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Epidemiology in Times of Bioterrorism Partnerships for Preparedness AAVMC/AASPH Joint Symposium April 22-24, Atlanta, GA By 1 Sasanya, JJ and 2 Khaitsa, ML 1 Great Plains Institute of Food Safety 2 Dept. of Veterinary & Microbiological Sciences North Dakota State University. Introduction.

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Epidemiology in Times of BioterrorismPartnerships for PreparednessAAVMC/AASPH Joint SymposiumApril 22-24, Atlanta, GABy1Sasanya, JJ and 2Khaitsa, ML1Great Plains Institute of Food Safety2Dept. of Veterinary & Microbiological SciencesNorth Dakota State University

  • What is Bioterrorism?
    • Deliberate release of viruses/bacteria/other germs to cause death in people/animals/plants (CDC, 2006)
    • Deliberate contamination of human food with chemical/biological/radionuclear agents = injury/death to civilian populations and/or disrupt social, economic or political stability (Khan et al. 2001)
  • The threat of biological terrorism depends on:
    • Availability of weaponizable agents
    • Production costs
    • Willing users
  • What are the agents of concern?

categories of agents cdc
Categories of Agents - CDC

A=High priority agents = highest risk to public/national security: Bacillus anthracis, Yersinia pestis, Variola virus,Filoviruses and Clostridial species

B= Second highest priority:

Salmonella, Escherichia, Brucella, etc

Moderate ease of spread; illness/low death rates

Specific enhancements of laboratory capacity; enhanced disease monitoring

C= Third highest: Emerging pathogens + genetic engineering for mass spread

Ease of access, production, spread; potential for high morbidity/mortality; major health impact

examples of diseases caused by agents
Ebola case in

Intensive care

Examples of diseases caused by agents

Smallpox photo

World Health Organization

Pneumonic Plague


Close-up of anthrax pustule

Inhalation anthrax CDC

bioterrorism preparedness and response
Anthrax attacks of 2001

in the US

Bioterrorism is a reality

Challenged preparedness understanding biothreat agents.

To remain unprepared is disastrous(Henderson, 1999)


Epidemiology is essential

Bioterrorism Preparedness and Response

broader role of epidemiology in public health
Broader Role of Epidemiology in Public Health
  • Determining disease origin/known cause
  • Investigate/control disease = known cause/poorly understood
  • Information on ecology/natural history
  • Planning/monitoring disease control programs
  • Assess economic benefits; benefits of alternative
epidemiology in times of bioterrorism
Epidemiology in Times of Bioterrorism
  • Disease outbreak Investigation
    • Epidemiologic Clues
  • Surveillance
  • Epidemiologic Modelling (Simulations)
  • Management of outbreaks
  • Research & Policy
    • Categorizing/evaluate list of bioterrorist agents; matters
    • Generating reference documents, Bioterrorism Readiness Plan(English et al, 1999).

Disease Outbreak Investigation

Epidemiologic Clues: (Wheelis, 2000; Treadwell et al. 2003)

  • Epidemic curve; Incubation periods (cause/mode)
    • Steepness; Bimodal curve two continued exposure(anthrax attack)
    • Several simultaneous point sources(Salad bar/Salmonella)
  • Odd patterns/organisms
    • Unusual/atypical illness: Adult measles-like/chicken pox; community based smallpox
    • Unusual temporal/geographic pattern:Summer influenza
    • Unusual strains/variants; antimicrobial resistance patterns
odd patterns organisms
Odd patterns/organisms
  • Naturally not transmissible without natural vector (Unnatural phenomena) pneumonic plague
  • Zoonoses/exotic disease outbreaks (e.g. pneumonic plague, hemorrhagic fevers) (Ashford et al. 2003; Lathrope and Mann, 2001)
  • Large epidemics with greater cases than expected (discrete population) (Bellamy and Freedman, 2001)
  • Multiple simultaneous epidemics of different diseases (Pavlin, 1999)
  • Unusual severity; route of exposure
epidemiologic clues significance
Epidemiologic clues: Significance
  • Combining clues facilitates early/further/rapid investigation, early implementation of control measures
  • Giving clues about source also supports the entire public health system; public
    • mitigate/ameliorate consequences of attack; Minimize resources; Avoids panic/paralysis of services
    • Builds credibility; Strengthen intelligence
disease outbreak investigation
Disease Outbreak Investigation
  • Molecular epidemiology: geographic origin; relatedness of outbreaks (natural vs genetic modification)
  • Field epidemiology: Timely response (IBS, 2004; CDC, 2001; Gregg, 2002)
  • Understand possible risk factors, vehicles, and agents for bioterrorism(Treadwell, 2003).

Survey team collecting blood, 1976-Congo


  • Traditional surveillance
    • Background rates of disease (Eitzen, 1997). Use/study of secular trends: Mortality/morbidity; project disease occurrence(Friis and Sellars, 2004).
    • Laboratory confirmation
  • Syndromic surveillance real time or Near-real time
    • Timeliness, High sensitivity and specificity, (Bravata et al, 2004)
    • Identifying isolated cases (Manhattan hospital employee) (O’Toole, 1999; Bardi et al, 1999); unexpected (cross contamination)
examples of surveillance systems
Examples of surveillance systems
  • Real-time Outbreak Detection System (RODS)
  • Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE)
  • Generalized linear mixed models (GLMM) Clustered attacks (small areas) (Kleinmann et al. 2004)
  • Lightweight Epidemiology Advanced Detection and Emergency Response System (LEADERS), The “drop-in, World Trade Organization Summit, 1999
        • Integrated System of Bio-hazard Surveillance and Detection
simulations epidemic models
Simulations/Epidemic models
  • Limited attacks/data; understand the threat(Mandl et al, 2004)
  • Useful in planning public health responses;
    • Reveal hidden risks of public health decisions
  • Emphasize the importance of early detection for rapid response/intervention (Meltzer et al, 2001)
examples simulations epidemic models
Examples Simulations/Epidemic models
  • Anthrax: Aerial attack 5 pounds spores, metropolitan area; 62,000 deaths/50%(IBS, 2004)

Aerosal anthrax, packed football stadium (74,000), passing truck 1 mile, 3 seconds, affect 1,850 audience and 1/8 of neighborhood

  • Smallpox:10 infected people; infect 2.2 million/9 months; 774 billion/ year(Modelling infectivity) (IBS, 2004)
  • “Dark Winter”, governments’ reaction: smallpox attack > 16,000 cases, 25 states,10 countries,1,000 deaths(Modelling reaction)
  • Plague: 4 days of first case, 3,000 deaths, 15,000 ill with plague-like symptoms (O’Toole and Inglesby, 2001)
  • Modelling readiness response, multiple geographic locations); “Toppoff”, Yesinia pestis(Inglesby et al, 2001)
  • Botulism: A model of cows-to-consumer supply chain; Several hundred thousand poisoned individuals if early detection is not timely (Weis and Liu e t al, 2005)

Gangrene and plague

Toppoff demo

management of cases attacks
Management of contagious diseases

Identify cases; Isolation (Vaccination); Quarantine; Response/Recovery (2º)

Coordination = command/control structures

Incident Command System (manage scene) /Unified Command (integrate resources)(CDC, 2001)

Liaise with response partners; complex(Koplan, 2001; CDC, 2001)

Management of cases/attacks (CDC/Lloyd); Red Cross, disinfecting body, Kikwit, DR Congo, 1995)

management communication and awareness watching the media storm public out rage
Management: Communication and awareness(Watching the media storm/public out rage)
  • Inform/educate public about realities of bioterrorism
  • Prepare to communicate(Lathrope and Mann, 2001)
  • “Evidence-based” communication style vs “adaptive-style” for fast moving emergencies
  • “We’ll tell you what we know today, and acknowledge that it may change by tomorrow”

Gerberding (2001)

communication and awareness
Communication and awareness
  • With and educating policy makers
  • Networks health workers/support personnel(Jernigan, 2002).
  • Health Alert Network (HAN)
  • Epidemic Information Exchange program (Epi-X)
  • Early Aberration Reporting System (EARS)
research policy matters
Research & Policy matters
  • 44% potential bioterrorist agents; 41% unknown causes globally(Ashford, et al. 2003)
  • Uncover unknown etiology of disease outbreaks (Legionnaire-philadelphia; Hanta virus-4 corners, NM)
  • Categorizing/evaluate list of bioterrorist agents
  • Evaluation/provision of guidelines to prioritize potential bioterrorist investigations
  • Determine etiology of deliberate attacks (Zilinskas, 2002)
  • Developing documents, Bioterrorism Readiness Plan
epidemiology s role at global level
Epidemiology’s role at global level
  • Global impact of 2001 anthrax attacks(WHO, 2004)
    • Spread during incubation periods; Collaborative disease surveillance and early warning systems in all countries
  • Global Infectious Diseases and Epidemiology Network(GIDEON)
    • Epidemiology module, every possible differential diagnoses known infectious disease in the world(Felitti, 2005).
  • Preparedness for Deliberate Epidemics (PDE)Support/advise WHO member states
  • International Health Regulations (IHR) 2005
global perspective
Global perspective

Global distribution of anthrax

global perspective23
Global perspective
  • Training/and networking: Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET)
  • Applied epidemiology and training programs (AETP)…Ebola 2000 -2001

EIS investigation sites

  • Indispensable contribution of epidemiology: Ensuring public health and security; social/economic stability
    • Leadership (Local/International)
        • Disease investigations
        • Collaboration
        • Policy/decision
        • Unforeseeable: Giving hope/confidence in a dark era
acknowledgment thanks
  • Dr. Margaret Khaitsa
  • Dr. Douglas Freeman
  • Great Plains Institute of Food Safety, NDSU
  • Atlas, RM. Bioterrorism: From Threat to Reality. Annual Review of Microbiology. 2002, 56: 167-185.
  • Centers for Disease Control and Prevention. 2006. Bioterrorism Overview. Last updated 02/26/06.
  • Felitti VJ. Global Infectious Disease and Epidemiology Network. JAMA, 2005; 293: 1674-1675.
  • Henderson DA, Smallpox: Clinical and Epidemiologic Futures. Emerg Infec Dis. 1999; 5 (4): 537-539.
  • Jernigan DB, Raghunatahn Pl, Bell BP, Brechner R, Bresnitz EA, Buler JC, et al. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Emerg Infec Dis. 2002; 8: 1019-1025.
  • Khan AS, Levitt AM, Sage MJ et al. Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workshop. MMWR 2001; April 21, 2000/49 (RR04);1-14.
  • Koplan J, CDC’s Strategic Plan for Bioterrorism Preparedness and Response. Public Health Reports / 2001 Supplement 2 / 116; 9-16.
  • Lathrope P, and Mann LM. Preparing for Bioterrorism.Proc (Bayl Univ Med Cent). 2001 July; 14:219-223.
  • O’Toole T and Inglesby TV. Epidemic response scenario: decision making in a time of plaque. Public Health Rep. 2001; 116 (supplement 2):92-103.
  • Perkins BA, Popovic T and Yesky K. Public Health in the Time of Bioterrorism. Emerg Infec Dis. 2002; 8: 1015-1018.
  • Scafer, K, 2001. “LEADERS” (Lightweight Epidemiology Advanced Detection and Emergency Response System)” [online]. Accessed 04/22/07
  • Treadwell TA, Koo D, Kuker K and Khan AS. Epidemiologic Clues to Bioterrorism. Public Health Reports/ March-April 2003; 118: 92-98.
  • Wheelis M, Investigating Disease Outbreaks under a Protocol to the Biological and Toxin Weapon Convention. Emerg Infect Dis. 2000; 6: 595-600.
  • Zilinska RA. Biological Attacks: Lessons of September and October 2001. Chemical and Biological Weapons Nonproliferation Program, Center for Nonproliferation Studies Monterey Institute of International Studies. December 12, 2002