Bioterrorism Preparedness Public health CBRN course Bonnie Henry, MD, FRCPC.

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


Day 4 Day 5 Day 7


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


Early Detection Mass Patient Care Mass Immunization/ProphylaxisEpidemiologic investigationCommunicationCommand and Control


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

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 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.


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

Bioterrorism Preparedness Public health CBRN course Bonnie Henry, MD, FRCPC.

Documents

Transcript of Bioterrorism Preparedness Public health CBRN course Bonnie Henry, MD, FRCPC.