Public Health Issues

1. Public Health Issues David S. Perlin, Ph.D. Public Health Research Institute at the International Center for Public Health Newark, NJ 07103 perlin@phri.org

3. October 2001 Anthrax OutbreakWhat went wrong? • Lead agency was unclear • Federal authorities appeared confused • Sloppy scientific thinking underestimated spore threat through mail system • First responders were inadequately trained for hazard • Public health Labs were poorly prepared to receive pathogens, provide timely diagnostics, or perform high volume sample evaluations • Federal and state priorities were unclear, and often conflicted. • Physicians were uneducated about disease • So-called “textbook” knowledge was often misleading or incomplete • Decontamination was difficult

4. Essential Elements of a Public Health Strategy Threat Assessment Preparedness Response

5. Potential Bioterrorism Agents • Bacterial Agents • Anthrax • Brucellosis • Cholera • Plague, Pneumonic • Tularemia • Q Fever Source: U.S. A.M.R.I.I.D. • Viruses • Smallpox • VEE • VHF • Biological Toxins • Botulinum • Staph Entero-B • Ricin • T-2 Mycotoxins

6. Deliberate v. Naturally-Occurring Outbreak Does it matter?

7. Bioterrorism preparedness should be an extension of our current medical and public health infrastructure.

8. Epidemic Diseases are all around us WHO: Mortality Trends (1997) Infectious and Parasitic 33.1% Circulatory 5 Infectious and Parasitic Diseases 29.3% Other 4 13.2% Deaths, millions 3 Perinatal Cancer 2 6.9% 11.9% 1 Respiratory 5.6% 0 HIV/ AIDS Acute Respiratory TB Malaria Diarrhea

10. Influenza kills more than 35,000 Americans each year The 1918 Spanish Flu pandemic killed over 40 million people worldwide with 450,000 deaths in the USA.

12. Emerging and Re-emerging Diseases

13. West Nile Virus 4156 Cases and 284 Deaths (1/1/03)

14. SARS Coronavirus

15. People are potent vectors of disease

16. PRERAREDNESS and RESPONSE

17. Linking of Response Systems First Responders Fire/EMS Medical & Mental Health Services Law Enforcement Public Health Emergency Management

18. Relationship Between Crisis and Consequence Management The Department of Justice assigns lead responsibility for operational response to the FBI, which operates as the on-scene manager for the Federal Government FEMA is the lead agency for consequence management and can use FRP structures to coordinate all Federal assistance to State and local governments.

19. The National Pharmaceutical Stockpile Program • National Electronic Data Surveillance System (NEDSS) • The Global Outbreak Alert and Response Network • Epidemic Information Exchange (Epi-X) • Laboratory Response Network • Metropolitan Medical Response System (MMRS)

20. Structure of the LRN CDC and USAMRIID. Expertise with unusual organisms. Specimen repository. Level D Federal LabsBSL-4 Rapid identification using molecular methods. Test evaluation. Level C Labs * BSL-3 Isolation and presumptive ID. Antimicrobial susceptibility testing. 24/7 response. Level B Public Health LabsBSL-2 + or 3 Early detection, rule out and refer. *State, research, federal Level A Clinical Labs BSC (Class II-B)

21. Metropolitan Medical Response System (MMRS) An operational system at the local level to respond to a terrorist incident and other public health emergencies that create mass casualties This system enables a Metropolitan Area to manage the event until State or Federal response resources are mobilized MMRS is a locally developed, owned, and operated mass casualty response system

22. Metropolitan Medical Response Systems Original MMRS Boston, New York, Baltimore, Philadelphia, Washington DC, Atlanta, Miami, Memphis, Jacksonville, Detroit, Chicago, Milwaukee, Indianapolis, Columbus, San Antonio, Houston, Dallas, Kansas City, Denver, Phoenix, San Jose, Honolulu, Los Angeles, San Diego, San Francisco, Anchorage, Seattle MMRS 1999 Hampton Roads (Virginia Beach)Area, Pittsburgh, Nashville, Charlotte, Cleveland, El Paso, New Orleans, Austin, Fort Worth, Oklahoma City, Albuquerque, St. Louis, Salt Lake City, Long Beach, Tucson, Oakland, Portland (OR), Twin Cities (Minneapolis), Tulsa, Sacramento MMRS 2000 Twin Cities (St. Paul), Hampton Roads (Norfolk),Cincinnati, Fresno, Omaha, Toledo, Buffalo, Wichita,Santa Ana, Mesa, Aurora , Tampa, Newark, Louisville, Anaheim, Birmingham, Arlington, Las Vegas,Corpus Christi, St. Petersburg, Rochester, Jersey City,Riverside, Lexington-Fayette, Akron MMRS 2001 Colorado Springs, Baton Rouge, Raleigh, Stockton, Richmond (VA), Shreveport, Jackson, Mobile, Des Moines, Lincoln, Madison, Grand Rapids, Yonkers, Hialeah, Montgomery, Lubbock, Greensboro, Dayton, Huntington Beach, Garland, Glendale (CA), Columbus (GA), Spokane, Tacoma, Little Rock MMRS 2002 Bakersfield, Fremont, Ft. Wayne, Hampton Roads (Newport News, Chesapeake), Arlington, Worcester, Knoxville, Modesto, Orlando, San Bernardino, Syracuse, Providence, Huntsville, Amarillo, Springfield, Irving, Chattanooga, Kansas City, Jefferson Parish, Ft. Lauderdale, Glendale, Warren, Hartford, Columbia

23. Strategic use of vaccines

24. Challenges

25. Contagious Outbreaks • Identification of clinical symptoms • Rapid and accurate diagnostics • Accurate reporting and open communication • Willingness to isolate and quarantine all infected populations • Mobilization of scientists to develop vaccines, therapeutics, new diagnostics, and determine the source of the outbreak

26. Drug Resistance what if the organism is drug resistant and we can’t treat? Molecular engineering is easy What would have happened during the anthrax outbreak? What good is the National Pharmaceutical Stockpile in this event? ”

27. Role of Healthcare Professionals • First line of defense. But what if they are early victims of the outbreak (e.g. Toronto)?

28. Hospitals as an amplifier of infection SARS Cases in Toronto

29. What about mass casualties? What would a plume of anthrax spores do in our area? The 1918 Spanish Flu pandemic hospitalized millions of Americans Can we handle the patients? Do we have enough lab capacity?

30. CONCLUSION Bioterrorism preparedness must be an extension of our current medical and public health infrastructure. Our ability to respond effectively to a new outbreak will depend on the robustness of the prevailing system.