Transcript Public Health IS a National Security Issue!

Health and National Security
Issues of the USA
International Conference on Bio-terrorism
KCDC of the Republic of Korea
August 6, 2004
By Michael Hopmeier
Special Advisor to the US Surgeon
General, WMD and Homeland Security
Unconventional Concepts, Inc.
3811 N. Fairfax Drive, Suite 720
Arlington, VA 22203 USA
703-797-4562
[email protected]
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© 2004 Unconventional Concepts, Inc.
Outline
• Threats to public health
• Current assets
 US Medical Preparedness
• Issues in Preparedness
• Public Health in the US
 Disease Prevention and Preparedness
• Summary
 Key Points
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“A bioterrorism attack anywhere in
the world is inevitable in the 21st
century.”
Anthony Fauci, Director, NIAID
Source: Clinical Infectious Diseases 2001;32:678
© 2004 Unconventional Concepts, Inc.
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Some Bioterrorism Agents
• Bacteria
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Anthrax
Brucellosis
Glanders
Plague
Tularemia
Q-fever
Source: http://etl2.library.musc.edu/bioterrorism/resources/ppt_files/5
© 2004 Unconventional Concepts, Inc.
• Viruses
 Smallpox
 Venezuelan Equine
Encephalitis
 Viral Hemorrhagic Fevers
 Nipah Virus
• Toxins
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Botulinum
Staphylococcal Enterotoxin B
Ricin
T-2 mycotoxins
E-coli (0157:H7)
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Bioterrorism is not the only threat
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1996 Mad Cow Disease
1997 Bird Flu (Avian)
1999 Nipah Virus
1999 West Nile Virus
2003 Monkey Pox
SARS 2003
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Emerging and Re-Emerging
Threats in the U.S. and Abroad
• Bovine Spongiform
Encephalopathy (BSE)
• Cryptosporidiosis
• Dengue
• Diarrheal Diseases
• Diphtheria
• E. Coli
• Ebola Virus
• Hantavirus Pulmonary
Syndrome (HPS)
• Human
Immunodeficiency
Virus (HIV)
• Influenza (Avian)
• Legionnaires’ Disease
• Listeriosis
• Lyme Disease
• Rift Valley Fever
• West Nile Encephalitis
• Tuberculosis (Multiresistant
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© 2004 Unconventional Concepts, Inc.
Public Health IS a National Security
Issue!
NIE 99-17D, January 2000 “The Global Infectious Disease
Threat and Its Implications for the United States “
“This report represents an important initiative on the part
of the Intelligence Community to consider the national
security dimension of a nontraditional threat. It
responds to a growing concern by senior US leaders
about the implications--in terms of health, economics, and
national security--of the growing global infectious
disease threat. The dramatic increase in drug-resistant
microbes, combined with the lag in development of new
antibiotics, the rise of megacities with severe health care
deficiencies, environmental degradation, and the growing
ease and frequency of cross-border movements of people
and produce have greatly facilitated the spread of infectious
diseases. “
People, produce, and animals !
© 2004 Unconventional Concepts, Inc.
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Causes of Mortality in the US
1900-2001
103,000
3,247
42 million
Infectious
Disease
Nuclear
(Japan)
Terrorism
Events
Soldier Deaths
in Battle
270 Million
Source: Multiple resources
© 2004 Unconventional Concepts, Inc.
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Leading Cause of Mortality in Adults
in US for 2002
Rank Cause of Death
Number
Deaths Per
100,000
Population
1.
Disease of the heart
700,142
29.0
2.
Malignant neoplasms
553,768
22.9
(Cancer)
3.
Cerebrovascular Disease 163,538
6.8
4.
Chronic Lower
Respiratory diseases
Accidents
(unintentional injuries)
Diabetes Mellitus
123,013
5.1
101,537
4.2
71,372
3.0
5.
6.
Source: http://www.infoplease.com/ipa/a0005110.html
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Leading Causes of Mortality Among
Adults aged 15-59 Worldwide, 2002
783,000
1,036,000
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2,279,000
HIV/AIDS
Ischeamic heart
disease
Tuberculosis
Cerebrovascular
disease
Anthrax*
*Data from 2001
1,332,000
Source: http://www.who.int/whr/2003/en/Facts_and_Figures-en.pdf
© 2004 Unconventional Concepts, Inc.
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6 Leading Causes of Mortality
throughout the world, 2002
Rank Cause
Total Deaths
1
Ischaemic Heart Disease
7,181,000
2
Cerebrovascular Disease
5,509,000
3
Lower Respiratory Disease
3,884,000
4
HIV/AIDS
2,777,000
5
Chronic Obstructive
Pulmonary Disease
2,748,000
6
Diarrheal Disease
1,798,000
Source: http://www.infoplease.com/ipa/A0779147.html
© 2004 Unconventional Concepts, Inc.
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Why Now?
• Increasing global travel
• Rapid access to large
populations
• Poor global security &
awareness
Why Now?
The world is becoming smaller!
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Sources of Agents for
Terrorism Use
• World Directory of Collections of Cultures
and Microorganisms
 453 worldwide repositories in 67 nations
 54 ship/sell anthrax
 18 ship/sell plague
• International black-market sales
associated with governmental programs
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Current Assets
US Medical Preparedness
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US Medical System
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Roughly 6000 hospitals
853,000 physicians and surgeons (2002)
2.4 million registered nurses (2002)
230,000 pharmacists (2002)
$22 billion spent on healthcare
construction (2002)
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Funding for Medical
Preparedness Activities
Grants directed towards Bioterrorism preparedness improve
overall preparedness in hospitals and communities
• HHS: $3.5B for Bioterrorism preparedness
activities in 2003
 HRSA: $500M to improve surge capacity and
hospital readiness
 CDC: $900M to improve public health capacity
• AHRQ: $5M for Anti-Bioterrorism Initiative
• NIH: $1.7B for bioterrorism research
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Cumulative Civilian Biodefense
Spending by Agency, FY2001-FY2005
DHS
22%
5%
DHHS
3%
68%
2%
-1%
-1%
DHS
DoD
DoA
EPA
NSF
DoS
DHHS
Total Spending for FY2001 - FY2005 = $22,107,800,000
US Government Civilian Biodefense
Funding, FY2001-FY2005
In Millions
4500
4000
FY 2001
3500
3000
FY 2002
2500
2000
FY 2003
1500
1000
500
DH
HS
tat
e
fS
.o
NS
F
De
pt
EP
A
Do
A
Do
D
DH
S
0
FY 2004
(estimate)
Fy 2005
(budget)
U.S. Government Expenditures
by Function 1940-1996
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13.213
Trillions of Dollars (1996)
12
10
8
5.481
6
4
1.7
2
0
National Defense
© 2004 Unconventional Concepts, Inc.
Nuclear Weapons
Infrastructure
Health
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2/3 of a Push Package
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The Strategic National Stockpile:
Push Packs
• Used to supplement and re-supply state
and local public health agencies in the
event of a national emergency anywhere
and anytime in the US with the 12 hour
Push Package containing:
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Antibiotics
Chemical antidotes
Life support medications
IV administration
Airway maintenance supplies
Medical/surgical Items
Source:http://www.bt.cdc.gov/stockpile/index.asp
© 2004 Unconventional Concepts, Inc.
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Project Bioshield
• $5.6 Billion over 10 years for privatesector procurement of vaccines
• Long-term authority for Government to
buy billions of dollars worth of new drugs
from private companies
• Allow FDA to quicken drug-approval
process during emergencies
• Includes 75 million doses of an improved
anthrax vaccine for the Strategic National
Stockpile
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Bioterrorism Agent
Vaccine Availability
Disease/Agent
Available Vaccine
Anthrax
AVA (BioThrax), inactivated
cell-free preparation, licensed
Plague
Formaldehyde-killed whole cell,
production discontinued in 1999, licensed,
does not prevent pneumonic plague
Botulism
Investigational pentavalent toxoid
botulinum antitoxin (equine)
Tularemia
Investigational New Drug
Q-Fever
Investigational New Drug
Smallpox
Hemorrhagic fevers
Typhoid
Viral Encephalidites
Vaccinia virus, live unattenuated, licensed
varicella immune globulin (VZIG)
17D yellow fever, live attenuated
Vi polysaccharide conjugate
IND TC83
Research, Development,
and Acquisition
Potential BioShield Procurements Under Consideration:
 Safer Smallpox Vaccine (MVA)
 rPA anthrax Vaccine
 Anthrax treatment products
• adjuncts to Antibiotics
 Botulinum antitoxin
• Equine
 Recombinant plague vaccine
 Botulinum vaccine
 Anti-radiation drugs and chemical antidotes
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© 2004 Unconventional Concepts, Inc.
Research and Development
Potential Future Candidates for BioShield
Procurement:
 Ebola-Marburg vaccine
 Rift Valley Fever Vaccine
 Novel antibiotics/antinfectives
 Novel antiviral drugs
 Polyclonal human anthrax and botulinum
antitoxins from transgenic animals
 3rd Generation anthrax vaccine
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© 2004 Unconventional Concepts, Inc.
Anthrax Vaccine Policy Questions
• Critical Questions – interim answers
• What size stockpile is enough? 75 million
doses?
 What will be needed in the event of an attack or
more than one attack?
 What is the value of vaccine after the attack?
• Antibiotic sparing
• Protection for residual contamination
 What vaccination policy should be followed?
• How much pre-event vaccination is needed?
 First responders
 Dense urban population
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Smallpox Vaccines: Unanswered
Questions
• How long can we rely on traditional New York
City Bureau of Health (NYCBH) vaccines?
 Known incidence of adverse events
 Evidence for higher than expected incidence of
myopericarditis
 Increasing public resistance to vaccination
• Will demand for safer vaccines require a
turnover of the stockpile to newer alternatives
when they become available?
• How much are we willing to pay for a national
stockpile of safer smallpox vaccines?
• Will the proven value of NYCBH vaccines to
control smallpox be a critical factor in the
decision?
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Issues in Preparedness
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Decision Making without Data
• Need to make decisions rapidly in the absence
of data
• Access to subject matter experts is required
• No “textbook” experience to guide response
• Understanding of “risk” evolved as outbreak
unfolded
• Need coherent, rapid process for addressing
scientific issues in midst of crisis
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Effects Magnification
Don’t need large numbers of casualties to
incur massive damage – economic,
social, psychological, political
 Example: Impact of anthrax via mail
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5 deaths
18 infected
30,000 treated with antibiotics
10,000 treated for 60 days
Many billions of dollars cost + impact
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Key Focus Areas
• Education
 Professionals
 Public
• Organization of Existing Assets
 Personnel
 Materiel
• Infrastructure
 Healthcare
 Labs
 Information
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Lessons Learned
• Detection and Surveillance
 Detection:
• For small outbreaks, medical professional reporting
more important than non-traditional systems
• Value of electronic syndromic surveillance for early
detection of larger outbreaks
 Ongoing Surveillance
• Need surge capacity to rapidly ramp up citywide
surveillance to triage suspect cases
– Hotlines, field activities, data analysis
• Prioritize management of data
– Linking Epidemic Information Exchange (epi) with labs
© 2004 Unconventional Concepts, Inc.
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Biological Agents
• Syndrome Recognition
 Most bio-terrorist agents initially induce
an influenza-like prodrome, including
fever, chills, myalgias, or malaise
 Syndromic patterns
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Rapidly progressive pneumonia
Fever with rash
Fever with altered mental status
Bloody diarrhea
descending flaccid paralysis
Respiratory Failure
© 2004 Unconventional Concepts, Inc.
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Public Health Response
to Bioterrorism
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Detection & surveillance
Rapid laboratory diagnosis
Epidemiologic investigations
Implementation of control measures
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Close Cooperation with Clinicians,
Healthcare, and First Responder
Communities
• Emergency departments, EMS
Responders, primary care clinics
• Infection control units
• Physician networks, private offices
• Hospitals
• Medical examiners, coroners
• Poison control
• Law enforcement, fire, and other first
responders
• Pharmacies
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Clues to Possible Bioterrorism I
• Single case caused by an uncommon agent
• Large number of ill persons with similar
disease, syndrome, or deaths
• Large number of unexplained disease,
syndrome, or death
• Unusual illness in a population
• Higher morbidity & mortality than expected
with a common disease or syndrome
• Multiple disease entities coexisting in the
same patient
• Disease with an unusual geographic or
seasonal distribution
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Clues to Possible Bioterrorism II
• Multiple atypical presentations of disease agents
• Similar genetic type of agent from distinct sources
• Unusual, atypical, genetically engineered,
or antiquated strain
• Endemic disease with unexplained increased
incidence
• Simultaneous clusters of similar illness in
non-contiguous areas
• Atypical aerosol, food, or water transmission
• Ill persons presenting during the same time period
• Concurrent animal disease
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Public Health in the US
Preparedness and
Disease Prevention
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What are the
Preparedness Priorities?
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Terrorism
Emerging Infections
Natural Disasters
Mental Health and Resilience
Chronic Disease Prevention
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How Can We Solve/Address
the Preparedness Priorities?
• Invest more resources in our public
health system
• Develop partnerships between law
enforcement, public health, and
education agencies at all levels of
government
• Expand international cooperation
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Why is Disease Prevention a
Preparedness Priority?
• 7 out of 10 Americans who die each
year are killed by a preventable chronic
disease
• Tobacco-related illnesses kill 435,000
people each year
• Obesity-related illness kills 400,000
Americans each year
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How Can We Solve/Address
Chronic Health Priorities?
Healthier behavior
 Eat healthy foods
 Be physically active
 Don't smoke
 Limit alcohol and avoid drug abuse
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How is the Surgeon General's
Office/HHS helping?
• Health initiatives such as:
 Steps to a HealthierUS
 Healthy Lifestyles & Disease Prevention
 Small Steps Campaign
• Increased funding for bio-terrorism
preparedness
• Better food safety through import
inspections
• Better public health and hospital planning
and coordination
• Increased use of volunteers through the
Medical Reserve Corps
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Summary
Key Points
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What are the Problems?
• Coordination
• Disorganized public health
infrastructure
• Lack of plans and programs in place
• Decision making without data
• Insufficient resources
• Incomplete understanding of threats
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Problem Solving Efforts
• Create a stronger public health
infrastructure
• Invest in surveillance systems to monitor
illnesses in humans and animals
• Billions of dollars spent on preparedness
• Enhancing international cooperation
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© 2004 Unconventional Concepts, Inc.
Key Points Summary
1. Infectious diseases and public health ARE
National Security issues, as well as a
worldwide problem
2. We need preparedness for all infectious
diseases and public health issues
•
including chronic health problems
3. Any public health system has to be able to
respond to all aspects of a disaster, or even
a non-disaster
4. There are always emerging problems
•
Continuous process
5. Science and Society need to integrate to
train the public on health issues
© 2004 Unconventional Concepts, Inc.
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PREPARING AND
DEFENDING THE PUBLIC IS
THE FIRST PRIORITY
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