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

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Bioterrorism preparedness

Bioterrorism Preparedness

Bonnie Henry, MD, FRCPC

Public health CBRN course


Goals of session
Goals 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 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 A (bacteria, viruses, and fungi) or toxins to produce death or disease in humans, animals or plants.

  • “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 concern
Biological Agents of Highest Concern (bacteria, viruses, and fungi) or toxins to produce death or disease in humans, animals or plants.

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 priority

Moderately easy to disseminate (bacteria, viruses, and fungi) or toxins to produce death or disease in humans, animals or plants.

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 B: Second Highest Priority


Category c third highest priority

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

Category C: Third Highest Priority


Characteristics of bioterrorist agents
Characteristics of Bioterrorist Agents because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 Bioterrorism because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

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 Bioterrorism because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Former 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 incident
Anthrax: Soviet incident because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

An accident at a Soviet military compound in Sverdlovsk (microbiology facility) in 1979 resulted in an estimated 66 deaths downwind.


Smallpox
Smallpox because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Rahmina Banu, 2001

Rahmina, 1975


Smallpox rash evolution
SMALLPOX RASH EVOLUTION because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Day 1 Day 2 Day 3


Smallpox rash evolution1
SMALLPOX RASH EVOLUTION because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Day 4 Day 5 Day 7


Smallpox rash evolution2
SMALLPOX RASH EVOLUTION because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Days 8-9 Days 10-14 Day 20


Smallpox1
Smallpox because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 vesiculo pustular rashes
DIFFERENTIAL DIAGNOSIS: because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impactVESICULO – PUSTULARRASHES

  • 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 pros vs cons

“Moderately” contagious because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

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

Today’s Perspective in Canada:Pros vs Cons


Smallpox isolation toronto 1909
Smallpox Isolation, Toronto (1909) because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact


National smallpox contingency plan v 4

Canada’s ‘search and contain’ strategy highlights: because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

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

National Smallpox Contingency Plan (v.4)


Vaccine administration
VACCINE ADMINISTRATION because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact


Vaccination the response
VACCINATION: THE RESPONSE because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact


Us vaccination experience
US Vaccination Experience because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • Plan for ‘first responders” (Phase 1)

  • Estimated 4 million eligible; expected 500K

  • Vaccination in teams by Public Health

  • Actual uptake: about 35,000


Us vaccination experience1
US Vaccination Experience because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 experience2
US Vaccination Experience because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 role
Public Health Role because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 role1
Public Health Role because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • Early Detection

  • Mass Patient Care

  • Mass Immunization/Prophylaxis

  • Epidemiologic investigation

  • Communication

  • Command and Control


Public health role2
Public Health Role because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • Mass Fatality Management

  • Evacuations/sheltering (humans and animals)

  • Environmental Surety

  • Community Recovery (rapid health risk assessment, mental health etc)


Public health role3
Public Health Role because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • ‘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 actions
Public Health Actions because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 Management System because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Chair, Board of Health

 Medical Officer of Health Senior Management Team

Public Health Incident Manager

Public Information

Liaison

Operations

Planning

Logistics

Administration

Claims/

Compensation

Mass Vaccination/Post Exposure Prophylaxis

Situation Assessment

Facilities

Staffing & Resource Needs

Human Resources

Hotline Operation

Costing

Reception Centre/Mass Care

Procurement

Resource Deployment

Communications Equipment

Miscellaneous Supplies

Case Management/Contact Tracing

Documentation

Environmental Inspection/ Sampling

Demobilization & Recovery

Nutrition/staff accommodation

Epidemiological Investigations

Recovery


The suspicious package
THE SUSPICIOUS PACKAGE because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 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 usa
Anthrax in the USA because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

  • 4 known letters

  • 11 cases of inhalational anthrax

  • 11 cases of cutaneous anthrax

  • 5 deaths from inhalational anthrax


The suspicious package1
The Suspicious Package because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact


The suspicious package2
The Suspicious Package because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact


The suspicious package3
The Suspicious Package because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Key Messages:

  • Stay calm

  • Remember, there is danger but there is time

  • Leave the package or letter but don't leave the scene


Impact on the public
Impact on the public because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact



Public health response
Public Health Response Events

  • 24 hour first responder hotline

  • Coordination with laboratory

  • Developing protocols with police, fire, EMS

  • Links with other Health Units, provinces, Health Canada

  • Info to businesses, hospitals, local physicians, consulates, the public…..


Triage of suspicious envelopes packages
Triage of Suspicious Envelopes/Packages* Events

  • 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 lab
Testing in the Public Health Lab Events

  • 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 lab1
Testing in the Public Health Lab Events

  • 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 lab2
Testing in the Public Health Lab Events

  • 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 results
Reporting Results Events

  • 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


Summary
Summary Events

  • 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


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