Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

1. Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

2. Acknowledgements This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for the purpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention Judith Yarrow Design and Editing Health Policy and Analysis; University of WA Washington State Department of Health Jeff Duchin, MD Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization Section Public Health - Seattle and King County Ed Walker, MD; University of WA Department of Psychiatry

3. Health Surveillance and Epidemiologic Investigation

4. Health Surveillance and Epidemiologic InvestigationLearning Objectives • Describe the basic steps in communicable disease case and outbreak investigations • Define “syndromic surveillance” and describe how it can be used to identify disease outbreaks • Identify potential sources of information for syndromic surveillance systems

5. Health Surveillance and Epidemiologic InvestigationLearning Objectives • Describe the Laboratory Response Network (LRN) • Define and describe its purpose and function in BT response • Identify resources available through the LRN for public health • Describe public health’s participation in the LRN

6. Disease Surveillance and InvestigationLegal Basis in Washington • RCW 70.05.070 gives the local health officer power to “take such measures as he or she deems necessary in order to promote the public health.” • RCW 70.05.090 requires physicians to report contagious diseases. • RCW 68.50.010 requires medical examiners to report deaths from contagious diseases. Notifiable conditions in WA

7. Disease Surveillance and InvestigationLegal Basis in Washington • WAC 246-101 specifies contagious disease reporting for health care providers, hospitals, laboratories, and local health jurisdictions: • Lists of notifiable conditions • Time frame for reporting • Responsibilities for disease control

8. Disease Surveillance and InvestigationLegal Basis in WA • Effective September 2000, the following are immediately reportable to the local health jurisdiction • All suspected illnesses caused by potential bioterrorism agents • Unexplained critical illness or death • Rare diseases of public health importance

9. Recognition of a BT Event Surveillance/Detection • Detect unusual medical events sooner rather than later • Depends on ability to identify a greater than expected number of “cases” or syndromes More on public health surveillance... 9

10. Syndromic Surveillance • Sensitivity to unusual clusters of disease syndromes compatible with naturally occurring or BT-related outbreaks • Influenza-like illness • Invasive bacterial disease • Encephalitis/meningitis • Unexplained critical illness or death • Rash illnesses

11. Syndromic Surveillance • Potential information sources • Primary care clinic visits • Emergency room visits • Calls to poison control centers • Pharmacy visits/requests • Nurse hotline calls • 911 calls

12. SyndromicSurveillanceProject A CDC-funded Project • Syndromic surveillance began in 1999 in King County • Traditional Public Health surveillance depends on labs and doctors reporting confirmed diseases (usually laboratory confirmed) • Syndromic surveillance identifies disease syndromes prior to confirmation • Goal is to identify an increase in disease syndromes, not confirmed case reports

13. SyndromicSurveillanceProject Aberration Detection • Hospital Emergency Department Discharge Data • Primary Care Clinic Discharge Data • Seattle Emergency Medical Services Calls (911) • Medical Examiner (ME) - Unexplained Deaths

14. SyndromicSurveillanceProject Hospital Emergency Department and Primary Care Clinic Discharge Data • Data extracted from clinical discharge diagnosis databases at three hospitals and nine primary care clinics • Transmitted electronically to PHSKC • Analyzed using CDC aberration detection program

15. SyndromicSurveillanceProject Seattle Emergency Medical Services Calls (911) • The number and type of triage protocols are monitored during each 24-hour period • Analyze using CDC Aberration Detection Software

16. Abdominal Pain Sick Unknown Breathing Problems Person Down Convulsions/Seizures Headache CVA/Stroke DOA Chest Discomfort Dizzy/Fainting SyndromicSurveillanceProject 911 Triage Protocols

17. SyndromicSurveillanceProject Medical Examiner (ME) Unexplained Death Surveillance • Data source: Daily Log from the King County ME • Definition: Unexplained death in a previously healthy person aged 1-49 years with hallmarks of infectious disease • Daily Log is reviewed daily for deaths meeting the definition of unexplained death

18. SyndromicSurveillanceProject Enhanced Surveillance Activities • Number and type of calls from Hospital-Based Consulting Nurse Hotlines • Year-Round Influenza Surveillance Infectious Disease Surveillance Systems

19. SyndromicSurveillanceProject Active Surveillance for School Absenteeism During Influenza Season • Ten schools participated in 2000 • Schools receive weekly reminders to report when absenteeism exceeds 10%

20. SyndromicSurveillanceProject Consulting Nurse Hotlines • Two hospital-based Consulting Nurse Hotlines participate • Total Calls and the proportion of calls for symptoms of influenza-like illness (ILI) are monitored: • Flu • Sore Throat • Colds • Fever • Cough

21. SyndromicSurveillanceProject Year Round Influenza Surveillance • King County Lab participates in CDC’s National Respiratory and Enteric Virus Surveillance System • 12 primary care providers submit specimens year-round from persons with ILI • Providers receive periodic e-mail reminders to submit specimens from persons with ILI

22. Outbreak InvestigationBasic Steps • Establish the existence of an outbreak • Verify the diagnosis • Develop a case definition (confirmed, probable, possible) • Identify cases • Characterize the outbreak (person, place, time) • Develop and test hypotheses

23. Outbreak InvestigationAdditional Steps • Determining appropriate containment strategies • Evaluation of expected and unexpected epi features of the outbreak • Identifying the population at risk • Prophylaxis (immunization/antibiotics) for exposed, isolation and/or quarantine for suspected/confirmed cases • Depends on disease and outbreak characteristics • Health officer and/or medical epi decision • If person-to-person transmission • Contact tracing and identification

24. Post-BT Event Surveillance • Active surveillance for suspected, confirmed, probable cases • Follow-up on case outcomes • Surveillance for vaccine and antibiotic-related adverse events VAERS - The Vaccine Adverse Event Reporting System

25. Laboratory Response Network • Multilevel network of local, state, and federal laboratories • Laboratories identified by increasing level of sophistication (A – D) • Facilitates sample collection, transport, testing, and training for laboratory readiness for bioterrorism

26. Laboratory Response Network For Bioterrorism D - Highest level characterization (Federal) Level D Lab BSL-4 C - Molecular assays, reference capacity Level C Lab BSL-3 B - Limited confirmation and transport Level B Lab BSL-2 facility + BSL-3 Safety Practices A - Rule-out and forward organisms Level-A Lab Use Class II Biosafety Cabinet

27. Laboratory Diagnosis of Category A Agents Required Bio-safety* Levels *BSL 2/3 - State and some local public health labs BSL 4 - CDC and USAMRIID

28. Laboratory Diagnosis of Category A AgentsProtocols for Testing and Referral • Level A protocols available at: • Level B/C protocols available through password-protected Web site for LRN-registered members http://www.bt.cdc.gov/LabIssues/index.asp

29. Laboratory Diagnosis of Category A AgentsResources for Testing and Referral • LRN members can • Search for nearest equal or higher-level lab via password-protected Website • Order reagents for B/C testing through password-protected Website • Specimen packaging and transport • General information available at: • Specific information available from public health laboratory http://www.bt.cdc.gov/LabIssues/PackagingInfo.pdf

30. Summary of Key Points • Early detection of a bioterrorism event requires sensitivity to unusual clusters of disease syndromes, in addition to traditional disease reporting. • Syndromic surveillance systems integrate data from a variety of sources and alert public health officials to potential outbreaks, prior to the establishment of a diagnosis.

31. Summary of Key Points • The investigation of any disease outbreak follows several basic steps. • Post-event surveillance includes systems to monitor for the development of new cases, case outcomes, and adverse events related to treatment and prophylaxis. • The Laboratory Response Network is a system of local, state, and federal laboratories identified by increasing levels of proficiency to respond to bioterrorism.

32. Resources • Centers for Disease Control and Prevention • Bioterrorism Web site • Epidemiology Program Office • Council for State and Territorial Epidemiologists • Roundtable on bioterrorism detection – summary of several syndromic surveillance systems in development http://www.bt.cdc.gov/ http://www.cdc.gov/epo/index.htm http://www.cste.org/ JAIMIA 2002;9:105-115