 Welcome to this third day of the Centers for Disease Control and Prevention, U.S. Army Medical Research and Material Command Satellite Training Program on biological warfare and terrorism, the military and public health response. And thank you for taking time out of your busy schedules to participate in this important activity. Unfortunately, the threat of bioterrorism is real and growing. As the former Health Commissioner for New York City and Commissioner during the terrorist attack on the World Trade Center, I take this concern very seriously. The bond that exploded that day caused massive devastation and fear. But imagine what the terrifying consequences would have been had it involved the silent release of a bioweapon. There is a pressing need to enhance our nation's ability to prepare and respond to the potential of a biological attack. However, this is not an easy task. As the discussions and presentations of the past two days have underscored, bioterrorism presents a special set of challenges to our public health system and medical providers, as well as to our emergency preparedness systems and our consequence management capabilities. Clearly, national leadership and support is essential. Yet realistically, so much will unfold on the local level. Indeed, it is the on-the-ground local providers, public health and healthcare providers like yourselves, who will represent the first line of response and the very cornerstone of our ability to detect, respond and treat cases of disease that may be part of a bioterrorist incident. This is why it is so essential that before a crisis occurs we build the knowledge and capacity for effective response. Training sessions such as this one are vital to this effort. Effective preparedness and response will also depend on a number of other crucial efforts currently being spearheaded by our department, and I just want to mention a few briefly. For example, the need to ensure a robust public health infrastructure for disease surveillance, epidemiology and outbreak investigation. The need for enhanced laboratory capacity to support rapid diagnostics in response. Enhanced communication systems to share critical and emerging information in real time. The development of a national pharmaceutical stockpile is a national resource for civilian use, as well as other strategies to expand capacity to support ongoing medical consequence management. And of course, both new and continuing investments in research to develop improved drugs, vaccines and diagnostics that might be necessary in the face of a bioterrorist attack. Much more could be said about the activities underway or planned by our department and our federal colleagues and partners, but I should let you return to your very full agenda. But again, let me thank you for taking the time to participate in this training program and to talk with us about this important concern. Together, we must ensure that we have the knowledge, tools, relationships and support to respond effectively should a terrorist attack occur. Thank you. This program is presented by USAMRAID, the United States Army Medical Research Institute of Infectious Diseases and the Centers for Disease Control and Prevention. Forty years ago, we prepared for nuclear war. Now the Cold War has ended and we face a new threat, unprecedented and unpredictable. It may not come with explosions. It may not come with rockets overhead. We may not see it when it happens while it quietly infects. Whether you're a soldier or civilian on the battlefield or at home as patients roll into your emergency rooms and clinics, your aid stations and field hospitals, will you recognize the symptoms? Will you recognize the signs? Will you know what to do? Welcome to day three of this special satellite broadcast Biological Warfare and Terrorism The Military and Public Health Response. I'm Bob Howard from the CDC and I'll be your moderator for this final segment of the broadcast. We'd like to thank everyone who has participated in this three-day video teleconference. The response has been outstanding with more than 20,000 registrants at about 700 downlink sites. And be sure to tell your co-workers who couldn't watch the broadcast at this time, the entire course will be taped and rebroadcast on October 2nd and 3rd at 11 a.m. till 5 p.m. each day. Now we'll finish up today with a final exam and evaluation for this course. We recommend that you complete and return the scan form to get your C-N-E, C-M-E and C-E-U credits. Or you can take the exam online by logging on to the website at www.biomedtraining.org. The deadline to receive credit for this course is October 31st. We'd like to thank our colleagues at USAMRAD for all of the great information that they've shared during the past two days. So during this broadcast, we'll talk about the threats that biological terrorism poses to the civilian public health and medical systems. Specific objectives to talk, to include in this conference is how to differentiate between a public health response to a bioterrorism event and outbreak investigations. Identifying the roles of primary care providers and public health professionals in a bioterrorism event so that all participants can communicate effectively and coordinate activities to work together as a team during a response. That's what we want to do. You'll also need to identify the components of a public health response as it relates to bioterrorism that we'll be hearing from professionals in many different fields of expertise who have come together today and are contributing bioterrorism preparedness strategies throughout the nation. They'll talk about their plans and ideas for ongoing preparedness activities. But it's very important for us to know what your ideas are and what plans you already have in place in the state and local level. There are also two questions and answer sessions in this broadcast and we hope to answer as many of your questions as we can possibly get to. Now, let's start off the program today by looking at this. Los Angeles, California Indianapolis, Indiana Atlanta, Georgia Washington, D.C. These cities are all very different in size and demographics but they do have one thing in common. They have been centers for threats of bioterrorism. Graphic images of the World Trade Center and the federal building in Oklahoma City are still vivid in our minds. While the possibilities of bombings are terrifying we are now also forced to confront the new and potentially even more devastating threat of biological terrorism. Bioterrorism is a real threat in America today. It is no longer just an idea or a concept in a novel or film. It has happened in our country. Anyone or any organization who wants to make a statement or harm our citizens for religious, political, ideological or personal reasons can use biologic agents. This poses new and different challenges to health departments, law enforcement, the military, politicians and the business community. They happen anywhere at any time and the public health workforce must be ready to act. You know, these video and print images have come into all of our homes and they're very sobering. This collage of clips vividly illustrates the fact that terrorist threats can occur anywhere at any time. Terrorists can choose from many different biological agents and make weapons that can be used without warning or unsuspecting populations in these days. The use of biological agents to threaten and harm the U.S. civilian population is very real. You can understand that bioterrorism preparedness is a major challenge to our nation's health system. But we must be ready to detect, investigate, characterize and respond to such threats to protect our communities. This program will help you become more prepared. To start things off, I'd like to introduce Dr. Ali Khan, the Deputy Director of Epidemiology and Surveillance of CDC's Bioterrorism Preparedness and Response Program and Dr. Denise Koo, Director of the Division of Public Health Systems and Informatics in the CDC's Epidemiology Program Office. Now these folks may look familiar to you if you watch the first part of this video teleconference. Welcome, doctors. As we saw in the previous parts of this course, public health professionals learn a lot from the military's perspectives on handling a crisis and throughout today's broadcast the military can benefit from public health's experience with these diseases. Now surveillance and outbreak investigations are very important to us. Dr. Khan, how does biowarfare differ from bioterrorism? Well Bob, as you learned from the first part of this course biowarfare is the use of biological weapons to cause disease or death on the battlefield. Now these biological weapons can be used for strategic or tactical purposes, but let's move on to the topic of today's broadcast. For bioterrorism, for public health purposes, we define it as deliberate or threatened use of biological agents to harm a large number of civilians. Now bioterrorists can be groups or individuals who want to gain credibility, garner publicity for their group or causes or simply disrupt daily activities. These persons or groups may have different backgrounds ranging from the far left to the far right of the political spectrum and some terrorists may just want to harm or kill large numbers of people. And sometimes we really need to accept the fact that their motives may be unknown to us. Now as you might expect public health responds differently to bioterrorism than the military would to biowarfare and one of the big differences is that public health professionals work with a large number of partners in our healthcare system, law enforcement and emergency management when we deal with the civilian bioterrorist event. Now another difference is that we would have to deal with the consequences of bioterrorism not on a battlefield but in our cities with populations that aren't limited to young healthy people. Yes and even though bioterrorism is attracting lots of attention today, as we mentioned in the first part of the video conference the crucial role of public health professionals during a bioterrorism was first recognized over 40 years ago. So in a sense we've just recently started refocusing on bioterrorism as a public health concern. This renewed focus stems from recent events as you have seen and as evidence a few years ago the FBI investigated 20 to 30 incidents that were thought to be bioterrorism threats. In contrast the number of threatened incidents this year alone totals over 200. If you remember Mr. Patrick's comments on aerobiology from day one of this video conference you realize that these threats can become a reality. Using the appropriately engineered agents, bioterrorists could cause large scale indiscriminate casualties. Well Denise, my brother who's a junior in college right now is actually doing PCR in his as part of his research studies and you know we've talked about traditional threats but are genetically altered organisms also somewhat of a concern? Yeah but you know I tried DNA sequencing in college and I could never get it to work so I think it's really a lot harder than people think. And then we also talked a lot on day one about how these agents are widely available but really it's not that easy. Yeah you're right, we nowadays we have the select agent rule which actually dictates who or makes you register before you transfer organism from one side to another side and I guess we hope on that theme the same things true for the internet. We like to say that there's lots of information available on the internet but as we all know that information necessarily isn't good information. Pretty clear to us here there's some real challenges posed to us by technology and the internet and both are good and the bad. Last year President Clinton and Congress recognized the importance of bioterrorism preparedness and the president announced his intentions to upgrade our public health systems for disease detection and early warning. A bioterrorism incident does occur. Which groups of health professionals are most likely to discover a bioterrorism incident? Well Bob as Ali mentioned earlier bioterrorism is targeted at civilians. This means that paramedics, emergency room physicians and other frontline healthcare providers could be among the first groups to realize that something unusual is taking place. Because information should flow from healthcare providers to their local public health departments I think that local health departments rather than the military or the police will become involved very early in the response to a bioterrorism event. Unless the bioterrorist makes an announcement it's impossible to tell when and where the next bioterrorism threat will arise and what type of pathogen may be used. We must be prepared for anything at the local level. This is why CDC is spearheading efforts to educate the public health community about bioterrorism. We want to help coordinate local, state and federal activities to ensure an effective response to a bioterrorism threat or event. Thanks Denise. Now these are all good points to remember throughout our discussion of public health bioterrorism preparedness. It's especially important to think about ways that we can work together with our partners which is the key theme for today. We've seen the types of threats that face our nation and we know that bioterrorism events have happened and continue to pose a danger. Now let's first take a look at a naturally occurring outbreak. In the spring of 1972 Yugoslavia found itself in the midst of a devastating smallpox outbreak that started from an imported case. After 45 years without a case of this disease healthcare workers transferred early patients through medical hospitals without proper diagnosis. These initial cases started an outbreak which forced the government to quarantine hundreds of persons and whole villages. Yugoslavia was in turn shut off from its neighbors. A mass vaccination program ensued. 18 million people within a period of three weeks received the smallpox vaccine. During the six-week outbreak 175 people were infected and 35 died. Vaccine and quarantine control measures proved successful and Yugoslavia was declared free from smallpox in May of 1972. Well this has got to be every public health official's nightmare. Now while we know that this particular smallpox outbreak was not deliberately caused it's amazing to think about how rapidly it spread throughout this community in this country because it was not detected early. You're right Bob, this is a really scary situation. Over the last two-three years I've reviewed numerous scenarios and none of them is scary as this one because it actually happened and it happened recently in 1972, five or six years before the disease was eradicated in a country with reasonable healthcare facilities it was in Europe. We now know that smallpox may exist and could actually be used as a bioterrorist agent and this example really highlighted what might happen today if a case of smallpox was not recognized early. It includes the possible need for mass vaccination campaigns. The Yugoslavians vaccinated 18 million of their 20.7 million citizens to get this outbreak in control. Also they had to use overly restrictive quarantine measures. Thousands of people were quarantined, even whole villages were quarantined and in all reality for its sensual purposes the entire country was immediately isolated from its neighbors when they learned of the outbreak. Now the big public health message in this story is that this outbreak could have been prevented if the disease was recognized earlier. It has an interesting side note Denise one of the first cases had a typical prodrome and he got an antibiotic developed a rash which everybody thought was a drug induced rash and then this guide was shown to all the house staff and eventually caused 35 additional people to get ill. So I guess the key medical lesson for this scenario is if you have an interesting rash don't necessarily show it to all the medical students and house staff. Wow, great teaching point Ali. This is really why we're here though. We really need to detect diseases like smallpox earlier and be able to curb their spread before they affect as many people as we saw in the Yugoslavia case. This is true for diseases due to natural causes or bioterrorism. As mentioned earlier we in public health rely on health care providers to consider unusual illnesses in your differential diagnosis and when indicated or suspected report the case or cases to public health and on the public health end we'll need to consider the possibility of an intentional threat to the public when we monitor the health of the population and when we conduct our investigations. Early detection and control of infectious diseases depends on strong partnerships between those at the front lines of health care and public health. We'll describe those partnerships throughout this broadcast. I assure you the word partnerships is going to be repeated throughout this broadcast. This traumatic smallpox scenario leads us into the discussion of public health critical agents. Now you learn quite a bit about the biological agents that can be used over time in the first two days of this teleconference. You know Ali when I reviewed the military's list of agents in the student materials and the public health critical agents list I noticed there was quite a bit of overlap between the two of them. Bob there are some common agents between our critical agent list and the military's published list of warfare agents so it's available in your student package. This isn't really unexpected if you think about it. The same agents are likely to kill or sick in large civilians or military people. But there are some critical differences here. Most importantly our list is driven by the unique public health and medical vulnerabilities of a large civilian population and the preparedness steps that are going to be necessary to address those vulnerabilities. The smallpox episode we just saw is a good example of how we determined what goes on that critical agent list. Smallpox is a high case fatality. It kills up to 30% of its patients. It's contagious or spread from person to person and based on scares of imported cases into the U.S. in the past it's likely to cause mass panic and social disruption. Most importantly going back to those preparedness needs a smallpox outbreak would require you to do a number of things to prevent further spread of the disease such as prepositioning diagnostics stockpiling vaccines developing specific response plans just to name a few. Now let me give you some background on how we developed the critical biologic agents for public health preparedness list or what we call our critical agent list. Earlier this year we gathered a group of infectious disease and public health experts, members of civilian and military agencies and law enforcement officials to help us determine which agents to concentrate on in public health. We ranked the agents in four areas. Public health impact delivery potential to large populations heightened public perception and specific public health preparedness needs. Now the public health impact criteria was pretty straightforward. It includes morbidity and mortality rates and how many people are likely to get sick and die if they're infected. The delivery potential criteria of an agent was the ease with which a virulent strain of the agent could be distributed in order to affect a large population. So this inherently describes the agent's ability to remain viable after it's released into air, food and water. Another way to deliver an agent to a large population efficiently would be if it spread person to person. Now this heightened public perception criteria took into account the potential amount of public fear and civil disruption that you could cause with this agent or even the threatened use of this agent. Now the last was the topic of public health preparedness needs and this is what I think distinguishes our list from the military list and a number of other lists that are published. The specific preparedness criteria that we used were enhancing surveillance prepositioning laboratory diagnostic capabilities, the necessity of stockpiling medications, vaccines or equipment. We also included increased awareness and education about the agent for healthcare workers, laboratorians and the public, like we're doing with this course which would be required for preparedness. We also reviewed the need for specific research and we took into account all of these criteria and following some general guidelines gave each item a score. We tallied the scores and then ranked these agents into categories A, B and C. And we have our new baby. The critical agents biological list for a public health preparedness was born. Denise, please take us through the categories in this in more detail. Well as you might expect, category A critical agent scored highest in all of the criteria. Besides being most likely to cause mass casualties, they require broad based public health preparedness efforts including the improvement of surveillance and lab diagnostics and stockpiling of medications. In your student, in your packet of student materials, you'll find a chart called clinical characteristics of critical biologic agents. This chart includes a lot of information about all of the category A agents. Keep in mind that this is not likely to be used list. Now you're looking at a list of category B agents which also have the potential for widespread dissemination and illness, but don't need public health preparedness efforts that are quite as extensive as agents in category A. This doesn't mean that there's nothing to do. We still need to selectively improve the awareness, surveillance and lab diagnostic capabilities for these agents. However, for category B agents, there are two requirements beyond those we would need for the agents in category A. In many cases, the stockpiles and surveillance activities for category A agents also cover the diseases caused by category B agents. The examples of category B agents that you saw are mostly fairly uncommon causes of disease, but biologic agents that raise concerns for food and water safety, like salmonella species, chigella, e.coli 0157, and cryptosporidium are also included on the B list because they could be used to infect people. Now category C agents are any pathogens that are considered to be emerging threats and might be used for widespread, deliberate dissemination. Some examples of agents in this category include Nipah virus, Hanta viruses, tick-borne hemorrhagic fever viruses and multidrug resistant TB. Plans for handling category C agents are also covered in general epidemiologic preparedness activities. Let's look more in-depth at these agents in category A because they are the primary focus for many of us. Ali, kind of take us through the beginning of this. I'll be glad to do so, Bob. The first agent in category A is Virialovirus, the agent that causes smallpox. We've heard about this in the last two days. As we touched on before, routine smallpox vaccination in the U.S. was discontinued in 1971 and smallpox was officially declared eradicated in 1980. Since then, published reports have circulated that the smallpox virus was mass produced as a biological weapon in the former Soviet Union. In addition, there were reports that some other countries may have retained Virialovirus instead of destroying their stocks or shipping them to the two official repositories here in the U.S. and in Russia. So we can no longer be sure who has access to this. Bacillus anthracis, the agent that causes anthrax, should be very familiar to you by now. This agent is normally found in soil and animal outbreaks worldwide. It's also easy to grow. The infectious spores are very stable so they could be spread over a very wide geographic area as a small particle aerosol. Now, an outbreak of anthrax may be hard to track. Instead of mapping weather conditions over in terrain, public health professionals may be faced with tracing a path through crowded city streets, subways or in crowded spaces like malls or large office buildings or airports. To even further complicate things, the clinical appearance of anthrax is unfamiliar to U.S. physicians and the laboratory would probably consider a positive culture for Bacillus to be a contaminant rather than a disease-causing agent and just chuck it out. And an autopsy which would definitely give you in diagnosis are getting rare, so that's not even necessarily a fail-safe anymore. Yes. And next is plague. When we talked about plague in the first part of this video conference, we pointed out that naturally occurring plague still exists in some places in the western United States. Your syniapestis, the causative agent, is generally passed to humans through bites from infected fleas. Plague disseminated via aerosol causes the more deadly form of the disease, mnemonic plague, which is also contagious through respiratory droplets. Next up is bot. Now, unlike the other agency category A, botulism is caused by a toxin which is produced by the microorganism Clostridium botulinum. Because botulinum toxin is the most toxic compound known, a very small amount can produce respiratory failure within 24 hours. This small amount of botulinum toxin can be delivered by aerosol in food or through untreated water systems. Now, tularemia caused by Francisella's tularensis is a naturally occurring zoonotic disease of rabbits and rodents. The bacterium is extremely infectious as a small particle aerosol and a well-documented hazard in the laboratory. Now, most tularemia strains cause mild infections, but there are some strains that have about 30% case fatality associated with them if they're not treated. Finally, the viral hemorrhagic fevers. This is a category A critical agents list because they're highly fatal again, contagious and definitely would generate a good amount of public health panic if they were released or disseminated in the United States. Now, the viral hemorrhagic fevers that we're specifically interested in are the filoviruses and the arenaviruses. Examples of the filoviruses include Marburg and Ebola which are spread among humans through blood or body fluids and if you look for them in nature, these generally presumably would be acquired from a research laboratory that handles these agents ordering a field investigation. Arenaviruses like Lhasa, Honin, Sabia, Machupo and Guanarito viruses cause Lhasa fever in Western Africa and the South American hemorrhagic fevers. Now, these viruses are naturally carried by rodents in different parts of the world. As a bioterrorist weapon, arenaviruses can be easily stabilized by the transmission in aerosol form. Actually, they're normally transmitted by rodents this way to people. Well, I think it's important to remember that the critical biological agents list is really a list in evolution. In the future, intelligence data and experience will form us about additions and subtractions that we need to make in order to keep the list targeted on public health preparedness needs. I'd also like to point out that these are by no means that bioterrorists could use to produce disease. Our general public health activities include ongoing monitoring of a designated set of diseases on the National Notifiable Disease List. Public health officials at state health departments and CDC collaborate in determining which diseases should be nationally notifiable, or in other words, which diseases should be reported by the states to CDC. At the local level, you are required by law to report cases of the state-specified diseases to your health department. The list for your state or local jurisdiction may be different, but it will generally include at least the diseases on the National List and any others of special interest in your state. Reports of diseases that are nationally notifiable are routinely sent to CDC, and virtually all of the public health critical agents in Category A are also on the National Notifiable Disease List, as well as many others in Categories B and C that could be used as agents of bioterrorism. You'll hear a lot more about the vital importance of reporting diseases later today. You know, it's intriguing for those of us at work in public health communications that those two agents, Smallpox and Ebola that are on Category A and the primary part of that list cause virtually no illness in the United States, but it's the one that writers in both novels and movies make such a big deal of, and it's a kind of thing we do have to be still on the lookout for. Thanks, Denise and Ollie, for that overview of public health critical agents. Now, let's take a follow-up look with a bioterrorism event that used a common agent on the National Notifiable Disease List with this story out of Oregon in 1984. On September 17th, 1984, the Wasco Sherman County Health Department received calls from folks reporting gastroenteritis after eating at several restaurants in the Dalles, Oregon and particularly eating from salad bars. Based on that preliminary information, the sanitarians closed the restaurant salad bars in the Dalles and they invited the state and the CDC to participate in an investigation of the outbreak. We knew that in a community of about 10,000 people, we certainly wouldn't expect to see dozens and dozens of people coming forward all at the same time with a common source. And so the challenge immediately was to try to find a common source. There were lots of interviews and there was lots of field work done in the restaurants in the area. There were 38 restaurants in the Dalles at the time and all of them were looked at. They looked, of course, for things like lots of lettuce some other common ingredient to the salad bars which seemed to be implicated that might be a common source that could readily explain this. We were afraid that we had some sort of interstate shipment of something that all of the restaurants had in common and that turned up negative and that was extremely puzzling because usually you can find a common source of something like this. We confirmed that illness was associated with eating at least 10 of the 38 restaurants in the Dalles. Eight of these 10 restaurants had salad bars and illness was associated with eating at the salad bars and not just for customers it turns out that employees of these restaurants also became ill after eating at their own salad bars or at salad bars at other restaurants in the community. As it escalated at one point somebody suggested the possibility that it had been an intentional contamination of the salad bars but frankly that seemed pretty far fetched to us. You know they say when you hear hoof beats you're supposed to think of horses not zebras and there had never been any report of an intentional contamination like this in the U.S. and nobody was stepping forward and claiming credit nobody seemed to have any motive it was just all of a sudden there were all these people getting salmonella typhimurium it looked like a common source but we couldn't come up with a plausible explanation for it. During the course of the outbreak investigation we got several reports of suspicious incidents in one case a patron was observed at the salad bar of one of the involved restaurants the patron put the ingredients on their plate sat down at a table and then went back to the salad bar and discarded the ingredients in the salad bar. With the benefit of hindsight one of those incidents was probably an example of the saboteurs deliberately contaminating the salad bar. There were really a couple of phases to this event the first one was the epidemiologic investigation and the control of the outbreak and before that was over we had spent thousands of person hours and we had cultured thousands of people and we had identified over 750 cases of salmonella typhimurium we got it under control and at this point the police, various police agencies, the state police the FBI the Attorney General's office the organized crime unit in fact from the state of Oregon the local law enforcement folks a number of different agencies were looking at the activities of the cult of the Rajneeshis they were suspected of a number of different crimes and in fact they were later some of them convicted of arson and wire tapping and a number of other things in addition to this intentional contamination of the food in fact if we had known what the law enforcement agencies knew we would have been a lot more suspicious we were public health types innocence and the law enforcement people already knew that these folks were attempting murder they had tried to torch the office of the land use planning folks in wasco county they had brought in homeless people from around the united states to get them registered to vote they had done a number of other things inside the commune like wire tapping the hotel at the commune had bugs in it all over the place they were already being investigated for a lot of things and so the police almost immediately believed that they had been involved with this contamination event passed by the FBI and the attorney general and the state police to go to the Pythagoras Medical Clinic which was part of the Rajneesh Medical Corporation and to go to their clinical laboratory and look for anything that looks suspicious to be as a microbiologist anything that might have been used to grow salmonella or if I found any salmonella to seize it as evidence and so that's exactly what I did I went into the laboratory the cultures that were growing in incubators I looked at their stock cultures and control cultures and I looked in freezers and refrigerators I talked to the medical technologist who worked there and then I found a set of control discs in a little vials and one of them was a salmonella and typhimurium control disc and we didn't know it at the time but that almost certainly was the source of the culture that they used to contaminate the salad bars and that was a possibility that an outbreak would be caused intentionally was not on our radar screen in 1984 today the possibility that an outbreak would be caused intentionally is on everybody's radar screen you hear a lot of people say that it's only a matter of time until some sort of bioterrorist event occurs in the United States and I would say to them it already has occurred and it was not imported by foreign nationals sneaking through New York or Los Angeles airport it was actually carried out by people who were living legally in the United States either as residents or citizens and not on the on the coast but right in central rural Oregon and it was not done for reasons of national espionage it was done to affect the voter turnout for a land use planning vote and so if people would do something like this it would take so many hundreds of people ill over something that trivial it frightens me to think what they might do if they had something much larger at stake well it's just a great example having Mike and Tom point out to us some of the things that they saw at the local level as this evolved and it really does help us to understand that the threat of bioterrorism is a reality right here in America right here in River City I'd like to start off introducing two new panelists my friend and colleague at CDC who I've done investigations with and work a lot in the building Dr. C.J. Peters who heads up our special pathogens branch at CDC and my friend at the state level Dr. Dennis Pirata who is the acting state epidemiologist for the state of Texas welcome gentlemen thanks for taking time to be with us today Denise I want to go back to you though on this particular one and talk a little bit about what was unusual about this might not be a naturally occurring event well Bob I think we're going to get into how to distinguish bioterrorism event from a naturally occurring disease outbreak a little later in this broadcast but I can point out some of the clues that we should look for right now because this case is a good example there are over 40,000 reported cases of Salmonellosis each year in the United States but the specific agent used in this case Salmonella typhimurium was not a common cause of illness in this area of Oregon so the first epidemiologic clue or epi clue for short is that the infectious agent was uncommon to the area now most of you know that Salmonella bacteria are often associated with foodborne disease outbreaks and they're usually found in products like dairy, meat or poultry or contaminated water supplies at that time Salmonella bacteria were not commonly known to be associated with items found in a salad bar so there's the second clue uncommon vehicles of transmission and the next clue many different items in the salad bar were infectious one dish could not be blamed and those who were ill ate at several different restaurants in the Dolly's Oregon there was no common thread linking all the restaurants each place had different food suppliers ingredients and food handling staff making a common source or cross-contamination likely this clue was really the most significant tip-off that the event was not necessarily a natural occurrence but the public health authorities in Oregon couldn't be expected to tell that this was a bioterrorism event they were in a different time I guess you could say a more innocent time we're moving into a new age that they helped usher in a time where we can't afford not to suspect every unusual event in fact the public health officials did consider that this outbreak was intentionally caused but that suggestion was dismissed because there was no known motive no claim of responsibility and then there's the fact that sometimes we just can't figure out the cause of an outbreak even after the investigation exactly Denise in addition to representing the first bioterrorism event identified in the US it also shows how important it is to consider the way very different scenarios that we may now have to face will play out understandably this bioterrorism event wasn't recognized for months a very major factor in the lack of the recognition was that the investigators and their consultants didn't imagine a scenario which would explain why and how someone would do such a thing there was no apparent gain there were no claims by terrorist groups and there were no attempts at extortion members of this cult were distrusted by the local law enforcement agencies and no evidence to link them to the disease outbreak no disgruntled employee could be identified another common cause of mischief in addition it appeared that there were multiple contaminations when it finally came to light that these were practice runs before the election the pattern of bioterrorism became understandable any unusual event that we witness must trigger at least a mental examination of the possibility that someone may have intentionally caused the event the challenge here will be to reach a position in which we can sift through the many many situations which will raise a red flag to arrive at the few that we really have the capacity and the need to investigate there's also a time factor can we do all public health investigations with a full court press an all out effort the period of time in which we can successfully intervene and that will only result in partial success may be very short in a bioterrorism event I'd also like to mention some problems related to so-called medical progress it was difficult to handle the bioterrorism event in the 80s but it may be even harder now because of the improvements in medical care I'm talking about for example a lack of open beds due to managed care automatic blood cultures that don't detect and consider the critical agents and medical progress in general which has pushed the knowledge of our critical agents out of the curriculum because of the infusion of new medical information but that's the gloomy side of preparing for a bioterrorism event there's a great deal of existing knowledge in public health that we can work from to make us better prepared to deal with future bioterrorism events exactly CJ certain aspects of the public health response to a bioterrorism event resemble the routine response to a natural occurring disease outbreak the specific steps to follow will be the same but the emphasis may differ as we'll see you know a point I have to go back to very quickly here Denise as CJ pointed out the improvements can sometimes present new challenges to us too and the technology, the science the changes really can present challenges that we have to be aware of when it comes to detecting these problems Denise I'd like to think that most of our audience are familiar with them but why don't we review the steps in a routine public health response okay well generally there are four components to the public health approach to a problem there's surveillance and monitoring to recognize problems identifying the cause through investigation evaluating implementing control measures to prevent further spread of the disease and developing programs and policies on a broader basis to ensure that problems do not recur of course once we develop new programs and policies the job isn't over we start back at the bottom of those building blocks again we have to continue to do surveillance to make sure the program is working to decrease the occurrence of disease you know Dennis as we look at somebody like you who works for a large state health department we have to ask what can you do to help us here to understand the flow of information when these outbreaks and these problems occur sure well let's go over the components of the public health approach public health surveillance and monitoring is an ongoing watch type kind of event local and state public health departments regularly collect information about many types of diseases or illnesses and as Denise mentioned all health care providers hospitals, laboratories are mandated by law to report cases of a variety of infectious diseases to their local health department plus any unusual disease manifestations or clusters each state has its own list of reportable diseases but it's really up to you the local health care provider to look out for and report those diseases as well as any other unusual diseases those reports are then sent to the state health department by the way there's a listing of state and territorial health departments in your student packet along with a case definitions document that describes what we might count as a case of illness for public health purposes please remember that we don't want health care providers to wait until they have confirmed diagnosis or to use this case definitions document as a clinical guidance to decide who should be treated instead of contacting the local health department in fact in many cases it's important to inform the public health department as early as possible this way quick actions can be taken to prevent further cases of disease we just want you to be aware that these case definitions exist and how they're used by public health professionals and as someone who works for a state health department I can tell you that the importance of these ongoing reports on diseases and health conditions is absolutely vital to the discovery and tracking of outbreaks our front line of information is you so when we receive initial reports of clusters of cases at the state level we may decide to do an investigation if the number of cases is greater than what we might expect we might simply call the provider to verify the diagnosis or we may decide that the cluster is rare enough or unusual enough that it may require investigation usually we do these investigations to identify the cause to control the spread and to prevent additional cases CJ no matter what the disease you can tell us more about what happens during the field investigation and lord knows you've done field investigations kind of walk us through some of this well Bob the first decisions are how much effort should be directed at the investigation and how soon should we start the two questions are interrelated and they usually decided upon after looking at the existing priorities in the public health system we balance that information against the available resources additional help needed to investigate and related factors keeping in mind the limited time factor that I talked about earlier we have to act quickly please remember that a bioterrorism event may not be immediately relevant evident but when suspicion increases the steps of the investigation must be greatly accelerated and the response to the event would have to happen just as fast if not faster the goal of all these investigations is to establish the disease-causing agent sometimes this is easy like investigating cases of diarrhea but sometimes an epidemiological team is called on to identify new diseases toxic shock syndrome, Legionnaires disease polarized pulmonary syndrome this is not necessarily easy the first step is putting together a case definition so that you can explain exactly what you are looking for as more cases are identified common links usually appear and these links can lead us to the cause for example in a food born outbreak we would ask patients about the foods they ate during the possible incubation period we might ask them where they bought the food where they consumed the food if an aerosol dissemination is suspected patients are asked about the different places they went during the incubation period just as common meals eaten at a restaurant or party can implicate a food born cause an aerosol event may be signaled by the appearance of sick people with exposures at the same site at the same time the site may mean a building in which aerosols were introduced through the air conditioning system or it may mean an outdoor area that is defined by the pattern of dissemination the subsequent wind currents and other meteorological events when all of this information is gathered public health investigators can systematically categorize the outbreak in terms of person place and time it's like newspaper reporting we try to find out who what where and when who was affected what kinds of exposures occurred where were they infected and when were they infected the missing part of the puzzle is the cause of the answers to the questions of how and why you know Dennis if all of the patient reports the same exposure then I guess you know you've got the cause right well not necessarily but if a lot of information is pointing to a probable cause we can still take immediate action to control the outbreak for example in the organ outbreak although the cause was not yet understood all of the patients reported eating at restaurant salad bars so the restaurant salad bars were closed these this brings up a very important point we often begin interventions before we know the how and the why of a disease or illness this could stop further exposures while you wait for information of the diagnosis but the investigation will need to continue in order to find the cause so Denise there is this big $64,000 question that's pending on us here and that is how do you determine the cause well we look at the common links as CJ mentioned we generate theories about how they became ill for example let's say that all the patients in a given outbreak ate a commercial cheese product and drank tap water both of which are plausible vehicles of infection is it the cheese or the water the next step is to narrow down our list of culprits by comparing these patients to other people in the same situation who didn't become ill so in the situation I just described since we think most everyone drinks tap water and maybe also eats lots of cheese products we couldn't recognize the cause as a contaminated water supply until we found that the people who were not sick did eat cheese but they drank bottled and not tap water so once the cause is identified control measures can be implemented if they aren't in place already as Denise already mentioned in this example the health officials could have the water supply coordinated or if it turned out to be the food product have the food product recalled for some diseases they can identify and treat additional exposed persons prophylactically to prevent them from becoming ill so in this kind of control measure if there is a systematic problem with the source of an outbreak a real life example would be perhaps the cryptosporidiosis problem in Milwaukee which was caused by inadequate filters for commercial water resulted in 400,000 illnesses you should know that no matter how short or long term the intervention measures are the local state and federal investigators will continue to monitor the public's health through surveillance to make sure that their actions have led to the end of the outbreak and that they will prevent recurrences and Denise we've been talking about the state and local health department's response to a public health outbreak what about the CDC what's our role in this kind of surveillance activity what do we do here well you knew we wouldn't leave out the CDC hope not let me start by saying that most people don't realize that the U.S. Constitution doesn't make any provisions for public health in this history class way back in high school anything not mentioned in the Constitution falls into the jurisdiction of state governments in normal situations the role of CDC is actually more like that of a coordinator the state and local governments actually run the show CDC routinely collects information on diseases from all of the states and by doing this we can help identify problems that cross state boundaries CDC can always provide assistance to investigations and laboratory diagnosis when requested and we help with investigations that involve multiple states keep in mind that much of the second half of today's program will describe the CDC's plan to enhance state and local preparedness efforts through improved detection and surveillance, diagnosis and characterization emergency response planning communication and education and we've been discussing the steps that public health professionals take in response to any disease outbreak now let's watch how all of these elements come into play in this example of a real life outbreak of an unknown disease upon quick surveillance five additional cases were discovered in area health facilities causing a swift mobilization of local, state and federal health constituents the disease, hantavirus pulmonary syndrome while local and state health departments in the Four Corners region had begun investigations the CDC in Atlanta was also aware of the situation after the states had completed a very thorough investigation in the laboratory and had begun to collect the epidemiological data we received a portion of this information on Thursday and started talking about it among ourselves we had a formal meeting we discussed the epidemiology clinical laboratory and we all agreed that there was really no single agent that we could think of that would cause this kind of pattern ideas came up influenza, inhalation anthrax mnemonic plague but they were all shut down because of some feature or another because we had good solid information we felt like it was something new and we felt like we had to mobilize on Friday we had an invitation and we had people on the way out to Albuquerque one of the reasons that we got involved was strictly a matter of resources the states do not have the specialized resources to test for every agent and they don't have the manpower to be able to put on a full court press in a situation like this at one point we had 25 or 30 people in the field and we had 75 people in the lab in Atlanta working on the samples so you can imagine how state health department itself very quickly over its head and as a matter of fact we were over our hands too we didn't have and don't have that kind of surge capacity so I think that of a necessity there's going to be a very tight collaboration here to get the resources on site to be able to do the investigation and to get the samples back to the lab and get them properly tested as soon as our team began to arrive they began to draw the investigation together to work with the four states to get the questionnaires done and to get out into the field and start doing the actual nuts and bolts epidemiology but this obviously took two or three days to get on the ground furthermore wireless was happening cases continued to flow in and we began to see an epidemic building in front of our eyes we then said about the classical sort of epidemiological investigation that you're all familiar with person-placed time during the outbreak investigators considered the idea of an intentional biologic release this theory was soon dispelled as they progressed through the standard steps of an epidemiologic investigation I think if I look back on Hanover's pulmonary syndrome one of the things that was so impressive was the way it stuck out the pattern was different and that should have made us think of a bioterrorist event and it did cross our minds and it did of course cross the minds of the tabloid press as well we were able to close the loop by showing that the genetics of the virus that was transmitted from the rodent to the human was exactly the same as the virus that occurred in the human tissues at death we were able to dispel any kind of idea that this was a terrorist event or some sort of intervention we were able to show that the widespread distribution of the virus was inconsistent with some sort of recent introduction and a whole variety of really very calming kind of things flowed out of this and left us then with a problem that we had to deal with in terms of prevention measures therapy and so on but that's a very specific problem that we're used to dealing with in public health in a bioterrorist situation presumably identifying the pattern as being that of a bioterrorist event will result in a whole different cascade of events for prevention control treatment so the investigation while it didn't prove it was a bioterrorist event opened up the way to showing why it wasn't a bioterrorist event rather than just shrugging and saying it doesn't look like bioterrorism to me the hantavirus outbreak investigation serves as a model for the public health response to biological terrorism confounding elements such as unknown agents media presence, coordination and communication of diverse partners and a need for quick solutions will all play a part in a response to biological terrorism remember that in any investigation time translates into suffering in human life in a bioterrorist event it's going to be even more compressed with the exception of smallpox these agents have very limited interhuman transmissibility they're not highly contagious with the exception of smallpox so the time when we can effectively intervene to change anything is essentially from the first case to the last case that is the spread of the incubation period of that disease and that may only be a few days so we don't have time to waste to get in there get the evidence that it's a bioterrorist event get the agent and effectively intervene to save lives and to prevent suffering you know this hantavirus outbreak was a pretty recent event Dennis would you call this a successful public health response? the investigations were really quite exemplary for the early 1990s clinicians with the Indian Health Service recognized a unique problem the Office of Medical Investigation was on top of the problem and the clinicians extended the list of suspected cases the local and state health departments were in the loop as well there was a careful assessment of the epidemiology microbiology and other features of the cases local authorities recognized that there was something amiss this was not your normal epidemic I was very impressed that our public health system was functioning at such a high level then CJ this was a nice piece of video and you had an awful lot of face time in this investigation you had an improvement in the way public health officials were able to respond in this situation from what happened in the Oregon Salmonella investigation Bob I think that during the hantavirus outbreak it really just took too long to get into the mode in which the unheard of was regarded as a real possibility only the tabloids thought it could be an intentional outbreak and they were blaming the government this epidemic was recognized in early May but we really didn't shift to a concentrated effort until the end of May once everyone's mindset changed it was only a few days until new information from a new perspective began to flow in when we knew that it was a hantavirus that it was multi-centric the deer mouse was a reservoir then we could begin rational control measures almost immediately each states reportable disease list usually includes a clause suggesting that any unusual diseases or illnesses should also be reported and even though hantavirus pulmonary syndrome is a naturally occurring disease the hantavirus outbreak validates the existence of that clause new or emerging diseases or unusual events like a terrorist event can be picked up early because we can't predict what new or potentially altered agents a terrorist might use it's very important to be alert for any unexplained illnesses or deaths remember early detection depends on the front lines of the healthcare system doctors, nurses emergency room personnel and other people with clinical responsibilities will see patients with reportable or perhaps unusual illnesses laboratorians may note an increase in a given type of laboratory results and both groups should report these occurrences to local and state public health departments keep in mind that public health professionals will not be able to investigate and identify a problem if it's not reported you know we've now come back to our real topic of the day and that's bioterrorism the public health response Dennis how about a typical disease investigation be similar to a bioterrorist investigation well during this hantavirus situation there was a concern that this might have been a terrorist event but despite the urgency and disruption of a suspected bioterrorism event the usual public health machinery must continue with surveillance and investigations the role in an epidemiological investigation will not change even if the outbreak is intentionally caused in suspected bioterrorism events just as in routine investigations we will all continue to ask the same questions who, what, where and when for a suspicious outbreak we still need to determine the characteristics of the illness, who was affected what were they exposed to and where and when they became infected this is the information that will lead us to how and the why of the equation which is the cause of the illness Denise what are some of the other things that you would look for here to determine if this was an endemic, ongoing problem or a potential bioterrorism event well as Dennis alluded to in the beginning it will be very difficult to tell whether the disease outbreak is naturally occurring or the result of a bioterrorism incident that's because sometimes there are few obvious differences between intentionally and naturally occurring outbreaks quite often the differences will only be made clear after intense epidemiologic, laboratory and environmental investigations are conducted this was the case in the haunted virus outbreak when epidemiologists and laboratorians joined forces to establish the link between human cases and deer mice and remember all of the investigative skills surveillance methods, diagnostic techniques and physical resources that are required to detect and diagnose diseases of unknown etiology are the same ones needed to detect bioterrorism events this is one of the benefits of what we call dual use tools not only will they prepare us to handle man-made threats they will also help us recognize and control naturally occurring emerging infectious diseases of the 21st century speaking of naturally occurring infectious diseases let's take a look at a timely outbreak in New York City in late August 1999 the New York City Health Department was contacted about 8 patients with no confirmed diagnosis with unusual yet similar symptoms of fever, difficulty thinking and paralysis all were older adults who reported spending time outdoors they also all lived within a 5 mile radius of the white stone flushing area of Queens when no obvious reason for this cluster was identified the health department consulted with CDC experts who provided an EIS officer and other assistants to aid in the investigation by September 3rd there were 14 potential cases and two deaths CDC and the state laboratory identified St. Louis encephalitis as the cause this mosquito-borne disease had been previously reported in New York City the health department then enlisted the Office of Emergency Management to help initiate mosquito spraying in the affected area as of September 12th 89 suspected cases were identified with three deaths mosquito spraying has extended to other areas including all five boroughs of the city before we talk about this ongoing outbreak in New York City I'd like to reintroduce the panelists that have joined us once again Dr. Ali Khan, Dr. Denise Koo with the CDC and our new panelists and I cannot thank her enough for being here she has a full dance card these days and that's Dr. Marcy Layton assistant commissioner and the Bureau of Communicable Diseases for the New York City Health Department Marcy thank you for being here it's a pleasure to give us some more background on what's happening sure I'd be glad to I think the most important thing for the audience to recognize about this outbreak is that the city was only able to detect the outbreak and more importantly respond as rapidly as we did because of an astute infectious disease physician who recognized something unusual and called us the first call was about two patients with muscle with encephalitis only one of whom had muscle weakness and that was unusual enough that she decided to call we spoke there were some unusual parameters in the laboratory results the spinal fluid in the blood blood specimens that made us think of a viral etiology and we tried to mobilize specimens to the state health department reference lab over the next several days there was a couple more cases and again it was this unusual syndrome of encephalitis with muscle weakness that was clustered in time and in space these patients all lived in the same neighborhood and when we interviewed their families and associations the only thing that was concerning is that they all seemed to enjoy spending time outside in the evening hours in addition to arranging for lab testing we did active surveillance for additional cases city wide and when we got preliminary results back from the state health department lab that were positive or suggestive for st. Louis encephalitis we promptly sent specimens to CDC for confirmation and while we awaited the results we began to mobilize with our emergency management agency and it was because of that pre-mobilization that we were able to actually begin our mosquito control measures within hours of getting the positive results from CDC sounds like that this went extraordinarily well Marcy what were the initial atypical clues at the beginning of the outbreak for you again it was though encephalitis occasionally happens in New York City what was unusual of the original six patients that I saw the first weekend the outbreak was reported five of them had this profound muscle weakness that was associated that often required ventilatory support and again it was clustered in space this was in one small area of the city and that alone was enough to have me go out on a Saturday to do the investigation well you know just as mentioned there are clues that can help you decide and certainly help Marcy here if you decide the outbreak is suspicious and even though this case turned out to be naturally occurring illness there's been an appropriate level of suspicion when we run into cases that are unusual now let's turn our attention to the list of epidemiologic clues or epi clues for short that's included in your student materials public health professionals refer to these clues during surveillance and investigations and they may help determine if your case is the result of an incident Denise can you kind of walk us through and describe how the audience can use these clues sure Bob I'd like to start by saying these clues don't take the place of an epidemiologic investigation but they are items that we should always be aware of to sort of maintain a good level of suspicion about a possible bioterrorism event remember public health officials try to figure out the who, what, where and when of a problem in order to decide how and why it happened so we should be suspicious when there are unusual characteristics of who, what, where or when what if you have usually healthy people suddenly becoming ill in an unexpected time or place or you have a strange disease that appears or the problem just doesn't seem to be a quote, routine outbreak routine might mean unvaccinated children with chicken pox an example of an unusual disease would be adults with what seems to be chicken pox yeah I agree with you Denise you know this list of epi clues that is in your student materials is something that Denise and I put together with the help of our colleagues many of whom you see in front of you right now now please keep in mind that this list can be grouped into many different ways I don't want anybody coming away from this with the thought that there's these 17 things magical number of 17 that's going to tell us if there's bioterrorism you can group them by person place or time you can group them by the degree of suspicion they hold for a deliberate outbreak that's right and this list is really just a brainstorm list you know a list of things that might make you think of bioterrorism because it's really very hard to predict what might a bioterrorist do so the clues really have sort of varying degrees of specificity on the one end there's one number 5 a single case of smallpox well that one's essentially path a mnemonic for bioterrorism but on the other end we've got number 13 simultaneous clusters of similar illness in non-contiguous areas domestic or foreign well we see that all the time really and so after you do the investigation you find out you can't trace this one to a foodborne illness we want people to think about the possibility of bioterrorism what do you think Marcy? yeah I mean looking at the list I mean the individual again to emphasize that that most of these individual clues almost all the time hopefully all the time will be due to natural causes a single case of botulism or a cluster of salmonella I think what's different both from the public health perspective and also the clinical physician perspective is that we need to keep bioterrorism in the differential diagnosis just in case this was the case in the salmonella outbreak in Oregon yeah I mean has Marcy just told you any one of these clues by themselves may not suggest bioterrorism but what you may actually end up doing is you may end up looking at a combination of clues and that may be your first hint that yeah this is no not only do we have not the right agent but we don't have the right person and we don't have the right place and then you go okay put together to suggest bioterrorism so you have to do the investigation to figure that out once again I want to thank Marcy and her health commissioner for breaking her away to come down during this ongoing investigation to help us here today absolutely critical I think these epi clues will be very helpful to you and can help raise the red flag of possible bioterrorism until now we've been talking about how the usual public health response is similar to the response to a bioterrorism event now we know that everyone watching out there right now probably knows how to react to a typical public health emergency and you may be familiar with the epi considerations that we just reviewed but you can probably guess that there are some other aspects of the bioterrorism event that will be very different one of the biggest changes that you can expect is the type and number of partners who will become involved now let's take a look at an investigation of an event that was suspected of bioterrorism or origins now pay close attention to the sequence of events once suspicion is aroused during the spring of 1999 three patients from the neighboring states of New Hampshire and Massachusetts became ill with similar symptoms all were suspected to have the rare disease brucelosis a disease typically caused by ingestion of unpasteurized milk what raised our suspicion initially was that we had three cases of brucelosis two confirmed one suspect all occurring within the greater Boston area within a relatively short time frame that is a month and a half to two months of each other brucelosis is an unusual disease we usually report one case every one to two years in New Hampshire so the occurrence of a case one case in southern New Hampshire was not particularly unusual however from what we were being led to understand from Boston and their health excuse me their health department in hospital the cases were pretty unusual that they had occurred so rapidly so when we had gone and done surveillance for the brucelosis cases we quickly became aware that there was an additional case diagnosed two weeks prior to this in the same Boston hospital so putting those two together that's what started to raise some concerns two of the three patients were thought to have acquired the disease through ingestion of infected meat or dairy products while traveling abroad however one patient had unusual circumstances surrounding her suspected route of infection that included petri dishes and culture material in her home this sparked a chain of communication and collaboration between local and state health officials the FBI the CDC and the U.S. Armed Forces Institute of Pathology microbiological instruments or equipment were reported to be in the apartment of this particular young woman in this case this resulted in a an alert to the infection control practitioner in the hospital that there may be some unusual circumstances surrounding the potential source of infection for this patient. After I received the initial call I made some attempts at obtaining more information about the case trying to contact family to obtain additional history those contacts were unsuccessful and in the course of doing this I became aware of the second case the case that had occurred in a 63 year old man reported from the same hospital at this point having two cases of a very unusual illness reported from the same hospital we requested the hospital laboratory repeat some of the testing to try to verify that this was indeed the diagnosis at about the same time I decided that we should really contact the state health department about this and get some input from them to see if there was a larger type of issue or what type of assistance they would be able to provide I also made contact with Boston's emergency medical services to see if they had seen any rise in cases of febrile illness after some discussion with all these parties we decided that we really did need to involve law enforcement because we had a woman with a very unusual illness very unusual circumstances with this culture material and we weren't quite sure whether this represented a terrorist event or was simply an unusual coincidence and for that reason I contacted the FBI late in the day Tuesday April 20th to notify them of this case and to raise some concerns that it could be a terrorist event we dispatched a team from the laboratory with appropriate transport boxes collection materials and appropriate protective gear and they went to the hospital and with the FBI opened up the materials that were stored in biohazard bags in a class 3 laboratory and took pictures the FBI took pictures of the materials for evidentiary purposes we then signed all that over from the FBI to us in a chain of custody transfer moved all the material here to the laboratory into a level 3 laboratory here in Massachusetts at the state laboratory and began triaging the specimens looking at them trying to decide which of them might be more likely to yield organisms and might be more suspect we brought it up to a room we had and to be the best suited for this kind of work at the time it was nearly a 3 so once we got the material in there we secured the room and we suited up fully in double tyvek double glove respirated north masks and then we proceeded to unwrap the material and record all information that was on every single flask this was different this wasn't the small little package this wasn't hazmat calling us up saying guys I think we have a false alarm here but why don't you come and contain it and put it in your container and take it to the lab and tell us what it is this was something where the cultures were there we could look into these packages and we could see it so in our minds where these are cultures of unknown origin we have to maintain a very high level of our actions it's almost like analogy is looking down a volcano and watching it come up at you it's like oh my god what am I looking at that's what it was like it was it was very scary and almost exciting but it was just something you'd have to be there that'd be it you'd have to be there I can say very much from experience that for at least a day in this with this investigation tensions and energy and nervousness work really quite high because we really didn't know if this was what this was and what was going on with the situation and the possibility of a bioterrorist threat really raises everybody's adrenaline level quite substantially so it was I think in that situation understanding roles and understanding responsibilities really can help ease the course of the investigations as they're going on we did not identify any agents from this material after 48 hours, 72 hours in culture we ruled out tolerances, we ruled out anthracis we ruled out brucellosis so we really didn't come up with anything positive findings here just to be absolutely certain we took some samples of a random selection of the materials and sent them to the army laboratories a while to read where they get some molecular testing on these specimens obviously one of the other important aspects of communication is to make sure that the usual process of passive surveillance between hospitals and physicians and infection control practitioners is happening well and making sure that those individuals are communicating rapidly within appropriate reporting time frames to local and state health departments and authorities are very important. I think having experienced this situation it gives me or I should say it gives us a greater appreciation for the need for preparing for having protocols in advance for sharing telephone lists with different parties that might be involved I think it also makes us think about the possibility of bioterrorism being associated with infectious disease situations that might come up that we wouldn't normally think of as being associated with bioterrorism not that that would be our first thought but it would clearly be in the back of our minds The threat of bioterrorism has created a new sensitivity to an importance of open communication between law enforcement and public health. This has not typically been a collaboration which has been well developed in the United States. We have been emphasizing that points of contact need to be identified in local public health departments and in local law enforcement agencies and with the local FBI agents. And I think that's something that's unusual for us to deal with in public health. Certainly most of our cases I don't involve the Boston police or the FBI and concerns are raised about patient confidentiality versus protection of the public health and where does that fall I think that it's key to have a relationship with law enforcement so that you can make reasonable decisions and that will both deal with patient confidentiality and the public health issues that are raised by these situations. Now this Brucellosis cluster was a naturally occurring event that was treated like a potential act of bioterrorism but before we get into this case I'd like to introduce Supervisory Special Agent Kathleen Cooke from the FBI's division of weapons of mass destruction. Colonel John Hoiman Deputy Commander of the Joint Task Force for Civil Support and Consequence Management for the United States Atlantic Command Commander Kevin Tonak from the Office of Emergency Preparedness at the Department of Health and Human Services Welcome to our panel. These were experts and these are experts who are going to help us clarify the roles that other agencies might play when pairing up with public health professionals during a bioterrorism event. Ali tell us a little bit about the collaborative efforts that we saw in this Brucellosis case. Bob as you saw the Brucellosis cluster carried out for us the importance of working together during a potential bioterrorism event even if it finally turned out to be a naturally occurring cluster. Now in that case you saw the collaboration between the local and state health departments, between the FBI, between DOD, between OEP we've not talked about it specifically in there but you saw that collaboration that's going to be needed. The point being if the local health practitioner recognizes an atypical clinical presentation, a rare disease or just a lot more deaths than there are customers at seeing, it should be reported to the local and state health department to promptly initiate an investigation. And let me add that the FBI needs the guidance of public health officials at the state and local levels in order to conduct bioterrorism investigations. In this case circumstances required the FBI to do an assessment of the likelihood that a deliberate attack had occurred public health information initiated this inquiry and helped refine it as additional information became available. When any cases initially reported by local public health officials the FBI may conduct interviews which would warrant further scrutiny and investigation by public health and the FBI. On the other hand the FBI may contact public health officials first alerting them to a threat. The FBI would then request information that would either support the need for more investigation or support an assessment determining that the threat is not credible. I'd like to say that the State Department of Health, the FBI CDC, Armed Forces Institute of Pathology demonstrated the great necessity and need for communication links between the states and the rest of the federal agencies. But beyond this it demonstrated at the local level that people need to know how to start that communication chain. I want to thank everybody sitting on this panel for helping us bring some clarity to this issue. This brucellosis case may have got you thinking about some of the aspects of potential bioterrorism events that are markedly different from a typical outbreak. Now let's spend some time talking about these differences. Ali, kind of help us out here. Well Bob, there are some special features that make a response to bioterrorism different than a natural outbreak. I'll give you all of the items first and then we can talk about the brucell. First and foremost during a bioterrorism incident the amount of time and the opportunities to make a difference is limited from the notification of the first unusual cases to the presence of potentially large numbers of sick people. Now this was clearly demonstrated by Dr. Kaufman who modeled a release of anthrax over a city using some experimental data. In that model you could prevent 60 percent of deaths if an effective intervention program was implemented on three after dissemination. Now this number of deaths quickly plummeted to about only 20 percent that you could prevent for any intervention that you could put in place about day five or later after dissemination. So during a bioterrorism incident there may be only a short window of opportunity to make a difference between the time that the first few cases are identified and when large numbers of people become ill or transmit disease from the initial exposure or even ongoing person to person spread depending on the biologic agent. Now during this window we must try to prevent further illness while reassuring the unaffected public. Other differences or different actions we need to think about that may take place during a bioterrorism response include this multi-agency involvement with the possibility of legal implications. This includes the criminal aspects of the investigation which could require lots of coordination and activities and investigations between public health workers, the FBI and law enforcement. We're also going to be required to mobilize many professionals and supplies very quickly to any location in the United States. Also, we're going to have to keep the public health well informed with accurate information to prevent panic. The bioterrorism event will have a significant emotional impact as well in both the community and those responding to the event. Now if this window of opportunity I described passes without appropriate intervention taking place large number of patients could overload hospitals and you could see many deaths in a very short timeframe. Furthermore if the agents really contagious the disease or illness may be carried to other cities across states across the country even internationally depending on the agent. Now fortunately for us, most of the public health critical agents aren't contagious. Now here you can see that this window of opportunity as I call it during an actual event using weaponized anthrax. Earlier on the first day of this USAMRA CDC broadcast I talked about the 1979 Sferdlas anthrax release in the former Soviet Union. Now although their data is confounded by potential treatment of exposed patients, you can see that about half of them became ill by day 8 after exposure and all of their first cases popped up on day 2 or 3. So this outbreak even using this data supports that you may have a little wider window of opportunity than the Kauffman model I talked about earlier but it still measures and measured in days not in weeks. During a bioterrorism event we'll have to find the release point of the agent quickly so that exposed persons can be found and given prophylaxis as soon as possible. Remember anthrax is almost always fatal if not treated in time. Again the initial detection of a bioterrorism event will most likely be made at the local level, your level. But once we have confirmed that an incident has taken place we will likely activate the federal response system. Now speaking of the federal response system Commander Kevin Tone at what will be the federal emergency administration or as we so frequently hear FEMA particularly in the news recently, what are they going to do during one of these bioterrorist events? Well Bob although I don't work for FEMA I can talk to the consequence management aspect particularly with regard to health and medical consequences. Three important points here the first point is that crisis and consequence management are coordinated through the FBI in the terms of for consequence crisis management and FEMA for consequence management. We are going to continue to work together in that group we can't possibly in a bioterrorism release expect that we're going to have a large detonation so that we'll know the exact transition between crisis and consequence management. But we have worked together before and I think that we have good planning in preparing for consequence during a crisis. The second is we're not going to do anything new in terms of federal health and medical asset moving to a state or local area. We have got to maintain the chain between the local people requesting it from state and state going to FEMA. And third we're all working to move forward and augment existing systems and that includes making sure that we follow the federal response plan. We have a graphic here that shows the overall federal response and the emergency support functions. There are 12 functions each agency has an assignment lead federal agencies and as you'll see emergency support function number 8 is assigned to Department Health and Human Services and we can draw on federal support from DOD, EPA, FEMA, the Veterans Administration and clearly in one of these we will be relying on our own people such as the Centers for Disease Control. So what does ESF 8 do during one of these crisis? Well our activities would include such things like threat assessment, health assessment, epidemiologic investigation, ensuring safe re-entry for the environment, patient care, patient transport, worker safety, vector control, making sure there's enough potable water that we've handled the infectious waste well and of course victim identification and mortuary services. FEMA is also responsible for providing coordination between federal and state emergency services agencies. You know, in addition to working with emergency management agencies, public health professionals will also need to work side by side with the FBI during one of these terrorist events. Agent Cooker could you walk us through a little bit more about the what and just exactly what's the role of the FBI going to be in one of these situations? Sure Bob, the FBI's role is determined in presidential directives and legislative statutes. Our agency has investigative jurisdiction over domestic terrorism violations that include the use or threatened use of a biological agent or toxin as a weapon. As I touched on earlier, one of the most important jobs that the FBI performs is a threat assessment. Of course we can only do that if the threat is announced ahead of time by the terrorist, but when a threat is received, whether written or verbal, it's analyzed by subject matter experts according to behavioral, technical and operational aspects. These experts determine if the terrorist has enough motivation, expertise and equipment feasible to follow through on the threat. The FBI always consults with the CDC and other public health officials to decide if an agent or toxin is stable or infectious enough to make that threat a reality. FBI responsibilities at the scene of an actual bioterrorism event fall under the category of crisis management. These duties could include conducting the threat assessment to determine if the threat is being an interagency response and escorting evidence to laboratories for analysis and preservation, which leads to the importance of meeting with local or state FBI field office during your preparedness planning phase. If your first contact with the FBI is made during the emergency it will only likely cause confusion. It's vital that we learn to work as partners before a bioterrorism threat or incident occurs. There's that phrase again of linking up with all of your local assets, all the tools in the toolbox and use them early on. You know, there are situations that require immediate notification of the FBI though by local health departments. What should public health officials do and when should they consider calling the FBI and local law enforcement directly? That's kind of a tricky issue, isn't it? You're right, Bob. It really is a tricky issue. But we've developed some guidelines. Several diseases caused by pathogens on our critical agent list are top priorities for immediate notification. Go back to those epi clues. The items on that list should substantially raise your suspicions about the origins of the disease or illness you're investigating. Of course your local health department will notify the state health department first. But if you feel that your suspicions about what you're witnessing have crossed that threshold as we've talked about about typical disease, you should notify the FBI immediately. I think Agent Kuker can tell us a little bit more about this based on some of the consultations over the last couple of months. Okay, thank you, Dr. Kahn. First of all, keep in mind that law enforcement officials and the FBI have their own chain of command to follow just like public health departments. We start locally and then progress to state and federal levels. Public health officials and the FBI have determined that this hot list of situations require immediate notification of local law enforcement, local FBI and emergency management. Call them when you have a confirmed case of smallpox or a case of viral hemorrhagic fever or inhalational anthrax or a disease that isn't endemic to the U.S. like Glanders. These situations should really stand out to you with the exception of a laboratory accident. There is no explanation but an intentional criminal act or terrorism to explain why you would be witnessing these cases in the U.S. Obviously the FBI should also be notified if an illness is caused by a genetically altered organism or if you suspect a deliberate sabotage of an air system, food or water supply as the cause of an outbreak after a preliminary investigation. I want everybody to remember that for all of these situations there will be a thorough preliminary public health investigation that will help you trigger your decision to call the FBI. Now during a normal day nobody runs across a genetically altered organism. Now remember those epi clues and the steps of a normal public health investigation to help you through these tough decisions. In some cases the state health department or your emergency preparedness office may make these calls for you. You need to really become aware of what to do in the event of an incident wherever and whoever you are. You know Ali it's it just kind of looks like to all of us that there are these out there that are trying to perform public health duties and that's really just an appearance that's not really the case. You're right Bob I mean it may seem like that but in truth public health officials will transcend all of these other federal agencies on the scene. The locals and state levels of public health will be responsible for performing your epidemiologic investigations and taking care of your public health response activities. Now don't expect us the feds to do that for you. The FBI related law enforcement agencies will work with your medical and public health response teams work with you during the Epian Lab investigation by sharing interview information and other materials. The FBI will also make sure that lab specimens arrive at the nearest certified public health lab for testing. So it's true we are the government we're here to help. Correct. So now we've addressed the roles of the FBI, FEMA, CDC and public health workers in a suspected state. And now let's hear from the military. As you can imagine you samber it and the entire Department of Defense have a long history of dealing with these types of bioterrorism issues much longer than ours and we can learn a lot from their programs but more importantly they have a role to play when protecting citizens from bioterrorism at home too. Colonel Hoyman can you tell us about the military's response plans for a bioterrorism event on your own soil? First of all Bob let me say that the Department of Defense forces will always be employed in a support role to some other lead federal agency. Unlike a Hollywood movie that we've seen recently we won't storm the streets with our troopers and demand that we're in charge. The military has usually called in to request a FEMA because the situation has gone beyond the local and the state to include the National Guard's capabilities. There's only one exception to this rule and that's that a local reserve unit may immediately respond to a bioterrorism event but just to alleviate or mitigate the loss of life and property and even in these situations the reserves must be called in by the governor. As you know the military's assets are designed for defensive and offensive warfare fighting but our equipment and our personnel can also respond to the nation's needs in a time of crisis. You've seen this happen when the National Guard is trying to respond to crises like forest fires floods and hurricanes as is going on right now but there are a few points to keep in mind when you're calling emergency military assistance from a reserve unit. First of all the response actions must not deter the unit from their ultimate mission and that's to protect the nation during war time. Secondly the use of military personnel must be reimbursed that includes for labor, operating cost equipment and repairs and by law emergency military response from your local reserve unit is limited to 72 hours. But as I said earlier the military is usually called in at the request of a federal agency such as FEMA and when we're called in under those circumstances our presence may continue for days or as long as needed. We're making plans now to assemble units that are ready for civil employment and we're constantly looking at ways to improve rapid responses that will follow the lead of the public health officials at the site of the incident. One example of an often requested unit is the Marine Corps chemical biological incident response force or we call them CBERF. This unit focuses on the medical, security and service support and quickly responds to incidents in a self-contained self-sufficient manner. The command I'm from the United States Atlantic Command is currently creating a joint task force for civil support to do consequence management which will respond to the request of a federal agency such as FEMA and then we will provide the command and control of the DOD forces that respond in a large scale incidents. This response can include anything from laboratory support, evacuation of personnel, hospital use or transportation of anything that could be required and we stay in the field on the site until the state and the local authorities are able to regain control of the situation. It's important that you know that the Department of Defense units are planning, training and exercise strategies for homeland defense and military assistance to the civil authority tasks and mission. There are units standing by today that are ready to get on the road or in their air quickly to the scene of an incident to begin providing that support to the local state and federal agencies. The bottom line is we want to deliver the right response at the right time. As a matter of fact you know part of the Atlantic Command's mission is to be interlinked with the national disaster medical system, right Colonel? That's absolutely right Bob. Commander Tonette tell us a little bit about the medical response systems and how some of the specialty teams being put together by your agency in the office of emergency preparedness are going to work. Sure Bob and before I go into the national disaster medical I'd like to emphasize that traditional roles and relationships of emergency organizations will be really stressed during this time, especially by an actual terrorism incident involving biological agents. All agencies that could report to an incident need to be effectively linked and at all levels. We have a graphic here that shows some of the important linkages and what we're trying to accomplish locally. We need to be able to link the first responders, fire, EMS medical and mental health services law enforcement, emergency management and public health and as we all know that at the time of an emergency is a lousy time to exchange business cards. A fundamental truth here is that all disasters are local and in this case multiple local disasters especially with an agent that could propagate to different communities could overwhelm local state, regional and even national resources. So the overall planning that we're trying to accomplish here at HHS and throughout all of the agencies really is at three levels. The first is we're trying a bottom up approach and that focuses on local agencies local public health and all those systems we just showed. For us right now this is focusing on the metropolitan medical response systems and how they'll help. The purpose of these response systems is to ensure that metropolitan areas health system is able to cope with human health consequences that can result from a bioterrorism event and this includes providing integrated pre-hospital hospital public health response capabilities at all levels. One of the things that we're trying to do is also to make sure that they are effectively linked with these other groups. We also have to make sure that they must ensure that their health workers are safe and able to operate in this area, that they can recognize the symptoms caused by these agents and that they can triage, mash casualties, be able to treat them and that hospitals can continue to function and plan for the onslaught and really of subsequent state and federal health and medical responders as they arrive. We have a graphic of each of the 47 cities that we're working with now and as we are also asking these cities, although they're spread out across the United States to really focus on many of the issues that Ali and Denise have brought up. Particularly for WMD plans and with regard to bioterrorism, we're asking them to make sure that they have early warning and notification systems that are linked with law enforcement and public health. That they're really focusing on mass prophylaxis and how they're going to treat. We could have the best national stock pile in the world and if we can't figure out a way to make sure that we get the antibiotics and vaccines into the mouths and arms of the people at the local community, it's going to fail. Our focus is also on mass casualty care, mass fatality management and environmental health and safety. When is it safe to go back into these areas? I think it's important to emphasize that each of these metropolitan areas is not going to approach this with a cookie cutter plan. We're asking them for performance plans and bioterrorism response systems have to be in conjunction with their current emergency response structure. Our second echelon, our next level of response capability is organized into teams such as primary care disaster medical assistance teams and specialty teams such as DMATS, mortuary teams and our veterinary medical assistance teams. The office of emergency preparedness manages the national disaster medical system which is a partnership between health and human services, departments of veterans affairs, department of defense and FEMA and it has more than 2,000 participating non-federal hospitals. The NDMS system is a voluntary group of medical minute men and women over 7,000 strong who become federalized in the time of request and can provide primary medical and certain types of specialized care to disaster victims and communities. The 25 level 1 DMAT teams that we have can be deployed within 24 hours and they're self-sufficient they can arrive at the scene of a bioterrorism event and for 72 hours provide medical services without the need for any resupply. They carry their own pharmaceutical caches, medical supply, food water and they have shelter, communications and other necessary equipment. In over the last two years we've provided additional specialized training and equipment to some of these disaster medical assistance teams and I'll really push the alphabet soup here and we call those the national medical response teams and they're actually made up of many of the members from these teams and they have a 4 hour call down and they specifically designed for weapons of mass destruction and bioterrorism. Thanks Kevin. You know, Ali the picture that you painted earlier about the possibility of large numbers of people becoming ill within a short period of time is very serious. I'd like if you could elaborate a little bit more about the possible ramifications of not detecting and reporting these unusual cases very early on. Well, although we can't really determine the precise risk of a large-scale bioterrorist event we do have lots of scientific data to prove that it is possible and during the last two days of this video conference you've heard people talk about what could be achieved and the heavy investment in these agents as part of formal bioweapons programs reinforces that this concern really is legitimate. Now without preparation at the local and state levels for early recognition and response, large number of people could suddenly become ill or die from exposure to an agent which could have happened days or potentially even weeks ago. As a result, everyday life would be disrupted and fear would more could become a major factor in people's lives. A delayed response could mean thousands of lives lost and costs ranging into millions of dollars. Now you can see why preparedness strategies need to be built at your level and not just mainly at your level but to include local, state, and federal levels. Other issues to include I would say would be how do you rapidly establish mass care and medical prophylaxis? How do you deal with the incident from the first few days until this federal response you heard about arrives on the scene? Now Bob, besides being our moderator, you're actually an expert in media training and communications. Could you tell us a little bit about the media aspects of bioterrorism? Yeah, sure can, Ali, and I'll get to that in just a moment. I would like to take this opportunity for just a second though. We told all of you at the beginning of this program that we literally absolutely cannot do this job without your input, without your cooperation, without your calls today. Now you're going to see in just a moment, if you're not already on the bottom of the screen, some phone numbers that we'd like you to use to call in your questions. We want to hear from you today and we'll try absolutely our best to get to your questions on the program today. So please do that over the next few minutes. Now Ali, back to what you're saying, I think that all of us who work closely with the media in these situations and these crises, myself included, have been amazed and the media rushes on to the scene when these news stories occur. You know within two hours of the school shootings in Denver, Colorado and in Atlanta, Georgia, as well as the World Trade Center bombing, there were dozens of reporters, cameras, trucks, helicopters, even rented cherry-picker cranes that were covering the story. You know, the heavily armored policemen, the EMT in the bio-containment suit, the distressed parent or weeping child, all of these images provide great drama and excitement and folks, that's what TV is all about and you know that. That's what media coverage is about, these visual images and it's important that you start thinking about how you want to have your city, state, county, agency or institution portrayed during a potential bioterrorism situation now, today. How are you going to work with the media? Who will be the source of the numbers and the data? Who are the key persons for the various agencies that could arrive and probably will arrive at the site? What's the role of the mayor, the police chief, the governor, the city council? Have you practiced these plans to consider the many variables that will occur? Absolutely during these events. It's vital to establish how information will flow starting at the very first moment that this event is suspected. You have to understand that the media can be used as a tool in helping you to control, protect and educate the public as the situation evolves. But you also have to understand that the media work in different ways. Television requires more camera ready personnel that can meet quick deadlines and they're going to be thirsty for any visual image while the print media will want to spend more substance time and background in those early hours. Now most importantly you have to understand that a vacuum can be filled. You deny a reporter they will find somebody else and if you don't have a strategy if you wait until the situation overtakes you the media will absolutely find other experts to fill the void that you've created and these so called experts can be harried victims, their family members, distracted government officials without correct information or even worse persons with private or political agendas they're just waiting for an opportunity to satisfy the media while you're back in the office planning your strategy. I urge you to take the steps now to plan your communication strategy, appoint a public health information officer, develop plans to provide critical information and messages of prevention, reassurance and confidence during the first few hours and days of these suspected events, practice your plans, make sure that local media outlets know that you have bioterrorism preparedness plans and let them know who they can contact. Make sure that everybody in your office or facility knows who will be answering the phones and those people that do answer the phones know how to distribute information. These people must also know what the overall action plan is. Keep in mind you and much of your staff is going to be in the field. As this event unfolds you and your staff should be in action not making up the steps as you go. Believe me folks the media and the public will see the difference if you're prepared and if you're not. Okay we've covered a lot of ground already. Let's review what we've talked about so far. We've discussed the steps that public health professionals take in their routine search for solutions for health problems including bioterrorism events. The four components to the public health approach are surveillance and monitoring to recognize problems identifying the cause through investigation evaluating the and implementing control measures and developing programs and policies to prevent recurrence. Answering the reporter's questions we talked about when to suspect that a case or cluster of cases might be caused by bioterrorism. We talked about what makes the bioterrorism event different from a typical public health outbreak and introduced the epi clues to help you along. We also pointed out that there will be new partners involved in the response to a bioterrorism hoaxer event and we gave you some gloom and doom forecast about how bioterrorism incident could unfold and what you might expect. I want to thank everybody on our panel of experts for sharing their expertise during the first portion of this broadcast today. Okay now's the time to call in with your questions for any of our panelists. If you're sending in the facts please use the forms of the fax questions to us. The live call in phone number is 1-800-527-1401 The fax number is 1-888-361-4011 International callers can reach us by phone at 1-301-827-3639 But you'll find that it's more economical for you to fax in order to be on hold. Now the international fax number is 301-827-3262 And remember, please call us from another room besides the one you're watching the television in. Turn down the volume, that's the other option here so we won't get feedback on our phones here. You'll be able to hear the broadcast through the phones. Dr. C.J. Peters rejoins us for a question and answer session from callers. We've got a few fax questions here. The first one I've got, and I understand that I just hear that we have a call in from Chicago, is that correct? Let's go ahead and hear that. Hello? Yes, we can hear you, please ask your question. This is Dr. Karachi from Chicago, Illinois. The question I have is, how do you respond to massive community illnesses arriving in the hospital setting step-by-step response so that I can understand, as a hospital epidemiologist, how to go about taking care of these issues. Dr. Karachi, we're actually going to talk about this during the second half of the teleconference and within your student materials you'll see some of our initial efforts in trying to help you prepare for this, that our hospital infections program has put together with the Association of Practitioners the hospital going through the first steps of what they need to do with in-house and how they link up with their local and state organizations to put together a plan to deal with these potential large number of casualties. Very good question, sir. Thank you. I would ask this question also of Ollie. This is the facts that we received in. Ollie, what would you define as some of the priorities of the CDC and our bioterrorism program over the next year? That's actually something that we're actively working on, Bob. We have a number of priorities and you've heard some of them during the first part of this course and you're going to hear the rest in the next two hours or so. But essentially they're targeted around our hours. What we see as the public health vision for bioterrorism is epidemiology and response capabilities. How do we strengthen that preparedness activities? Critical. How do we make those preparedness things happen in our local and state communities and at the federal level? Laboratory. How do we preposition diagnostics? How do we put together the appropriate test that you will need out there to get the job done for you? Communications and training. These are all some of the points that are going to be critical to an efficient and quick bioterrorist response and something that CDC will be working with their partners and their new partners to try to make happen. Kathy and I would ask this question of you and it might be a question and it's certainly one that I think a lot of people might be thinking and that is when the FBI becomes involved in a case you certainly have a legal law enforcement responsibility but what is your driving concern when you initially become involved in these investigations? Is it legal or public health? It's always public health first of course. We're for the safety of the public but we're also our end goal is to prosecute whoever caused this. That would be the end goal. So public health drives you right from the very beginning? Of course, yes. CJ, this question for you and as somebody who's been involved in multiple investigations in multiple disease causing pathogens what do you think about these new rapid detection devices that we see floating around, advertised that people are talking about? Is there value in them? Are they going to become more important to us in these investigations? Bob, I think part of this depends on what you mean by is. Yes, there is value to them. They are the right way to go. They will become extremely important but from what I can tell of the evaluations that I've seen, the experiences that I've seen, they're not ready. You're better off controlling a situation, getting a list of the participants and the people who are taking proper samples so that definitive testing can be done because that's going to have to be done anyway. These quick tests have too many false positives and too many false negatives to base life-threatening decisions on. Ali, do you have a quick contribution on that? I actually got another question faxed in question for CJ. Now, as some of you may already know Dr. Peters actually is a world-renowned expert on dangerous viral pathogens and he describes the Honevirus outbreak in this book. He also talks about his personal experience with filoviruses and arena viruses in this book. Now, so I'm going to turf this question to you, CJ, as they say. This is a caller from Minneapolis who asks us, what do you think about the role of Honevirus as a potential bioterrorism agent? Thanks, Ali. You get your payoff outside the green room. I think that these are transmitted by aerosol. Today, we don't know how to grow them and stabilize them. I wouldn't say about tomorrow. That's one of the questions that we have to always be aware of. These are manufacturing problems and they may be solved. CJ, thank you. And books will be available in the lobby. That wraps up the first question and answer session. I'd like to thank all of our panelists for their input and thank you for calling your questions in. In the next part of the broadcast, we're going to look over a suspected bioterrorism event, whether you're from the community, a public health professional, a laboratory or in the military. But right now, we're going to take a break to allow you to relax and reorganize. We'll see you back here in about five minutes.