environmental Inspection/ Sampling
Situation Assessment
Staffing & Resource Needs
Resource Deployment
Documentation
Demobilization & Recovery
Facilities
Human Resources
Nutrition/staff accommodation
Claims/Compensation
Costing
Procurement Reception Centre/Mass Care
Communications Equipment Miscellaneous Supplies
Chair, Board of Health Medical Officer of Health Senior Management Team
Epidemiological Investigations
Recovery
Public Health Incident Management System
THE SUSPICIOUS PACKAGETHE SUSPICIOUS PACKAGE
May be reported any time or any place Since 2001 many examples have been
letters delivered or packages discovered This is a law enforcement and public health
responsibility
Anthrax in the USAAnthrax in the USA
4 known letters11 cases of inhalational anthrax11 cases of cutaneous anthrax5 deaths from inhalational anthrax
The Suspicious PackageThe Suspicious Package
The Suspicious PackageThe Suspicious Package
The Suspicious PackageThe Suspicious Package
Key Messages:Stay calmRemember, there is danger but there is
time Leave the package or letter but don't
leave the scene
Impact on the publicImpact on the public
Toronto Public Health Case Definitions for Biological EventsPriority Public Health Response First Responder Action
Priority 1 (High):1.Overt threat such as a letter, note or picture; or2.Obvious target such as media outlet, political or religious target or large corporation3.Human exposure has occurred (i.e. package has been opened)4.A substance is present
On-scene responseObtain personal decontamination
informationObtain contact information for those
exposedAdvise CPHL of priorityAdvise re environmental
decontaminationProvide counseling to exposed
individualsObtain lab results and communicate to first responders and exposed persons
Call Public Health ImmediatelyFrom 8am-8pm: 416 338-0069
After 8pm: 416 527-3461
Priority 2 (medium):1.Overt threat such as a letter, note or picture; or2.Obvious target such as media outlet, political or religious target or large corporation3.No human exposure has occurred (i.e. package has NOT been opened)4.A substance is present
Obtain contact information for relaying lab results
Advise CPHL of priorityAdvise re environmental
decontaminationCounsel individuals involved as neededObtain lab results and communicate to first responders and involved persons
Call Public Health with contact information and incident number on
semi-urgent basis:8am-8pm: 416 338-0069After 8pm: 416 527-3461
Priority 3 (low):1.No overt threat, and2.No obvious target3.There is human exposure (i.e. a package has been opened)4.A substance is present
Obtain contact information if sample sent to CPHLAdvise CPHL of priorityProvide personal and environmental decontamination advice if requested
If sending sample to the lab, call Public Health with contact information and incident number when practicable
Priority 4 (lowest):1.No overt threat, and2.No obvious target3.There is no human exposure (i.e package has not been opened)
Provide reassurance and environmental decontamination advice if requested
Call Public Health only if involved persons requesting specific advice
Public Health ResponsePublic Health Response
24 hour first responder hotlineCoordination with laboratoryDeveloping protocols with police,
fire, EMSLinks with other Health Units,
provinces, Health CanadaInfo to businesses, hospitals, local
physicians, consulates, the public…..
Triage of Suspicious Triage of Suspicious Envelopes/Packages* Envelopes/Packages* A general process is outlined below, in
some areas public health may play role of onsite assessment and/or transport to lab– Police notified - call 911.– Police contact local Health Unit.– Decision is made re lab testing, management
of exposed individuals– Police transport material to lab.
*all environmental specimens are tested in the Central Public Health Lab
Testing in the Public Health LabTesting in the Public Health Lab
Open and examine package in a negative pressure containment lab using level 3 protection.
Gram stain, +/- spore stains for bacteria on any material (powder, etc.) present.
Cultures, motility, biochemicals as required.
Testing in the Public Health LabTesting in the Public Health Lab
Testing performed while maintaining chain of custody procedures and evidence documentation.– Photograph material– preserve DNA, fingerprints, handwriting
CPHL does not do chemical analysis or tell the police what the substance is.
Testing in the Public Health LabTesting in the Public Health Lab
Send any suspicious organisms to the NML in Winnipeg for confirmation.
All samples must be treated as possible forensic evidence.– maintain chain of custody– preserve DNA, fingerprints, handwriting etc.– alert police of similar incidents from different
jurisdictions
Reporting ResultsReporting Results
Phone results to health unit and to police, within 24 - 48 hours of receipt of sample.
Written report to health unit (Medical Officer of Health) and police, within 1 - 2 weeks.
Police contacted re deposition of material– material returned to police– material destroyed by police order
SummarySummary
Roles public health will play will vary by health unit
Will certainly have a key role in public communication
Will most often have lead for follow-up of contacts/people exposed
Will have lead role in determining of PEP/vaccination
Need to understand roles of other players in your community