The Anatomy of Bioterrorism: A Glance at the Abyss: The Anatomy of Bioterrorism: A Glance at the Abyss Patrick F. Luedtke MD, MPH Deputy State Epidemiologist Utah Department of Health


Objectives:: Objectives: Learn the recent history of massive disease outbreaks in humans tied to biological agents in water, food and air Understand the epidemiology of bioterrorism as it applies to disease outbreaks in human populations.


Objectives II:: Objectives II: 3. Understand the importance of primary and secondary disease surveillance systems in a “BT world.” 4. Be able to critically appraise the bioterrorism preparations of your facility.


What I Will Cover:: What I Will Cover: What I think we know… Why I think we know it… What I think it means… What I feel we should do… And just a little “What I think we don’t know…”


Characteristics of BT Outbreaks: What I think we know…: Characteristics of BT Outbreaks: What I think we know… 1. Variable incubation periods for a given agent: no single “lights & sirens” response 2. Critical issue of “the epidemic curve” (point, propagated, continual source outbreaks)---import of communicability! Specific disease needs are indeed specific! The “Big 8”---6 Category A agents plus SARS & Influenza


Why I Think We Know It…: Why I Think We Know It… Water---Milwaukee, March-April 1993 Air---Las Vegas exercise (anthrax, SARS) Food---Schwan’s ice cream 1994 Agricultural---Monkeypox spring 2003 (Economic: the FMD prototype?)


What I Think It Means: Water: What I Think It Means: Water 1. Milwaukee: ---delayed presentation/variable incubation ---importance of surveillance systems, including novel systems ---lack of “lights & sirens” response need ---point source BT outbreaks may be massive


Cryptosporidiosis in Milwaukee:: Cryptosporidiosis in Milwaukee: Cryptosporidium Intracellular, protozoan parasite, described 1907 Cause of human diarrhea 1976 Increased importance with onset of HIV/AIDS led to improved diagnostics and recognition as common pathogen ~ 3-4,000 reported cases in U.S./yr (40 states) Jan-Feb, 1987 – Carroll Co., Ga Outbreak of cryptosporidiosis – est. 13,000 cases Contamination of “adequately” treated public water supply Hayes, et. al. NEJM 1989;320:1372-6


Cryptosporidiosis in Milwaukee: Cryptosporidiosis in Milwaukee April 5, 1993 – citywide shortage of antidiarrheal agents, increased absenteeism among hospital employees, students, and school teachers, shortages of bacterial enteric culture media April 7 – two laboratories identified cryptosporidium oocysts in stool of 7 adults Estimated 403,000 cases of watery diarrhea 4,400 hospitalized


Cryptosporidiosis-Milwaukee, Mar-Apr 1993Retrospective identification by telephone survey: 1st laboratory ID (April 7) Outbreak ID (April 5) Cryptosporidiosis-Milwaukee, Mar-Apr 1993 Retrospective identification by telephone survey NEJM 1994;331:161-167


Onset Dates of Human West Nile Virus Cases, Colorado, 2003: Onset Dates of Human West Nile Virus Cases, Colorado, 2003 N=2944 + bird + mosquito + horse + chicken


Epi Curve 8/6/2004: Salmonella: Epi Curve 8/6/2004: Salmonella


What I Think It Means: Air Determined Promise ’03: What I Think It Means: Air Determined Promise ’03 Las Vegas, August 2003 ---Several liters of plague slurry released on “The Strip” on a Friday night ---First cases present 36 hours later ---640 Saturday flights in Las Vegas airport (all over US and 6 other countries) ---Simultaneous presentations throughout US! (Dr. Thompson’s quote---NORTHCOM)


What I Think It Means: Air: What I Think It Means: Air 2. Florida, anthrax/International, SARS: ---delayed identification may be deadly ---importance of clinician education ---“tiered” surge capacity: the need for “pre-event” hospital designations ---propagated source outbreaks of BT agents require “new thinking”


Anthrax, September-October 2001The Astute Clinician: Anthrax, September-October 2001 The Astute Clinician Photo editor hospitalized in Florida, with N & V, fever, incoherent, 3 days after trip to North Carolina CSF exam – gram positive rods Dr. Larry Bush diagnoses anthrax, contacts public health triggering investigation and recognition of anthrax attack 22 cases, 5 deaths Patients with unrecognized cutaneous anthrax were being treated in NY at that time


Anthrax: Potential Lethality: Anthrax: Potential Lethality “…between 130,000 and 3 million deaths could follow aerosolized release of 100 kg of anthrax spores upwind of Washington, DC area – lethality matching or exceeding that of a hydrogen bomb” Inglesby, et al. Anthrax as a biological weapon. JAMA 1999;281:1735-45.


Anthrax – Large scale aerosolized attackKey concepts for surveillance: Anthrax – Large scale aerosolized attack Key concepts for surveillance First sign - patients presenting with non-specific “influenza-like” illness Early recognition critical – treatment effective if given early, before classic clinical picture present If a large release were to happen: By the time the 1st astute clinician makes a diagnosis, many or most patients will be past the point where treatment is effective


SARS: Prototype of the Unknown?: SARS: Prototype of the Unknown? Feb. 20-25: 23 yo female at Hong Kong hotel Mar. 1 - Admitted Tan Tock Seng Hospital, Singapore Clinically – pneumonia, microbiologic tests negative Treated with antibiotics and began to improve at day 9


SARS Epidemic Curve Tan Tock Seng Hospital, Singapore Feb-Mar 2003: SARS Epidemic Curve Tan Tock Seng Hospital, Singapore Feb-Mar 2003 Hsu L-Y, et. Al., Emerging Infectious Diseases 9:713;2003 http://www.cdc.gov/ncidod/EID/vol9no6/03-0264.htm


SARS Chains of transmissionSingapore: SARS Chains of transmission Singapore CDC. Severe Acute Respiratory Syndrome-Singapore, 2003 MMWR May 9, 2003 / 52(18);405-411


Effect of Travel and Missed Cases on SARS EpidemicSpread from Hotel M, Hong Kong: Effect of Travel and Missed Cases on SARS Epidemic Spread from Hotel M, Hong Kong MMWR 2003;52:241-47


SARS – Emerging infection: SARS – Emerging infection Emergence from animal reservoir Potential for recurrence seems real High case fatality rate, no treatment, no vaccine Impact – human, health care, economic Rapid global spread facilitated by: Missed cases International travel Amplification in health care settings Control difficult once established


SARS Chronology (from Utah perspective): SARS Chronology (from Utah perspective) Nov. 16 – atypical pneumonia, Guangdong Province, China Feb. 11 – WHO notified, 305 cases, 5 deaths, Guangdong Feb. 21 – physician from Guangdong checked into Hong Kong hotel At least 12 guests and visitors infected Feb 26 – Mar 5 - hotel contacts hospitalized and triggered outbreaks in Singapore, Hong Kong, Hanoi, and Toronto March 8– an individual later arrived in Utah after travel in Hong Kong with respiratory illness Not hospitalized until after March 15 Subsequently laboratory confirmed SARS March 12th, 15th – WHO  SARS worldwide health threat


SARSKey facts for Surveillance: SARS Key facts for Surveillance Rapid detection needed to prevent spread Clinically nonspecific presentation Especially difficult with background of respiratory illness Laboratory testing helpful, but no test can reliably detect or exclude diagnosis early in course Knowing the risk of exposure is key to diagnosis Interaction between public health and clinicians key to recognition and control if it reemerges


What I Think It Means: Food: What I Think It Means: Food 3. Minnesota ice cream (or Costco almonds): ---delayed discovery is the rule ---importance of surveillance systems ---low level, widely spread geographic events are “under our current radar” ---low level continual source outbreaks may be massive


National outbreak of SE from ice cream – (continued): National outbreak of SE from ice cream – (continued) Survey of Schwan’s customers estimated 29,100 cases in MN (vs. 150 detected) 224,000 cases in U.S. (vs. 593 detected) During peak outbreak months (Sept-Oct) 3,299 cases SE nationwide (71% increase) Outbreak-associated cases (593) found in 41 states


Outbreak-associated confirmed Salmonella enteritidis cases, Minnesota, Sept-Oct 1994 NEJM 1996;334:1281-6: Outbreak-associated confirmed Salmonella enteritidis cases, Minnesota, Sept-Oct 1994 NEJM 1996;334:1281-6 Announcement of results October 7 Recall October 9


Surveillance:Salmonella, Ice Cream and Minnesota: Surveillance: Salmonella, Ice Cream and Minnesota Massive outbreak – widely distributed product Difficult to detect widely distributed cases due to low level exposure above background risk Surveillance is insensitive (cases vs. estimated disease) Detected due to a cluster in one (lucky/good) state Increased exposure to product Increased testing in that region A very active surveillance and laboratory testing program


What I Think It Means: EcoBT: What I Think It Means: EcoBT Monkeypox/Foot & Mouth Disease: ---a single event may have unpredictable repercussions (ie, flight from Gambia) ---vectors are everywhere ---BT can equal economic terrorism ---the real concern is often long after the exposure


Monkeypox outbreak 2003: Monkeypox outbreak 2003 Monkeypox rare viral disease, usually West and Central Africa (African squirrels, rats, mice, rabbits) Clinically similar to smallpox, but usually milder, much less person-to-person transmission Outbreak May-June 2003 72 cases (37 lab-confirmed) in 6 states Traced to exposure to prairie dogs that were caged with exotic African animals (pets)


Gambian giant-pouched rat: Gambian giant-pouched rat


Monkeypox:Risk of importation of zoonotic disease: Monkeypox: Risk of importation of zoonotic disease Monkeypox – imported 2003 Rapid detection by alert clinicians Rapid public health response involving human, animal health agencies at local, state, federal levels Probably prevented establishment of new disease in this hemisphere


What’s Next: EcoBT: What’s Next: EcoBT Implications of Foot and Mouth Disease: ---100 million cattle in US ---40 million pigs No FMD in US since 1929!!! Recent experience of countries with FMD outbreaks: UK 2001


I’m sure you’ll agree – cartoon: I’m sure you’ll agree – cartoon


What BT (probably) won’t look like:: What BT (probably) won’t look like: A single, discrete event (i.e., tornado, earthquake, plane crash) A uniform disease (e.g., anthrax has three clearly defined clinical presentations; tularemia has six!) A clear attack on a defined entity


What should we do? Be alert for:: What should we do? Be alert for: Groups of persons becoming ill around the same time Sudden increase of illness in previously healthy persons Sudden increase of the following non-specific illnesses: a.) Pneumonia, flu-like illness, fever with atypical features


What should we do? Be alert for:: What should we do? Be alert for: b.) Bleeding disorders c.) Unexplained rashes and mucosal or skin irritation d.) Neuromuscular illness such as muscle weakness and paralysis e.) Diarrhea Simultaneous outbreaks in humans and animals populations Temporal/geographic clustering


What I Think We Don’t Know…: What I Think We Don’t Know… The role of emergent, massive triage in BT events: exposure verses symptomatic The importance of surge capacity in BT events that evolve over long periods The proper construction of surveillance systems to “catch” BT outbreaks


WINSTON CHURCHILL: WINSTON CHURCHILL “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”


The “Big 8”:: The “Big 8”: 1. The six category A agents 2. SARS 3. Pandemic Influenza


What We Feel We Should Do:: What We Feel We Should Do: The critical need, “pre-event,” to designate hospitals as the “sick” hospital and the “less sick” hospital The need to staff a committee empowered to address the above (Members?: UHA, UMA, UDOH, LHOA, DES/Governor, IHC, U of U,…) as well as the “pre-event, event and post-event” $$$ repercussions


What We Feel We Should Do: II: What We Feel We Should Do: II 3. The critical need, “pre-event” to designate triage areas to interrupt dz transmission A need to draft triage guidelines for the “Big 8” A need to address “flex” guidelines for varying case levels (eg, 10, 100, 1000) A need to draft possible timeline guidelines for the “Big 8”