Public Health Issues

David S. Perlin, Ph.D.Public Health Research Institute

at the International Center for Public HealthNewark, NJ 07103

perlin@phri.org

• Lead agency was unclear• Federal authorities appeared confused• Sloppy scientific thinking underestimated spore threat through mail

system• First responders were inadequately trained for hazard• Public health Labs were poorly prepared to receive pathogens,

provide timely diagnostics, or perform high volume sample evaluations

• Federal and state priorities were unclear, and often conflicted. • Physicians were uneducated about disease• So-called “textbook” knowledge was often misleading or incomplete• Decontamination was difficult

October 2001 Anthrax OutbreakWhat went wrong?

Threat Assessment

Preparedness

Response

Essential Elements of a Public Health Strategy

Potential Bioterrorism Agents

• Bacterial Agents– Anthrax– Brucellosis– Cholera– Plague,

Pneumonic– Tularemia– Q Fever

Source: U.S. A.M.R.I.I.D.

• Viruses– Smallpox– VEE– VHF

• Biological Toxins– Botulinum– Staph Entero-B– Ricin– T-2 Mycotoxins

Deliberate v. Naturally-Occurring Outbreak

Does it matter?

Bioterrorism preparedness should be an extension of our current medical and public health infrastructure.

Circulatory

Cancer

Respiratory

Perinatal

Other

33.1%

29.3%

11.9%

5.6%

6.9%

13.2%

TB MalariaDiarrhea

012345

Deaths, millions

AcuteRespiratory

HIV/AIDS

WHO: Mortality Trends (1997)

Infectious and Parasitic

Infectious and ParasiticDiseases

Epidemic Diseases are all around us

The 1918 Spanish Flu pandemic killed over 40 million people worldwide with 450,000 deaths in the USA.

Influenza kills more than 35,000 Americans each year

Emerging and Re-emerging Diseases

4156 Cases and 284 Deaths (1/1/03)

West Nile Virus

SARS Coronavirus

People are potent vectors of disease

PRERAREDNESSand

RESPONSE

Linking of Response SystemsMedical & Mental Medical & Mental Health ServicesHealth Services

First RespondersFirst RespondersFire/EMSFire/EMS

Emergency Emergency ManagementManagement

Public Public HealthHealth

Law Law EnforcementEnforcement

The Department of Justice assigns lead responsibility for operational response to the FBI, which operates as the on-scene manager for the Federal Government

Relationship Between Crisis and Consequence Management

FEMA is the lead agency for consequence management and can use FRP structures to coordinate all Federal assistance to State and local governments.

•The National Pharmaceutical Stockpile Program

•National Electronic Data Surveillance System (NEDSS)

•The Global Outbreak Alert and Response Network

•Epidemic Information Exchange (Epi-X)

•Laboratory Response Network

•Metropolitan Medical Response System (MMRS)

Structure of the LRN

Level A Clinical Labs

BSC (Class II-B)

Level B Public Health

Labs BSL-2 + or 3

Level C Labs * BSL-3

Level D Federal Labs BSL-4

CDC and USAMRIID. Expertise with unusual organisms. Specimen repository.

Rapid identification using molecular methods. Test evaluation.

Isolation and presumptive ID. Antimicrobial susceptibility testing. 24/7 response.

Early detection, rule out and refer.

*State, research, federal

Metropolitan Medical Response System (MMRS)

An operational system at the local level to respond to a terrorist incident and other public health emergencies that create mass casualties

This system enables a Metropolitan Area to manage the event until State or Federal response resources are mobilized

MMRS is a locally developed, owned, and operated mass casualty response system

Original MMRSOriginal MMRSBoston, New York, Baltimore, Philadelphia, Washington DC, Atlanta, Miami, Memphis, Jacksonville, Detroit, Chicago, Milwaukee, Indianapolis, Columbus, San Antonio, Houston, Dallas, Kansas City, Denver, Phoenix, San Jose, Honolulu, Los Angeles, San Diego, San Francisco, Anchorage, Seattle

Metropolitan Medical Response SystemsMetropolitan Medical Response Systems

MMRS 1999MMRS 1999Hampton Roads (Virginia Beach)Area, Pittsburgh, Nashville, Charlotte, Cleveland, El Paso, New Orleans, Austin, Fort Worth, Oklahoma City, Albuquerque, St. Louis, Salt Lake City, Long Beach, Tucson, Oakland, Portland (OR), Twin Cities (Minneapolis), Tulsa, Sacramento

MMRS 2000 MMRS 2000 Twin Cities (St. Paul), Hampton Roads (Norfolk),Cincinnati, Fresno, Omaha, Toledo, Buffalo, Wichita,Santa Ana, Mesa, Aurora , Tampa, Newark, Louisville, Anaheim, Birmingham, Arlington, Las Vegas,Corpus Christi, St. Petersburg, Rochester, Jersey City,Riverside, Lexington-Fayette, Akron

MMRS 2001MMRS 2001Colorado Springs, Baton Rouge, Raleigh, Stockton, Richmond (VA), Shreveport, Jackson, Mobile, Des Moines, Lincoln, Madison, Grand Rapids, Yonkers, Hialeah, Montgomery, Lubbock, Greensboro, Dayton, Huntington Beach, Garland, Glendale (CA), Columbus (GA), Spokane, Tacoma, Little Rock

MMRS 2002MMRS 2002Bakersfield, Fremont, Ft. Wayne, Hampton Roads (Newport News, Chesapeake), Arlington, Worcester, Knoxville, Modesto, Orlando, San Bernardino, Syracuse, Providence, Huntsville, Amarillo, Springfield, Irving, Chattanooga, Kansas City, Jefferson Parish, Ft. Lauderdale, Glendale, Warren, Hartford, Columbia

Strategic use of vaccines

Challenges

Contagious Outbreaks

• Identification of clinical symptoms• Rapid and accurate diagnostics• Accurate reporting and open communication• Willingness to isolate and quarantine all infected

populations• Mobilization of scientists to develop vaccines,

therapeutics, new diagnostics, and determine the source of the outbreak

Drug Resistance

what if the organism is drug resistant and we can’t treat?

Molecular engineering is easy

What would have happened during the anthrax outbreak?

What good is the National Pharmaceutical Stockpile in this event?

Role of Healthcare Professionals

• First line of defense.

But what if they are early victims of the outbreak (e.g. Toronto)?

Hospitals as an amplifier of infection

SARS Cases in Toronto

What about mass casualties?

What would a plume of anthrax spores do in our area?

The 1918 Spanish Flu pandemic hospitalized millions of Americans

Can we handle the patients? Do we have enough lab capacity?

CONCLUSION

Bioterrorism preparedness must be an extension of our current medical and public health infrastructure.

Our ability to respond effectively to a new outbreak will depend on the robustness of the prevailing system.