 Welcome back to our broadcast. In this part of our program, we'll be talking about current, ongoing public health preparedness strategies for bioterrorism. As many experts have said, it's no longer a matter of if an event will occur, it's a matter of when. The steps that public health professionals are taking now to develop, organize and enhance our investigative communication and diagnostic tools will help all of us prepare for a possible bioterrorism event. Now we have some new panel members with us now. Dr. Scott Lillebridge is the director of the Bioterrorism Preparedness and Response Program at CDC. Dr. Stephen Morris is the director of the laboratory services in the Bioterrorism Preparedness and Response Program at CDC. And Dr. Marcy Layton is back with us once again from the New York City Department of Health and she's rejoining our panel. Thanks everyone for being with us today. I think we made it clear in the first part of this program that state and local health departments will play a major role in a bioterrorism event. That's absolutely a given. Now let's talk about some of the things that CDC is doing now to help public health professionals prepare for such an emergency. Later in this broadcast, you'll hear about CDC's future plans. Dr. Lillebridge, why do we need a preparedness plan? Bob, that's a good question. I believe a population survival during a bioterrorism event depends on the development of preparedness capacity at the state and local level. A good plan will help you get there and provide information on how best to use these capacities during a time of crisis. One of the first steps in preparedness planning is to determine the roles and responsibilities of everyone in the state and local health systems. The duties assigned to these people should become automatic in times of need. There should be no doubt as to what actions each person will take during a bioterrorism hoax or event. In addition to working on a bioterrorism preparedness strategy that defines roles and responsibilities, we need to consider these ongoing bioterrorism preparedness issues. First, we need to consider tuning up our epidemiologic skills. Case finding, disease detective work are extremely important. We need to begin looking at enhancing our surveillance capacities. And I can't emphasize how important it is to develop new partnerships in this arena. I know that other states and local public health communities have ongoing meetings with their law enforcement, EMS and medical communities. And there's been an artificial separation many times between the medical and the public health community. We need to close that gap. We also need to improve our laboratory capacity and provide specialized training like this broadcast. Thanks, Scott, for that overview of what's coming down the pike for us. But before we delve into current ongoing preparedness activities, let's find out what our nation's largest city is doing to raise awareness for bioterrorism preparedness. Marcy, take us there. Sure, Bob. In part due to recent terrorist events like the World Trade Center bombing and the Sarin incident in the Japanese subway, New York City has recognized that the threat of bioterrorism is real and like Oklahoma City showed us, it could happen anywhere. Over the past four years, the New York City Health Department has been working very closely with our Mayor's Office of Emergency Management, as well as other local agencies and representatives from the medical lab and veterinary communities to make sure that we have a coordinated response in the event of a citywide biological disaster. Raising awareness requires educating health care providers, first responders and all others that would be involved in a bioterrorism response. In New York City, the Department of Health continues to offer training to these groups on the potential for a bioterrorism event in our city, along with an overview of the most likely critical agents that could be used. Emphasis is always placed on the key aspects of the illnesses or diseases that should prompt the health care provider to suspect that a critical agent may be the cause of the patient's illness. The audience is always reminded to promptly report their suspicious findings to the local health department. Some of the groups that we have targeted for education are primary care providers, emergency medicine and infectious disease physicians, laboratorians, infection control practitioners and medical examiners. We've also reached out to first responders like the local EMS, hazmat and police. All of these professionals will likely be on the front lines if a bioterrorism incident occurs. You know, Marcy, you brought up a key issue here in preparedness. Making sure that everyone that could be involved knows to be on the alert for signs of a suspected terrorism event, bioterrorism event. Now this brings us to our first section on preparedness, enhancing detection and surveillance. Scott, what can we do right now in this area? Bob, I think there's a great number of things we can do in the surveillance and epidemiology area. First of all, epidemiologists are naturally suspicious and when there's unusual events or a strange distribution of illness, I think that's time to help organize and respond early for those kinds of things. We need to upgrade our surveillance capacity again, as we mentioned, and that may involve looking at new sources of information. We've heard earlier that consideration for 911 types of surveillance, healthcare utilization, and increased training and awareness are extremely important at the clinical level. I've got to emphasize that it's important to remember that unless an alert clinician picks up the clues from a potential bioterrorist illness and orders the proper lab test, the whole cascade of response may never happen in a timely fashion. You know, Steven, it's been interesting. Every person that has sat on this panel, the FBI agent, the epidemiologist, our health officer, state epidemiologist, they've all talked about the word laboratory. It's become abundantly clear to us that the laboratory is going to be a crucial role in surveillance and detection. Labs often discover organisms first. Kind of walk us through, are the nation's labs prepared to meet terrorism preparedness challenges? Well, Bob, I think the biggest concern in the recent past was that most labs and operation had limited capacity to diagnose pathogens that could be used by terrorists. One reason for this is because critical agents don't produce illnesses that are current major health problems in the United States. This was a major concern when we began to do bioterrorism preparedness planning ourselves, and it was determined that laboratories needed an upgrade on every level. Laboratories across the country must be able to receive a specimen from the site of the suspected event and be able to confirm a diagnosis very quickly because the lab is a major link between uncovering a hoax or verifying an event. So the existing system of laboratories now includes basic diagnostic capabilities to identify these agents, and these labs are supported by a larger system of labs with more advanced diagnostic capabilities. This multi-level network of bioterrorism response laboratories will support epidemiological investigations at all levels and can rapidly and accurately determine the agent used. The network also provides ongoing case surveillance after an incident has been confirmed. Here's how it works. The CDC and its partners have developed a national network of laboratories at levels A through D. This network provides support to epidemiologic investigations and ongoing case surveillance at the local, state, and federal levels. Most local health department laboratories, as well as many clinical laboratories, are level A labs. They provide early detection capabilities, including the ability to accept, test, and transfer specimens. As you can guess, these labs perform the most basic, necessary functions which are crucial in their surveillance and detection of critical agents. Level B labs use more sophisticated procedures to test for specific agents, and they can minimize false positives. State health department and some county laboratories, as well as big city laboratories, are at level B. They must also be able to forward specimens and organisms to higher level laboratories. Specialized and advanced testing happens in labs at levels C, which include some state and federal laboratories. These labs can perform toxicity testing and eventually will use advanced diagnostic technologies like nucleic acid amplification and molecular fingerprinting. Level D labs are very specialized, and they also have the highest level of containment and expertise in the diagnosis of rare and dangerous biological agents. Federal labs at CDC, the Department of Defense, and the Department of Agriculture all perform at level D. These labs have the ability to develop and evaluate new tests and methods, and have the capacity to detect genetic recombinance. The capacity of certain divisional labs at CDC that are specifically responsible for the identification of high profile agents on our critical agents list will also be upgraded. The functions of these laboratories will be upgraded to include performing confirmatory assays or tests, validating advanced diagnostic technologies, molecular epidemiology, banking of strains, and training. The best part of the multi-level lab network is the ability of the higher level labs to work closely with the state and local labs to rapidly determine if there is a critical agent present. You know, there have been some other improvements in this area, though, having there, Steven. Yes, Bob. Because of the urgent need to identify critical agents rapidly, there have been a number of new technologies and assays developed. Validation of new technologies is coordinated through CDC's rapid response and advanced technology laboratory, the Department of Defense labs, and other network laboratories. If these new technologies pass the tests, they are and will be made available to appropriate members of the laboratory network. The rapid response and advanced technology laboratory also provides round the clock service to rapidly identify agents in incoming specimens so that they can be triaged to specific laboratories at CDC for confirmation and the results quickly sent to response teams. These dramatic improvements in the laboratory can only help with bioterrorism preparedness if public health professionals and laboratorians work closely together, establishing clear communications in both directions. Preparedness is a two-way street and we will need to help each other in the event of an emergency. Thanks, Steven. If a bioterrorism event occurs, anxiety levels will just go off the scale and it will be crucial to act quickly. Scott, how can health care professionals help themselves to rapidly carry out investigations and response activities during one of these bioterrorism incidents? Bob, good question. Like other disaster responses, the greater the integration of services and knowledge of duties, the more effective, coordinated, and rapid the overall response will be. On the other hand, delays in the communication of findings or recommendations or delays in administering prophylactic medications could mean large numbers of sick or dying patients. One of the most important jobs you can perform at the scene of an incident is consultation. It will be necessary to provide information on various drug treatments for affected individuals as well as prophylaxis for those individuals who are exposed. In working with our partners, we found a need for the most basic improvements to communicate this critical public health information. Fortunately, the Health Alert Network is being developed by CDC to ensure access to all kinds of information to address this great need for public health information, especially during a bioterrorism event. Thanks, Scott. I can speak from experience on the next subject, the coordination of media and public relations material. We must include the media in our communications and alert capability preparedness strategies. Accurate public information that is quickly delivered to the media can go a long way in calming fear and widespread panic. The Bioterrorism Preparedness Coordinator and the CDC's Bioterrorism Preparedness and Response Program will help ensure that the correct federal officials receive up-to-the-minute information, and these designated officials will provide frequent updates to the news media throughout suspected or actual biological terrorist events. These reports can include public health information, health alert treatments, guidelines and travel advisories, and like all other components of the public health response to bioterrorism, making health information available to the public also requires advanced preparedness by the CDC and its state and local partners. The CDC's Bioterrorism Preparedness and Response Program can assist state and local public health departments with media requests for bioterrorism related information, and will train public health information officers in media relation courses. The CDC participates in ongoing public health educational activities to raise awareness for the public health community's role in bioterrorism preparedness and response. Bioterrorism activities are held in general public sessions distributed through video news releases or provided on the CDC website, and this website will also include emergency information during an actual bioterrorism event. That's great. Another important aspect to CDC's current Bioterrorism Preparedness activities is training. It's the backbone of each of the five strategic components that we've talked about. Many of you are new to bioterrorism preparedness. Training and research will enable you to become subject matter experts or at least be better informed so that you can help train others, other partners in the response. Training of the general public is also an important tool in raising awareness and can help calm public fear if an incident does occur. Everyone in training programs like the Epidemic Intelligence Service Officers and the Public Health Prevention Specialist, along with all the other CDC staff, are being educated about microorganisms that could be used by bioterrorists. Training programs are also available for emergency responders, emergency room personnel and other health workers who may be the first to examine and treat victims of bioterrorism. Scott, what about some of the preparedness strategies for the thousands of people out there who are watching this program from medical centers and health care facilities, not only here but around the world? Great. Let me mention a few words on that. I'd like to specifically address that portion to that portion of our audience. By now you probably realize that there are many things that you can do to help recognize and respond to a bioterrorism event. But the most important steps should already be in place, and I'm talking about basic surveillance, basic epidemiology functions. Both of these functions are so important when dealing with naturally occurring diseases and suspicious outbreaks. The difference is, during a suspicious incident, the speed and efficiency of your reporting is paramount. To help you better understand your role in a possible bioterrorism event, learn the internal reporting systems in your hospital, VA hospital or clinic. Get to know the infection control practitioner. This person is a wealth of information about surveillance and epidemiology and response. A valuable resource for those of you in medical settings is the Bioterrorism Readiness Plan, a template for health care facilities, and a copy of it is in your student packet. It was developed by the Association for Professionals in Infection Control and Epidemiology and the CDC, and will be updated to reflect public health guidance and new information as it becomes available. Now keep in mind that it is a template and it can and should be used and adapted to your specific facilities needs. Marcy, you've been sitting there very patiently listening to us to kind of go on about this for some time. I'd like for you to tell us a little bit more about what New York City has planned for these bioterrorism events. Sure, I'd be glad to. We've been working for four years now on a good number of plans, so let me just highlight some of them. Since early detection, as you've heard, is key to an effective response, we're enhancing our surveillance systems again by increasing awareness of bioterrorism in the health care and lab communities, as I mentioned earlier. We're also attempting to make it easier to report to us while in return we provide the health care community with timely feedback on disease trends in the city. Surveillance, like preparedness, is truly a partnership and works best when communication is a two-way street. Although I can't overemphasize the importance of provider reporting, in New York City we've also recognized the need to develop non-traditional surveillance systems. These unique systems do not depend solely on physician or lab reporting and they monitor the presence of clinical syndromes, especially flu-like illness, which is the earliest symptom of many critical agents like plague, smallpox or anthrax. We've identified in New York City existing computerized data sources like 911 calls and ER emergency room and mission logs that are readily available to us, and this timely data is geographically representative of our city and contains information on clinical symptoms. Surveillance methods that we've also developed look at unexplained infectious deaths in previously healthy adults or children that we've developed in conjunction with our vital registry using death certificates. Once we're unfortunate enough to identify an unusual disease occurrence and recognize that, we would need to put into action the notification, coordination and response protocols that we've pre-developed. This will ensure rapid communication among everyone involved with the response so that each of our roles is clear and well-defined ahead of time. We're also continuously working on developing surveillance instruments, epidemiologic protocols and databases with mapping programs to help us quickly determine the site of exposure during a large-scale bioterrorism incident. Recognizing the fact that the site we're trying to identify with our epi-investigation will also become the crime scene we've begun to regularly meet with the local FBI and the New York Police Department to discuss how we will coordinate our epidemiologic and criminal investigations. As soon as the critical agent is identified, we will need to quickly provide the medical community with information on the clinical management of the corresponding disease. Disease is very few physicians know much about or have experience with. And because of that, we've developed medical protocols, pre-developed medical protocols that address the more likely critical agents that could be used and have the ability to rapidly distribute these protocols to key areas in all city hospitals using our computerized broadcast facsimile and we would also use our website. If a bioterrorism event does occur, we will plan or we are planning to establish a medical hotline staff by health department medical professionals to answer urgent questions on treatment and preventive care. Much of our bioterrorism preparedness is being done in close conjunction with the mayor's office of emergency management and other local city agencies and local hospitals. This group is developing a contingency plan for addressing the difficult issue of mass medical care and mortuary needs that may be required during a large-scale incident. We will likely need to rely on the federal government for medical assistance teams, antibiotics and other medical supplies and we need to have pre-prepared plans on how we will integrate these federal resources into our local medical system. Marcy sounds like the city of New York has put an awful lot of energy, time and resources into their emergency preparedness plan. You know, I hope the subject isn't getting you down but at this point I'd like to remind everybody that there is some good news out there about all of this bioterrorism preparedness. We'll also be more prepared to deal with any naturally occurring infectious disease outbreaks if we plan well for this. This is one of the benefits of what Denise called dual-use tools. Not only will they prepare us to handle man-made threats but they'll also help us in recognizing and controlling naturally occurring emerging infectious disease outbreaks, hazardous material accidents and other biological disasters like pandemic influenza. Now we've come to the point in our program where we'd like to hear about some bioterrorism preparedness strategies. We wanted to find out what's happening with lines of communications, surveillance issues and other plans that you have in the works at the state and local level. And we know there's a lot of good work being done out there and we asked one state to share with us some ideas that they had. Now calling in from I believe it's Louisville, Kentucky is somebody that has an excellent step or two that they've taken. They're going in the right direction and they'd like to share that with us now. If we could go to that please. Hello? Yes, we hear you. Yes, I'm Dr. Garrett Adams. I'm Medical Director of Communicable Disease and Jefferson County Health Department in Louisville. Speaking this afternoon for Dr. Melinda Rowe who is our health officer but she happens to be in Lexington describing our readiness plan over in Lexington and so I am going to tell you what we've done. In 1979, the Jefferson County and Louisville merged health departments developed a hazardous materials unit and so we have a long history of coordination and cooperation with EMS Fire and law enforcement. In early 1988, 1998, excuse me, FBI Special Agent and the Director of Emergency Management Agency met over coffee at the Cracker Bell to discuss implementation of the President's directive. The FBI assembled community leaders whose involvement would be critical in responding to a terrorist event, city and county government, officials, EMS, city and county police, city and county fire, Bell, South and others. The motto for this Louisville, Jefferson County crisis group has been leave your ego at the door. They've gotten to know each other on a first name basis and Dr. Rowe has said that the best advice she can give to communities is to get to know your FBI and EMA people and start talking. I think it's very important that you remember that if you meet at the Cracker Bell you have to leave your ego at the front door. We have an opportunity for a question here and I'd like you to ask that if you could about the importance of linkage and talking and working together. Well, this has just been indispensable to know each other and I think our experience will sort of bring some of the issues that you brought out so well in the program so far. In October of last year an anthrax threat was received at a local health facility and Dr. Rowe was a member of the group page and within minutes she and the FBI special agent representative physician representative of EMS were all on the scene at the site. Everyone knew each other. They had had exercises together. They respected each other and knew each other's roles. FBI set up a conference call with US Amrit, CDC and Quantico and these consultants knew our microbiologist at the University of Louisville and recommended that we take specimen to the University of Microbiology Laboratory. The special agent accompanied the specimen to the laboratory and watched as it was being tested and when it was evident that this was a hoax that there was no environmental risk to the workers in the building. The agent and Dr. Rowe as the health officer of this county walked into the building to reassure the people. The entire incident was handled without any panic and there was a minimum of wheel spinning and hysteria. That sounds like an absolutely positive wonderful response. Thanks for calling in with that question and once again the importance of talking ahead of time no such thing as a good surprise. It's good to hear that so much is in development already and we hope that the information you're hearing today as we just heard can help you even more. Now keep up the good work out there and preparedness planning. One of the key things that we need to build at the state and local level is the ability to link to each other and other federal agencies as we just heard. One of the recent and very important developments in this arena is the creation of the Health Alert Network. Now Dr. Patrick Carroll from the CDC's Public Health Practice Program Office will tell us more about how this network works. By now many of you have at least heard of the Health Alert Network. In fact many of you have requested and have been awarded funding specifically to establish a Health Alert Network infrastructure in your community. Despite the fact that so much has been said and heard about the network there are still a few misconceptions and remaining questions about this system. So I'd like to take a few minutes to further describe what it is and what it's not. The Health Alert Network is designed to provide a solid foundation for the transmission of all kinds of electronic information. For example, person-to-person email communications, access to information on the World Wide Web, broadcast of health alerts, receipt of distance learning programs like this one, and transmissions of surveillance data, graphic images and so forth. The Health Alert Network is an underpinning element of CDC's larger effort to upgrade bioterrorism preparedness throughout our public health system. But it's important to note that the augmented information and communications capacity provided by the Health Alert Network will be of use in addressing all other health threats as well. Although it may be difficult to comprehend the full impact that a bioterrorism event could have on our communities, it's easy to see how a ubiquitous communications and learning system will be crucial in preparing for and responding to bioterrorism or any other threat to our public health. There are four specific goals of the Health Alert Network. Our first goal, and it's an ambitious one, is to connect all full-function local public health agencies to the internet using high-speed, high-bandwidth, always-on internet connections, along with up-to-date web browsers and email software. This technology, coupled with appropriate training and local staff support, will dramatically enhance the capacity of local public health officials to communicate with their colleagues in times of crisis, to access and share prevention and control information via the web, and to send and receive confidential or sensitive information through secure electronic channels. It also provides the foundation upon which next-generation surveillance and other data systems can be built. The second goal of the Health Alert Network is to ensure that all state and local public health agencies have the capacity to receive training via distance learning technologies. The public health community regularly faces new and unfamiliar threats to health. Detecting and responding to bioterrorism is but the latest such challenge. In this case, of course, we in the public health community have a lot to learn in a hurry. Currently, training in bioterrorism preparedness and response is available through satellite programs such as this one provided by the Public Health Training Network. Increasingly, distance learning programs will deliver interactive instruction directly to the computer desktop through the Internet. One such course we are developing is a distance-based program in public health informatics. Through this web-based course, many hundreds of public health leaders and senior program managers will learn how to systematically and successfully manage the acquisition, development, and deployment of new information systems and information technologies for public health. They will also learn how to effectively work with the information scientists and technologists who will join with us to build these systems. The third goal of the Health Alert Network is to ensure that all local public health agencies have the capacity to rapidly broadcast information and health alerts to key subgroups in their communities. For example, in the event of an actual bioterrorist incident, local public health officials might urgently need to send disease control information to all emergency department physicians, to infection control nurses, first responders, and so forth. Now, a variety of technologies can be used to broadcast information such as broadcast fax services, auto dial systems, and internet-based email lists. But whatever the technology is employed, the Health Alert Network will ensure that this kind of information broadcast capacity is available comprehensively to local public health officials throughout the country. Given the importance of technology to the Health Alert Network, internet connections, satellite dishes, broadcast fax machines, and so forth, it is tempting to think that the Health Alert Network is nothing more than this, new hardware, new technology. It is very important to realize that this is not the case. Equating the Health Alert Network with new computers is like equating a fire department with new fire engines. Fire engines are, of course, necessary in any community fire safety system. But fire engines don't fight fires. It's people trained in the use of this equipment that fight fires. However, a community ensures that it has an adequate system for fire safety by measuring that system against established standards, performance standards for individual firefighters, and organizational standards like minimum response time for the fire departments themselves. The Health Alert Network is very much the same in that internet connections, distance learning technologies, and information broadcast systems will not in themselves protect us from bioterrorism and other health threat, which leads me to the fourth and final goal of the Health Alert Network, to develop the tools by which public health agencies can assure that they have the human and organizational capacity to protect and promote the health of our communities against bioterrorism and all other health threats. In concert with our state and local partners, work is underway to establish both individual and organizational standards for bioterrorism preparedness and for other essential public health services. With these standards to guide us, we can assure that health departments have not only the necessary technical tools, but also the demonstrated individual and organizational capacity to detect and respond to bioterrorism and other public health threats. I believe the Health Alert Network represents one of the most substantial investments in many years in some very critical, foundational elements of our public health system. The network will provide much enhanced communication, information, and distance learning capacities, and will promote the development and use of standards by which we can assure appropriate individual and organizational capacities in all of our public health agencies. I hope that all of you, as public health professionals, will play a vital role in working with your colleagues to develop and utilize the Health Alert Network. Thank you. You know, Dr. O'Carroll made a critical point. We need a well-trained workforce. It's not just about connectivity. Everyone out there is responding to a bioterrorism threat or incident who needs lots of information and training. We know that. Next, we'll talk about some examples of how to put this training to use. But first, I'd like to reintroduce our panelists for this segment of the program. You've met them earlier in our broadcast today. Dr. Ali Khan with the CDC, Agent Kathleen Cukor from the FBI, and Dr. Dennis Parata from the Texas Department of Health. Now, as we mentioned earlier before, there have been different types of, and there are different types of bioterrorism acts. Ali, give us, if you can, some of the definitions here. I think the first thing we need to realize is that bioterrorist events can either be threatened or recognized. Now, you may have heard them commonly referred to either as overt or covert, although these terms are not truly synonymous. Threatened incidences of bioterrorism are self-explanatory. A terrorist threatens their intended victim, the police or the media, that a bioterrorist event will happen, or has happened, hoping to generate publicity for their group or cause. Threatened events need careful investigation, and if they are strongly suspected to be real, the wheels of bioterrorism response should start to roll. Now, a recognized event are outbreaks where no warning is necessarily given or responsibility is taken, but it's certain that a bioterrorist event has taken place, generally based on the medical and public health assessment of an outbreak, and you've already heard about some of those components with the epiclues. Now, a recognized event will trigger a multi-agency response based on your actions, and let's also admit that there is a gray area that exists between these so-called threatened events that we're told about, and these recognized events that we find out about, and this gray area is sort of like a twilight zone because the outbreak is recognized, it seems suspicious, however, it could either be a naturally occurring disease or an intentionally caused outbreak. We saw good examples of this suspiciousness with the Hanoveris pulmonary syndrome outbreak in the southwestern United States and the brucellosis cluster in the New England area last year. Both were considered to be bioterrorism incidences until they were proven otherwise through the standard steps of the epidemiologic investigation. Yeah, and I think recognizing and evaluating the twilight zone of suspicious events is a critical component of preparedness. It can make all the difference in a timely response to an actual bioterrorist event. Recognition and initial investigation is the job of the public health system. So in the past, most emergency preparedness strategies and terrorist incidents focus primarily on threatened events, like bomb threats. We know that from experience that most suspected bioterrorism events are hoaxes, also called threatened biological incidents, or as my friend Ali likes to call it, TBI's. Each TBI could potentially represent a significant danger to the public and needs to be thoroughly investigated. You know, sometimes it's not even necessary for a terrorist to have actual possession to generate publicity for a cause. Lord knows we've seen that throughout the country. Sometimes the mere mention of one of these disease-causing agents can garner media attention. Kathleen, if you will, can you give us some more information on these threatened biological incidents or TBI's? Sure. Dr. Kahn mentioned that the TBI's or threatened biological incidents are much more common than actual events. I'd like to give you some numbers to back this up. So far, there have been more than 100 threatened incidents of biological, chemical, and radiological terrorism this year. Over 160 of these have been bioterrorism. Each of these threats used an enormous amount of time, energy, and money to investigate. But we can't afford to ignore them because they could be real. This is a hard lesson we've already learned from witnessing other terrorist acts in our own country. And TBI's do make us aware of our shortcomings in preparedness efforts. So there is something to be learned about each one that we encounter. I think this underscores the importance of the collaboration between CDC, FBI, and the other agencies involved. Just last year, the CDC published information on seven such events in the Morbidity and Mortality Weekly Report. Let's take a look at some discussion cases for a couple of TBI's. Ollie will give us a little background on each of these hoaxes, how they developed, and then we'll talk about the decisions that were made along the way, whether they were wise or perhaps not so wise. Let's start with this one. An abortion clinic receptionist receives a letter with white powder in it. The note states that the recipient has been exposed to anthrax. The receptionist then shows the letter to four other people in her office before calling 911. The police, ambulance, fire department, local hazmat teams, full court press, you know, everybody shows up. They quickly inform everybody in the office that they should strip to their underwear. Then they're sprayed down with some sort of bleach solution before being sent to the hospital for antibiotic therapy. I don't know. The thought of me standing there stark naked with bleach over me is a pretty dramatic picture which I don't think anybody wants to see. Is this a bit excessive, Kathleen? Yes, it's a bit excessive. This early response was an example of a lack of education and scientific information available at the local level. All of us should be working to define a lot of steps to follow based on the situation at hand. For example, the receptionist shouldn't show the letter to anyone limiting the risk of possible exposure. And the local health department should also be on the scene as well. They need to collect information on all the exposed persons and provide a name and number of public health professionals who'll give them some follow-up and give them the results of the lab analysis, prescribed prophylaxis if necessary. All of the exposed to the materials should be considered for contamination and this really can be done with just plain soap and water. I would just tell them to wash their face and hands, go home for a shower and just to launder their clothes at home. Seems like a very reasonable, well thought out and measured response. Now, this threatened biological incident that I'll talk about now began when someone found a container marked plague in a public high school. The container unfortunately sat down and didn't know what to do with it and they didn't even know to call their state health department for help. Well, I'd really say that the local and state health department needs to make their presence known in Miss Lynn Alley. In this case, there was no information, no implication for public health. I think it would be important that someone was, we knew that someone was making a threat or it actually produced a viable biological material. The scenario would be very different if we were to contain a critical agent. As public health officials, we need to let everyone know what we do and we also need to develop plans to prepare for situations like this. Who's going to take the samples? Who's going to process them? These are just a couple of the many questions that need to be answered during your preparedness planning meetings. Dr. Perrata is right. Coordination and communication are key issues in most threatened incidents. And we can't impress enough upon you that the FBI Weapons of Mass Destruction Coordinator in your local city do so now. There are 56 field offices across the United States and over 400 resident smaller offices. Okay, at this point, we've talked about some ways to handle different threatened biological incidents. Well, don't forget that you won't know if the event is real or a hoax until the investigation and lab work is performed. Let's discuss some general guidelines on how to handle a TBI a threatened biological incident that is genuinely considered to be a real terrorism incident. Dennis, tell us if you would, what would you do at the local and state level? Well, I think the most important step for handling one of these TBI incidents needs to take place during the preparedness planning periods. As we saw earlier, there could be numerous agencies involved in a response determining which each one will contribute, where the resources are needed most and how all of the groups will work together needs to be coordinated before an event takes place. You can't make bioterrorism preparedness plans by yourself. You really do need the entire community's input and involvement. One suggestion I have is to have a state health department professional who will be the focal point for contact for health related issues during a bioterrorism incident. This bioterrorism preparedness coordinator would work with local health and medical personnel, law enforcement, and state governments, and be the single point of contact for the FBI, CDC, and other federal agencies that may be called on the scene. Of course, it would be great to have local bioterrorism preparedness coordinators too, but we know that funding may be more limited for positions at that local level. The coordinator should clearly identify points of contact and communication paths. Everyone involved in bioterrorism preparedness needs to know when and who to contact in their phone for a suspected bioterrorism event. When the threat is seriously considered to be real bioterrorism, the local response plan is activated, and depending on your individualized plans this might include notifying the infection control practitioners in area hospitals, emergency medical services, hospital administration, the state health department, hopefully, local law enforcement, local FBI field office, just to name a few. Depending on the severity of the situation and the local capacity to handle it, the state may activate their emergency response plan which will bring state health department practitioners, state law enforcement, and other state resources to the scene. At this point, the state can call on the resources of our federal partners like CDC's bioterrorism preparedness and response program to help us with on-site investigations. The same kind of communication would occur within the law enforcement circles as well with the FBI called in a few minutes after the activation. Obviously, the state health department's bioterrorism preparedness coordinator will play a major role in the continuing situation. I'd like to add to some of your comments, Dennis. By saying that CDC would be called in, I really want to emphasize that the local and state health department will continue to be in charge of all public health issues using their epidemiologic and diagnostic resources. They will assist the FBI in collecting samples from any suspected devices or packages or evidence of the substance from any packages that are used on the community. These samples will immediately be transported by the FBI to the nearest appropriate laboratory for analysis. Now preparedness strategies must include many support systems to help you in the event of a large-scale bioterrorism incident. Local responders won't be able to handle it alone. Medical emergency preparedness teams may be sent to the scene to help out whether patients may require prophylactic medications and post-exposure immunizations to prevent illness along with many others who actually are just suspected of having exposure. The National Pharmaceutical Stockpile will help with vaccines, medications, and antitoxins during such situations. Now laboratory support must be maintained at the local, state, and federal levels and the CDC can help coordinate this support, and you've heard about this from Steve Morse. This is where new technologies in the rapid response and technology laboratory will be most helpful. And there are some other issues that we must deal with in the aftermath of these so-called TBI's that is now a confirmed bioterrorism event. State health departments need to think about aftercare management for those persons exposed along with the others who are suspected of being exposed. The state and local response teams will also need to make sure that the suspected victims are enrolled within the CDC and ATSDR's bioterrorism registries to sort of receive information in long-term monitoring. I'd like to remind everyone that once the FBI is notified that there is an ongoing epi-investigation because of suspicious circumstances the situation might warrant a preliminary investigation by the FBI. Considering the needs of both public health and law enforcement as the teams work to determine if this is a real threat or a hoax. If the incident turns out to be a false alarm the public health emergency may subside but the criminal investigation will continue. During this time it will also be necessary to calm the public fear and panic that an act of bioterrorism can cause. Many psychological responses can surface not only in patients but in the responders as well. We've seen cases of that already. The FBI may call in other agencies to assist with some of the psychological treatment of bioterrorism issues but you must be able to clearly explain the risk involved while calming anxiety and patients health care workers in the local community. The public health information officer can help by disseminating information to the media in a timely manner calming public hysteria. If there is a far-reaching emergency the information officer will also work with the FEMA officials to set up a joint communication center. This center will include information from all the agencies involved in a large response so that emergency information and media duties can be handled more effectively by the proper agency. Kathleen point that you just brought out is so good is that the team members here will bring so many strengths to the table in these situations that's very important. We've talked about threatened biological incidents now let's get into the challenging and gray area of suspicious outbreaks which may or some of the things that we can expect in this area. I think what we can expect in this area is that the public health investigation that has suspicious elements won't garner the immediate attention of the media and other publicity outlets like a threatened event usually does and as we've seen there'll be no sirens, there'll be no bells, there'll be no whistles going off saying bioterrorism has occurred in your community and because of the delay between exposure and onset of illness also called the incubation period and the examination of the agent may actually go unrecognized for days or weeks until people get sick. The shortest possible incubation period for the agents on our list is one or two days if it's anthrax but it can be much longer like seven to 17 days for smallpox. So what we see as our role as public health professionals is more like a watchdog when we start talking about suspicious diseases and recognize events. Each year local health departments conduct investigations of disease outbreaks most of which you never hear about but these investigations are the best hope for the early detection of unannounced bioterrorism in the community. You can guess that a suspicious or unusual outbreak will demand much more active role of public health professionals before it's proven to be a recognized bioterrorism event as opposed to a naturally occurring disease or a threatened event. Again rapid surveillance and epi investigation are crucial to incriminate bioterrorism as a cause for an outbreak as large groups of people will likely be appearing in hospitals, doctor's offices with similar symptoms. Eventually the disease will be recognized to make no doubt about that but it's in the earliest stages when the first few cases that start showing up that we will have the opportunity to make the biggest impact. The sooner you recognize it the better it's going to be. Dennis what can you tell us about the pain of a recognized event? Well let me explain the recognized event by using this example. Let's say a local infection control practitioner becomes suspicious about an unusual cluster of cases and calls the local health department. Through their work local surveillance and epidemiology the suspicions are reported to the state health department's epidemiology group and the bioterrorism preparedness coordinator. Then according to the local bioterrorism preparedness plan calls are placed to the local police, local field office of the FBI. Depending on the circumstances other local agencies may also be contacted. The coordinator may make other calls on your behalf to help your team with the event and will probably contact the bioterrorism preparedness and response program at CDC to request their support. The suspicious cases may turn out to be a naturally occurring disease as we saw in the hand of virus outbreak in the brucellosis cluster. But still as public health officials you must continue your response efforts just as you would with a routine outbreak. But Ollie what really happens if it is a bioterrorism event? Essentially Bob this recognized event now follows the same response steps as a threatened event that became a reality that I just talked about a couple of minutes ago. As the incident unfolds additional state and federal responders will arrive to help you with patient care will bring you these prophylactic medications these post exposure immunizations if necessary depending obviously on what the agent is. The FBI will start to conduct the appropriate investigations and the rapid response and technology laboratory will assist with further laboratory testing and the public health information officer that we've all mentioned a couple of times hopefully will deliver information to the media in a timely manner. Now as you can see it's vital to be prepared for all of these potential tasks before they became a reality. And remember our window of opportunity to make a distance is very short only the length of that incubation period. Quickly identifying and responding to these recognized events we hope will save lives. And the key to having a good response is having a well thought out bioterrorism preparedness plan that involves all of the appropriate players then adapting the plan as needed to your locality frequent exercises and rehearsals will show areas that need improvement you should always hold a lessons learn meeting after your rehearsal to go over what went wrong and what went right. You should be honest with yourselves upon reviewing these exercises use them as learning tools and include plans about what your team can do better the next time it's also important to learn from previous responses to the actual hoaxes and other recognized biological incidents. We've seen good examples of those today. The bottom line is that bioterrorism situation could quickly become extremely complicated. A good outcome will hinge to a great degree on the preparedness plans that were worked out by you ahead of time. Thanks everyone for that detailed overview. Now let's take a look at this discussion case of a recognized bioterrorism event. Now we'll separate the case into stages and we'll talk about the decisions that were made along the way. It's a busy morning rush hour in the northeastern city of metro village. Population 3.5 million. 500,000 use the subway system as their main means of transportation. Unknown to the community, law enforcement and subway officials terrorists have gained access to 10 subway cars overnight in the metro train yard. They've placed aerosolized canisters containing a fine anthrax powder in the intake ducts leading to the ventilation system within these cars. The targeted trains are used in seven of the most frequently traveled subway lines in metro village. The timing devices are said to release the anthrax starting at 7.30 a.m. and contain enough compound to last approximately one hour. The height of the morning rush hour. Dennis, very quickly, what kind of group might have staged this event? This is scary. This is a real sophisticated event and I think this is probably something that state supported. We have an organism in enough quantity created in a fashion that can be dispersed using a dispersal mechanism. The security of the metro system was broken. This isn't your homegrown thing. This is really something maybe state supported, very sophisticated. This is really what worries us from a public health standpoint that this may actually happen. Now I guess based on animal data and some of the sferd loss data we talked about earlier these people will probably start to see patients I would say in about two to three days. Who's up first this morning? We have Jodie Perry. She's in exam eight. She's 27 years old and she has a history of asthma. Her husband brought her in a few minutes ago and he said she's been having difficulty breathing since this morning. Okay, let's go. Oh thank goodness doctor. It's my wife. She's asthmatic and she seems to be having some sort of serious attack. All right, we'll take care of her. How long has she been this way? At least since last night. She hasn't been able to sleep and neither have I. She's been coughing and wheezing and her inhaler doesn't seem to work. And on top of that she's been sick to her stomach. Okay, let me listen to her chest. Well there's a question and she's moving air pretty well. There's some scattered wheezing. Is she febrile? 102 degrees. How long has she had this fever? At least since last night. That's when I took her temperature. Has she been coughing up anything? Yeah, I guess so. Just a little bit of white gunk. Check her O2 sat and her peak flow. Let's get a chest X-ray, a complete blood count as well and call respiratory therapy to get her breathing treatment. I'll start her on steroids. Is she gonna be all right? She should be fine. We're just gonna run some tests to make sure she's moving enough oxygen and to determine if there's been an infection that triggered this asthma attack. We'll talk to you again once the results are in. Just take it easy. It shouldn't take too long. It's gonna be all right, honey. I'm gonna be right here. Okay. Let's see. Well, it looks like you're running a little bit of a fever. 101 degrees. See, I knew it. I've been feeling badly since yesterday. I even went to my doctor. I told that old man that I needed antibiotics. Did he give them to me? No. He told me to go home and buy me fluids. Advice wouldn't even worth my $5 copay. Now look at me in the ER. We'll see what we can do for you. Now, let me get some more information for the doctor. Now, I know you were saying that you were feeling tired and experiencing shortness of breath. Anything else? I have a headache. Also, I've lost my appetite. Oh, hey, Michelle. Just a one-on-one see. Who's the other attending on today? Andy Herman? Oh, right. She was at Presbyterian for years. I heard she's with us now. I think she's on at 11. Okay. Can you order a chest x-ray for the guy on exam 3? He's a 6-year-old male with complaints of chest pain, occasional dry cough. He has a fever, myalgia. He's feeling pretty awful. Sure, no problem. You need to go into exam 2. Hey, any word on the peri-case from this morning? I admitted her to ICU when you were on your break because her O2 sats weren't... were getting worse. I saw the chest x-ray earlier, but I asked for radiology to reshoot it. The first one must have been rotated. The mediastinum was a little too wide. I was just wondering how she was doing. I'm not sure. I'll call up there and find out. How are you? Fine. How are you, Dr. Rogers? Well, it's been about a year since I've seen you. Welcome aboard. Glad to have you. Thanks. You must well just jump right in. I could use your help. Sure. What do you have? I've had a few cases of people complaining about cough, shortness of breath, and fever. I've got their x-rays back. I've had to ask for a few repeats because they seem to be coming back slightly rotated. Anyway, there's no infiltrate, so I'm not suspecting pneumonia. I've asked the lab to do a rapid flu test. Something doesn't seem right about these cases. Hmm. It could be almost any chest infection. Hard to say. Did you ask about occupational exposure? Well, the first case, a 27-year-old asthmatic female works as an undercover cop on the subway. The 6-year-old man is a retired volunteer downtown, and the 35-year-old male works as a stand-up comedian slash waiter, so there's no occupational connection. It's just that these cases keep reminding me of one I had a day and a half ago. They put the cause of death as pneumonia. But now I don't know. Well, let's wait and get the results back from the lab. Uh, it's getting a bit busy around here today, so if you think they're stable, I think you should probably go ahead and let them go home. Does it feel tender when I do this? Very. Have you had a sore throat? Every night. Is it kind of dry and scratchy? Mostly scratchy. Are you just keeping you awake at night? Yes. You know, Doc, what's going on? I've been here all afternoon. I know you have. We've started to get very busy here. I'm sorry you had to wait, Kena, but we're going to start you on some antibiotics, and I think you should be able to go home soon. And you're going to feel better in a few days, okay? Take care. Well, I had no idea what I was in for when I signed on here at general. It's getting a bit thick around here. It certainly is a normal. He has a confirmed mediastinal widening on the asthmatic and the waiter from this morning. He could be in esophageal tear with mediastinitis, but they think they see another widening on a 60-year-old as well. He has a history of cancer. I'll go back and check him for a tumor or other mass. This is bizarre. Two cases of the widened mediastinum. Between us, we've had about five patients admitted for various pulmonary problems. You know, all told we found another dozen or so patients sent home with similar symptoms. We didn't even bother getting chest x-rays on those cases. I think we better consider calling an infectious disease for a consult. Should I call the infection control nurse? I mean, are we at risk here? Could this be contagious? Yeah. I think that's a wise idea. Really? You do, huh? Okay, come on down. That was radiology. It looks like they found some interesting results from the x-rays today. Several have shown a widened mediastinum. Oh, really? Hey, we picked her up over in Sunnydale. Her relative called. She's been having trouble breathing for the last several hours. Okay, let's see. We're running out of space here. Why don't you put her in exam one? I'm telling you, it's like this everywhere. We've been running cases like this to all the area hospitals. Also, I'm afraid your asthmatic from this morning died an hour ago. Oh, no. I can't believe it. I forgot to get to the bottom of this. Well, let's try to get an autopsy ASAP. We can't. Our husband has refused one. Oh, you're kidding. No, but look, we've got a bigger problem on our hands. Now, we need deep in patients in the triage area. Our staff and resources are maxed out. On the bigger picture, I think we need to page the city health officer and let her know what's going on here. Well, Dennis, we can sure see here as this evolves that preparedness strategies for hospitals and clinics are very important. Absolutely. You should see my blood pressure during that session. This emergency room had a large number, a huge increase of unknown kinds of conditions, all of them looking about the same. Not once have we talked about calling the local health department. Dennis, I agree. It was actually sort of painful to watch it. There was this unusual sign that the doctors kept mentioning the white and media stynum. And as you've heard over the past several days, very few things that can cause that and would look like otherwise healthy people. And one question that came to mind, Dennis, I think we should have this. Oh, absolutely. Can't anybody run a gram stain? Just do a little bit of work here and get us some information. That wasn't happening here. Let's talk about some of the other things that this hospital could and should be doing. Well, I think we've picked up on the key issues here that they should have very quickly involved the laboratory in the diagnostic issues. They should have called the local health department. This was unusual and they figured that out was unusual and they should have been contacting the local and state health department. Let me make a point that I think maybe we should have a new epi-clu at this point. Anytime you find yourself using the word media stynum, this many times in a normal conversation, you should call the health department. Good afternoon. I'm Joe Washington. What started out as the suspected large number of influenza cases across the city has taken a mysterious turn. There have been reports of approximately 100 sick people appearing at area hospitals and clinics for care. Earlier, there was speculation that Metroville citizens may be suffering from some sort of new Spanish flu or Hong Kong bird flu. Now the cause of the sickness is unclear. This epidemic, some are referring to as the Metroville mysterious illness began yesterday when people in and around the Tri-County area became sick. Action 11's Jennifer Jensen is live at County General Hospital with this report. Joe, here at County General, doctors have been inundated with patients suffering from the mysterious Metroville illness. Approximately 100-plus patients have appeared at emergency rooms throughout Metroville. Dr. Eli Rogers is the attending physician here at County General. Dr. Rogers, can you tell us what's happening here? Well, we've had numerous cases of people ill with fever, cough, shortness of breath, and chest pain. Is it true that you've ruled out a new flu as the cause of this illness? We've done some quick tests for influenza type A and they've all come up negative. We'll have to wait a few days for the cultures to get back. We're not seeing typical symptoms of the flu though. These people don't have runny noses or sore throats. What do you think is causing this? We have no conclusive evidence right now, but the city health department is starting an investigation and have begun to test blood and tissue samples in their laboratories. Dr. Rogers, have there been any deaths associated with this illness? There is one suspected death right now, but an autopsy was refused by the family of the patient, so we were... I'm sorry, I'm needed in the ER. Well, thank you Dr. Rogers. And Joe, we also caught up with Mayor Claiborne today to find out about the city's reaction to this epidemic. Mayor Claiborne, do you know what we are dealing with? What's happening in Metroville? We are asking that everyone please keep calm until we have a confirmed diagnosis. We're fortunate that Metroville's public health department is one of the tops in the nation. I trust they'll get to the bottom of this soon. All area hospitals have sent blood and tissue samples to the state health department. They have been in contact with the centers of disease control and prevention and will send those samples on to them. As soon as we receive word back from the CDC, we will let you know. Mayor, how do you respond to the suggestion of isolating all persons with fever, cough and chest pain? Right now, hospital staffs are struggling to keep up with the surge of patients. I urge the public to stay calm. We have some of the best scientists and doctors in the Metroville area and state health departments. They're on the job and I promise you they'll get to the bottom of this. Mayor, are you positive that this is a natural outbreak or could it be something more intentional? At this point, we have no evidence that there's anything but a natural epidemic of some sorts. I caution residents to stay calm and contact your personal physicians or public health clinics if you begin feeling ill. That's all I have to say today. One more question. And, Joe, that's all we have from the mayor. We'll keep you posted on this mysterious illness in Metroville. For Action 11, this is Jennifer Jensen. You walk out of a hospital, four microphones in your face, you are not going to have a good day. I'd like to talk a little bit about the media exposure in this situation. You know, what happens to the lines of communications, to the local, state and federal levels, the FBI, the CDC, all of these things that come into play here? Dennis, it really gets difficult, doesn't it? It sure does. I think this is a good example to suggest that everybody that's going to be playing in this particular field needs to have some sort of media relations training. I mean, the mayor came out and while her words were probably factual and good, she looked unprepared and then at some time she even looked like she might be hiding something. The poor physician was not prepared to do that and that's okay, but I think they probably would have benefited by some good training. Marcy was talking about her best scientist were on the job and in New York City that would mean you. What is the local health department supposed to be doing right now? What do you think they're doing? There's a lot of things that will need to go on all at the same time. I mentioned communication and coordination, but there are two things that have to go on simultaneously. One is active surveillance to define the extent of the problem. Is this just localized to this one hospital or is it city-wide? And basically simultaneously with trying to figure out what the diagnosis is and getting good lab specimens to reference labs at the state or CDC is doing an epidemiologic investigation to try and figure out if there's any common associations between these patients. And probably the most important thing you need to do is call in some help and I would call CDC. Let me make a point about calling CDC. We've talked a couple of times about EIS officers coming in, but when you call CDC it's not a young EIS officer that shows up. Essentially all CDC shows up and all of that support that you don't see shows up. So we are always anxious to come and help. Now I think in addition to the epi-investigation I'd personally do a clinical investigation on the actors in this scenario to see what was going on with them. Now if Metroville actually had these two epidemiologists helping them out, I would guess at this point they should have figured out that anthrax had been released in the subway. Mom, please don't cry. I'm okay. Really? No. No, I wasn't on the subway that day. I feel fine. I haven't come down with a fever or cough and I'm not in any pain. From what I've heard on the news, someone or some terrorist group released anthrax throughout the subway trains No. They haven't said who or why. All I know is that it was released a few days ago and people have died. Yes. All of my friends are fine. Fortunately, none of them took the train that day either. Mom, it's crazy here. The entire city is shut down. A lot of people are sick so most of the businesses can't operate. The police and fire departments are swamped with phone calls and all the area schools have closed and nobody seems to be going outside. No. I've heard this isn't contagious. But who knows what to believe? I don't know what I'm going to do. I'd love to come home but I don't know if I can catch a flight. The airports are packed. I guess I could drive but the traffic's been outrageous. Everyone's trying to leave at the same time. I love you too. Oh, hang on a second. There's a breaking story on the news. I'll call you back. Bye. We interrupt our regularly scheduled programming for this important news bulletin. With the latest, here's Action 11's Joe Washington. Good evening. In just a few moments Mayor Emily Claiborne will be speaking to us from City Hall about this wave of illness that is torn through Metroville. As we reported earlier sources tell us that the deadly bacteria anthrax was spread in the subway station a few days ago. No one has yet claimed responsibility. We've been told that the FBI is now involved in this investigation. Let's go now to Mayor Claiborne. Good evening, Metroville. I come before you tonight to confirm what has already been speculated in the media. City and state public health officials along with the Centers for Disease Control and Prevention and the Federal Bureau of Investigation have confirmed that an unknown terrorist organization has disseminated spores of anthrax bacterium into our subway system. Sadly, there have been 950 confirmed deaths. After thorough investigation is believed that this event occurred on Monday, November 1st sometime during the morning rush hour. We are working with Federal agencies to receive medical assistance but we must act quickly to ensure the health of our citizens. Having said that allow me to take a moment to talk about the disease anthrax. It's important for you to know it is not contagious. Please understand it will not spread from one person to another. Therefore, if you were not on the subway system on Monday there is a very small likelihood that you were infected. However, if you were a subway passenger on Monday, antibiotics are available. Those of you who were on the subway that day and are feeling ill please report to your doctor immediately. For those of you who were passengers but are not feeling ill you can visit area public health centers and make shift clinics throughout the city. By ill I mean you have a temperature of greater than 101 with a fever. I must ask you to not attempt to obtain antibiotics unless you are a part of this at risk group. Current supplies are limited but should be enough for the amount of people health officials believe were exposed. So let's ensure that those in need shall receive medicines first while additional supplies are on their way. Also, I caution you to not visit area emergency rooms unless it's absolutely necessary. We've had several reports of area ERs inundated with panic citizens which is only preventing those in need from receiving proper help. Does anyone have any questions? Mayor? Marcy, this has got to be yours and Dennis's worst nightmare. A thousand people dead, close to a thousand people dead. We're watching this, the system is broken. How could it have been fixed? What could we have done better? Not seeing what was going on behind the scenes at the health department and other city agencies, it's hard to judge too much but you like to think that there was a window of opportunity that was missed. We heard about that in the section on anthrax and it makes you wonder whether the officials involved in the situation had talked about this ahead of time in the investigation of the health care providers. I think that this seems like a site where they just caught them completely by surprise and they just hadn't thought about this being a possibility. I'd just like to echo exactly what Marcy said because if the event happened on Monday and now we're talking about Saturday that they're just confirming this, we've probably lost that window of opportunity and that's going to be a very large tragedy and we've talked about this. The mayor talked about all the preparedness things that they had not put in place already for this outbreak and she talked about the things that the response component that's going to have to be ready. She talks about antibiotics, where they're coming from and somebody thought out all those possibilities with stockpile, etc. So you need to think of these things before they happen, you need to be prepared before they happen and this scenario without focusing on the number recognize that it's possible that this could occur. Again, the lines of communication just simply weren't clearly established here. Dr. Layton, how would New York City calm the public fears in this kind of situation? I think we all recognize that our only open way of communication with the public is through the media. We would need to work with the media to get a message out, to put things in perspective and let people know who's at risk and who needs to be treated and as importantly who's not at risk and needs to stay home so that the limited healthcare resources can go to those who need it most. For both Marci Otley and Dennis, thanks for contributing on this very sobering scenario. Right now I'd like to go over a few housekeeping details and then we'll take a quick break. In order to receive continuing education credits for this course, you must complete the final exam on the evaluation form. The exam is open book so feel free to use any of the printed reference materials in your notes when filling in the form in your packet. Each participant who successfully completes the program will receive an award letter that describes the credits to be awarded. These letters should be sent out before the end of the year. By the way, you will receive credits faster if you take the exam at the website. The evaluation form addresses bioterrorism preparedness issues for many future video conferences and your input is vital to the improvement of these programs. Not only will your feedback help it helps determine the most critical information for future bioterrorism preparedness courses. And there's one last minute change to the evaluation form. Please add Colonel John Hoyman to line 113. Now we'll be back in a few minutes to talk about CDC's initiatives for helping state and local assistance in bioterrorism preparedness efforts. Welcome back everyone. In this part of our program we'll talk about how CDC will help you with bioterrorism preparedness and response by describing programs and technologies that we're working on for the near future. We'd also like to welcome back Dr. Lillebridge, Dr. Morris, and Dr. Coo. Scott, if you will please tell us a little bit about how the CDC plans to enhance public health capacities in this regard. Bob, I'd be glad to. Let me start off by saying that a survey conducted by the National Association of County and City Health Officials showed that nearly 84 percent of local health departments do have community disaster plans in place but only 24 percent had emergency response plans that included a bioterrorism component. We are now in the process of adding a bioterrorism component to all public health strategies at all levels of the public health community. The administration in Congress recognized that public health is an essential and unique partner in any domestic preparedness and they awarded resources to expand vital capacity in all public health areas. This month approximately 44 million dollars are being awarded to states through cooperative agreements and several large cities in key areas. First of all is response planning to help get public health practitioners at the state and local level involved in response planning in a way that they haven't been involved in the past. Brings them to the table. The third area is epidemiology and the fourth area is the health alert network particularly areas of communication and training. As a result of these expanded partnerships and funds we will be able to achieve a more rapid notification of a bioterrorism event. We'll have a better, well-planned and coordinated response and we'll be able to continue to do so. The third area is well-planned and coordinated response. We'll have additional laboratory capabilities to identify unusual organisms and toxins and most of all we'll have a better trained workforce. The CDC is in the process of preparing also a document of our strategic plan with our companion agency the agency for toxic substances and disease registry and it will include information on plans for future bioterrorism preparedness and activities and should be available on our website soon. Bob, I'd also like to mention one last thing is that this preparedness effort will need to continue for about 3 to 5 years until we get to a point where we're going to be comfortable. Improving public health surveillance activities is a major focus of preparedness planning. We hope to make local public health departments stronger through local and state resources and improve communications at the national level. This all depends on the preparedness plans of course and Denise tell us a little bit about surveillance activities. Well first, I'd like to break down the term surveillance into three key actions. There's gathering and evaluating data interpreting these data and detecting problems and using the data for public health action. So what are some of the steps we're taking in public health? Well first of all we need to form better partnerships with health care providers especially at the local level. This will greatly improve our ability to gather data. We have to make sure that health care providers are aware of the role of public health in response to a problem and their role in making sure that we hear about potential problems. Providers must know how to contact their health department and what to report. Public health departments need to underscore the importance of detecting and reporting unusual illness or disease by publicizing separately those illnesses or diseases on a critical list. When health care providers are aware of their crucial role in public health surveillance and know how and what to report we expect that information about key cases will quickly pass from various sources to the most critical destination the local health department. From there the details can rapidly passed on to those who need to know. In this way a potential bioterrorism event can be picked up on in hours and not days. Now as you might have guessed throughout today early detection of a potential bioterrorism event will require the effective linking of data for many different sources. We've mentioned building better partnerships with first responders and health care providers whether they're in emergency departments infection control or poison control centers. We hope that these alliances will lead to electronic links that can make all our jobs easier. With state and local partners CDC is developing a national electronic disease surveillance system. This integrated network of systems will facilitate the monitoring of all reportable diseases and conditions including those illnesses and injuries that may be caused by an act of bioterrorism. We hope that this disease surveillance system will capture data that is already in electronic form especially from the health care system. For example automated electronic capture results from both public and private laboratories will be faster, easier and more complete than waiting for reports filed through normal channels. This information would then be available to local and state health departments and CDC to look for items of concern as we described earlier when we were talking about epidemiologic clues. We might detect changing antimicrobial resistance patterns the same disease widely spread across the country or any other evidence of either naturally occurring or intentional outbreaks. These are patterns that we might miss if we're not able to gather such data on a large scale basis. You know we've already brought up the fact that if you have suspicions about an outbreak you shouldn't wait for laboratory confirmation of your suspicions before contacting the state health department of the CDC. Boy we've heard it throughout the day today that laboratory analysis plays a vital role in the diagnosis of an agent used in the bioterrorism event and that diagnosis must be made quickly. So the prevention and treatment decisions can be made. Steve and I know this is a major focus of the CDC's bioterrorism preparedness and response plans kind of take us into that. Sure Bob. Well as Denise just mentioned it will be important to automate the results of testing from both public and private laboratories so that this important data can be shared with anyone who needs access to it. We also need to develop and test analytical methods for detecting subtle changes in disease patterns. This is necessary because so many agents especially naturally occurring organisms can be altered to produce more virulent strains. These analyses can also detect a few cases of rare disease or even a slight but abrupt increase in a common illness which may be an early indicator of the event is in progress. Now I've already talked about the rapid response and advanced technology laboratory and the availability of our laboratory response network for bioterrorism but I want to mention other improvement at the CDC labs which is the development of the laboratory based system called Bionet. This system is similar to an existing system called PulseNet. We use molecular fingerprinting techniques to characterize strains of critical viruses, bacteria, fungi or parasites that can or will be used in bioterrorism events. Some special features of this system include the ability to trace aerosol exposures to particular locations, determining if a critical agent has genetically engineered to be resistant to particular drugs and providing sequence data for strain specific diagnostic assays. With all of these laboratory improvements we will not only handle a bioterrorism event with confidence we will also be able to detect other naturally occurring diseases more quickly. Now Scott will talk to us about the last item of capacity building which is actually the item that makes all the rest of this possible. Take us there Scott. Okay Bob. Without training and education about all the issues involved with bioterrorism preparedness none of the other strategies will work in order to perform your duties quickly and efficiently, especially in emergencies you must be well trained. You might start by examining the workforce needs and the existing training programs in your health facility then finding a way to integrate bioterrorism preparedness into existing training frameworks. There are other medical response teams already activated in your community that deal with bioterrorism. You may be able to include bioterrorism preparedness in their existing training and then you're ahead of the game. Those of you in public health departments can help your partners in their training efforts by working with them in educational activities to help them collaborate with you more effectively in the event of a bioterrorism emergency. Such examples of activities include seminars on public health surveillance joint educational activities for the medical community in public health hospitals and clinics have in-service training or grand rounds other educational programs will be needed to be tailored to specific regional or specific training needs in your community. CDC will assist the state and local epidemiologic offices in preparing this specialized training. Denise, tell us more about testing. All righty. Well, everybody knows that important part of ensuring the success of training and you'll know that feeling yourself at the end of this program. CDC can also help you assess the effectiveness of your bioterrorism preparedness strategies through frequent and realistic exercises. These drills help people from all emergency services organizations learn how to respond not only to a particular bioterrorism emergency but also to a broad range of consequences caused by that emergency. These exercises or rehearsals are an invaluable training tool in handling a real-time event and will allow people to meet and work with colleagues in other emergency service organizations. You should contact the bioterrorism preparedness and response program at the CDC for help in putting together a drill or an exercise. And a quick reminder for our audience for Denise, Scott or Steven if you want to make a phone call and to ask them a question, do so right now. Thanks everyone as a related part of the training. I'd like to add that it's important to know how much and what kind of information the media will need to know at different stages of the suspected bioterrorism incident. It will be necessary to make sure that the person assigned as public health information officer knows how to relate the most timely and accurate information to news sources so that the public is armed with the necessary information to prevent the spread of disease and calm public hysteria. Remember, we need to focus on the local level and progress to the state level. State health departments have much to add in this planning process including lots of experience. They also have much to lose in an ill-planned response if it goes wrong. Moving on to other issues, a main concern for many medical professionals is the availability of enough pharmaceuticals to treat the injured and the exposed victims of a bioterrorism event. CDC's stockpiling expert Steven Bice can give us some insight on stockpiling efforts. A release of selected biological or chemical agents targeting the U.S. civilian population will require rapid access to quantities of pharmaceuticals, antidotes, vaccines, and other medical supplies. No one can anticipate exactly where a terrorist will strike and few local governments have the resources to create sufficient stockpiles on their own. Therefore, a national stockpile is being created as a resource for all. The CDC National Pharmaceutical Stockpile Program is responsible for the purchase, storage, and deployment of pharmaceuticals, supplies, and equipment that localities will need in a chemical or biological terrorist event. Stockpile Program is also responsible for training state and local responders concerning the contents and use of stockpile items. This may include technical assistance to state and local governments in emergency response capacity. In a biological or chemical terrorist event, state, local, and private stocks of medical material will become depleted quickly. The Stockpile Program will support local first-response efforts with a general resupply package followed by quantities of material specific to the terrorist weapon used. It's essential to understand that the Stockpile Program cannot possibly be a first-response tool. State and local jurisdictions must recognize that they will be the true first responders and plan and act accordingly. However, the Stockpile Program will help bolster state and local responses to a terrorist attack and will be key in mitigating the results of this type of terrorism. The FBI, CIA, and Defense Intelligence Agency staff continue to share their insights regarding biological and chemical threat agents. CDC's selection process for the specific pharmaceutical antidotes, vaccines, and other medical equipment in the National Stockpile involved extensive input from these experts and more. The selection is based on four principles. Plausibility of the threat, Lethality of the threat, Treatment Effectiveness, and Potential for Shortage. Decisions about deploying necessary components of the Stockpile may be based on empirical evidence, such as, the overt release of chemical or nerve agents or credible intelligence information. Deployment also may be based on more subtle indicators, such as unusual morbidity and mortality identified within the context of the nation's disease outbreak, surveillance, and epidemiology network. If a terrorist event occurs, CDC leadership will rapidly coordinate with state and local leaders as well as other federal agencies to assess its impact and identify needs for Stockpile resources. The program then will coordinate transport and delivery of necessary Stockpile components to the impacted area. CDC is committed to have the first components of the Stockpile delivered to the nearest safe airfield within 12 hours of the decision to deploy. This initial delivery can be followed by additional items delivered at 24 and 36 hour intervals as needed. This material probably will be quite specific to the terrorist weapon used since this is likely to have been identified in time for these shipments. CDC will share the specific list of Stockpile components with official public health or first response agencies once it is fully developed and approved. The overall role of CDC is to ensure that local, state, and federal public health partners coordinate efforts and work with the medical and emergency response communities to prepare for acts of biological and chemical terrorism. The role of the National Pharmaceutical Stockpile Program is to maintain a national repository of life-saving pharmaceuticals and medical material to be delivered to a terrorist event in order to reduce morbidity, mortality, and human suffering. Thank you. Thank you, Steve. And we have begun to receive both questions. Denise, this first fact is absolutely intriguing to me. I'm going to pose it to you. Very good question. Why weren't more children impacted in the Sferd Law smallpox outbreak? Well, you know, that's a very interesting question. And this is, of course, referring to day one where they presented the information by Dr. Matt Messelsen. And I think there's several different possibilities here. I mean, of course the obvious question is, are children not susceptible to anthrax? But I think there's other questions that we, as epidemiologists, would ask, well, were the children not exposed? I mean, this exposure presumably happened early in the morning. Maybe they weren't outside. They were at school, you know, whatever time had happened. But the other questions that we would always ask, again, as epidemiologists, do they manifest the disease differently? So people didn't detect that they were ill. And of course the last question that you would have to ask is, were they ill, but somehow somebody didn't document it or really understand that they were ill or were allowed access to the children? Thanks, Denise. We have a call from our friends. I'd like to thank you for calling from Chicago, Illinois, and Chicago, we can hear you. Please give us your question. Yes, my question is about in hospitals we don't have many airborne isolation rooms. And if there is a potential smallpox and bioterrorism occur, how do you go about getting assistance from the state or federal government to provide hospitalization of such individual into negative pressure rooms? And the second question is, does the current mask that we use are efficacious to prevent inhalation of smallpox virus such as N95? Ali? That's an excellent question. Let me take your second question first. The available data suggests that any small particle aerosol that's between 1 and 6 microns in diameter should be blocked by an N95 plus preferably mask. However, those specific data to prove that has not been garnered yet, but it should be protective and we would recommend that these HEPA filter masks be used and you use the strict respiratory isolations as dictated in a number of hospital infection programs. Let's go back to your first question. This is the most difficult question. The federal government isn't going to come out and build a whole bunch of negative pressure isolation rooms all over the U.S. in anticipation of a smallpox outbreak. I think we need to recognize that we maybe go back to a fallback that we used in the past, which is that if you have a single patient and you have a room, you can isolate them there. If you don't, you're going to have to find a ward and cohort patients together as long as that ward has its own ventilation system and anybody going into the ward, obviously including housekeeping staff etc., would need to be vaccinated. If that option doesn't work, then you're going to have to find a bigger option, which is that we may specifically have to designate whole hospitals to be smallpox hospitals. Again, you would cohort all your patients in that one designated hospital or two designated hospitals in the community and again, anybody who went in and out of that hospital in addition to using the appropriate precautions, you would try to get them vaccinated. Scale, magnitude and availability facilities are going to have so much to do with this. We have another very interesting facts in here and this also, once again, kind of goes to I'll ask this question of you because we hear this a lot from states that don't have and have not received any kind of preparedness grants from the CDC. What are those states going to do? What can they do? Bob, this is the strength of our Biotears and Preparedness and Response Program. We have been able to put out money in the number of different areas in terms of lab, epi-surveillance, preparedness, specific preparedness grants. When all was done and told as Dr. Lillebridge, the director should have told you to all 50 state health departments and three of the large cities. Now, unfortunately due to limited funds, there wasn't sufficient funds to get money to each and every state for all of those components. The way the system is structured, even if you didn't get money for laboratory support, you will have access to the reagents. So if you want to do diagnostic testing, CDC will provide you the reagents. We will provide you the protocols. It doesn't matter that you didn't get a grant from us. The same thing for how to put together a preparedness plan in your community. You don't need to have gotten money from us to put together your preparedness plan. We will give you what information we have. We will share that with you by the VEB Web and a number of other sources to get that information to you. And that's true for a number of the other components. It's available to everybody. Got another phone call from our friends in Northampton, Massachusetts. I'd like to ask you, we can hear you. Please keep your question brief and go ahead. My question is the widened media stynum. How soon after exposure to inhalational anthrax might it develop and what percentage of patients with inhalational anthrax do develop a widened media stynum? Can you answer that briefly? Sure. As Dr. Seeslack told you on the first day, anywhere from 60 to 80% may manifest that sign and when they get it is going to depend on their incubation period. But usually initially they'll come in with a nonspecific febrile illness and within 24 to 48 hours you'd see the widened media stynum. Stockpiling of medications and equipment is another important piece of the preparedness puzzle. I think that what we have here is a very significant issue, Ollie, that I think a lot of people are asking about. What can we say about this? About stockpiling? Yes. Hopefully, Steve Weiss laid out some of those concerns for you in the last roll-in if this question had come in earlier. But CDC is actively involved in a national pharmaceutical stockpile and let me try to make the point that this isn't going to be a pharmacy. This is going to be a complex system that will include regional supplies of drugs that will include vendor-managed inventory to get these supplies out quickly depending on what the needs are. So it's going to be a number of different components to get this stuff to people and it would include numerous antimicrobials. It's not necessarily going to be a fluoroquinolone stockpile. There will be additional antibiotics and anecdotes in the stockpile. I'd like to get close to the conclusion here of our presentation. Once again I want to thank all of you for viewing in with us today. Your contributions have been very important to us. I'd like to ask Denise any final thoughts or comments from you on this. I think we just wanted to sum up briefly. We've mentioned many, many times ensuring that you'll be ready for a bioterrorism event requires preparedness planning now. We want to build a good response team, establish contact with potential partnering agencies like we've discussed, the local FBI field office and law enforcement, public safety officials, local hospitals and coroners, emergency planners, form a bioterrorism preparedness committee with these partners and any others who you would expect to respond to an actual bioterrorism event. Participate with other emergency planning agencies outside of public health such as terrorism task forces, advisory committees or community planning teams. With all of these groups discuss and determine each organization's roles and responsibilities and develop an emergency operations plan perhaps with the help of local emergency management or civil defense agency. And as I mentioned before in the training session, rehearse your plan through exercises. When a real event happens you'll want to automatically identify the basics like the treatment measures for public health critical ages and who to call for what kind of help. I think that brings us to the close of the information we wanted to share with you today. I just wanted to let you know out there that all of the presenters who spoke to you today, whether they were live or on tape, are real laboratorians, epidemiologists or healthcare workers, they're people just like you, we're not paid actors and we will be the people you'll be talking to on the phone if you have some questions about bioterrorism issues and hopefully we can avoid some of the nasty scenarios that we've been talking about for the last three days working together. Now please, let us know how to improve the course for next year. If you like this education that you've begun, we need to refine it to make it better. And let me end by thanking yourself Bob for being a moderator, our producer, Mindy Frost and our script writer Mary Ziegler. And I'd just like to finally say that there's a wonderful story about the public health officer who went to New York and was walking down the street, had tickets to go see a concert that night and stopped a fellow on the street in New York and said excuse me, I'm just here, I'm a public health officer, I'm from the state of Georgia, I'm from the state of Alabama, whatever and can you tell me exactly how to get to Carnegie Hall and of course the fellow in New York said practice, practice, practice and that's exactly how you're going to get good at this. You're going to practice it, you're going to work on it and hopefully next year when we see you will have done that. You've put those practice plans in place. And now for the final exam, in order for you to receive continuing education credits for this program, you must complete the final exam either at the website or by filling in the scan form correctly. You of course, you have to if you must receive a passing score, in order to get this done you have to complete that process. It's also necessary to fill out the course evaluation in order to receive credit. Take the exam online by logging on to the website at www.bio med training .org. Now the last day to take the exam at this website is October 31st and the exam is open book once again. Feel free to use any printed materials and refer to your notes. There is no time limit except the one imposed on you by your site facilitator. Each participant who successfully completes the program will receive an award letter, not a certificate which describes the credits to be awarded. These letters should be sent out by the end of the year. And that wraps it up and brings us to the end of day three of this special video conference on Biowarfare and Terrorism the military and public health response thanks to everyone who participated and supported the making of this broadcast, especially all of the agencies involved, our friends at the FBI, at USAMRA the US Army, the CDC the state health officers involved. Thank all of you for coming here and do this and on behalf of everyone at USAMRA, the CDC, the FDA thanks for joining us for Biological Warfare and Terrorism, the military and public health response. I'm Bob Howard with the CDC signing off and wishing you a good day. Hello, as you've seen today when it comes to infectious diseases the public health community plays a key role in the prevention and control of problems affecting the health of our population. We have experience with detecting and investigating problems and moving quickly to implement appropriate control measures. We also provide technical assistance as needed to other agencies or to the healthcare community. It's for these reasons that the administration has affirmed public health's vital role in our nation's preparedness for bioterrorism. Currently CDC and its traditional partners are bolstering capacity, forming new partnerships and developing plans to protect our communities from the consequences of bioterrorism. As a result of congressional recognition that public health is an essential partner in any domestic bioterrorism response it has awarded resources to expand vital capacity at all levels of our public health system. In fiscal year 1999, $144 million dollars were provided to the Department of Health and Human Services in special new funding to improve the nation's public health surveillance network. This will quickly detect disease symptoms from a possible biologic agent and protect against the consequences of these biological and other unconventional attacks. These funds are especially targeted at response planning, organizational capacity building, improving biologic and chemical laboratory testing, strengthening our surveillance system and epidemiologic response, and implementing rapid communications. Every dollar we spend on preparing public health locally for even the possibility of a biological or chemical release among our civilian population is a dollar well spent on saving a crumbling local public health infrastructure. The medical expertise, laboratories, and communication network needed to counter bioterrorism can be put to work immediately to detect diseases in the community from any source, whether natural or deliberate. We win on both fronts. All of us, public health workers, frontline professionals, and our military colleagues need to move forward to quickly prepare for and respond to the threat of bioterrorism. Thank you. And thanks to you, Sam Red, for collaborating with us on this program. We enjoyed working with them and sharing our joint expertise to provide you with information we think will be beneficial. I must admit, I'm thinking twice about my original diagnoses. I'm starting to suspect some sort of toxin here. Well, I'll go ahead and get Lauren's blood down to the lab for testing. Okay. And in the meantime, why don't we give the neurologist and poison center control a call? Okay. Now, about that brain Doctor Matthews, I'm so glad you could see me on such short notice. I don't know, I thought it was my new contacts or something, but I just started having double vision a couple hours ago. I even had to have my husband drive me here. Okay. Well, let's try something else. Now, hold your head still and follow my finger. I'm going to move it to your left and then to your right and then up and down and then finally in and out. Okay. Thank you. What do you think it is, Doctor? Well, you're having some difficulties with muscles that move your eyes. They seem a bit weak and your pupils also aren't changing their size correctly. So that's why you're seeing double and your vision is blurry. It's not your contacts. I'm afraid it might be something neurological. Oh my. Well, now I don't want you to be overly concerned. But to be on the safe side, I'm going to send Dr. St. Joe's to a neurologist for further testing. His name is Dr. Heisy and he's a good friend of mine, so I know he'll take good care of you. Okay. If you say so, Doctor. I'll make sure that our receptionist gets you into his schedule as soon as possible. Well, let's see. You know what? It's kind of late today. So what we'll do is we'll get you an appointment as early as possible tomorrow morning. Tomorrow? Yes. Okay. Hey, Rick Heisy. It's me, Nancy. How are you? Well, I'm glad to hear that. Listen, I'm calling to check up on a patient of mine that I referred to you yesterday, Lorraine Samuels. She's really a sweet woman. I believe she had an appointment with you early this morning. Why? You haven't seen her yet? Okay. Well, while your nurse is pulling the records, I thought I ought to call you because the ER called me and they're sending me another patient who's presenting the same symptoms. It's odd. I was beginning to think that what? She's a...