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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

introduction
Introduction
  • 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?

http://www.pbs.org/wgbh/nova/bioterror/about_p.html

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

http://www.ph.ucla.edu/epi/bioter/hemfevapha_id.html

Pneumonic Plague

CDC

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)

Preparedness/response

Epidemiology is essential

Bioterrorism Preparedness and Response

www.pbs.org/newshour/health/images/anthrax/.jpg

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).
slide8

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).
surveillance

Survey team collecting blood, 1976-Congo

CDC/Conrad

Surveillance
  • 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)
simulations
Simulations
  • 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

http://phil.cdc.gov/phil/details.asp (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

http://www.vetmed.lsu.edu/whocc/mp_world.htm

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 http://www.cdc.gov/eis/about/s2000.htm

http:www.who.int/csr/about/partnerships/en

conclusion
Conclusion
  • 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
Acknowledgment/Thanks
  • Dr. Margaret Khaitsa
  • Dr. Douglas Freeman
  • Great Plains Institute of Food Safety, NDSU
  • AAVMC/AASPH
          • THANK YOU AUDIENCE
reference
Reference
  • Atlas, RM. Bioterrorism: From Threat to Reality. Annual Review of Microbiology. 2002, 56: 167-185.
  • Centers for Disease Control and Prevention. 2006. Bioterrorism Overview. http://www.bt.cdc.gov/bioterrorism/pdf/bioterrorism_overview.pdf. 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. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4904a1.htm.
  • 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]. http://www.tricare.osd.mil/conferences/2001/agenda.cfm. 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