Biological Threats

Outbreaks, Attacks and Accidents

Prevent, Detect and Respond

A Global Health and National Security Imperative

Gerald W Parker, DVM, PhDAssociate Vice President Public Health Preparedness and Response

Texas A&M Health Science Center

Interim Director, Institute for Infectious Animal Diseases

Texas A&M AgriLife Research

Topics

Evolving Biological Threats and Policy

Lessons observed: 2 Cases

2001 Anthrax

2014 Ebola response

National Security Strategy

Global Health Security Agenda

Evolving Biological Threats

Threat Agents Traditional threats remain

Engineered and advanced threats

Emerging infectious diseases

Threat Events Accidental release

Deliberate elicit use by offensive weapons programs State

Non-state

Lone actor

Naturally-occurring, emerging trans-boundary infectious diseases (zoonotic)

Therapeutic resistance

DURC

Traditional

Threats

Emerging

ThreatsAdvanced

Threats

Popular Biology ~2025

“Pathogenic microbes can be resilient,

dangerous foes.

Although it is impossible to predict

their individual emergence in time

and place, we can be confident that

new microbial diseases will emerge.”

– IOM, 1992

Emerging Infectious

Diseases

Biodefense & Emerging Infectious Disease Highlights

Biological &

Toxin Weapons

Convention

Sarin

attack in

Tokyo by

Aum

Shinrikyo

H5N1

Pandemic

potential

CDC Laboratory

Response Network &

Strategic National

Stockpile

Al Qaeda 911

& Anthrax

letter attacks

CDC and NIH

Biodefense

preparedness

programs

expand rapidly

SARS

H5N1

Pandemic

potential

Project

BioShield

H5N1 Pandemic

Influenza Emergency

Supplemental

Appropriations

Hurricanes

Pandemic & All

Hazards

Preparedness Act

H1N1

Pandemic

Middle East

Coronavirus

Ebola

1972 1995 20161997 1999 2001 2003 2004 2005 2006 2009 2012 2014

ANTHRAX ATTACKS OF

2001

2001 Anthrax Attack

Observations

The 2001 attacks may be easiest type of bioterrorist strike to confront even so their impact was far-reaching:

Two branches of the Federal Government were temporarily shut down & U.S. Postal operations significantly disrupted

Only 22 individuals contracted anthrax (11 inhalational & 11 cutaneous)

More than 33,000 required post-exposure antibiotics

Direct economic cost (losses) ~ $3 Billion

Decontamination of Senate office building, Postal Process plant and AMI building cost ~$320 Million

Observations (Continued)

The response from medical, public health & law enforcement communities was massive.

1000 physicians, epidemiologists, public health official & medical practitioners.

U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) performed 30,000 tests on 10,000 samples.

400 contractors & as many 400 government workers needed to decontaminate just the Hart U.S. Senate Office Building.

These attacks revealed weaknesses in almost every aspect of U.S. bio-preparedness.

The failure to communicate a clear message to the public was on of the greatest problems.

Key Lessons Learned

Establish clear chain of command for incident response

1. Develop check list of key immediate actions

2. Expand cooperation between medical, public health & law

enforcement communities

3. Establish reliable 1st responder communications

4. Exchange liaisons, increase 1st responder training & joint exercises

Key Lessons Learned Continued

Develop comprehensive communication strategies

1. Develop coordinated media strategy

2. Prepare public messages in advance

3. Establish joint information center for sharing data

Improve ability to detect a biological attack early

1. Expand environmental detection systems

2. Improve clinical & forensic diagnostic capabilities

3. Alert medical community immediately

Key Lessons Learned Continued

Develop local distribution plans for antibiotics, vaccine

administration & provision of treatment of mass casualties

1. Develop stockpile and mass delivery strategies

2. Incorporate mental health needs into response plans

3. Strengthen civil defense

4. Need Anthrax Vaccine and surge capability

Expand local & regional surge capacities for mass-casualty care.

Improve large-area decontamination capabilities

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8

Time after Attack (days)

Perc

en

t In

fecte

d i

n I

ncu

bati

on

Pe

rce

nt W

e C

an

Sa

ve

w

ith

Ora

l A

nti

bio

tic

sDetect

Decide

Distribute

Dispense

Baccam, P. & Boechler, M, “Public Health Response to an Anthrax Attack: An Evaluation of Vaccination Policy Options,”

Biosecuirty and Bioterrorism: Biodefense Strategy, Practice and Science Vol 5, #1, 2007 pp. 26-34.

Saving Lives Requires Fast, Effective Response

Summary

2001 anthrax letter attacks demonstrated biological risk is real

Even small scale attacks can have national & international impacts;

Defense against biological attacks requires extensive preparation, coordination & vigilance;

Must be underpinned by robust research foundation

Saving lives after an attack requires effective response that is fast with robust logistics to deliver medical countermeasures

Microbial forensics established as a new science

Laboratory biosecurity, personal reliability, and biosafety

Current Concern: Aerosol ReleasePast Experience: 2001 Anthrax Attacks

Number that received

antibiotic treatment

30,000

Number of illnesses 22

Number of deaths 5

Decontamination 3 Buildings ~$320 M

Direct Economic Cost >$1 B

Number that will need antibiotic treatment 1.9-3.4 M

Number of illnesses ~450,000

Number of deaths ~380,000

Decontamination City wide

Projected Economic Cost >$1.8 T

1 gm via letters 1-2 kg via cropduster

The Simplest Versus the

Most Realistic Attack Scenario

Comprehensive Biodefense

Strategy

THREAT

AWARENESS

PREVENTION AND

PROTECTION

SURVEILLANCE

AND DETECTION

RESPONSE AND

RECOVERY

BW related

intelligence

Proactive

prevention

(vaccination)

Critical

infrastructure

protection

(collective

protection)

Attack warning

(biosurveillance)

Attribution

(forensics)

Response planning

Mass casualty care

(surge medical care)

(rapid distribution of

medical

countermeasures)

Risk communication

Medical counter-

measure development

Decontamination

HSPD-10

A Common Comprehensive Resilience Framework

PREVENTION PROTECTIONSURVEILLANCE

AND DETECTIONRESPONSE AND RECOVERY

ANTICIPATION OF FUTURE THREATS

INFORMATION MANAGEMENT AND COMMUNICATIONS

TRAINED, EQUIPPED &PROTECTED RESPONDERS

RESEARCH, DEVELOPMENT, AND ACQUISITION

THREAT ASSESSMENT AND AWARENESS

PUBLIC PREPAREDNESS

POST-EVENTPRE-EVENT

Filovirus Emergence

Since 1976

Martines RB, et al. J Pathol 10-9-2014 E-pub ahead of print

WHO Sit Rep

Guinea

Liberia

Sierra Leone

01/06/2016

Current Outbreak In West Africa

• Liberia declared EVD free

Jan 2016

• Sierra Leone declared EVD free

• Guinea declared EVD free

Nov / Dec 2015

• Mali declared EVD free

Jan 2015

• Senegal & Nigeria declared EVD free

Oct 2014

• WHO declares “public health emergency of

international concern”

• Outbreak spreads to include Guinea, Liberia, Sierra Leone, Senegal, Nigeria, and Mali

Aug 2014

• WHO notified of rapidly evolving situation.

• MSF -unprecedentedand warned of difficulties combating EVD

March 2014

• Epidemic began in Guinea -index patient thought to be a 2 year old child

Dec 2013

Why was this outbreak so bad?

2013-2016 Ebola epidemic is the largest in history

> 28,000 cases, >11,000 deaths

N Engl J Med Oct 16, 2014; 371(16):1481-1495

Contributing factors

Delayed recognition, diagnosis, and public health response

Epicenter located on a 3 border region

First cases: Gueckedou and Macenta Highly interconnected populations

Easy connections by roads: rural and urban areas

EVD spread to cities

Overcrowding and poor sanitation

Cultural and social factors

Distrust of government authorities

Inadequate health care infrastructure

From Liberia to Dallas

Depart Liberia 19 September

Arrive Dallas 20 September

Ebola Virus In Texas

First case to be diagnosed in U.S. …

Sept 20: Mr. Thomas Eric Duncan arrives in U.S. from Liberia

First cases of secondary transmission…

Oct 10: Nurse (Nina Pham) who provided care to index patient developed fever and tested positive for EVD

Oct 15: 2nd nurse (Amber Vinson) who provided care for index patient reported with fever and tested positive for EVD after traveling to Ohio

First Ebola Virus Disease Diagnosis in U.S. Occurs in Texas

Texas has sophisticated and one of the nation’s best emergency management system, but

Texas faced unique public health emergency that required extraordinary efforts from public health experts, health care workers, emergency responders, and private sector partners, as well as local, state, and federal leaders

Disaster response requires coordinated response among state and local governments, community support organizations, and multidisciplinary responders Emergency management, public health, search & rescue, law enforcement,

transportation oversight, environmental controls, communications, and logistics

Public health is a team sport

Forensics of the Ebola Response

Decision Making: Who’s in charge?

HazMat: How clean is “clean”?

Communications: media, media, media

Contact tracing & monitoring

The lack of vaccines and therapies

Health care worker protection

Irrational, but legitimate public fear

Ethics: individual, local, national, global

Hospital surge capability & capacity Laboratory testing

Disasters Are Managed Locally

Trial By Ebola. Vanity Fair; February 2015

1. Hospital care

2. Identification and isolation triage

3. Hospital Preparedness Program

4. Education and training

5. Hospital care – experimental drugs

6. Personal protective equipment

7. Control order authority

8. Epi monitoring and contact tracing

9. Disposition of deceased

10. Housing and social services

11. Laboratory testing and sample transport

12. Guidelines for monitoring HCW

13. Incident command

14. Decontamination and waste removal

15. Communications

16. Care of domestic animals

17. Task Force future role

Texas Task Force Infectious Disease Preparedness

& Response

31

Transportation assures rapid global spread of emerging diseases

Emergence of new, virulent pathogens

(50 appeared since 1973)

The Natural Threat

SARSH7N9

WHO calls Middle Eastern virus,

MERS, ‘threat to the entire world’

May 29, 2013

West Nile virus: Dallas declares

state of emergency

August 16, 2012

The Modern Reality of Emerging Infectious Diseases

Major Emerging and Reemerging Infectious-Disease

Outbreaks, Epidemics, and Pandemics, 2002 through 2015.

: Figure 1 From Sands, et al., The Neglected Dimension of Global Security—A Framework for Countering Infectious

Disease Crises, NEW ENGLAND J. OF MEDICINE (Jan. 13, 2016)

Bioterrorism Report Card:

U.S. unprepared

October 12, 2011

Syria, North Korea,

Iran, Egypt, etc.

Iraq arrests five in 'al-Qaeda

chemical weapons plot‘Al-Qaeda planned to strike targets in Iraq,

Europe and North America with chemical

weapons…

June 2, 2013

33

The Escalating Threat of CBRN Attack

A Common Comprehensive Resilience Framework

PREVENTION PROTECTIONSURVEILLANCE

AND DETECTIONRESPONSE AND RECOVERY

ANTICIPATION OF FUTURE THREATS

INFORMATION MANAGEMENT AND COMMUNICATIONS

TRAINED, EQUIPPED &PROTECTED RESPONDERS

RESEARCH, DEVELOPMENT, AND ACQUISITION

THREAT ASSESSMENT AND AWARENESS

PUBLIC PREPAREDNESS

POST-EVENTPRE-EVENT

The effective dissemination of a lethal

biological agent within a population

center would endanger the lives of

hundreds of thousands of people and

have unprecedented economic, societal,

and political consequences.

We must continue to work at home with

first responders and health officials to

reduce the risk associated with

unintentional or deliberate outbreaks of

infectious disease and to strengthen our

resilience across the spectrum of high-

consequence biological threats.

National Security Strategy 2010

Global Health Security Agenda 2014

A NATIONAL

BLUEPRINT FOR

BIODEFENSE: LEADERSHIP AND REFORM NEEDED

TO OPTIMIZE EFFORTS

BIPARTISAN REPORT OF THE BLUE RIBBON

STUDY PANEL AND BIODEFENSEOCTOBER 2015

Institute Sponsors: Hudson Institute Inter University Center

For Terrorism Studies

Essential Tasks in Responding to a Biological Incident of

Potential National Significance:

Priority Considerations, Decisions & Actions

Save Lives Ensuring rapid identification of attack, diagnosis and confirmation

Providing medical care

Distributing & administrating medical countermeasures as needed and in time

Maintain Order and Continuity of Operations Ensuring coordinated multi-disciplinary response

Ensuring security of assets

Ensuring security and operation of critical infrastructure

Manage the Crises and Prepare for Future Incident Sharing essential information and intelligence

Enhancing protection

Increasing detection capabilities

Local Public Health and Emergency Management Are On

the Frontline of Global Biologial Threats

Source: Kilpatrick AM, et al. Drivers, dynamics, and control of emerging vector-borne zoonotic diseases. The Lancet 380:9857, 1-7 Dec 2012, pp. 1946-55. www.sciencedirect.com/science/article/pii/S0140673612611519Note: Air traffic to most places in Africa, regions of South America, and parts of central Asia is low. If travel increases in these regions, additional introductions of vector-borne pathogens are probable.

Biological Threats

Outbreaks, Attacks and Accidents

Prevent, Detect and Respond

A Global Health and National Security Imperative

Gerald W Parker, DVM, PhDAssociate Vice President Public Health Preparedness and Response

Texas A&M Health Science Center

Interim Director, Institute for Infectious Animal Diseases

Texas A&M AgriLife Research