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

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Preparing for and Responding to Bioterrorism
Information for the Public Health Workforce
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Acknowledgements
This presentation, and the accompanying
instructors 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 instructors
guide.
Patrick OCarroll, 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
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Health Surveillance and Epidemiologic
Investigation
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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

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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 healths participation in the LRN

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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
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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

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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

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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...
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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

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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

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A CDC-funded Project
Syndromic Surveillance 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

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Aberration Detection
Syndromic Surveillance Project

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

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Hospital Emergency Department and Primary Care
Clinic Discharge Data
Syndromic Surveillance Project

• 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

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Seattle Emergency Medical Services Calls (911)
Syndromic Surveillance Project

• The number and type of triage protocols are
  monitored during each 24-hour period
• Analyze using CDC Aberration Detection Software

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Syndromic Surveillance Project
911 Triage Protocols

• Headache
• CVA/Stroke
• DOA
• Chest Discomfort
• Dizzy/Fainting

• Abdominal Pain
• Sick Unknown
• Breathing Problems
• Person Down
• Convulsions/Seizures

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Syndromic Surveillance Project
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

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Enhanced Surveillance Activities
Syndromic Surveillance Project

• Number and type of calls from Hospital-Based
  Consulting Nurse Hotlines
• Year-Round Influenza Surveillance

Infectious Disease Surveillance Systems
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Active Surveillance for School Absenteeism During
Influenza Season
Syndromic Surveillance Project

• Ten schools participated in 2000
• Schools receive weekly reminders to report when
  absenteeism exceeds 10

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Consulting Nurse Hotlines
Syndromic Surveillance Project

• 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

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Year Round Influenza Surveillance
Syndromic Surveillance Project

• King County Lab participates in CDCs 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

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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

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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

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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
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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

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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
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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
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Laboratory Diagnosis of Category A Agents
Protocols 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
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Laboratory Diagnosis of Category A Agents
Resources 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
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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.

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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.

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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 20029105-115