Transcript HISTORICAL ASPECTS SMALLPOX

Public health CBRN course
Bioterrorism Preparedness
Bonnie Henry, MD, FRCPC
Goals of session
 To provide a review of bioterrorism agents and
history of BT use (with a focus on anthrax and
smallpox)
 To review potential roles for public health in a BT
incident
 To review principles of laboratory testing of
‘suspicious packages’ and continuity of evidence
Bioterrorism Preparedness
Bioterrorism is the
intentional use of
microorganisms
(bacteria, viruses, and
fungi) or toxins to
produce death or
disease in humans,
animals or plants.
Electron micrograph of
anthrax bacteria
Electron micrograph of
ebola virus
Category A
“Biologic Threat Agents”
•Can be easily disseminated or transmitted person-toperson;
•Cause high mortality, w/potential for major public health
impact;
•Might cause public panic and social disruption; and
•Require special action for public health preparedness.
Biological Agents of Highest Concern
Category A
 Smallpox – variola major
 Anthrax – Bacillus anthracis
 Plague – Yersinia pestis
 Botulism – Clostridium botulinum toxin
 Tularemia – Francisella tularensis
 Viral hemorrhagic fevers – arenaviruses,
filoviruses (Ebola, Marburg, Lassa, Junin)
Category B: Second Highest Priority
 Moderately easy to
disseminate
 Cause moderate
morbidity and low
mortality
 Require specific
enhancements of
diagnostic capacity
and enhanced disease
surveillance
 Coxiella burnetti (Q fever)
 Brucella
 Burkholderia mallei
(glanders)
 Alphaviruses (Venezuelan
encephalomyelitis and
Eastern and Western
equine)
 Rickettsia prowazekii
 Toxins (Ricin, Staph
enterotoxin B)
 Chlamydia psittaci
 Food safety threats
(e.g.Salmonella, Shigella. E.
coli O157:H7)
 Water safety threats (Vibrio
cholerae, Cryptosporidium
parvum)
Category C: Third Highest
Priority
 Pathogens that could
be engineered for
mass destruction
because of
availability, ease of
production and
dissemination and
potential for high
morbidity and
mortality and major
health impact
 Nipah virus
 Hantavirus
 Tickborne
hemorrhagic fever
viruses
 Tickborne
encephalitis viruses
 Yellow fever
 MDR TB
Characteristics of Bioterrorist Agents
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Mainly inhaled - may be ingested or absorbed
Particles may remain suspended for hours
May be released silently with no immediate effect
Person-to-person spread happens for some agents
Long incubation periods mean "first responders” may
be primary health care providers
 Agents may be lethal or incapacitating
 Vaccines & antitoxins exist for some agents
Recent Examples of Bioterrorism
1984: Salad bars contaminated with Salmonella by Rajneeshe cult
members to influence local election in The Dalles, Oregon / 751
people affected (8 salad bars)
1995: Sarin nerve gas release by Aum Shinrikyo in Tokyo subway /
At least 9 failed attempts to use biological weapons
1996: Pastries contaminated with Shigella by disgruntled lab
worker in Dallas
Recent Examples of Bioterrorism
Former Soviet Union’s extensive biological weapons program
thought to have found their way to other nations
Iraq acknowledged producing and weaponizing anthrax and
botulinum toxin
Currently, at least 17 nations believed to have biological weapons
programs
Anthrax: Soviet incident
An accident at a
Soviet military
compound in
Sverdlovsk
(microbiology
facility) in 1979
resulted in an
estimated 66
deaths downwind.
Smallpox
 Variola virus
 Declared eradicated by WHO in 1980
 Civilian vaccination stopped 1972, healthcare
workers stopped in 1977 and CF stopped
1988
 Known stockpiles remain in CDC and Institute
for Viral Preparations, Moscow
 Virus spread by aerosol
 Incubation period: average 12 days (7-19
days)
Last Case, Variola major
Rahmina, 1975
Rahmina Banu, 2001
SMALLPOX RASH EVOLUTION
Day 1
Day 2
Day 3
SMALLPOX RASH EVOLUTION
Day 4
Day 5
Day 7
SMALLPOX RASH EVOLUTION
Days 8-9
Days 10-14
Day 20
Smallpox
 Vaccination
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Within 3 days will likely prevent disease
Within 5 days is life-saving (ameliorates)
Canada has about 320,000 doses
?long term immunity
Cell culture and oral vaccine in research
Research on antivirals also ongoing
(particularly Cidofovir)
DIFFERENTIAL DIAGNOSIS:
VESICULO – PUSTULAR RASHES
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CHICKEN POX
ERYTHEMA MULTIFORME - BULLOUS
COWPOX
MONKEY POX
HERPES ZOSTER (Shingles) - DISSEMINATED
DRUG ERUPTIONS
HAND FOOT AND MOUTH DISEASE
ACNE
IMPETIGO
INSECT BITES
Today’s Perspective in Canada:
Pros vs Cons
 “Moderately”
contagious
 Virus not robust
 No natural reservoir
 Able to vaccinate
 Able to control
 Improved medical
care
 Better pop’n health
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30% mortality
Misdiagnosis
Long incubation
Low level of
“Immunity”
 Pop’n mobility
 Immunocompromised
 Mass panic, hysteria
Smallpox Isolation, Toronto
(1909)
National Smallpox Contingency
Plan (v.4)
 Canada’s ‘search and
contain’ strategy
highlights:
– Early detection, immediate
notification
– Immediate isolation of cases
– Immediate deployment of
smallpox responders
– Immediately vaccinate all
those directly exposed, all
known direct contacts, all
local personnel…
– Intensive contact tracing
– Rapid set up of isolation
facilities
– Rapid set-up of local
Smallpox assessment
centres
 Assumption:
In the absence of
smallpox anywhere in
Canada
A risk of disease and
death from a vaccine,
no matter how small,
may be unacceptable
Especially when preattack vaccination is
considered
VACCINE ADMINISTRATION
VACCINATION: THE RESPONSE
US Vaccination Experience
Plan for ‘first responders” (Phase 1)
Estimated 4 million eligible; expected
500K
Vaccination in teams by Public
Health
Actual uptake: about 35,000
US Vaccination Experience
 Complications:
– US Military: 10 cases myopericarditis/240,000
primary vaccinations; 1 cardiac arrest 5 days
post vaccine
– Civilian: 1case pericarditis, 1 case
myocarditis, 5 cardiac ischemic events (3 MIs,
2 angina), 2 deaths (both cardiac arrest)
– No cases in 110,000 military re-vacinees but
2/5 civilians were re-vacinees
US Vaccination Experience
Stockpile of ~200 million doses of
cell culture vaccine + 15 million calf
lymph vaccine (from 1978,1958)
Threat felt to be diminished post
acute phase of the war in Iraq
Phase 2 practically is on hold
although still not official (almost 4
years later)
Public Health Role
 Health effects of
emergencies recently
highlighted
 In most jurisdictions
the Medical Officer of
Health is part of the
municipal/regional
emergency response
team
 Have a mandated lead
role in events
involving biologic
agents
Public Health Role
Early Detection
Mass Patient Care
Mass Immunization/Prophylaxis
Epidemiologic investigation
Communication
Command and Control
Public Health Role
Mass Fatality Management
Evacuations/sheltering (humans and
animals)
Environmental Surety
Community Recovery (rapid health
risk assessment, mental health etc)
Public Health Role
 ‘Secondary’
responders
 Key role in
communication with
the public for biologic
emergencies
 Can be liaison or link
between healthcare
facilities and first
responders, the
community
 Have legal authority
for many restrictive
actions
Public Health Actions
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Promptly investigate original case
Confirm laboratory results
Identify & interview case contacts as needed
Initiate active surveillance for additional cases
Take immediate public health prevention action as needed
Collaborate/notify MOHLTC, Health Canada as indicated
Alert local medical community/public
Determine need for Rx of contacts/health professionals
 Mobilize needed assets at local, provincial, federal level
 Maintain contact with case family & reporting MD
Public Health Incident Management System
Chair, Board of Health
Medical Officer of Health
Senior Management Team
Public Health
Incident Manager
Public Information
Operations
Mass Vaccination/Post
Exposure Prophylaxis
Liaison
Planning
Logistics
Situation Assessment
Administration
Facilities
Claims/
Compensation
Staffing & Resource Needs
Hotline Operation
Reception Centre/Mass Care
Case Management/Contact
Tracing
Environmental Inspection/
Sampling
Epidemiological Investigations
Recovery
Human Resources
Procurement
Resource Deployment
Communications
Equipment
Documentation
Miscellaneous
Supplies
Demobilization &
Recovery
Costing
Nutrition/staff
accommodation
THE SUSPICIOUS PACKAGE
 May be reported any time or any place
 Since 2001 many examples have been
letters delivered or packages discovered
 This is a law enforcement and public health
responsibility
Anthrax in the USA
4 known letters
11 cases of inhalational anthrax
11 cases of cutaneous anthrax
5 deaths from inhalational anthrax
The Suspicious Package
The Suspicious Package
The Suspicious Package
Key Messages:
Stay calm
Remember, there is danger but there is
time
Leave the package or letter but don't
leave the scene
Impact on the public
Toronto Public Health Case Definitions for Biological Events
Priority
Public Health Response
First Responder Action
Priority 1 (High):
1.Overt threat such as a letter, note or
picture; or
2.Obvious target such as media outlet,
political or religious target or large
corporation
3.Human exposure has occurred (i.e.
package has been opened)
4.A substance is present
On-scene response
Obtain personal decontamination
information
Obtain contact information for those
exposed
Advise CPHL of priority
Advise re environmental
decontamination
Provide counseling to exposed
individuals
Obtain lab results and communicate to
first responders and exposed persons
Call Public Health Immediately
From 8am-8pm: 416 338-0069
After 8pm: 416 527-3461
Priority 2 (medium):
1.Overt threat such as a letter, note or
picture; or
2.Obvious target such as media outlet,
political or religious target or large
corporation
3.No human exposure has occurred
(i.e. package has NOT been opened)
4.A substance is present
Obtain contact information for relaying
lab results
Advise CPHL of priority
Advise re environmental
decontamination
Counsel individuals involved as needed
Obtain lab results and communicate to
first responders and involved persons
Call Public Health with contact
information and incident number on
semi-urgent basis:
8am-8pm: 416 338-0069
After 8pm: 416 527-3461
Priority 3 (low):
1.No overt threat, and
2.No obvious target
3.There is human exposure (i.e. a
package has been opened)
4.A substance is present
Obtain contact information if sample
sent to CPHL
Advise CPHL of priority
Provide personal and environmental
decontamination advice if requested
Priority 4 (lowest):
1.No overt threat, and
2.No obvious target
3.There is no human exposure (i.e
package has not been opened)
Provide reassurance and environmental
decontamination advice if requested
If sending sample to the lab, call
Public Health with contact information
and incident number when practicable
Call Public Health only if involved
persons requesting specific advice
Public Health Response
24 hour first responder hotline
Coordination with laboratory
Developing protocols with police,
fire, EMS
Links with other Health Units,
provinces, Health Canada
Info to businesses, hospitals, local
physicians, consulates, the public…..
Triage of Suspicious
Envelopes/Packages*
 A general process is outlined below, in
some areas public health may play role of
onsite assessment and/or transport to lab
– Police notified - call 911.
– Police contact local Health Unit.
– Decision is made re lab testing, management
of exposed individuals
– Police transport material to lab.
 *all environmental specimens are tested in the Central Public Health Lab
Testing in the Public Health Lab
Open and examine package in a
negative pressure containment lab
using level 3 protection.
Gram stain, +/- spore stains for
bacteria on any material (powder,
etc.) present.
Cultures, motility, biochemicals as
required.
Testing in the Public Health Lab
Testing performed while maintaining
chain of custody procedures and
evidence documentation.
– Photograph material
– preserve DNA, fingerprints, handwriting
CPHL does not do chemical analysis
or tell the police what the substance
is.
Testing in the Public Health Lab
 Send any suspicious organisms to the
NML in Winnipeg for confirmation.
 All samples must be treated as possible
forensic evidence.
– maintain chain of custody
– preserve DNA, fingerprints, handwriting etc.
– alert police of similar incidents from different
jurisdictions
Reporting Results
 Phone results to health unit and to police,
within 24 - 48 hours of receipt of sample.
 Written report to health unit (Medical
Officer of Health) and police, within 1 - 2
weeks.
 Police contacted re deposition of material
– material returned to police
– material destroyed by police order
Summary
 Roles public health will play will vary by
health unit
 Will certainly have a key role in public
communication
 Will most often have lead for follow-up of
contacts/people exposed
 Will have lead role in determining of
PEP/vaccination
 Need to understand roles of other players
in your community