Bioterrorism

Bioterrorism & Public Health Surveillance Systems: Integrating the Medical Incident Commander, Public Health, and Emergency
Management
Robert J. Coullahan, CEM Assistant Vice President Disaster Preparedness & Consequence Management Programs Science Applications International Corporation robert.j.coullahan@saic.com
IAEM 48th Annual Conference - R. J. Coullahan
FOCUS
Review the Threat and Effects of Bioterrorism Examine Scenarios of Biological Attack Early Warning, Recognition & Reporting Needs Medical, Public Health & Emergency Management Linkages Surveillance Systems Initiatives & Pilot Programs Building on Lessons Learned
Roadmap toward Enhancing Linkages

Exploring the Role of IAEM
IAEM 48th Annual Conference - R. J. Coullahan 2
THREAT AND EFFECTS

Review the Asymmetric Threat
Illustrative Bioincident Timeline Defining Biological Warfare & Biological Terrorism Agents and Factors for Successful Bioagent Release
BIOLOGICAL WEAPONS - HISTORY

Oldest of the NBC triad of weapons Used for > 2,000 years:
6th Century B.C.: Assyrians poison the wells of their enemies with rye ergot. 1767: Sir Jeffrey Amherst gives blankets laced with smallpox to Native Americans. World War I: Germany allegedly releases Cholera in Italy; plague in St. Petersburg. World War II: Oct 4, 1940 Japanese release plague bacteria at Chuhsien resulting in 99 deaths.
THE THREAT OF BIOTERRORISM
Generalized Bioincident Timeline
SBCCOM BW RESPONSE TEMPLATE
From: Improving Local and State Agency Response to Terrorist Incidents Involving Biological Weapons, US Army SBCCOM, Final Draft, 1 Aug 2000
BIOLOGICAL WARFARE AND TERRORISM DEFINITIONS
Biological Warfare
The intentional use of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants.
Biological Terrorism
The threat or use of biological agents by individuals or groups motivated by political, religious, ecological or other ideological objectives.
BIOLOGICAL WEAPONS
Availability, lethality, stability in storage.
Large quantities can be produced. Can be disseminated as an infective aerosol with modifiable decay.
BW/BT EDUCATION
Detection of an attack is difficult because bio agents have no immediate warning properties and clinical symptoms take hours (or days) to develop. Reliable bioagent air monitoring equipment is
lacking.
Difficult to delineate the extent of a BW attack.
A high index of suspicion needs to be present.

MEDICAL BW DEFENSE
ATTACK
ONSET OF ILLNESS
Pre-exposure Immunization (active) Drug Prophylaxis Training
Incubation period (minutes - 3 weeks)

Diagnosis (class or agent specific) Passive Immunization (immune serum) Pre-treatment (drugs)
Overt Disease
Diagnosis
Treatment Communication
11
INITIAL SIGNS OF A BW ATTACK

Many patients with the same illness Compressed epidemic curve with dominant respiratory signs High exposures may present early Pre-existing chronic disease may also present early Symptoms may be unusual for age Non-endemic infection
Multiple, simultaneous outbreaks

Dead animals before humans
KINETICS OF A BIOLOGICAL AGENT ATTACK

X X
TRANSMISSION SECONDARY INFECTIONS
X X X X X X X X
SMALLPOX EBOLA
2nd TRANSMISSION
XXXXXXXXXXXXXXXXXXX X X X X
2nd TRANSMISSION
X X X X X X
MARBURG VEE
Sequelae
X X X X
2nd TRANSMISSION
Q FEVER TULAREMIA
XXXXXX
PLAGUE ANTHRAX
XXXXXXX
XXXXX XXXXX
BOT A SEB (Staph Enterotoxin B)
X = deaths
RICIN
XXXXX
10 11 12 13 14 15 16 17 18 19 20 21 30 60 90 120
Onset of Symptoms Range (days)

BACTERIA AND RICKETTSIA

Bacillus anthracis Brucella abortis, suis, melitensis Clostridium botulinum Vibrio cholera Burkholderia mallei pseudomallei Yersinia pestis Shigella dysenteriae Francisella tularensis Salmonella typhi Coxiella burnetii Rickettsia rickettsii prowazekii
Complete congruence of bacteria and rickettsia on AMEDD P8 list (DoD) and Select Agents List (CDC)
14
TOXINS
Toxins on AMEDD P8 (DoD) list; also found on Select Agent List (CDC) Botulinum Perfringens T2 Mycotoxins Palytoxin Ricin Saxitoxin Staphylococcal enterotoxins Tetrodotoxin Additional agents found on CDC Restricted Agents List
(42 CFR Part 72 / RIN 0905-AE 70)
Abrin Aflatoxin Conotoxins Diacetoxyscripenol Shigatoxin
Also:
Palytoxin
15
AEROSOL / INFECTIVITY RELATIONSHIP

Particle Size
(Micron, Mass Median Diameter)
Infection Severity Less Severe
18-20
15-18 The ideal aerosol contains a homogeneous population of 1 to 5 micron particulates that contain viable organisms
7-12
4-6
(bronchioles)
Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size
1-3 (alveoli)
More Severe
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Arena viruses Alphaviruses
FIRST BREAKTHROUGH IN BW DEVELOPMENT OF VIRAL BW AGENTS

Orthomyxovirus
Influenza
Argentinian HF, Bolivian HF, Lassa Chikungunya Eastern, Venezuelan, and Western Equine Encephalitis
Hantaviruses
Korean HF
Phlebovirus
Rift Valley Fever
Nairovirus
Congo-Crimean HF
Flaviviruses
Dengue, Omsk HF Tick-borne Encephalitis, Yellow Fever
Filovirus
Marburg, Ebola
Orthopoxviruses
Smallpox / Monkeypox
SECOND MAJOR BREAKTHROUGH IN BW

Dry agent preparations for: Anthrax Tularemia Q fever VEE SEB BOT
Additives Electrostatic inhibitors Stabilizers

4 KEY FACTORS FOR SUCCESS OF A BIOLOGICAL ATTACK

1. Agent 2. Delivery 3. Agent / Munition Dissemination Systems
4. Meteorological Conditions
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FACTOR 1. THE BIOLOGICAL AGENT

Lethal
Bacillus anthracis Botulinum toxin Francisella tularensis Yersinia pestis Smallpox (variola) Ricin toxin
Incapacitating
VEE Virus Q Fever Staph Enterotoxin B (SEB)
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FACTOR 2. DELIVERY OF THE BW AGENT

Particle Size
The ideal aerosol contains a homogeneous population of 1 to 5 micron particles that contain a maximum concentration of viable organisms
(Micron, Mass Median Diameter)
Infection Severity Less Severe
18-20
15-18
7-12 4-6
(bronchioles)
1-3
(alveoli)
More 21 Severe
TECHNIQUES FOR AEROSOL GENERATION

High Explosive
Explosive (99.9% of agent killed) Attenuated Explosive Gas Pressurization Mechanical Atomization
Attenuated Explosive Gas Pressurization Mechanical Atomization
HIGH SHOCK
Common, Simple Hostile Environment
NO SHOCK
Complex More Efficient
FACTOR 3. THE BW MUNITION

For 1,000 organisms available with a munition efficiency of 1%, only 10 organisms are available in the aerosol to cause infection. The other 990 are killed by dissemination or by dropping out of the aerosol as a large particle.
Line Source
Dry
Liquid (Double nozzle) Liquid (Single nozzle)
Point Source Non-Explosive Bomblet
Explosive Bomblet
20
40 60 Percent Efficiency
23
80
DISSEMINATION OF DRY BW AGENTS
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FORMATION OF THE PRIMARY AEROSOL
initially visible large particles fall out later invisible, behaving like a gas can penetrate HVAC without HEPA filtration
25
FACTOR 4. METEOROLOGICAL CONDITIONS

(Based upon Caulders Equations of a given amount of Anthrax)
Inversion
Downwind Travel with 50% Casualties
Strong Moderate
Non-Inversion
36 km 30 km 28 km 19 km 2 km
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Slight Neutral Lapse/Bad

Release at 100 feet in 10 mph wind
CONSTRAINTS ON SUCCESSFUL BIOLOGICAL ATTACK

Agent concentration
Must be matched to volume of target area
Munitions efficiency Biological Decay Rate

Ultraviolet light, humidity stress, oxidation
Meteorological conditions
Wind speed Inversion layer
RESPONSE OPERATIONS: National Pharmaceutical Stockpile (NPSP)

to maintain a national repository of life-saving pharmaceuticals and medical materiel that will be delivered to the site of a bioterrorism event in order to reduce morbidity and mortality in civilian populations.
28
From: Stephen Bice, CDC,NPSP briefing before the NACCHO Bioterrorism & Emergency Response Advisory Committee, Kissimmee, FL, Feb 2000
Members include pharmacists, public health experts, and emergency response specialists. Arrive on-scene ahead of the 12-Hour push packages. Hand-off materiel to authorized state representative.
NPSP continued
Provide technical assistance.

Coordinate closely with incident command structure (State and Federal EOCs). Maintain continuous contact with the CDC NPSP Operations Center.
NPSP SUPPLIED CHEMOPROPHYLAXIS ANTIBIOTICS

- CIPROFLOXACIN - DOXYCYCLINE
VACCINE
MASS PROPHYLAXIS
distribution and medical application of appropriate antibiotics, vaccines, or other medications in order to prevent disease and death in exposed victims. identify populations at risk a much greater number than those actually exposed. activate prophylaxis distribution (and follow up) plan through Neighborhood Emergency Health Centers (NEHC), optimize use of local pharmacists in the planning.
priority emergency antibiotic prophylaxis for use by essential emergency personnel independent stockpile, publicly acknowledged.
SCENARIOS
Background of Scenario Development and Use Examine Scenarios of Biological Attacks - Aerial Anthrax Release - Smallpox Release
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Example Scenarios
Bombing + Chemical Attacks Chemical Attacks in Subway
Biological Aerial Attack

Line of Flight Altitude: 1,000 ft Release: 5km 20% 50% infected infected
Biological Attack in Major Airport
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Scenario Analysis
Objective
Analyze appropriate threat scenarios; overlay on conventional response capabilities
Scenario Analysis
Start with Threat Scenarios Enlist domain experts Use computational simulation tools to assess impact on target
physical models GIS databases (demo- graphics, emergency assets, street maps, )
Scenario Evolution
Scenario Outcome
Casualties
Predict Impact
Property Damage Economic Impact
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Conventional Response Overview

Event
State Monitors & Assesses State Assistance Required Local Response Request for State/Federal Assistance State Response Sufficient Governor Requests Presidential Declaration Federal Assistance Provided Federal Assistance Denied Appeal
Local Response Sufficient
No Assistance Required
Routine State Response
Extraordinary State Response
Governor Declares Emergency Governor Activates National Guard
No State Declaration
Biological Incident Life Cycle Without Preparedness

Limited Response
Insufficient medical supplies Large number of deaths Public Panic Mass Self-evacuation Public services collapse
CHAOS
Incident
Exposure of Population
Recognition
Days
Medical Treatment
Slow Intervention Symptomatic victims treated with antibiotics Those suspected of exposure treated with Ciprofloxacin
EMS Private Physicians Urgent Care Hospitals / MCOs Pharmacies
PHS
State PHS, CDC & DoD provide expertise & confirmation of pathogen
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The Incident Begins

20 km 0 7 0 0
Crop duster flies at 1000 AGL in uncontrolled airspace releasing Anthrax along a 5km cross wind flight path
Flight Path 5 km
0 0
Anthrax cloud has grown to encompass a 5 km x 20 km footprint. Within this region reside 1.5 million people
Prevailing Wind
The Population is Exposed

5% exposed contract Anthrax 20% exposed contract Anthrax 50% exposed contract Anthrax
Civilian Posture Risk in the open high in vehicles moderate in buildings low
250,000 Exposed
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Day 2 - The Incident Goes Unnoticed

Epidemiology
100 % of All Cases
Initial Phase Early Acute
80
60 40
12,500 people are in

the initial phase of illness.
Late Acute
20
0 1 2
Progression of Illness 3 4 5 6 7 8 Days Post Exposure 9
24
None
48
72
96
120
144
168
Non-specificEMERGENCY symptoms not likely to be attributed to Anthrax unless other information was available.
RESPONSE
39
Day 3 - The Outbreak

100
% of All Cases
Epidemiology
7500 people are in the early acute phase and are exhibiting moderate flu-like symptoms 5000 people are in late acute phase and are experiencing severe respiratory distress
0 24 48 72 1st Chance None to Detect
Initial Phase Early Acute Late Acute
80 60
40
20 0 1 2 Progression of Illness 3 4 5 6 7 8 Days Post Exposure 9
96
120
144
168
EMERGENCY RESPONSE EMS, ERs, & private physicians experience a rapid rise in emergency patients. Tests for common pathogens concurrent with symptom-based treatment. Large number of patients requiring ventilators rapidly exhaust local supply. The state health department laboratory & epidemiologist will be involved. If anthrax is suspected an enzyme-linked immunosorbent assay (ELISA) could IAEM 48th Annual - R. J.would Coullahanbe performed rapidly. be requested, though it is unlikely that Conference such a test
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Day 4 - Anthrax is Strongly Suspected

Epidemiology
30,000 people are in the early acute phase 26,000 people are in late acute phase 4,000 people are dead
Once symptoms begin, pulmonary and meningeal anthrax are usually (90%) fatal despite antibiotic therapy and intensive care. 0 24 100 % of All Cases
80
60 40
20
0 1 2
Progression of Illness 3 4 5 6 7 8 9 Days Post Exposure 120 144 168
48 72 96 1st Chance Samples Without a rapid None monitoring system time is lost in identifying the Anthrax outbreak. to Detect to CDC Further time is lost by clinicians unfamiliarity with this disease, preventing rapid identification and EMERGENCY accurate diagnosis. RESPONSE Large number of cases makes it likely that samples will be sent to both the State health department lab and CDC. Poison Control Center will coordinate community medical resource needs (ventilators, antidotes, ) Public service announcements will commence.
Day 5 - Anthrax is Confirmed

100 % of All Cases
Epidemiology
162,500 people showing symptoms
80 60 40 20 0 1
22,000 people are dead
Progression of Illness 2 3 4 5 6 7 8 Days Post Exposure 9
48 72 96 120 144 168 1st Chance Samples Treatment None to Detect to CDC Inadequate CDC confirms pathogen is anthrax - dispatches Epidemic Investigative Service (EIS) EMERGENCY RESPONSE officers to assist state and local health officials The rapid rise in patient load overwhelms all local response capability Mortuary services cannot cope with the number of dead Governor calls up National Guard and asks for additional Federal assistance Local health authorities request 100,000s Anthrax test kits Treatment requires penicillin, tetracycline, erythromycin, or ciprofloxacin Growing panic among the populace, many attempt to flee the area. IAEM 48th Annual Conference - R. J. Coullahan 42 Public bulletins are aimed at reducing panic and preventing full scale evacuation.
24
Day 6 - The Toll Continues to Mount

Epidemiology
200,000 people are showing symptoms 72,000 people are dead
100 % of All Cases
Initial Phase
Early Acute Late Acute
80
60 40
20
0 0 24 1 2
Progression of Illness 3 4 5 6 7 8 9 Days Post Exposure168 120 144
48 72 96 1st Chance Samples Treatment No None to Detect to CDC Inadequate Resources 100,000s of doses of ciprofloxacin are needed to treat the community EMERGENCY RESPONSE The vaccination series should also be administered to victims Response effectiveness is severely limited because prophylaxis, vaccines, ventilators, , are in short supply. Whole scale self-evacuation of the city is underway. The emergency response ranks have been reduced as they too become victims . National Guard units begin to enter the region. FEMA, Public Health Service and the FBI have activated the Joint Operations 43 IAEM 48th Annual Conference - R. J. Coullahan Command (JOC) and begin to organize the Federal response.
How Can Lives Be Saved ?

Reducing Deaths
A quick look patient information template containing questions like Where do you work ? Where do you live ? How do you commute ? Would provide enough information to develop exposure patterns. 100 90 80 250,000 Exposed
National Surveillance System linking hospitals, public health agencies, and the FSL consequence management community.
Awareness and specialist training for the medical community would assist in early detection. Strategically placed medical supplies sufficient to treat thousands of victims is required
Deaths (x 1000)
70 60 50
40
30 20 10
0
1 2 3 4 5 6 7 8 9 Start of Intervention (days)
44
Early intervention could save tens-of-thousands of lives.

Smallpox Scenario Terrorist nation-state with ties to former Soviet Union has bio weapons program focused on smallpox and other diseases
Smallpox Scenario
Terminal C Terminal B
Terminal D
Terminal A Parking
Terminal E
Major Airport
Thanksgiving Day Terrorists begin releasing smallpox from concealed sprayers in Terminals C & D IAEM 48th Annual Conference - R. J. Coullahan 46
Smallpox Released in Terminal

Particles are invisible & have a long dwell time
(@ 7 hours 3.4% of 3 micron particles remain aloft)
Smallpox discharge lasts 10 minutes Terrorists are vaccinated and do not retrace their steps
Tens of thousands of passengers and workers pass through C become infected contaminated areaTerminal of whom 2,500
Event is unnoticed, no claims of responsibility

47
2,500 Infected People Disperse
Infected board flights to thirty eight US cities

Smallpox Prognosis
Incubation Ananthum Exanthum Prodrome Final Phase
Exposure
12 days avg.
Symptoms Symptoms Symptoms Symptoms Symptoms Fever, severe headache Largely Asymptomatic obvious on Lesions in Lesions oral cavity Scabbing & & backache skin scab separation Critically Contagious
5 3 days days avg. avg.
10 days avg.
20 days avg.
Days
10
20
30
40
49
50
Response Timeline
400
Infected (x 1000)
300
. . . . . . . .
~12 new victims during contagious period
weakened State & Federal resources Assumption required to provide local Each victim infects community needs
390,000 Victims Local Infrastructure badly
200
100
Vaccination selected 3rd of Generation Growing panic among the personnel begin Non-specific symptoms Terrorist incident presumed 2nd Generation Reporting Network Issues populace. (There are only 4.9M doses FBI WMD coordinator initiates likely to be attributed to flu State Health Department Medical facilities overwhelmed Eruptive initial cases Poison Control Center will - nophase rapid monitoring system Public bulletins issued to reduce Federal involvement stockpiled) laboratory & epidemiologist A rapid rise in emergency Public Notification Law enforcement needed to keep likely -to be misdiagnosed as unfamiliarity with disease prevents panic & prevent full scale coordinate community Governor activates NG become involved. patients arouses suspicion 1st Generation commences chicken pox immediate medical diagnosis evacuation from cities order resource needs CDC contacted
0 10
20
Days
30
40
50
50
Actions to be Taken
Identify infected population and their contacts. (Massive undertaking-will require tracking all infected persons whereabouts since prodrome).
Keep public informed through special media programming. Teach good public health techniques using mass media.
Set up screening centers to triage concerned people. Establish acceptable method and level of isolation. Maintain security at treatment and supply facilities.
Provide State and Federal resources to replace losses in local capabilities.

Notify drug companies of the likely requirements for over-thecounter medicine. IAEM 48th Annual Conference - R. J. Coullahan 51
CONSEQUENCES OF THE SMALLPOX RELEASE

By the 50th day after the airport spraying as many as 400,000 people could be infected with up to 100,000 dead or dying. Without vaccine the epidemic will continue to grow geometrically, though an effective quarantine will slow the growth. Facilities to treat terminally ill will need to be created Other temporary treatment facilities will have to be stood up to handle the large number of casualties. Transportation to secondary treatment centers will be required. Mortuary facilities will be overwhelmed and strict sanitation rules will have to be reinforced. Re-establishment of vaccine production (2-3 yrs) will be needed to re-eradicate smallpox
Special Considerations
Active role of civilian healthcare organizations in surveillance, response operations, and preparedness is crucial.
A national surveillance system enables early intervention, the linkage to the emergency management system is vital.
Recognize the unique C/B WMD impacts on critical infrastructure/key assets decon, reoccupancy. Facility re-occupancy criteria must be defined and enforced to assure public confidence, essential to continuity of operations. Private sector contingency planning for C/B incidents: reoccupancy, liability, critical incident stress management. Alert & Warning Systems: NWR & EAS (SAME); civil emergency messages; public health/EMA decision protocols. Avoiding stovepipe design and implementation of emerging public health surveillance systems integrate with EM enterprise.
UNFOLDING OF BIO INCIDENT+

Public Health Monitoring & Surveillance
Number of Affected Persons
911 Calls Increase Hospital Admissions Up Dead Animals of Multiple Types
National/Local Data Collection & Analysis

Unexplained Infection Outbreak Data Assessment Investigation of Origins & Nature of Outbreak
Federal Response Operations

Pharmaceuticals Medical Treatment Mass Care Emergency Public Information Structure Decontamination Food
Symptomatic Patients Mortality
Bio Agent Dispersal

+
FEMA F64-Cc
Bio Agent Determined to be Public Health Time Result of Terrorist Attack Emergency (PDD-39 Policy Applies) Presidential Emergency Declaration (Stafford Act)
MEDICAL, PUBLIC HEALTH & EMERGENCY MANAGEMENT LINKAGES

Review Medical and Public Health Interface
Training and Decision Support Clinician as Medical Incident Commander Hospitals Role of Laboratories
The Response Community

Emergency Medical Services - EMTs, Paramedics Emergency Medicine - Physicians, Physicians Assistants - Emergency Depts., ICUs, Labs Hospitals and Managed Care Organizations Private Practitioners Medical Examiners/Coroners Veterinary Medicine, Animal Control Public Health Services Emergency Management Law Enforcement/Crisis Management Fire/HAZMAT
Medical & Public Health Interface

Index of Suspicion
57
Clinicians: The Medical Incident Commanders

Medical Surveillance Medical Diagnosis
Clinical Laboratory Tests

Triage and Treatment
ICU
Recognition & Reporting
Clinician Training: Incentives?
59
Challenges for Hospitals & MCOs
60
HOSPITALS
Number of Hospitals in U.S. (AHA, 1998): 6,021 - 5,015 non-federal, short-term general or other specialty hospitals - 1,006 Federal, long-term care, and hospitals for the mentally retarded.
Hospital Ownership - 3,026 non-government, not-for-profit - 771 investor-owned - 1,218 State and Local Government JCAHO and HCFA are addressing MCI preparedness; recent AHA forum on MCI finding: there is no financial framework for funding hospital preparedness.
ROLE OF THE LABORATORY IS VITAL

Classification of Bioterrorism Response Labs
Level D Lab BSL-4 Level C Lab BSL-3 Level B Lab
D - High level characterization and secure banking of isolates

C - Molecular methods - PCR, etc. and toxigenicity testing B - Ability to confirm & characterize agents and perform antimicrobial susceptibility A - Ability to rule-out diagnosis of key agents and forward organisms to next level
Level-A Lab
62
BIOSAFETY LEVEL - 4 (BSL-4)

HEPA Air Filter
UV airlock Disinfectant dunk bath Glove cabinet
Suited Ops
Suit disinfectant shower, UV airlock,
Autoclave
Shower out Change in
Special sewage treatment
CDC USAMRIID Others

63
PUBLIC HEALTH SYSTEM

Included in the Local Public Health System:
Public Health Professionals Primary Care Personnel Hospital Staff EMS Personnel Laboratory Personnel
Defined by CDC
PUBLIC HEALTH SURVEILLANCE SYSTEMS

Surveillance Systems
Initiatives and Pilot Programs - Syndromic - Data-based Relevance to Emergency Management information systems and decision support
65
PUBLIC HEALTH SURVEILLANCE

Public Health Surveillance is defined by the CDC as the ongoing, systematic collection, analysis, and interpretation of data (e.g., regarding agent/hazard, risk factor, exposure, health event) essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control.
Bioterrorism: Examples of Potential Surveillance Data Sources

Laboratories Infectious disease specialists Hospitals Infection control Physicians offices Poison control centers DNR - Fish & Game Veterinarians Medical examiners Death certificates Police/Fire/EMS Quarantine EPA Pharmacy data County Agriculture Extension
Early Warning Surveillance and Reporting
data capture and normalized baseline data: monitoring the pulse of the city. local/regional data aggregation. incident recognition and rapid confirmation. initial incident size-up and rapid screen of surrounding geographical areas.
Gaps in F-S-L PH Communications

CITY or COUNTY HEALTH DEPT.
LIMITED NO
NETWORK CONNECTIV ITY...
LIMITED NETWORK CONNECTIV ITY (HANs )
STATE HEALTH LAB
NETSS NEDSS
NO DATA COLLECTION AND REPORTING HEALTH-CARE PROVIDERS CDC CONFIRMATION
69
Bioincident Data Management
70
Surveillance Data Capture Continuum

Evolutionary Capability
SYNDROMIC SURVEILLANCE
Manual entry/automated upload

Physicians Offices City/County Public Health Departments (DBMS Servers)
Automated extraction & upload

Data Extractor Application
Hospitals &
Clinics Managed Care Pre-Admission
Patient Records Database
Veterinary Offices
State Public Health DBMS & Consequence Assessment Tools
Based upon ICD-9 Codes
DATA-BASED SURVEILLANCE
71
SEMI-AUTOMATED DATA CAPTURE
AUTOMATED DATA EXTRACTION
Essential Information Elements for Syndromic Surveillance

Hospital Emergency Departments:
HOSPITALS
MANAGED CARE EMS MEDICAL EXAMINER PHARMACIES ANIMAL CONTROL
# of medical (non-trauma) ER visits.** # of hospital non-trauma admissions. # of infectious disease patients reported.
Hospital Intensive Care Units Pre-admission clearances 911 Emergency Medical Services runs:
# of non-trauma EMS responses. in the past 24-hour period.
Deaths reported to Medical Examiner/Coroner:

# of deaths reported. # of medical examiner cases pending.
Sentinel Pharmacies:
# of over-the-counter (OTC) flu meds and anti-diarrheals.
Unusual # of animal deaths.

Data Elements (contd.)

**Hospital Emergency Department Reporting: Medical non-trauma ER visits including: a. b. c. d. gastrointestinal disorders; respiratory disorders; rash/fever; all other visits.
Hospital non-trauma admissions.
Number of infectious disease patients reported.

Syndromic Surveillance Prototype Rapid Syndrome Validation Project (RSVP)

Sandia National Laboratories
Alan Zelicoff, MD
Senior Scientist Center for National Security and Arms Control, SNL
University of New Mexico School of Medicine New Mexico Department of Health

Data-based Surveillance Initiatives
75
Data-based Surveillance Initiatives

CDC-sponsored grantees
DoD GEIS (Tricare)

Other
76
Early Detection System for Bioterrorist and Natural Disease Threats Using Syndromic Surveillance in the
Greater Washington, DC, Area

From: Julie Pavlin, MD, MPH, Chief, Strategic Surveillance, DoD-GEIS
ESSENCE: An Electronic Surveillance System for the Early Notification of Community-based Epidemics
Earlier detection of aberrant clinical patterns at the community level to jump-start response Rapid epidemiology-based targeting of limited response assets (e.g., personnel and drugs) Rapidly equipping civil government leaders with outcome-based exposure estimates
Risk communication to reduce the spread of panic and civil unrest

Proposed Evolution of ESSENCE:

NOAA Weather Civilian Pharm Data Civilian Surveillance System
MHS Surveillance System
MHS Outpatient Data
MHS Lab, Rad, Pharm
EMS Call Data

Civilian Emergency Rooms
Managed Care Data
Poison Control Center
Entomology Data
79
Program Specific Reports and Summaries
MMWR Weekly Tables
MMWR Annual Summaries
Current Situation
CDC
Statistical Surveys for Chronic Diseases, Injuries and Other Public Health Problems
HARS CDC
STD*MIS
TIMS
NNDSS
EIP Systems
PHLIS
Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc.
State Health Department
HARS
STD*MIS
TIMS
NETSS
EIP Systems
PHLIS
Reporting by Paper Form, Telephone and Fax
Data Sources
Physicians
Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc. Chart Review
City/County Health Department
HARS
STD*MIS
TIMS
NETSS
EIP Systems*
PHLIS
Lab Reports
STD*MIS (Optional at the Clinic)
TIMS (Optional at the Clinic)
*EIP Systems (ABC, UD, Foodnet)
Courtesy: R. Spiegel, CDC
Integration Project

From: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.
80
Proposed Integrated Surveillance TB Systems Solution

Secure Server
STDs
Notifiable Disease Reports
CDC
EIP Systems
HIV/AIDS CDC Electronic data interchange (EDI) using HL7 or other standardized format
Lab Surveillance
Data Sources
Secure Internet
Paper Forms, Telephone and FAX Physicians
State Health Department
HIV/AIDS
Shared Facilities and Services, e.g. common interface, software components, terminologies and data files
Chart Review
Lab Reports Electronic data interchange (EDI) using HL7 or other standardized format
Secure Internet
Secure electronic reporting
Vital Statistics
City/County Health Department
HIV/AIDS
Shared Facilities and Services, e.g. common interface, software components, terminologies, and data files
Emergency Departments
Medicaid, Medicare Encounters
Courtesy: R. Spiegel, CDC
STD Clinics
TB Clinics

Hospital Discharge 81 Data
Other Related Projects:

National Electronic Disease Surveillance System
Electronic Laboratory Reporting pilots Data Elements for Emergency Departments pilot project Bioterrorism cooperative agreements Standards Development Organizations activities HL7, SNOMED, LOINC State integration activities
Integration Project
82
The NEDSS Solution

A common framework for surveillance information systems:
Common data architecture (model, definitions, coding) Automated electronic reporting of data, e.g. electronic laboratory reporting Consistent user interface Secure Internet pipeline for reporting to CDC Reusable software components Shared analysis and dissemination methods
Integration Project

83
Some Requirements for Integrated Systems

Patient registry matching Rapid development and deployment of data entry screens Internet data entry Pyramid reporting and synchronization (clinic to local to state to CDC)
HL7 import and export

Integration Project
84
Data Flow for Decision Support

NCA
National Command Authority
COURSES
OF ACTION
OEP CDC
Public Health Assessment Tool Set

DATA FUSION & VISUALIZATION
SPHS
State Public Health Agency

DATA AGGREGATION & ANALYSIS
City/County Public Health Dept.
LPHS
Veterinary Medical Offices
DATA AGGREGATION & ANALYSIS
Emergency Depts./ICUs: Hospitals MCOs

IAEM 48th Annual Conference - R. J. Coullahan DATA CAPTURE & UPLOAD
Private Physicians Offices
85
Bioincident Health Emergency Response, Assessment, Logistics and Decision Support
86
Federal Response Level Federal Agencies

Bioterrorism C2 Environment
Biocon 1 Biocon 2 Biocon 3 Biocon 4 server Biocon 5
BIOCON Levels based upon pre-established thresholds of reported data.
State Response Level

Tally/State A Rules
Thresholds based on rules.

A State Public Health Dept.
server
A OEM / EOC
server
Tally/State A Rules
B State Public Health Dept.

server
B OEM / EOC
server
Response Operations
Response Operations
City or County Response Level
Tally/County A Rules server server
Tally/County B Rules server server
City/County A Public Health Departments.
City/County A Emergency Management
City/County B Public Health Departments
City/County B Emergency Management
HOURGLASS HOURGLASS HOURGLASS HOURGLASS
Response Operations
HOURGLASS HOURGLASS HOURGLASS HOURGLASS
Response Operations
87
BIOHERALDa conceptual End-to-End Architecture
BUILDING ON LESSONS LEARNED

National Y2K Information Coordination Center (ICC) Established by Executive Order 13073 (As Amended 15 June 99)
Information sharing and coordination within Federal government and key components of public and private sectors (including international). assist federal agencies and the Chair in reconstitution processes where appropriate. to assure that Federal efforts to restore critical systems are coordinated with efforts managed by Federal agencies acting under existing emergency response authorities.
National Y2K ICC Operations Model Mission and CONOPS

Spectrum of Information Transmission and Interchange Means
Media; In-Person; Telephone; Secure; FAX; VTC; Collaborative S/W; e-mail; Cables; ICRS; Internet
Information Inputs Types of Info.

Original -- from incident
ENTRY
ROUTING
REVIEW AND COORDINATION
PRODUCTION
Business Rules Defined and Implemented in the Database Permissions
Customers White House

B u s i n e s s R u l e s
Assessed, reviewed by other than originator B u Summarized reports s by intermediate levels i n Sources e s Depts. / Agencies State/Local/Tribal via s States & FEMA International
Direct
Coordination & Analysis Individual Analysis Products Report Sector Summary V/I Summary Overall Summary Graphics Multimedia
Presidents Council on Y2K IIWG/DIWG CDRG
Via Database
Sector Desk Display
Format
D/B ready
Not D/B ready
R u l e s
Coordination: D/A;Domestic International; Another Sector; Vital Interest; Another Vital Interest; JPIC; External Other
D/A
Congress S/L/T Public International Industry
89
Display Info Matrix Incident Report Other Report
Media Article Media Image Resolution Internet Page e-mail Reference Material
Information Coordination Center
90
Information Coordination & Reporting System (ICRS)

Data base autofill information from D/As, States, and infrastructure owner/operators in agreed-on templates. Cyber Reporting System (Green-Yellow-Red). Other Dept./Agency reports and data SITREPs. GIS, images, display and briefing materials
State Status Report

Normal
Reduced Capacity, Capability or Service
Significant Reduced Capacity
Y2K Related Yes/ No/ UNK
Remarks
Please describe reason for reduced capability
Transportation
Communications Public Works & Engineering Fire Fighting Mass Care Health and Medical Services Urban Search and Rescue Hazardous Materials Law Enforcement Food Energy Emergency Services Financial Services Government Services Correctional Facilities Overall Assessment
Reduced Services
Significant Outages Significant Outages

< 24 Hours
Reduced Capacity
G G G
Reduced Capacity
Reduced Capacity Reduced Capacity Reduced Capacity
Loss of Services Significant Loss of Service
G G
Reduced Capability Heavily Engaged Committed Heavily Engaged Committed Need Backup Need Additional Resources Significant Shortages Serious Threat to Health Significant Backlog Significant Disruptions Significant Disruptions
G G G G
Reduced Food Availability Temporary Failure Heavy Usage Reduced Services Reduced Services
G G Additional remarks (please be brief) SEND
Reporting Station: Newark, NJ Reduced Capacity,

Normal G G G
Capability or Service
Reduced Capacity/ Minor Outages Reduced Food Availability
Significant Reduced Capacity

Significant Outages Significant Shortages
Remarks Please describe reason for reduced capability
City/County Report
Power/Fuel Food Water Communications Transportation Emergency Services Health/Hospital Law Enforcement Nursing Home Sewage Correctional Facilities Finance Government Services Overall Assessment
Reduced Capacity
< 24 Hours
Heavy Usage
Y
Total ATC Failure at Newark International Airport Need Backup
Reduced Reduced Capacity Capacity
Reduced Capacity
Reduced Service
Significant Loss of Services
Martland Medical Center and Newark Beth Israel Medical Center on diversion; EDs, ICUs at capacity
G G G G G G
Heavily Engaged Committed Reduced Capacity
Need Backup
Life Threatening Serious Threat to Health Security Compromised
Temporary Failure
Manual Operations
Reduced Services
Significant Disruptions
Reduced Services
Significant Disruptions
All Air traffic halted
Decision Support System (DSS)
94
ICC Legacy and Public Health Information Infrastructure

ICC software applications are government off-theshelf capabilities F, S, L access could be readily authorized. CDC has challenged States & local jurisdictions develop an integrated architecture (NEDSS, BPRP) ICC ICRS and DSS lessons learned can be leveraged to define feasible PH/EM implementation options. Expand business rules to include private healthcare providers as reporting entities. Evaluate utility in FY01-02 bio WMD exercises such as TOP OFF II.
COORDINATING INITIATIVES
96
ENHANCING LINKAGES
CDC Bioterrorism Preparedness & Response Program. FY01 Public Health Improvement Act (a.k.a. Public Health Threats and Emergencies Act) Agency for Healthcare Research & Quality (AHRQ) Bioterrorism Initiative.
97
CDC BIOTERRORISM PREPAREDNESS AND RESPONSE PROGRAM (BPRP)

Facilitate and Support State and Local Bioterrorism Preparedness and Response Planning
Create a National Health Alert Network Strengthen State and Local Surveillance, Epidemiology, and Laboratory Diagnostics Capabilities to Rapidly Identify and Address Infectious Disease Outbreaks Related to Terrorism
98
CDC FY 2000 PRIORITIES

Enhance Outbreak Response, Coordination, and Support
Focus on Decreasing the Populations Vulnerability to Biological Agents

Improve Laboratory Readiness Enhance Local-level Epidemiology and Surveillance Improve Use of Information Technology in Preparedness process Improve Response to a Smallpox Emergency Enhance Public Health Preparedness at the Local IAEM 48th Annual Conference - R. J. Coullahan 99 Level.
BIOTERRORISM READINESS ASSESSMENT TOOL

Essential Service #1: Monitor health status to rapidly detect and identify an event due to hazardous biological, chemical or radiological agents (e.g., community health profile prior to an event, vital statistics, and baseline health status of the community)
1.1
1.1.1
Indicator: Monitoring for Rapid detection Does the LPHS monitor community and health indicators which may signal biological, chemical and radiological incidents?
Yes
No
DK
Target of this DOJ/CDC Survey: Public Health Responders Coordination by Local Public Health Agency (Director), with the survey to include the entire local public health system: Public Health Professionals
1.1.1.1 1.1.1.2 1.1.1.3 1.1.1.4 1.1.1.5 1.1.1.6 1.1.1.7 1.1.1.8 1.1.1.9 1.1.1.10 1.1.1.11 1.1.1.12 1.1.1.13 1.1.1.14 1.2 1.2.1
1.2.1.1 1.2.1.2 1.2.1.3 1.2.1.4 1.2.1.5 1.2.1.6 1.2.1.7 1.2.1.8 1.2.1.9 1.2.1.10 1.2.1.11 1.2.1.12 1.2.1.13 1.2.1.14 1.2.1.15 1.2.1.16 1.2.1.17
Other If yes, how frequently are the following Daily Weekly Monthly Freq (D) (W) (M) rates monitored: (O) Hospital admission D W M O ICU occupancy D W M O Unexplained deaths (Medical D W M O Examiners/Coroner cases) Unusual syndromes in ambulatory patients D W M O Influenza-like illness D W M O Ambulance runs D W M O 911 calls D W M O Poison control centers calls D W M O Pharmaceutical demand (antimicrobial D W M O agent usage, etc.) Emergency department utilization D W M O Outpatient department utilization D W M O Absenteeism in large worksites D W M O Absenteeism in schools D W M O Others (specify) Indicator: Hazard Analysis and Risk Assessment Does the LPHS perform, or have access to, hazard assessments of the Yes No facilities within its jurisdiction? If yes, are hazards at the following facilities assessed: Yes No Academic institution and other laboratories Yes No Agriculture co-op facilities Yes No Chemical manufacturing and storage Yes No Dams, levies, and other flood control mechanisms Yes No Facilities for storage of infectious waste Yes No Firework factories Yes No Food production/storage plants Yes No Military installations (includes National Guard units & Reserves) Yes No Munitions manufacturers or storage depot Yes No Pesticide manufacturing/storage Yes No Petrochemical refinery/storage facility Yes No Pharmaceutical companies Yes No Radiological power plants or radiological fuel processing facilities Yes No Reproductive health clinics Yes No Ventilation systems for high occupancy buildings Yes No Water treatment and distribution centers Others (Specify)
DK = Dont know Not at Dont all Know (No) (DK)
No No No No No No No No No No No No No
DK DK DK DK DK DK DK DK DK DK DK DK DK
DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
Primary Care Personnel

Hospital Staff EMS Personnel Laboratory Personnel
100
PUBLIC HEALTH THREATS & EMERGENCIES ACT

Passed Senate on 27 October 2000 Authorizes bioterrorism program initiatives Establishes Working Group on the Public Health and Medical Consequences of Bioterrorism (DHHS Secretary; FEMA Director; AG; Secretary USDA) $215M authorized for public health countermeasures $6M authorized for demonstration program to enhance training, coordination, and readiness.
AGENCY FOR HEALTHCARE RESEARCH & QUALITY (AHRQ)

Agency for Health Care Policy Research reauthorized December 1999. Congressional direction to execute a Bioterrorism Initiative. Research and studies to improve healthcare outcomes (reducing morbidity and mortality) and cost-effectiveness. Examine role of private healthcare providers in bioterrorism readiness.
AHRQ BIOTERRORISM INITIATIVE

Bioterrorism Initiative launched 29 September 2000 FY00 Congressional mandate; $5M appropriated Competitive ID/IQ task order procurement; 6 teams. Study & Analysis Task Areas:
Surveillance & Detection Decision Support Systems Clinician Training Hospital Capacity Assessment
Task Order #1 - to assess the linkages among the medical care, public health, and emergency preparedness systems to improve detection and response to bioterrorist events.
SO WHAT DOES THIS MEAN TO EMERGENCY MANAGEMENT ?

without active technical exchange among the emergency management and public health leadership we risk development of another generation of independent stovepipe systems.
there is an opportunity to consider systems interoperability to optimize the integrated emergency response. we need to actively engage the public health and healthcare provider communities as they develop & implement new decision support systems. IAEM 48th Annual Conference - R. J. Coullahan 104
HELP DEVELOP ROADMAP FOR ENHANCED LINKAGES

1. What are and how effective are the current linkages among involved entities? 2. How can the involved entities centrally plan, train, and work collaboratively before, during, and after a bioterrorist event? 3. How can inter-organizational cooperation be enhanced? 4. What is the current communication capacity among these entities? 5. How can communication of vital information to responders and the public be improved? 6. How can advanced information technology be used to provide access to real-time, dynamic data for involved entities? 7. How can effective communication and collaboration be established with primary care physicians in physician offices, clinics, and managed care organizations?
OPPORTUNITIES FOR IAEM

Participation in AHRQ Bioterrorism Initiative. Solicitation of IAEM membership on options for enhancing linkages. Engage the private healthcare enterprise and public health system on architecture.
Shape input to a roadmap for bioterrorism preparedness and response improvement.

Attribution
National Guard Local Emergency Responders National Research Council Metropolitan Medical Response System CDC FEMA FBI SBCCOM State Emergency Management Agencies
Special Thanks to:

Dr. Steven Hatfill, SAIC Mr. Bill Patrick, BioThreats Assessment Mr. Gary T. Phillips, SAIC Dr. D.A. Henderson, Johns Hopkins University Dr. Joshua Lederberg, Rockefeller University Dr. John Parachini, Monterey Institute of International Studies Dr. Richard Spiegel, BPRP/NCID, CDC Further Information: Robert J. Coullahan, CEM Assistant Vice President Disaster Preparedness & Consequence Mgmt Pgms Director, Readiness & Response Division Science Applications International Corporation 1410 Spring Hill Road - Suite 400 M/S SH-4-4 McLean, Virginia 22102 USA T (703) 288-5325 or (703) 288-6325 F (703) 288-5426 or (703) 744-7550 E robert.j.coullahan@saic.com

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Bioterrorism & Public Health Surveillance Systems: Integrating the Medical Incident Commander, Public Health, and Emergency

IAEM 48th Annual Conference - R. J. Coullahan

Roadmap toward Enhancing Linkages

THREAT AND EFFECTS

IAEM 48th Annual Conference - R. J. Coullahan

BIOLOGICAL WEAPONS - HISTORY

THE THREAT OF BIOTERRORISM

IAEM 48th Annual Conference - R. J. Coullahan

Generalized Bioincident Timeline

IAEM 48th Annual Conference - R. J. Coullahan

SBCCOM BW RESPONSE TEMPLATE

IAEM 48th Annual Conference - R. J. Coullahan

BIOLOGICAL WARFARE AND TERRORISM DEFINITIONS

A high index of suspicion needs to be present.

Pre-exposure Immunization (active) Drug Prophylaxis Training

Incubation period (minutes - 3 weeks)

INITIAL SIGNS OF A BW ATTACK

Multiple, simultaneous outbreaks

KINETICS OF A BIOLOGICAL AGENT ATTACK

BOT A SEB (Staph Enterotoxin B)

Onset of Symptoms Range (days)

BACTERIA AND RICKETTSIA

IAEM 48th Annual Conference - R. J. Coullahan

Abrin Aflatoxin Conotoxins Diacetoxyscripenol Shigatoxin

IAEM 48th Annual Conference - R. J. Coullahan

AEROSOL / INFECTIVITY RELATIONSHIP

Infection Severity Less Severe

Arena viruses Alphaviruses

FIRST BREAKTHROUGH IN BW DEVELOPMENT OF VIRAL BW AGENTS

SECOND MAJOR BREAKTHROUGH IN BW

Additives Electrostatic inhibitors Stabilizers

4 KEY FACTORS FOR SUCCESS OF A BIOLOGICAL ATTACK

IAEM 48th Annual Conference - R. J. Coullahan

FACTOR 1. THE BIOLOGICAL AGENT

IAEM 48th Annual Conference - R. J. Coullahan

FACTOR 2. DELIVERY OF THE BW AGENT

(Micron, Mass Median Diameter)

Infection Severity Less Severe

TECHNIQUES FOR AEROSOL GENERATION

FACTOR 3. THE BW MUNITION

Point Source Non-Explosive Bomblet

DISSEMINATION OF DRY BW AGENTS

IAEM 48th Annual Conference - R. J. Coullahan

FORMATION OF THE PRIMARY AEROSOL

IAEM 48th Annual Conference - R. J. Coullahan

FACTOR 4. METEOROLOGICAL CONDITIONS

Downwind Travel with 50% Casualties

Slight Neutral Lapse/Bad

Release at 100 feet in 10 mph wind

CONSTRAINTS ON SUCCESSFUL BIOLOGICAL ATTACK

Munitions efficiency Biological Decay Rate

RESPONSE OPERATIONS: National Pharmaceutical Stockpile (NPSP)

IAEM 48th Annual Conference - R. J. Coullahan

Provide technical assistance.

NPSP SUPPLIED CHEMOPROPHYLAXIS ANTIBIOTICS

IAEM 48th Annual Conference - R. J. Coullahan

Biological Aerial Attack

Biological Attack in Major Airport

IAEM 48th Annual Conference - R. J. Coullahan

Property Damage Economic Impact

IAEM 48th Annual Conference - R. J. Coullahan

Conventional Response Overview

Local Response Sufficient