Dallas County Bioterrorism Program: Dallas County Bioterrorism Program: Overview and HighlightsOverview and Highlights

David Buhner MD MSDavid Buhner MD MS

EpidemiologistEpidemiologist

Dallas County Department of Health Dallas County Department of Health and Human Servicesand Human Services

OVERVIEW OVERVIEW

Large-scale terrorism in Large-scale terrorism in the US is a realitythe US is a reality

1993—World Trade Center bombing1993—World Trade Center bombing

1996—Alfred P. Murrah Federal 1996—Alfred P. Murrah Federal Building bombing in Oklahoma CityBuilding bombing in Oklahoma City

2001—Destruction of the World 2001—Destruction of the World Trade CenterTrade Center

Chemical and biological Chemical and biological attacks are a realityattacks are a reality

1978—Deliberate contamination of 1978—Deliberate contamination of Israeli citrus exports with mercuryIsraeli citrus exports with mercury

1982—Deliberate contamination of 1982—Deliberate contamination of Tylenol with cyanideTylenol with cyanide

1984—Deliberate contamination of 1984—Deliberate contamination of salad bars with Salmonella in Oregonsalad bars with Salmonella in Oregon

1995—Tokyo Sarin gas attack1995—Tokyo Sarin gas attack 2001—The US anthrax attacks2001—The US anthrax attacks

The Scope of the ThreatThe Scope of the Threat

Office of Technology Assessment: Office of Technology Assessment:

Used under optimal conditions Used under optimal conditions biological weapons could have an biological weapons could have an impact similar to a small nuclear impact similar to a small nuclear device.device.

The Toxin of The Toxin of C. botulinumC. botulinum

C. botulinum C. botulinum lives in the soillives in the soil.. Evenly dispersed and inhaled 1 gram Evenly dispersed and inhaled 1 gram

of botulinum toxin could kill 1 million of botulinum toxin could kill 1 million people.people.

After the 1991 war, Iraq admitted to After the 1991 war, Iraq admitted to the possession of 19,000 liters of the possession of 19,000 liters of concentrated toxin, 10,000 liters concentrated toxin, 10,000 liters loaded into military weapons.loaded into military weapons.

Potential Agents of BioterrorismPotential Agents of Bioterrorism

Toronto SARS EpidemicToronto SARS Epidemic

361 cases reported between 2/23/03 361 cases reported between 2/23/03 and 6/7/03, with 33 (9%) deathsand 6/7/03, with 33 (9%) deaths

Some control measures used:Some control measures used: -over 18,000 people quarantined -over 18,000 people quarantined -closure of businesses -closure of businesses -closure of schools-closure of schools Economic losses projected at Economic losses projected at

1,000,000,000 dollars1,000,000,000 dollars

The Latest in Feline FashionThe Latest in Feline Fashion

Historical EpidemicsHistorical Epidemics The European Black Death (bubonic The European Black Death (bubonic

plague) of the 1300’s is estimated to plague) of the 1300’s is estimated to have killed 1/3 of the European have killed 1/3 of the European populace within 2 years.populace within 2 years.

Epidemics due to Old World diseases Epidemics due to Old World diseases introduced into the New World with introduced into the New World with the arrival of Europeans are the arrival of Europeans are estimated to have killed 90% of the estimated to have killed 90% of the native inhabitants.native inhabitants.

Public Health:Public Health:Epidemic Disease DefenseEpidemic Disease Defense

Traditional role: control of infectious, Traditional role: control of infectious, communicable diseases of “natural” communicable diseases of “natural” origin in the local populace.origin in the local populace.

There is little debate about the There is little debate about the decades-long deterioration that has decades-long deterioration that has been allowed to take place in the been allowed to take place in the local public health infrastructure in local public health infrastructure in the US.the US.

Unique Features of BioterrorismUnique Features of BioterrorismUnlike other forms of terrorism:Unlike other forms of terrorism: Public health system is THE crucial factor Public health system is THE crucial factor

in an effective response.in an effective response. Bioterrorism may be covert, with a delay, Bioterrorism may be covert, with a delay,

due to the incubation period of the illness, due to the incubation period of the illness, in the appearance of the problem.in the appearance of the problem.

Bioterrorism can be self-propagating due Bioterrorism can be self-propagating due to person-to-person spread; early to person-to-person spread; early identification and institution of effective identification and institution of effective public health measures can limit what public health measures can limit what otherwise might be a catastrophic otherwise might be a catastrophic outbreak of disease. outbreak of disease.

New Role for Public Health: New Role for Public Health: Watchdog for BioterrorismWatchdog for Bioterrorism

Good news: the skill set, personnel, and Good news: the skill set, personnel, and physical resources required for this role physical resources required for this role are little different from those required for are little different from those required for traditional public health functionstraditional public health functions

Bad news: public health infrastructure Bad news: public health infrastructure deterioration and failure to keep up with deterioration and failure to keep up with the modern pace of technological change the modern pace of technological change critically compromise local public health’s critically compromise local public health’s ability to respond with the speed and ability to respond with the speed and efficacy required to limit the damage from efficacy required to limit the damage from a large-scale attack of bioterrorisma large-scale attack of bioterrorism

Federal ResponseFederal Response In 1999 The Centers for Disease In 1999 The Centers for Disease

Control and Prevention (CDC) first Control and Prevention (CDC) first received congressionally received congressionally appropriated funds to enter into appropriated funds to enter into multi-year cooperative agreements multi-year cooperative agreements aimed at upgrading state and local aimed at upgrading state and local health department preparedness and health department preparedness and response capabilities relative to response capabilities relative to bioterrorism.bioterrorism.

1. Preparedness Planning 1. Preparedness Planning and Readiness Assessmentand Readiness Assessment

The worst time to determine how to The worst time to determine how to respond to an emergency situation is respond to an emergency situation is during the emergency.during the emergency.

Need adequate planning and Need adequate planning and preparationpreparation

Need training exercises to assess Need training exercises to assess the adequacy of the plans and the adequacy of the plans and preparationpreparation

2. Surveillance and 2. Surveillance and Epidemiologic CapacityEpidemiologic Capacity

Rapid disease detection requires a Rapid disease detection requires a sensitive surveillance system.sensitive surveillance system.

Detected cases must be investigated by Detected cases must be investigated by epidemiologists to:epidemiologists to:

1) discriminate sporadic cases from 1) discriminate sporadic cases from outbreaks of diseaseoutbreaks of disease

2) discriminate natural from 2) discriminate natural from intentionalintentional

3) identify the population at risk so 3) identify the population at risk so they may be treatedthey may be treated

4) identify appropriate control 4) identify appropriate control measures to limit spread to the unaffectedmeasures to limit spread to the unaffected

3. Laboratory Capacity3. Laboratory Capacity

Rapid and correct identification of the Rapid and correct identification of the particular biological agent in an outbreak particular biological agent in an outbreak is of fundamental importance becauseis of fundamental importance because

1) public health consequences differ 1) public health consequences differ

2) control measures differ2) control measures differ A well-equipped lab with highly trained A well-equipped lab with highly trained

personnel is a critical necessity.personnel is a critical necessity.

4. Communications and 4. Communications and Information TechnologyInformation Technology

Public health surveillance and outbreak Public health surveillance and outbreak response require that large amounts of response require that large amounts of real-time data must be collected, stored, real-time data must be collected, stored, sorted, integrated, analyzed, and sorted, integrated, analyzed, and interpreted and the results communicated interpreted and the results communicated to the appropriate person(s).to the appropriate person(s).

Effective communications systems must Effective communications systems must link public health officials, first responders, link public health officials, first responders, government officials, physicians, and all government officials, physicians, and all other agencies and organizations likely to other agencies and organizations likely to be involved in a large-scale outbreak of be involved in a large-scale outbreak of illness.illness.

5. Risk Communication and Health 5. Risk Communication and Health Information DisseminationInformation Dissemination

The importance of informed, timely , The importance of informed, timely , and effective communication with and effective communication with the public and the media, especially the public and the media, especially during a public health crisis, cannot during a public health crisis, cannot be overstressed. be overstressed.

6. Education and Training6. Education and Training

All individuals involved in a All individuals involved in a response to bioterrorism must response to bioterrorism must possess the up-to-date skills and possess the up-to-date skills and knowledge necessary to carry knowledge necessary to carry out their responsibilities.out their responsibilities.

Highlights of the Dallas Highlights of the Dallas County Bioterrorism ProgramCounty Bioterrorism Program

Highlight Highlight II

Regional and Regional and

Organizational Organizational

CooperationCooperation

The Importance of a Regional The Importance of a Regional ApproachApproach

Substantial population flow takes Substantial population flow takes place daily between Collin, Dallas, place daily between Collin, Dallas, Denton, and Tarrant counties, as well Denton, and Tarrant counties, as well as to and from more distant counties.as to and from more distant counties.

The effects of bioterrorism are The effects of bioterrorism are unlikely to respect jurisdictional unlikely to respect jurisdictional boundaries.boundaries.

The Problem of Caring for The Problem of Caring for Victims of BioterrorismVictims of Bioterrorism

Hospitals lack the empty beds and staff to Hospitals lack the empty beds and staff to manage a sudden influx of large numbers manage a sudden influx of large numbers of patients (no surge capacity). This is a of patients (no surge capacity). This is a nationwide problem.nationwide problem.

No hospital wishes to accept the role of No hospital wishes to accept the role of epidemic disease hospital in the event of epidemic disease hospital in the event of an outbreak.an outbreak.

Where will large numbers of suddenly ill Where will large numbers of suddenly ill patients be cared for in the event of an patients be cared for in the event of an outbreak?outbreak?

A Regional Quarantine and A Regional Quarantine and Treatment FacilityTreatment Facility

Representatives of the four counties Representatives of the four counties (public health and government), (public health and government), DFWHC, PMH, JPS, the VA, NTCOG, DFWHC, PMH, JPS, the VA, NTCOG, local medical societies, and others local medical societies, and others have been meeting regularly for have been meeting regularly for more than a year to address this more than a year to address this problem. problem.

Highlight Highlight IIII

Dallas County Dallas County

LaboratoryLaboratory

DCHHS Bioterrorism Preparedness DCHHS Bioterrorism Preparedness and Response Laboratoryand Response Laboratory

A state-of-the-art, CDC-sanctioned, LRN A state-of-the-art, CDC-sanctioned, LRN laboratory (operating at BSL-3) capable of laboratory (operating at BSL-3) capable of conducting CDC-validated confirmatory conducting CDC-validated confirmatory testing for a wide variety of organisms (a testing for a wide variety of organisms (a Confirmatory lab) Confirmatory lab)

Provides services to all of North Texas Provides services to all of North Texas including Collin, Dallas, Denton, Tarrant including Collin, Dallas, Denton, Tarrant counties, and TDH Region 2/3counties, and TDH Region 2/3

Provides critical training and support to Provides critical training and support to local hospital and clinical laboratories local hospital and clinical laboratories (Sentinel labs)(Sentinel labs)

Highlight Highlight IIIIII

Epidemiologic Epidemiologic

Response TeamsResponse Teams

The Benefits of Public HealthThe Benefits of Public Health

Institution of effective treatment as soon Institution of effective treatment as soon as possible after exposure can save the as possible after exposure can save the lives of individuals epidemiologically lives of individuals epidemiologically identified as having been exposed to identified as having been exposed to infectious diseases and/or toxins.infectious diseases and/or toxins.

Implementation of effective control Implementation of effective control measures can prevent the spread of measures can prevent the spread of communicable illnesses from exposed, communicable illnesses from exposed, infected individuals to the previously infected individuals to the previously unexposed and uninfected. unexposed and uninfected.

Epidemiologic Response TeamsEpidemiologic Response Teams Rapid investigation of reported cases can Rapid investigation of reported cases can

take maximum advantage of the lag time take maximum advantage of the lag time (incubation period) between exposure and (incubation period) between exposure and the onset of illness.the onset of illness.

Dallas County has provided for a rapid and Dallas County has provided for a rapid and flexible response to outbreaks of illness by flexible response to outbreaks of illness by forming response teams consisting of, as forming response teams consisting of, as necessary, physicians, epidemiologists, necessary, physicians, epidemiologists, nurses, laboratorians, and the appropriate nurses, laboratorians, and the appropriate equipment and supplies.equipment and supplies.

These teams are available 24/7 and capable These teams are available 24/7 and capable of managing multiple, simultaneous of managing multiple, simultaneous outbreak investigations.outbreak investigations.