Epidemiology in Times of Bioterrorism Partnerships for Preparedness AAVMCAASPH Joint Symposium April

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Epidemiology in Times of BioterrorismPartnership
s 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
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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.htm
l
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Categories of Agents - CDC

• AHigh 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

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Examples of diseases caused by agents

• Ebola case in
• Intensive care

Smallpox photo World Health Organization

http//www.ph.ucla.edu/epi/bioter/hemfevapha_id.ht
ml
Pneumonic Plague CDC
Close-up of anthrax pustule
Inhalation anthrax CDC
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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

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

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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).

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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

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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

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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

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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).

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Surveillance
Survey team collecting blood, 1976-Congo CDC/Conra
d

• 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) (OToole, 1999 Bardi et al, 1999)
  unexpected (cross contamination)

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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

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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)

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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 gt 16,000 cases, 25 states,10
  countries,1,000 deaths (Modelling reaction)

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Simulations

• Plague 4 days of first case, 3,000 deaths,
  15,000 ill with plague-like symptoms (OToole 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
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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)

http//phil.cdc.gov/phil/details.asp (CDC/Lloyd)
Red Cross, disinfecting body, Kikwit, DR Congo,
1995)
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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
• Well tell you what we know today, and
  acknowledge that it may change by tomorrow
• Gerberding (2001)

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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)

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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

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Epidemiologys 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

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Global perspective
Global distribution of anthrax
http//www.vetmed.lsu.edu/whocc/mp_world.htm
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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/abo
ut/s2000.htm
httpwww.who.int/csr/about/partnerships/en
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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

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Acknowledgment/Thanks

• Dr. Margaret Khaitsa
• Dr. Douglas Freeman
• Great Plains Institute of Food Safety, NDSU
• AAVMC/AASPH
• THANK YOU AUDIENCE

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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/biote
  rrorism/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,
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• Khan AS, Levitt AM, Sage MJ et al. Biological and
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• Koplan J, CDCs Strategic Plan for Bioterrorism
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• Lathrope P, and Mann LM. Preparing for
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• Treadwell TA, Koo D, Kuker K and Khan AS.
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• Wheelis M, Investigating Disease Outbreaks under
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