Transcript Dr. Perlin's Keynote Talk - Public Health Research Institute

Public Health Issues
David S. Perlin, Ph.D.
Public Health Research Institute
at the International Center for Public Health
Newark, NJ 07103
[email protected]
October 2001 Anthrax Outbreak
What 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
Essential Elements of a Public Health Strategy
Threat Assessment
Preparedness
Response
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
Deliberate v. Naturally-Occurring Outbreak
Does it matter?
Bioterrorism preparedness should be an
extension of our current medical and
public health infrastructure.
Epidemic Diseases are all around us
WHO: Mortality Trends (1997)
Circulatory
29.3%
Infectious and Parasitic
33.1%
Other
13.2%
Perinatal
Cancer
6.9%
11.9%
Respiratory
5.6%
5
Infectious and Parasitic
4
Diseases
Deaths, 3
millions 2
1
0
HIV/ Malaria
Acute TB
AIDS
Diarrhea
Respiratory
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.
Emerging and Re-emerging Diseases
West Nile Virus
4156 Cases and 284 Deaths (1/1/03)
SARS Coronavirus
People are potent vectors of disease
PRERAREDNESS
and
RESPONSE
Linking of Response Systems
First Responders
Fire/EMS
Medical & Mental
Health Services
Law
Enforcement
Public
Health
Emergency
Management
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.
•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)
Structure of the LRN
Level D
Federal Labs
BSL-4
CDC and USAMRIID. Expertise with
unusual organisms.
Specimen repository.
Level C Labs *
BSL-3
Level B Public Health
Labs BSL-2 + or 3
Level A Clinical Labs
BSC (Class II-B)
Rapid identification using molecular
methods. Test evaluation.
Isolation and presumptive ID.
Antimicrobial susceptibility
testing. 24/7 response.
Early detection, rule out and
refer.
*State, research, federal
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
Metropolitan Medical Response Systems
Original MMRS
MMRS 1999
MMRS 2000
MMRS 2001
MMRS 2002
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
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
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, LexingtonFayette, Akron
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
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
Strategic use of vaccines
Challenges
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
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?
Role of Healthcare Professionals
• First line of defense.
But what if they are early victims of the
outbreak (e.g. Toronto)?
Hospitals as an amplifier of infection
SARS Cases in Toronto
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?
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.