 Good afternoon. I'm delighted to introduce the second day of this live satellite course entitled Biological Warfare and Terrorism, the Military and Public Health Response. This joint project between the U.S. Army Medical Research Institute of Infectious Diseases and the Centers for Disease Control and Prevention is instrumental in providing very critical knowledge to you, our first line of defense, against biological warfare and terrorism. Terrorism has certainly heightened over the past decade. Instances such as the World Trade Building, the embassies in Kenya and Tanzania, and the Federal Building in Oklahoma City are devastating examples that our nation's citizens are targets at home and abroad. Complicating this already frightening scenario, there are nation states and terrorist groups that have both the political will and the technical capability to use chemical and biologic agents as instruments of terror and warfare. Details of the Iraqi Chemical and Biological Warfare program and the terrorist capabilities demonstrated by the Japanese cult, Am Shinrikyo, are two solid examples that offer credibility to the potentially imminent threat that faces this nation. We must prepare to meet that threat. Yesterday you learned how to recognize and manage the medical consequences of several biological agents that could be used against the military on the battlefield as well as our civilians at home. It is imperative that you now take that knowledge and apply it to the full spectrum of responses should we ever be faced with an actual biological attack. It's important to know about biological agents, but your responsibilities go further. Ask yourselves, would I recognize a mass casualty scenario that is the result of a bioweapons attack? What assets would I have available to assist in identifying the one or more agents responsible for the casualties? You will explore these questions and their responses in today's sessions. Through this training, we hope to prepare you to respond medically to a biological attack. I want to thank the Army Surgeon General, General Ron Blank, and the Commander of the Army Medical Research and Materiel Command, General John Parker, for their active and continuing support in the education of biological and chemical defense. I also really want to commend you, your recognition of a potential disaster and your determination to learn all you can to prepare for that disaster. Your preparation is what will make the difference between life and death for our nation's citizens and our military men and women. You are a most valuable resource for the protection of our nation. Thank you. For nearly 50 years during the Cold War, military power in this world was bipolar. Balance between the Western Free World and the Eastern Bloc countries tied to the Soviet Union. The classic threat was one of mutual assured destruction. In the military, we trained and prepared daily for our response to a nuclear holocaust. Since the fall of the Soviet Union and the end of the Cold War, the classic threat has disappeared and there is no longer a well-defined balance of global military power. Nations with contrary ideologic and economic motives have altered the global political environment such that the world today is more complex, uncertain, and volatile. This change in the balance of power over the past decade has led to the proliferation of weapons of mass destruction, including biological weapons as the primary threat we now face. Our nation's chemical and biological defense doctrine first calls for increasing our intelligence about the individuals or organizations potentially capable of releasing a biological weapon. Second, developing physical countermeasures. Third, improving the medical countermeasures used against these biological agents. And finally, and probably the most important at this stage, educating and training medical and public health personnel. This is why we are here. Our ability to protect the warfighter on the battlefield against these biological weapons will depend on you, the medical professions watching today. This is our third satellite broadcast educating both military and civilian professionals in the medical management of biological warfare and terrorism-related casualties. I want to personally thank the United States Army Medical Research Institute for Infectious Diseases, the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Public Health Training Network for their outstanding collaboration to make this year's broadcast a tremendous success. And finally, thank you for responding to the call for action by learning about these threats and how you can prepare our nation to respond domestically as well as on the battlefield. The Center is for Disease Control and Prevention. Forty years ago, we prepared for nuclear war. Now the Cold War has ended, and we face a new threat. Unprecedented. And unpredictable. It may not come with explosions. It may not come with rockets overhead. We may not see it when it happens while it quietly infects. Whether you're a soldier or civilian on the battlefield or at home, as patients roll into your emergency rooms and clinics, your aid stations and field hospitals, will you recognize the symptoms? Will you recognize the signs? Will you know what to do? Welcome back everyone to day two of Biowarfare and Bioterrorism, a military and public health response. I'm Lieutenant Colonel Ted Cieslach, and with me is my partner, Major Mark Kordepeter, also from the Operational Medicine Division at USAMRAD. You may remember Mark from such video vignettes as Smallpox, What's In It For You, or Botulism, Friend or Foe. Now Mark actually helped produce and screenwrite this year's show. If there's something you didn't like about the show, please call or email Mark. If you have any compliments, put my name on them. Well thanks Ted. I want to let you know though I've got call forwarding to your number just so you know. Good afternoon everyone. Now we have three objectives for today. The first is to take you through the steps of managing a biological weapon attack on the battlefield. Second, to identify the epidemiological tools to distinguish a biological weapon attack from a natural disease outbreak. And third, to describe their proper triage and field management of biological weapon casualties. But before we get into today's topics Ted, I want to give us a brief rundown of what happened yesterday for those who weren't able to see. Okay well yesterday we reviewed some of the major threat agents and we didn't cover every agent that could potentially be used in a biowarfare or bioterrorist attack. But we tried to pick agents that represented the various categories bacteria, viruses, toxins, weapons of assassination, etc. Those of you who watched yesterday can receive continuing medical education credit for that day. Feel free now to watch one, two, or all three days of this program and to receive credit for the number of days you do watch. Now we didn't have a chance yesterday to answer very many of your phone questions or fax questions. We are going to try our best to do that today. So we would encourage you to continue to telephone in with your questions and to fax your questions in. And we'll try to get to as many of those as possible throughout the course of today's broadcast. Now remember those of you who have registered for the course can get credit and it's important though to take the test in order to get that credit and you can take that test online at our website and that's the same website that you use to register for the program and that's www.biomedtraining.org. Now you should plan to take the test when you're done watching as much of the show as you intend to watch. If you watch all three days, take the test at the end of those three days. Now you can take the test online up until October 31, 1999. Now if you take the test using the Scantron form please make sure you write this course number on the form. It's SB0034 and make sure that's on the answer sheet. Now today is primarily geared toward those of you who are in the military. But since military and civilian personnel may need to work together in a real incident it helps for us to know a little bit about each other. Therefore non-military viewers may find today's program useful as well. Now tomorrow's program has been produced by the CDC and focuses on bioterrorism. Alright well let's go ahead and get started. We find it useful to consider what we call the ten commandments of medical management. As the day progresses we'll touch on each of these topics. Okay so let's jump right into that then. The first commandment of how to manage a suspected or a purported bioterrorist incident if you will thou shalt maintain an index of suspicion. Now that's one of the trickiest parts perhaps of dealing with biological warfare and terrorism. But I think in today's climate that actually should be a lot easier with all the publicity that bioterrorism has had recently with what's gone on in Operation Desert Storm Desert Shield with our discovery of the Iraqi arsenal and its extent and the Soviet arsenal and its extent. I would think that for most of you out there biological attacks against our soldiers can be thought of as a real possibility. And we should emphasize education of our medical professionals about this threat and about the prevention and treatment of biological warfare casualties. Of course that's the main reason we're here today Mark. Well that brings us to our second commandment. Thou shalt protect thyself and thy patients. You need to know how to protect yourself before you can help others. This includes using certain precautions when caring for patients and things like mop gear when you're in the field as well as collective protection. It also involves ensuring that your immunizations and your unit's immunizations are up to date. The Department of Defense's Anthrax Vaccine Immunization Program is a force-wide effort in this regard. Okay, third commandment. Thou shalt adequately assess the patient. And patient assessment actually involves many different factors. In a mass casualty setting, assessment begins with triage. Now triage comes from the French word trié, which means to sort most likely on the battlefield. You're going to be faced with multiple patients and limited resources. And when that happens, we need to talk triage. And we'll talk more about triage in depth later in today's broadcast. Now remember, your assessment has to include not only that individual patient but also the situation as a whole. Since a biological attack may be silent, the first indication of a problem may be a wave of casualties coming into your age station with similar complaints. But it may also start with just a patient or two. The fourth commandment, then, is thou shalt decontaminate as appropriate. You must know how to avoid further contamination when treating and evacuating patients as well as contaminated remains. Okay, with that said, though, I think it's also important to realize that decon certainly plays a lesser role in the management of biological casualties than it would in case of chemical casualties. And I think many people in the audience probably understand that, and that's not to downplay the importance of decon. But remember, biological agents have incubation periods and all likelihood patients are going to present several days after they've been exposed. In that time frame, they may have taken several showers. They may have changed clothes several times. There's probably little to decon. So decon certainly plays a very important role in chemical casualty management. It plays a role in biological casualty management, but that role is likely to be a little less important. Now, that brings me to the fifth commandment, thou shalt establish a diagnosis. Now, this would involve employing whatever assets are available, and that might include biodetectors. It might include laboratory backup. But above all, it's always going to include good history-taking and good physical exam performance skills. That brings us to our commandment number six, thou shalt render prompt treatment. Now, this includes caring not only for those patients who are already ill, but also for those who may have been exposed and are in the incubation period. There are effective medical countermeasures which are already developed or under development. If we use them appropriately, we can prevent or minimize casualties and conserve the fighting strength of our forces. The seventh commandment, thou shalt practice good infection control. Now, we need to understand how to implement proper infection control procedures. And obviously, we have a lot of help in this regard. There are infection control nurses. There are public health practitioners. But all of us at least need to know the basics of infection control. If we can take care of conventional patients, though, we already should understand these. In this sense, really, the management of biological casualties certainly is no different than the management of conventional infectious disease casualties. Now, our eighth commandment is, thou shalt alert the proper authorities. Now, this would include the chain of command, the command surgeon, preventive medicine, and it might also include the chemical officer and others. Ninth commandment is, thou shalt assist in the epidemiologic investigation. Mark, you're a preventive medicine officer. I think most people out there in the audience are very unlikely to have had the degree of training in preventive medicine that you may have had. We realize not all of you are preventive medicine doctors. Not all of you are infection control nurses or public health nurses. But still, every one of you out there, whether you are a blue collar patient care type of doctor, whether you're a ward nurse or a clinic nurse, whether you're a medic, or even perhaps a fireman or policeman, you still need to have a basic grounding in epidemiology. So you'll at least need to be able to function as an amateur epidemiologist of sorts. And, Ted, this also includes understanding the medical surveillance system and what it can do for you. If we don't know the baseline rates of disease in theater, we won't know whether or not we're seeing something unusual. That's a good point. Hopefully throughout the course of today's broadcast, we're going to give you the information necessary for you to function competently as a closet shoe leather epidemiologist. Now, the Centers for Disease Control will elaborate on that discussion and build on it on day three. And we encourage you to watch tomorrow for that reason, amongst many others. Now, Mark, will these hours of instruction we're going to give them today qualify them to sit for the preventive medicine boards? Ted, I don't think so, but perhaps they might be enough to sit for the pediatric ID boards. I think it would be, actually. The 10th and final commandment. Ted, that was my line. Sorry. Well, I'll go ahead. The 10th and final commandment is, thou shalt know and spread the gospel. Mark's right. We've given each of you a copy of the Book of Aitzen. This is our blue book, the Book of Aitzen. You probably have it not in this format, but rather in your student manual, but the information is the same. We want you to sleep with it, learn it, live by it. During the show, we'll discuss other resources available to you. Now, we also encourage you to share these resources with anybody who wasn't able to watch with you today, any colleagues you have out there. Now, we'll have videotapes available, so if you didn't get enough of Ted during the show, you can watch him over and over until your heart's content. I would encourage you to do that. Now, you'll need to check our website, though, later around late October or early November to find out how to get those videos. Now, also, we are rebroadcasting the show on October 2nd and 3rd. That broadcast was specifically arranged so our National Guard and Reserve forces could watch during their weekend drills. Now, people can sign up for that course once again on the website in case you've forgotten that website is www.biomedtraining.org. Okay, Mark, well, let's get into the meat of today's instruction, perhaps. Today, we're going to focus on the use of the agents we discussed yesterday against our military forces. And yesterday, I told you that it's useful to think of the threat on three levels, the strategic level, the tactical level, and the terrorist level. Today, we're going to concentrate on the first two of those, the strategic and the tactical threat. Tomorrow, during the CDC's portion of the broadcast, the focus will be on the terrorist threat. Now, as such, as a military threat, as a strategic and tactical threat, possible targets of some of these biological pathogens might include rear area command centers and key facilities, perhaps troop assembly areas, ports of embarkation and debarkation, perhaps supply points, airfields, industrial centers. And those things might be done, those attacks might be carried out on those facilities prior to the outbreak of formal conventional hostilities. But in addition to these military targets, we in the military still need to concern ourselves about civilians, because there may be civilians in our areas of operation. We need to know how to care for pediatric patients and elderly patients, because those patients may be in our areas of operations as well. And probably nowhere is this more true than in the field of communicable diseases, because remember, in public health and in communicable diseases, there are no boundaries. Those diseases that are affecting our military population can cross over into the civilian population and vice versa. Now, an adversary could time the use of a biological pathogen release to coincide with the incubation period of the pathogen before an offensive maneuver. Troops who are in a weakened state from illness will be more prone to fatigue, have a slower reaction time, and will have more difficulty making decisions. This reduces our ability to wage war and defend ourselves. Remember that biological agents can be used singularly, or they can be used in combination with other biological agents or with chemical agents, and that may cause certainly significant confusion in diagnosis, it can cause delays in appropriate treatment, and it certainly magnifies or at least has the potential to magnify the incapacitating and or lethal effects of some of these agents. Now keep all of this in mind as you watch today. We have a full length scenario for you, which we've broken up into six segments. We'll show you each of those segments as they highlight various teaching points as the day progresses. I'd like to give a special thanks to the 405th Combat Support Hospital, a reserve unit out of Middletown, Connecticut. These folks are near and dear to my heart. They spent eight long months with me in Bosnia in 1997, and they helped us put our scenario together. Now remember that none of these soldiers you'll see as a professional actor, but they've done a great job nonetheless. Okay, let's go to the scenario. You are a medic assigned to the 405th Combat Support Hospital. Your unit has been deployed to Eastern Europe to assist an ally in a border dispute. Pockets of conflict have erupted and troops are amassing on the border. So far, your unit has been spared large numbers of casualties, but things are about to change. I just heard a rumor. Oh, yeah, what's that? We're gonna begin a lot of casualties in soon. How many? Who knows, maybe 20, maybe 50. Oh, man, that means we're gonna get swamped. Don't mean other IV. Yeah, it's gonna be a long day. Yeah, let's get to work. Sergeant, guys, we just got two patients in for sick call. They don't feel too good. I think one of you needs to come out and take a look at them. All right, ma'am, I'll be right there. Well, I'll handle this one. Okay. What are you soldiers doing? Oh, I think we died. I feel terrible. Got some traumas coming in. What seems to be wrong with you? I ain't going over here. I can't stop coughing. What a bad headache. How long you had these symptoms? Started this morning. I'll get someone to do some battles on you to be with you in a second. How are you feeling? Oh, crap. I coughed on my lungs. It's not like you're coughing up some blood. How long has this been going on? Last night. You guys got the same patch on you from the same unit? Yeah. Anyone else in your unit sick? Oh, wow. They're underway. Damn. It's all we need on top of these traumas. Lieutenant, did you call for the doctor? All right, we'll get the doc in right away. Take a look at you guys, see what's going on. All right, hand tight. Sergeant Rice. Yes, sir. Captain Kubeck. Listen up. Division Surgeon just called. Unit up the road just got hit with a large mortar attack. A lot of trauma casualties. We're going to be hit. We're going to be hit very, very hard. We need to institute the mass cow plan. We need to set up a triage area right here in front of EMT. So, Captain Kubeck, get all your EMT personnel. Get them down here now. Let's get moving. Yes, sir. Sergeant Rice, what did you call me about? These two soldiers here, sir, came a little while ago. They both have similar symptoms. Headache, cough, body aches, chills. This one here has been coughing up blood since last night. And he informs me half his unit is in the same condition and they're on their way in. Man, these soldiers look sick. But we've got a unit that's got the flu plus the trauma casualties. We need to triage these casualties with the other trauma casualties. We need to get moving. We need to get moving now. Okay, sir. Okay, so what's going on here? What's going on in our scenario? Well, it appears to be that they have some similar symptoms. Among those are headache. Some had myalgias. And at least one of them, interestingly, had a cough productive and bloody sputum. Okay, great. Great. So, that describes the clinical features of some of these patients pretty well. Cough with bloody sputum. Mark? Could this be a BW incident? Certainly possible. You know, aside, of course, from this being a show about biological warfare, certainly, you know, as we said, biological weapon situation might, the first clue might just be a number of patients coming in with similar symptoms. So, and that could be a couple of patients or it could be a mass cowl. And one of the clues, I guess you could say, and this is kind of early to tell, but you do have what sounds like a whole unit that's involved or at least a large part of a unit. So, certainly, that points to something like a point source outbreak, and that certainly could be consistent with BW. Doesn't necessarily mean it is, but that's something we'll talk about later that it might be a clue. Okay, and I think it's important to remember that with a biological warfare attack, we may not have some of the warning signs that we would have with other forms of attack. Conventional attacks, obviously, there's going to be bombs going off. There's not going to be subtle. We're going to know we've been hit with a conventional weapon. Nuclear weapons, I think that probably goes without saying. Chemical weapons, the casualties, usually tightly clustered in time and space, immediately following some event. But in a biological casualty situation, we might not have bombs bursting in air or rockets flying overhead, et cetera, et cetera. I think it's important also to remember that, again, this is, or this appears to be, a mass cal situation. And in a mass cal situation, conventional treatment priorities have to be abandoned. And this means a radical departure from the traditional practice that we usually employ, that of providing early, complete, definitive treatment to each and every patient on the basis of his individual needs. In my office, in the pediatric clinic, that's what I try to do. I take each patient as they come, and I try to work through diagnosis and treatment before I go on to the next patient. But obviously, in a mass cal situation, we abandon that. It also means that care may be provided at lower echelons than it otherwise would be ideal to provide that care. So we may have people with relatively less training, combat medics, corpsmen, et cetera, providing very, very critical care. Now, in the Army and in the Navy, the dental officer is an important triage officer. And I'm not sure how the Air Force works. Colonel Bradshaw, I wonder if you could, does the Air Force use dentists for triage? Well, in certain circumstances, that might be true in the Air Force as well. However, in general, we tend to try and use the most senior medical officer. It could be a flight surgeon, it might even be a general surgeon. But there, again, under certain circumstances, where we have our mass casualty collection points, it could be a physician's assistant or even a nurse, perhaps. Okay, well, thanks. I think you get the point. I think you see that in a mass cal situation, especially on the battlefield, perhaps, the usual paradigms kind of break down. And we tend to do things a lot differently than we would under ideal circumstances. Now, you're going to find in your student materials an outline of the four triage categories. And those categories are delayed, immediate, minimal, and expectant. And together they form the acronym DIME. And I think it would be useful to go to our video scenario. And we're going to discuss triage to a group of soldiers at the bedside. Okay, let's talk triage. Everyone familiar with the Army Triage System? DIME, right? Delayed, immediate, minimal, expectant. Good, so let's talk about a scenario. You're at the 28th Combat Support Hospital. You're 50 miles from the front lines and it's a very quiet day here at the 28th. No patients at all except for one young soldier. And this young soldier's pretty sick and Doc here says he thinks he has anthrax. Now, and he's probably not going to make it. What category does he go in? Delayed? I say immediate. Okay, I hear some people saying immediate. I go with immediate since he's the only patient here. I think I'd get right on top. Good, all of those are good points. And you see there's a difference of opinion here and that's good because there really is no right or wrong answer to most triage situations. And a patient who would go in one category in one set of circumstances might well go in another category under a different set of circumstances. So some people might say, well, he's got anthrax, he doesn't have much hope, he's probably expectant. Other people would say, but he's your only patient, you're not doing anything else, you're going to devote all your attention to him anyway, therefore you call him immediate. On the other hand, somebody brought up the point that you've only got one patient, you really don't call that triage anyway. So all of those are very good points. If I was taking a multiple choice test, I might have said he was immediate and again I'm going to devote all my attention to him. So very, very good. Now let's change the scenario a little bit. Let's say same sleepy 28th combat support hospital, not much going on, but now a deuce and a half lands at your front door, disgorges five patients. One of those guys has a suckin' chest wound, one has a spurting femoral artery, you've got a couple walking wounded and you've got snuffy with his anthrax. Now what category does he go in? Expected. Expected. Okay, good. Now he's got a lot of answers and he might be expected under one set of circumstances. I think a lot of people would say he was delayed. Myself, I might say well, I'm going to devote my attention initially to the sucking chest wound, then I'm going to patch the spurting femoral artery, then I'm going to look at this young patient with anthrax and I might be doing a lot of these things simultaneously. Some, what this depends on your resources too. So triage is dynamic, not only dependent on the disease situation, but on the amount of resources you have. Now let's change gears again and let's say same 28 combat support hospital, but now you've gotten word that the battle is not going well, the front lines have been broken, the 18th airborne corps is fighting a desperate defensive battle and you've got word that 20 C-130s are about to land at your airstrip in the next few minutes. Now where does this young patient with anthrax go? Expected. Now he clearly is expected. So again, the teaching point here is that triage is dynamic dependent on the situation and triage is also dependent on the operator. For example, I'm a pediatrician. If I'm the only doc here and I've got somebody shot through the head by an M16, well, he's expected. There's not much I'm going to do for him. On the other hand, if I was a neurosurgeon with adequate resources, perhaps I would view that patient a little bit differently. So again, triage is dynamic dependent on the situation, it's dependent on the resources and it's dynamic dependent on the operator. Okay, so we've heard a little bit about triage and I suspect most people in the audience have heard a fair amount about triage already. And for you, this should be easy. Triage for biological warfare casualties is conceptually no different from garden variety triage. We begin with the primary survey. We're going to talk more about that later. I think it is important, though, that you have to remember your ABCs. I think you take a biological warfare course or a chemical warfare course. It's easy to get led down the primrose path. You're thinking biological casualties. It's easy to forget the airway, but why don't you at the same way you still do the basics, Mark? Of course, you know, Ted, the goal, of course, is to do the greatest number, the greatest good for the greatest number of people and, you know, the highest priorities to keep those patients alive. There are some of the diseases, though, that are caused by the classic BW agents that are lethal and they will require immediate treatment to save the patient. Some of those are things like anthrax, plague, botulism. Now, one thing I wanted to mention, though, is that if you have that patient with anthrax, I think it's important to say that the severity of that disease is going to certainly determine where that patient goes. Just because someone has a label of anthrax doesn't mean they're hopeless. So if they're early on in the course, you catch them at a good time, they might be categorized as anywhere. They might be immediate, they might be expected. So it's going to depend on where that patient is. No, I think you're absolutely right. We said in the video that triage was dynamic depending on the operator. And it's also, I think, dynamic dependent on where in the course of a disease a given patient is. Obviously, a patient who has full-blown fluorid symptomatology from anthrax, probably a little less likely to survive than a patient that you catch in the early prodromal phase. But I think above all, having the ability to make a diagnosis will be helpful in triaging patients. If we can make a diagnosis quickly, I think more appropriately and more effectively. And we'll discuss laboratory diagnosis in great detail again later in today's course. And of course, Ted, as you said earlier, in a biological weapon attack, we place less emphasis on decontamining patients and certainly that applies before their triage as well as after when we're actually treating them later. So typically we think that patients, by the time they come to us after a biological attack, they're past that incubation period. Chances are they've changed their clothes, maybe showered. We think there's little chance of aerosol spread. And of course, if we weren't going to decontaminate them, the best thing is just soap and water for most cases. You know, I think it is important to emphasize to the studio audience out there, though, that if you're uncertain about what you've been exposed to, if there's the possibility that you've got a chemical exposure or a mixture of chemical and biological warfare, then full decontamination certainly would be appropriate. Obviously, resources are going to play into this but full decontamination prior to final triage and definitive treatment would be indicated in some situations. Plays a lesser role in bio than in CAM, obviously. But life-threatening injuries such as cardiac arrest, massive hemorrhage, respiratory distress still need to be taken care of even while a patient may be being actively decontaminated. Now, we're going to talk about infection control later in the broadcast, but only two of the classic biological warfare agents are communicable person to person. We talked about this yesterday and I'll reiterate here that those are smallpox and pneumonic plague and perhaps to a somewhat lesser degree some of the viral hemorrhagic fevers. But if you suspect there's been a biological attack and you're concerned that you could be infected by your patients, that should still not limit your ability to triage these patients. If you're concerned they're infective, use standard precautions. Ideally, you would use a HEPA mask if you had those available. Standard surgical masks would be adequate in virtually all battlefield scenarios. So again, most of your patients are not going to be infectious except smallpox and pneumonic plague. If you're not sure, wear a mask but you still need to do the right things. Great, Ted. Well, we've talked quite a bit about triage. Now let's go back to the 405th cache and see how they've progressed since Colonel Noel declared a mass cow. Attention, attention. Mass cow alert. All personnel aboard to your duty stage. So what do we got here? Sucking chest fluid, sir. Let me take a look at it. It's pretty bad. Okay, we're going to have to put a chest tube in here. So give me the chest tube, get it to me as quickly as possible. Also get me an intubation set in case she has to be intubated. Also oxygen. Get it put on her right away and I'll be back to check her soon. No, not for her. Okay. What do we got here? She's stepped on a landmine and has bilateral tidpid fractures. Oh, yeah, okay. They're pretty bad. Well, I lose my leg. You've got a pretty bad injury there, soldier. Okay, she's going to need another IV line. Has she had any blood? Yes, she's had four units. Okay, and does the orthopedic wear this? Right, she's going to the OR. Okay, fine. All right, give her some morphine, 10 milligrams IM stat. Just lay down there, soldier. You're not going to lose your legs. You're going to be fine. Just relax. Take a close eye on her in case she gets shocky. Ow, ow, they hurt. Okay, this soldier came in with three others from his unit. They all have fever and cough. Okay, temperature? 102. Okay, can you sit up there, soldier? No haemoptysis, the other ones actually do. Good. Has it been productive? Yes. Okay, take a deep breath for me. Good. Okay, good. Does this hurt? Does this hurt? You smoke? No. Okay, good. All right, he sounds pretty junky. All right, so let's get some studies on him. I want a CBC, I want a sputum culture and get a gram stain with that. Yes, sir. And let's get, and the chest tricks very of course. Also, start him on some IV receptor, one gram Q24 and some erythromycin 500 Q6. Okay. Okay, let's see the next one. Okay. Well, welcome back everyone. As you can see from our scenario there's a pretty nasty bug going around. We've got somebody coding there at the end. We've got some guy coughing up some sputum. He's febrile. We've got somebody else with some haemoptysis. So, you know, that's pretty easy to see that these guys are pretty sick. But what happens, though, if we have something a little more subtle? How do we know when something's out of the ordinary? Well, whether we're concerned about military or terrorist use of biological agents or even disease unrelated to biological weapons, we need to have an epidemiological surveillance system in place that closely monitors unusual illnesses or outbreaks. To help us discuss surveillance, we're glad to introduce Colonel Toti Sanchez. Toti Sanchez is Chief of Epidemiology at the Army Center for Health Promotion and Preventive Medicine, also known as the Chipm. Colonel Sanchez has extensive field experience working about breaks and in Somalia. Welcome, Colonel Sanchez. Welcome. Tell us, why do we do surveillance? Well, Mark, we need a theater-wide epidemiological surveillance program which is specifically tailored to a specific mission or geographical area which focuses on specific diagnosable disease entities and various syndromes. Now, that way we can identify problems before they get out of control. At the theater of operations with multiple sites, one or two cases of an illness of diarrhea may not appear to be a problem, but if we can suspect that they represent a theater-wide increase in diarrhea, then this might prompt an investigation into a possible source. We would then look at our food and water sources, for example, for potential ways in which this illness might be spreading. In addition to monitoring for large outbreaks, we can also use surveillance data to measure the impact of certain diseases or injuries. For example, if we collect or monitor light-duty or lost-duty information, we can quantify the impact that these diseases or injuries have on the day-to-day mission. Now, the commanders are particularly interested in that type of information. Now, Todi, before I went over from internal medicine into preventive medicine, I didn't have any idea what these people out there did or who they were even. I suspect many of our audience members don't know either. Can you tell us what they're out there doing? Well, in the Army, surveillance in the field will be managed by the preventive medicine officer. It's also known as the PMO in your video scenario. That's an individual who has a formal training, who's usually a doctor with formal post-grad of training in public health and epidemiology. What we should remember, however, is that that person relies heavily on the information that he receives from the care providers at the medical treatment facilities. So, at the Battalion 8 stations or at the combat support hospitals, if there's no good data generated from those guys as to what they're seeing, then the PMO's ability to translate that into appropriate control measures is going to be very limited. Now, typically, as I recall, we use a weekly reporting system in the field and then if we have a disease outbreak going on, you know, especially if it's got a short incubation period and we have a lot of cases in a short period of time, then we can shorten that reporting period to just a daily report. Now, of course, if something's out there really concerning if one of the care providers at one of the battalion 8 stations sees something he's really worried about, we'd hopefully get an immediate phone call. Colonel Sanchez, you know, I was deployed to Panama with the Cuban refugee crisis and I was kind of vaguely aware that there were preventive medicine people out in the field. Well, you're not unique, Ted. That's a question that I often get. In the Army, there is some baseline level what's called field sanitation teams which are the advocates within the units and these are usually one or two enlisted personnel who have short-term training in field PM. There's also individuals enlisted who receive longer training three to six months in duration who are epidemiology technicians and these individuals are in turn supervised by an environmental science officer who is an individual officer who has a bachelor's degree in environmental health. Last but not least, there's also the vet officer, a veterinary officer, very important and that officer works in complement to the PM personnel that I've already mentioned. Of course, Ted, you know, in any suspected outbreak situation, the PMO can call on any of these people that Tony's just mentioned for assistance. In addition, the Theater Army Medical Laboratory, also known as the TAML, or the hospital lab in theater could play an important role in investigating an outbreak and we'll talk more about the TAML later in the program. Now, if there are problems that go beyond the capabilities of those people in theater, then the PMO or the command center could then call for assistance from some preventive medicine specialists outside the region at maybe the regional medical center or the local CHIPM. In addition to those assets that you mentioned, Mark, we should also remember that there are specific teams that can be tailored for the situation. For example, at the Center for Health Promotion where I work, we have what are called SMART or EPICON teams, Epidemiology Consultation teams and these are teams that are task oriented depending on the situation and they can conduct full-fledged environmental assessments and or outbreak investigations. In addition to those, there are other specialized teams which can be called in chemical and biological threats and they are known as the CBRTs or chemical biological response teams. Okay, now we've heard from Colonel Sanchez and from Major Court of Peter a little bit about the army assets in theater, but I think all of you realize that rarely does the army deploy by itself anymore. In fact, most of the time if we go to war, we go to war as a joint task force. So I'm a little interested in what the other services may have to offer. Now I know in the audience today we have some experts we're fortunate to have with us, for example, Captain Kevin Hansen from the Uniformed Services University of the Health Sciences in Bethesda. Captain Hansen is a Navy Preventive Medicine Officer and Captain Hansen, I understand that you were instrumental in starting the DNBI surveillance reporting system that we use during Operation Desert Shield Desert Storm. So I wonder if you could explain maybe for the audience out there what Navy medicine assets would be there in theater for us to take advantage of. Sure. As you know, the Navy Medical Department supports the Marine Corps and the Marine Corps itself has a very robust preventive medicine capability, Navy Preventive Medicine capability built into it. We have preventive medicine technicians, environmental health officers, entomologists. Each of the Marine Expeditionary Forces also has a Navy PM physician assigned to the force and depending on the size and scope of a deployment you'll see any or all of these players. The Navy or the Marine Corps preventive medicine structure is surveillance oriented and many Marine Corps units do surveillance on a routine weekly basis and so they are keyed into the concepts mentioned about surveillance. We also have the ability to augment the organic preventive medicine folks assigned directly to the Marine Corps with Navy Preventive Medicine units. We have four of these units worldwide and each of these units is responsible for a given region and when there are any teams of additional preventive medicine physicians, environmental health officers, preventive medicine technicians and others can be task organized and augmented to that operation and we also support our Navy operations afloat with that type of preventive medicine unit augmentation when necessary. Okay, well thanks Captain Hanson. Just absolute coincidence but we also happen to have in our audience today Colonel Dana Bradshaw. Now Colonel Bradshaw I understand that you are the chief of preventive medicine at the Air Force and why don't you tell us what the Air Force brings to the war in terms of preventive medicine surveillance assets. Okay, thank you. We have several types of assets that we can bring into a theater. The core team that we use is what we call the prevention aerospace medicine team or what we might be called the PAM team and that we deploy in increments initially it starts out with an aerospace medicine physician and a public health officer and then bringing in additional public health officers bio environmental engineers and the technicians that support them to be our initial group that will do disease surveillance, disease non-battle injury kind of surveillance environmental and health hazard threat assessment and all the things that you normally would associate with preventive medicine activities and the ability to do surveillance. We also have what's called a theater epidemiology team and the theater epidemiology team again includes either preventive medicine physician like myself or an aerospace medicine physician who is also of course trained with an MPH as part of their training and then again public health officers, a lab officer an entomologist and folks like that they would function more at the command level and they would help support the activities particularly in analysis and interpretation of the surveillance information that's coming in. We also have the bio environmental engineering NBC team basically nuclear biological chemical type surveillance, environmental surveillance that support these activities and we also in Southwest Asia have fielded a computerized medical record that we call Desert Care 2. This assists us in automated tracking of DMBI type information and it's sort of a precursor to what is being worked on in a joint service capability of the theater medical information program. Well thanks very much Colonel Brashan, hopefully that gives you a better idea of what's available or will be available to you out there. With that let's take it back to you Mark. Great, well I'm sure we'll be coming back to our colleagues from the other services for some input a little later in the program. Now let's get back to those intrepid medics at the 405th Cache and see how they're doing as they start to recognize it's something to foot and let those preventive medicine personnel start to earn their pay. Hey soldier, you're now looking too good, how long have you been sick? Since last night sir. Last night, what are your symptoms? I've been coughing and I had a fever and I had chills. Okay, what have you been coughing up? I decided I was starting coughing green phlegm. Okay, any blood in it at all? Any streaking? I've started having blood in my cough this morning. Let me see that, let me see that. No, that's not streaking, that's clots. Okay, we need to listen to your lungs. Let's have you sit up here soldier. Put that mask back on. Take some real deep breaths of the oxygen. I want you to take some deep breath with your mouth open. Real deep, real deep. That's good. Okay, do that again, real deep breath open. Okay soldier, you got some noise in there. You got a pneumonia going on. Let's have you lie down. Real deep breath. Listen in the front here. Okay, some deep breaths again. How long have you had these red spots on your chest? You got a rash all over your chest. You got red spots? You haven't seen those, huh? Okay. You're going to be okay soldier. We're going to run in some intravenous antibiotics. We're going to get you better. Just breathe the oxygen, okay? Take some real deep breaths. There's Dr. Slupian. There's Koenig. We need to talk. We've got a problem here. This soldier is really sick. He's got a hemorrhagic rash. He's got patechiae. He's got purpura. He's got amoptosis. This is not a simple pneumonia. Any other patients? Purpura? Purpura coughing up sputum, sometimes productive. Sometimes pink and frothy and that kind of thing. Okay, all right. High fevers, et cetera. Okay, what we need on these patients, we need chest x-rays right away. We need sputum, gram stain in cultures. We need blood cultures. We need typing cross and coags, PT, PTT. They're bleeding. We have to alert the blood bank. We have to alert the lab. They're going to be really busy. What are the NBI rates for the region? What's the NBI? Disease non-battle injury. It pertains to the infectious agents and the surveillance rate of these diseases in the area. The only person that has that data is a preventive medicine officer. We need to involve him right away. I'll call him for you, sir. Get to PMO. Meanwhile, you folks get busy with these patients. I'm going to take care of this fellow. He's really sick. Let's get moving. I'll call him for him to arrive. Let me ask those of you in the audience out there. What is an epidemic? It's more cases than you expect to see of any particular disease. Okay, excellent. More cases of a given disease than you would expect to see perhaps in that particular area, in that particular situation. How would you recognize an outbreak? I think you probably answered that already. You see more cases than you expect. Basically, it's a higher than normal background rate or a rate of disease that's higher than the normal background rate. Based on that, how many cases does it take to have an epidemic? It could be one of a rare disease. Absolutely. A single case could be an epidemic if it's a disease that isn't expected to be seen in a particular region. For example, inhalational anthrax in New York City. You heard on yesterday's show in the United States in many, many, many years. So even a single case of inhalational anthrax in New York City could constitute an epidemic. Mark, let's take it back to you. Well, and the real question then is why are we harping on this? Well, because of that ninth commandment we talked about, thou shalt assist in the epidemiologic investigation. You need to know at least and have some rudimentary epidemiologic skills to do your job in the battlefield. You know, most of the time physicians, nurses, and other healthcare workers receive very little formal epitraining in school. Okay, that's why we're going to ask you to give us the short course today. So, Tony, why don't you give us the short course version of Epidemiology 101? In fact, before you give us that course why don't I start us off? I was actually assigned to an Epicon team that one of the teams you spoke of. Last year I was called to Fort Bliss, Texas to investigate or to assist in investigating a diarrhea outbreak. And we had learned that 99 soldiers from a single air defense artillery battalion had been hospitalized over roughly a two day period of time. So that was an epidemic. Well, Ted, maybe, but not necessarily. I mean, it's not just enough to know the number of cases that you have a lot of cases. You got to know the rate of disease as we discussed earlier in the surveillance section. You can't be able to compare the previous rates of disease in previous days or weeks or months to what you're seeing at the time. And you can do this for the whole area or you can do this by unit, for example. Now, Ted, I think in your case I would assume that 99 cases of diarrhea probably aren't admitted to that hospital every day. So I suspect you're probably right. That probably was an epidemic. But it makes a very key point and it's one of the critical steps in an outbreak investigation. Okay, well, in my case, Mark, it seemed pretty obvious the baseline rate of admissions for diarrhea at William Beaumont Army Medical Center in El Paso was about one admission per day. So we felt 99 patients in a day or two was clearly a rise from background. But I think you're right. I think it wouldn't always be as straightforward as we had it. No, I won't. And even in your case, even before we can definitely say that we have an epidemic, let's verify the diagnosis. Now, we would prefer doing that with reliable laboratory tests. However, often, especially in the field scenarios, these may not be available. So you have to do so with the best available information you have at hand, and that's usually clinical criteria. Now, for formal reporting purposes, one of the handouts in your course packets contains the CDC's case criteria manual, which lists diagnosis based on laboratory, clinical, and epidemiologic criteria. Okay. So is it enough to know at this point that I've got a diagnosis of diarrhea? Or do I actually have to know what the diarrhea is due to? Do I need to know this is Salmonella diarrhea before I can proceed? At this point, you don't have to know exactly what's causing your problem. It's enough to know that the patient has diarrhea. It's enough to know that you have a firm case definition you can go on. And the etiologic diagnosis can come at a later time. As I said, in some cases, you may never get an etiologic diagnosis. Even in those cases, you can conduct a successful epidemiologic investigation, which might then lead to some useful measures being taken. And I'll use the example back in the 1800s, John Snow in the London was in the middle of a large collar outbreak, and this story sort of become legendary in epidemiologic circles. But basically, John Snow was able to map out where all the cases were coming from in the city. And this is, of course, before he's able to really grow cholera or actually give treatment for it. But by mapping out the cases, he was able to find that they're all linked to this one water source. And what he ended up doing to control the outbreak, at least mythologically, is to go and take the handle off the Broad Street pump and thus ended the outbreak of cholera. Well, it certainly is a great story. I think it would be useful now to listen to Dr. Dave Dennis tell his story, a plague expert from the CDC's branch at Fort Collins, Colorado. And in this episode here, he's going to discuss an outbreak of suspected plague that occurred in India back in 1994. And I think this will show you how making an ideologic diagnosis can be problematic, in fact in more ways than one. I don't think there was any way to really determine quickly what the evolution of the outbreak was. And it certainly could have been an unnatural event as far as we know. Especially the situation in Sarat, where there was mnemonic plague cases. What happened was there was an explosion over a period of a few days of about 100 cases of severe pneumonia with respiratory insufficiency, and rapid death, and the high fatality in persons who weren't treated quickly. In fact, there was about 40 deaths among those 100 cases that occurred in those first few days. The thing that was unusual about it was there had been no antecedent plague in Sarat for decades. There was no known cycling of plague in the rodents and their fleas in the city. There had been no reports of rat die-off that were brought in that city. There were no bubonic plague cases which you would expect to be very much greater in number than the mnemonic plague cases and to precede the mnemonic cases. That was not in place. So, I mean, in actuality it makes a very good scenario for an accidental or a determined event. We still don't know really what happened, but the best conjecture at that time was that someone had come in from the area where they had reported the outbreaks of bubonic plague and the countryside into Sarat at the time that they were incubating the disease, developed secondary mnemonic plague, and then there was a burst of cases arising from exposure to that and secondary cases accounting for those mnemonic plague cases and deaths that occurred in the city and then a quickly died out and without evidence of there being rat plague or bubonic plague cases occurring there. Okay, well I chose this interview with Dr. Dennis for several reasons. First of all, it uses a potential bio-agent plague to make its point. Second of all, this outbreak in India is still very controversial and Dr. Dennis discussed some of that controversy. It's gone down in the history books as a plague outbreak, but there are some skeptics and in fact some of these cases in India smell a lot like cases of melioidosis, another potential biological weapon. And this goes to show you that diagnosis is often difficult even with diseases like plague which present in this clinical hallmark type of fashion. So yesterday we talked about how everyone should recognize plague based on bloody sputum, the idea that this is too easy. And again I think this drives home that point. You've already touched on one of the key points that we should come away from this segment is that it's not that easy to verify the cause of an epidemic in most cases. In fact, the most ideal disease epidemics, for example, we don't identify the causative agent in approximately 50% of cases. So because of this, it's important to establish a good case definition and that case definition needs to be composed of simple objective criteria as well as contain epidemiologic variables. For example in the scenario that we're watching you might consider using a case definition that has the components of fever and respiratory symptoms. Well Ted, in addition, I think you also may want to specify some kind of duration in your case definition. And once again to use the example of Colonel Sanchez, in addition to using fever and respiratory symptoms that we've had over the past 24 hours to that definition. And this way you're narrowing your focus to those who are recently ill as opposed to maybe those who have been ill for a week ago. But your definition is still broad enough that you're not going to miss anyone at this point. Okay so in our scenario then the one that we're playing out in video for you, a case definition of perpuric rash and bloody sputum would probably be too restrictive. I might miss cases. Exactly. Once you've done this calculate your rates and your baseline rate and establish the existence of an epidemic by comparing it to the baseline rates of that same illness or disease. Well let me turn back then to the outbreak at Fort Bliss. I don't want to confuse the audience here but we were alerted to the Fort Bliss outbreak because of this number of hospitalizations the 99 soldiers who were hospitalized. So initially we were looking at diarrhea severe enough to cause hospitalization. Would that be a good case definition perhaps to use? Well in that specific case given that you were using hospitalization in the definition it was appropriate given that the large number of cases occurring in a short span of time were being put in the hospital. What's bad about it is that you may have missed and indeed missed some not many cases that were mildly symptomatic. The good thing about it is since more of the patients were in the hospital you were able to have a captive population that you could interview. So what do I do now? Well now you can start counting your cases. What you do is you cast a wide net, you look beyond those specific patients you have already seen or shown up at the hospital and you start talking to those case patients to narrow down who else in that unit or area might have been involved. No sooner you do that you start developing what's called a line listing of cases and non-cases. This is critical. If you have this then you won't get lost. If you don't do it, if you develop a case listing then you may get confused about how many cases you really have. Now Ted here's where this real shoe leather epidemiology aspect comes in because once you've identified cases based on your case definition you're going to hit the pavement and try to track those cases down or any additional cases down and you want to talk to them then. You want to find out who's involved, you want to know where they've been and you want to know what they've been doing when in that situation. I agree very much Mark. You need to orient yourself as to person, place and time. In terms of person you need to find out what the demographics are in that population of affected patients that is what their ages, races, genders and ranks are. In terms of exposures you want to find out what their occupational specialties are. It might be that certain specific type of soldiers doing specific activities are affected. Maybe it's their leisure activities and not the work habits that are put in them at risk. You need to find out if they're taking previous medications or vaccines that may put them at risk or protect them in specific syndromes. You also want to find out whether the risk occurs principally indoors or outdoors depending on the location of the individuals, whether working or where they actually spend most of their time. Also you want to find out if they're wearing mob gear at the time. Finally you want to be able to place cases what we call spot mapping them by location or unit. This is very simply done by just putting them in a map. You also want to do it by time. This is done using epicures and we'll discuss more at Lentos later. In the case of the outbreak that I was involved with at Fort Bliss virtually every patient we saw was a young enlisted troop. They came from the same air defense artillery battalion. All of them were AIT students. They all had been confined to a few blocks a few square block area of the post. They all had a lot of exposures in common. They all had the same mess hall they all drank from the same water buffalo all went to the same latrine and they all got screamed at by the same first sergeant. Ted, in that situation then since they had so many common exposures it may be helpful then to find the atypical case, the one who just doesn't fit in with the other ones. We call that person an outlier. If you can explain how those outliers became ill then that can help you solve the puzzle. Mark, you're making me look smart and that's not always easy to do but that's exactly what we did do in this case. We found this second lieutenant and this second lieutenant was one of the patients that got hospitalized. He was not in that air defense artillery battalion. He was not authorized to eat in that mess hall but he did. He was kind of the tip off that it may have been that mess hall because that was the only two things that linked him with the other patients and that's what we thought was the implicated exposure based on that. Ted, what we want the audience to understand is that epidemics don't just occur. They don't just occur by chance whether they're natural or they're due to a biological attack. An epidemic requires a necessary unique combination of events to include an agent harmful agent coming into contact with a group of susceptible hosts in the proper environment. So the real purpose of an investigation of an epidemic is to describe the outbreak and to explain the how and why the outbreak took place. This information will help as a course plan personal protective measures, proper therapeutics, determine casualty estimates and prevent further exposure. So to provide this explanation you now need to develop a hypothesis. And then we need to mention Ted too that while you're waiting to solve that outbreak puzzle if there are any important medical interventions, you don't want to delay them. Okay, so you're saying I shouldn't withhold the ABCs, the IV fluids, etc. while I try to figure out whether this was standard army issue red Kool-Aid that made these soldiers sick or cream-chip beef on toast? Exactly, Ted. And if you suspect how something is being transmitted you may need to institute control measures as soon as possible. And obviously that's going to be especially important when we start dealing with BW specifically. In your case, Ted, as far as developing a hypothesis goes it sounds like you feel that the exposure in question came in at the mess hall. You know, as difficult as it would seem to believe that a U.S. Army mess hall would be implicated. I'm allowed to say that because my dad was a photo master. That's what it seemed to be. Now remember that the whole reason for the EPI investigation is to be able to implement control interventions to prevent further exposures. That's probably you want to know more about what's going on simply other than the mess hall that's involved. For example, you want to know what specific food items might be involved. What practices at the mess hall have placed soldiers at risk. And then by knowing these you may be able to change practices. You know, here we actually we're at a real advantage in the army as opposed to how easy this may have been in the civilian world. The army mess halls actually keep sign-in rosters. So at every meal we could actually go back and determine specifically which soldier ate at which mess hall and furthermore which meal they ate at which mess hall. They made it even easier because they kept their menus. So once we had an implicated meal we were able to go back get the menu, show the menu to the soldiers and say, you know, try to think back a few days ago and circle the foods you thought you ate at a particular meal several days ago. So hopefully, Ted, then you can narrow down more to just, you know, even a specific meal or a specific food. That's what we did or that's what we tried to do. Now we attempt to do that correlation in a scientific way and the way we do that in terms of numbers is by comparing the rates of illness among those who have eaten a certain food or drank something like in your case or being exposed to a specific item versus those who didn't eat or weren't exposed to that specific item. Now, if there's an association you should see a higher attack rate, higher illness rate in those that were exposed or consumed those items compared to those that didn't. Well, basically when it all boiled down we crunched all the numbers. We thought it was probably breakfast on this one particular day where the exposure occurred. We had a few foods that we were concerned about that seemed to wash out when we crunched the data. And again, pastries at breakfast on this particular day, the ice machine, the soda dispenser, all of those looked like they could potentially be the implicated agent. Well, given that you have those suspicions now, now you got to test the hypothesis to see if the data really fits with the established facts. So what you do is you look at, for example, the interval between that particular breakfast or exposure you think had to do with it and the uncivil illness. And to see if it's consistent with what you would expect for that kind of diarrheal disease. Also, did everyone who was sick eat that particular food or were there people who ate the implicated foods who failed to get sick? You know, now, Ted, at this point, you can, you know, you've got a fair amount of information, so you might be able to formulate some conclusion about your investigation. Now, you need to make sure, sorry about that, you need to make sure that you base that on some common sense, biological plausibility and the differences you've seen in the patients and risk between those who are ill and well. Did you ever come to conclusion? Did you ever figure out how those guys got infected? Well, basically eventually cleared the cream chip beef on toast. That was not implicated. But when we looked at the rates of illness in soldiers who partook of various activities who used the soda machine, who used the ice machine, etc., compared to those who didn't, it seemed that the soft drinks gave us the highest risk. It wasn't the ice apparently because soldiers who used ice in juices, for example, didn't get sick. It wasn't the glasses themselves because soldiers who used the same glasses for other beverages didn't get sick. But it seemed to be the soda and we ultimately tracked it to the soda dispenser machine. Oh, that's great. Now you're ready to take the next step. You have to implement some control measures as good or bad as your conclusion may have been. You have to reach out and outline steps to interrupt transmission or exposure. Now, if this turned out to be a vaccine preventable disease, you could consider reducing the risk of individuals by immunizing, for example. In some cases, you could also prescribe certain medications as prophylaxis to prevent them from getting sick. But you still have some few missing tidbits of critical data. For example, how did the dispensers get contaminated with what? Well, as far as with what we got lucky, we were able to isolate a Norwalk-like virus from the stools of several of our patients. So that was that answer. I agree. You did get lucky, especially as we've heard before, that, you know, half the time you might not get the etymologic diagnosis and GI outbreak. Right. That's right. We got lucky also in that the index case, the first case that we could find that got ill in this particular outbreak, appeared to be a baker, and he had a lot of access to the mess hall. He baked the baked goods. He used the soda dispenser, etc. When we determined that this did occur in a mess hall, we were interested in talking to the personnel. And this baker, a lot of the personnel related to us, that this baker got sick with gastroenteritis before any of the troops did. So he, again, seemed to be the index case. Well, now the baker gives you another opportunity to test your hypothesis. Now you know that the engine is Norwalk or a Norwalk-like virus. You can look up the incubation period in the book for this agent and see if it fits with the time frame between the preparation of the items by the baker and when the troops got sick. Well, it did. It seemed to be about 36 hours between the time the baker got sick, roughly the incubation period of Norwalk virus. Well, I think it would be logical then that somehow this cook must have gotten in there and contaminated your soft drink dispenser. Right. And so what we did was implement control measures then. We recommended the baker improve his personal hygiene. But seriously, it came down to the usual suspects, hand washing. So we recommended better hand washing. Re-emphasize the need for that. Now you've implemented some control measures that, but the ultimate thing is to see whether these control measures that you've implemented actually have an effect. Whether they reduce transmission or result in a reduction or hopefully a total elimination of the problem. Well, again, we did reaffirm the necessity that food service people wash their hands. We also advised cleaning the soft drink dispensers thoroughly. We recommended possibly using paper cups so soldiers wouldn't go back up and repeatedly put their dirty cup up to the soda dispenser. But I have to give you an example of that. And in fact, they were already on top of this situation. They were worried from the very beginning that the mess hall could have been the exposure. They had already instituted some control measures and in fairness to the food service people, they were also on top of things and already working towards that. You know, Ted, that opens the door for another important point and that's keep the chain of command in the loop and that was one of our, I believe well, you know, in fact, Mark, interesting you should mention that. There was a reason that a blue collar pediatrician like myself was asked to participate in this Epicon team even though I'm not an epidemiologist. There initially was some reason to believe that this outbreak could have been sinister and that's because it occurred right after the embassy bombings in Nairobi and Dar es Salaam. So, turns out that the command was very on top of this and that's going to lead into our next segment recognizing a very specific outbreak. But again, the command was on top of this. They had that index of suspicion, that heightened sense of alertness that one needs to do this. They were very interested in knowing why all their troops were in the hospitals and in the latrines and now out on the air defense artillery ranges. So, again, very on top of it and that was a big break for us. Now, I think that that essentially wraps up our discussion on outbreak investigation. We took you through the steps that Colonel Sanchez uses and now we're going to take a ten minute break to allow you to catch up, get a cup of coffee and the like. When we return, we'll look at clues which might indicate that an outbreak could be secondary to something sinister, to a biological warfare attack, for example. Enjoy your break. Well, welcome back everyone. We hope you enjoyed your break. Now, we've spent a fair amount of time talking about epidemiology and I'm sure a lot of you are saying why do I need to know all of this epidemiology? I'm not going to function as an epidemiologist on the battlefield and perhaps to a degree that's true. But again, you are a critical cog in this whole system of surveillance and epidemiology. So, you at least need to be able to serve if you're down at one of the lower echelons as that initial sentinel ever vigilant for the first event that would set the epidemiologic system in motion. Okay, so now that we know about how to conduct an epidemiologic investigation, the next important question that we want to ask ourselves is how do we apply this knowledge to the biological battlefield? Now, I think it's important to understand that the medical effects of a biological attack can certainly mimic those of very many endemic diseases. And because of this medical personnel are going to have to be extremely alert in order to differentiate the initial cases resulting from a biological attack from cases of infection caused by natural agents out there on the battlefield. So, let me start off by asking Mark, how do you decide if an outbreak was caused by a biological warfare agent or a natural infectious disease source? Well Ted, there are actually a number of tips that, you know, a number of clues that could tip you off to something unusual out there. In fact, some of those you'll find in your books at home in your student manuals. Okay, why don't you give me an example here? Well, let's say an endemic number of casualties which occurs within hours or maybe a couple days within each time frame. And, you know, most of those would occur probably within 24 hours of each other. However, that could depend a little bit on the incubation period of the pathogen. If you have a longer incubation period, those casualties may be spread out a little more. Well, Mark, as I said before the break, a dumb biological warfare guy like myself was actually asked to be a part of this high speed, low drag, epicon team the extremely tight cluster of cases that occurred there at Fort Bliss was one factor that made somebody in the command and somebody in the preventive medicine section there think that in fact this probably was something or could have been something sinister. Well, you know, Ted, another tip of might involve a disease as the unusual, not only in terms of the number of cases you see, but especially if it's clinically unusual or it's occurring in a place where it's not supposed to be. This may be diseases are an anomaly encounter in a particular region or country. That wasn't the case in your example, obviously. Okay, well, can you give me an example then where it would be the case? Well, Ted, let's talk about yellow fever, for instance. You can see yellow fever normally in somewhere in Africa or South America, whereas if you saw it in Asia, that might be something unusual. Or if you saw Venezuelan equinecophilitis in Korea, for example, only occurs in Central or South America. Or how about, you know, to use the example you mentioned before about an inhalational anthrax in New York City, I think an inhalational anthrax just about anywhere would be a concern. Another clue you might think of is multiple diseases in the same patient or perhaps multiple simultaneous or successive outbreaks. Now, evidence suggesting a point source outbreak is very important. So, if a biological agent has been used, you would expect more likely than not to have a large number of military personnel be exposed at about the same time. This will cause what we determined to be an explosive epidemic of casualties. So, it would be useful at this time to construct an epidemic curve to describe the distribution of those cases in time. And that is helpful in determining the source of the exposure and the possible model transmission, what may have gone on. Now, by calculating the purported incubation period, which is a time interval between exposure to the onset of clinical disease, we can then perhaps determine and start to guess what are the etiologic agents or agents involved. Now, most often than not, in a biological warfare attack, you see an epidemic curve characterized by a single large peak with a rapid rise in full of cases as you see here. Now, all cases fall within that range of that incubation period and most if not all are caused by a common source of exposure at one point in time. Now, that would be in stark contrast to naturally occurring epidemics where the number of cases increases but it's more spread out over a period of days, weeks or even months as you see in this next curve. Now, if the epidemic curve is characterized by cases occurring over a longer period of time without a clear peak, then that would suggest a continuing rather than single common source outbreak. Thirdly and lastly, in the case of a person-to-person transmission problem such as what occurred with epidemics or pneumonic plague, as you mentioned before, you're more likely to see this third type of curve where you have continuing peaks of cases spread fairly uniformly depending on the incubation period of the agent. Back to you, Ted. Okay, well, again in my case, our buddy the baker seemed to be a point source. That was another reason to worry though that this outbreak may have been sinister because of this point, the seeming point source origin. And again, I have to give a lot of credit to all of you who have seen this in the last six, their defense artillery battalion. They certainly recognize that possibility early on. Well, Ted, we could talk about some of the other clues. Perhaps one would be a higher death or infection rate than you normally see with a specific disease. You might also see large numbers of dead or dying animals, especially if those animals have the same disease as the human population has. And in fact, what you may see sometimes is sort of a reserve I'll give you an example with plague for instance. You typically see plague amongst the rats and then followed by that you see plague amongst the humans. Well, if you see the reverse of that where you see plague amongst the humans first and then the rats later or humans and rats at the same time, that could be a clue that something funny is going on. Another thing you might see is some strange insects that aren't normal for a particular area. You can get some of the information here and also animal die-offs in the field from your preventive medicine sections. Mark, in your video scenario, you want to look at all those that you've mentioned. But in addition, if you have an aerosol exposure, which is the most likely scenario, you could see illness limited to a localized geographic area. For example, military personnel that have been stationed in a valley or a platoon, maybe a small group of individuals that just came back from a number to a region, or you could also see casualties occurring downwind or downstream or within a supply line pattern. Now another possibility, the possible clue is a disease that presents as an aerosol route of infection and normally that disease doesn't present that way. We talked about that yesterday to a small degree and let me just reemphasize here. A good example of this would be plague. Plague, as I think I said yesterday, occurred naturally in the jungles of Vietnam. If you practiced medicine or nursing at an aid station during the Vietnam War, you may well have been familiar with plague. What kind of plague would it have been? It would have been bubonic plague contracted by the bites of fleas living on rats in the Vietnamese jungles. Seeing a case of bubonic plague in Vietnam probably wouldn't have raised any suspicions. Seeing a case of pneumonic plague should have raised suspicions. Anthrax. Anthrax is rare in most parts of the world, certainly very, very rare in the United States, but in some areas a cutaneous case might not raise a lot of suspicion, but an inhalational case probably would. Staphanerotoxin B, another great example. Staphanerotoxin B is a disease well known to probably most of you, even if you don't realize you know about it, you probably had S-E-B disease in the form of food poisoning. So if I saw a case of food poisoning determined it was due to S-E-B, might not be anything sinister, but if it was aerosolized S-E-B, it would be pneumonia, and if I saw a pneumonia due to S-E-B, that almost has to be sinister. Okay, now all the clues we've given you so far could be seen with an attack on either a military population or a civilian population, but in addition to these clues there are some clues that are specific to the military, and I think most of these are probably no brainers for you out there, but I'll elaborate a few of them anyway. Casualties that occur during time of conflict, obviously there's an active conflict going on, that should tip you off that maybe what you're seeing wasn't just accidental, and one of the reasons the Fort Bliss outbreak initially raised suspicions is, again it did occur right on the heels of the Nairobi Embassy bombing, so our index of suspicion was already heightened as to terrorism. I think it goes without saying that if you're bopping along the battlefield there and there are bomb fragments, artillery shell fragments, especially if you have a story that there were these bombs that made popping sounds rather than conventional explosive sounds, that probably would tip you off that hey, maybe I'm dealing with something a little unusual here. If you had reports of misting or fogging being done by aircraft or by ground-based vehicles obviously that might be a clue. Sometimes bad guys out there do us the favor of alerting us to their intentions so if an aggressor makes a claim obviously that's helpful. If you have a lower attack rate in people who were wearing mop gear or protective gear as opposed to people who were not or if you have a lower attack rate amongst people who were indoors or in foxholes or in bunkers at the time some event occurred as opposed to those who were outdoors, obviously that would tip you off as well. Again, I think most of those are no brainers. Great Ted, well we've talked about a number of the clues which might tip you off to a BW attack and as I said before you'll find a complete list in your student materials and those are on pages 8 and 9. I think it might be useful to mention now that we've given you all this knowledge that we could see it put into practice or we would like to see it put into practice. I think the best way to do that is to turn to Dr. Matt Messelsen at Harvard and he will discuss for us his investigation of the 1979 anthrax outbreak in Sverdlovsk. So let's go to Dr. Messelsen. When I went the first time to Sverdlovsk I thought that of the two hypotheses, one that it was food born and two that it was air born that it was still quite plausible that it was food born, but there's nothing like data to decide between two hypotheses and when we found after two years of interviewing of families of those who died that the people who died worked in factories and other places that were in a very narrow zone and when we found that the six villages which reported dead sheep were all on a straight line, the same line that was the center zone of where the people worked who died and when we found that on Monday April 2nd that the wind direction as recorded by the local airport was exactly in that same direction all day long then it was obvious that this had been an air born release. There was previous patho anatomical evidence suggestive that it was inhalation anthrax but the problem with that evidence is that we don't have any good patho anatomical reports of true gastrointestinal anthrax and so a differential patho anatomical diagnosis rigorously speaking is not possible without that further evidence however it was suggestive from the fact that there was more involvement of mediastinal and thoracic nodes than of mesentery nodes although there was also involvement of meningitis it was suggestive that it was inhalation but it was epidemiology that not only solved it but also told us when it happened during the day on April 2nd and where it came from the military microbiological facility something that of course autopsy couldn't tell you. Well Ted you know I think that provides a great example of how spot mapping cases can help you solve the epidemiological puzzle. Well I think that about wraps up our Epio 101 course doesn't it? I think so Mark before we quit though there's something that's bothering me about all this okay I'm a blue collar pediatrician as I think I've said several times I joined the army so they would pay for my college and didn't expect to go to war but now all of a sudden here I am people are shooting at me in the battlefield conducting Epi investigation interview patients, calculate attack rates and the like Well Ted you make a good point and you know as we've talked about before with our colleagues from the Navy and the Air Force and the Army there are Army and Navy PM teams in theater and you know those people can assist you in performing these investigations however you know let's say your communication lines are down you can't let them know something's going on or they can't get there immediately and four vehicle convoys that can take a while to get a convoy together so you need to know where to start you know basically to get that investigation ball rolling okay so in a nutshell what can I do to get that ball rolling What do you think Colonel Sanchez? Well if you see something unusual Ted make a list you go checking it twice and you're going to find out who's not here nice but you know seriously to establish a general case definition and start taking names of those who you think are an institute some kind of therapy because you would normally based on the limited information you have Okay well thanks Colonel Sanchez now before we move on to the next part of our program I think it would be useful to hear Dr. Dennis as he discusses how to use some of these epidemiologic teams and he used them in conducting his investigation of the purported plague outbreak in India so let's go to Dr. Dennis What is needed to respond to a plague case or a plague cluster of cases or an outbreak is a multidisciplinary team in effect a SWAT team and that really is what was needed in India you know they needed a team of epidemiologists who understood plague including clinicians who could determine whether or not the clinical signs and symptoms really were compatible with plague they needed microbiologists that had a mobile laboratory at least to have the reagents and to have the materials to do a presumptive diagnosis of plague and they needed to have the entomologists and the zoologists the ecologists that understood the natural cycle of plague and how it could have spread to the human population and if they had a team of those people they could have gone in and made sense out of that outbreak in Surat in 24, 36, 48 hours but they missed the boat. Okay another component of modern force protection involves the use of bio detection equipment on the battlefield I think before we discuss detection though it's important to understand the difference between detection and diagnosis and I like to think of this in a couple of ways I like to think of detection as something that's done at baseline in other words no event has occurred at least to our knowledge we're just out there going about our business and we have out there in the hopes that they will alert us when an event does occur on the other hand diagnosis I like to think of as being done after the event something has happened and now we're trying to figure out what furthermore I like to think of detection as usually employing environmental samples so I'm assaying air or dirt or pond scum or whatever when I talk about diagnosis typically we think of clinical specimens sputum, blood, urine and the like well we're fortunate to have with us today Lieutenant Colonel Don Buley, Colonel Buley Colonel Buley is deputy program manager for detection at the joint program office for biological defense Colonel Buley can you tell us about some of the systems currently available for bio detection? Yes Stan currently we have limited capability fielded in fact our first systems weren't fielded until 1996 right now we currently have the Army's integral integrated detection system and their associated long range biological standoff detection system the Navy's intram biological agent detector a rapid prototype and we are fielding an advanced concept technology demonstration system called the portal shield for fixed site protection these systems are currently all detect to warn technologies. Well sir you know I've heard about you know I've heard the term detective warn can you tell me first of all what's detective treat mean? Well detective treat allows you to be able to do in essence have real time data for detect to warn detective treat in essence is our processing time is too long to reach that and what we're looking at then is being able to provide a confirmatory sample to the appropriate medical personnel to be able to make that final determination if in fact a biological attack has occurred. Well Colonel Beal you mentioned several systems and I've heard of some of these systems referred to by their acronyms so the biological integrated detection system I've heard of referred to as bids and then the LRBSDS and the IBADS systems and you know after a while all of this starts to sound like a bunch of alphabet soup so I wonder if you could take us through them one at a time let's start with bids what is the bids or the biological integrated detection system? Well the bids is the army's land-based biodetection system and it was originally developed to detect and identify long line source releases basically it's a combination of interrelated technologies that allow it to do generic detection as well as identification we currently have two companies fielded and the most current system is a semi-automated system capable of presumptively identifying eight agents simultaneously in under 30 minutes well sir you mentioned a number of systems as Ted said now how does this the bids different from one of the other systems you mentioned I guess it was the LRBSDS a long-range biological standoff detector well the LRBSDS is our standoff or early warning system it's mounted on a UH-60 helicopter and is capable of providing a differentiation between a man-made particulate aerosol and a naturally occurring aerosol cloud and it's able to do that out to about 50 kilometers this particular technology however will not be able to differentiate and provide information if in fact it is a bio cloud or not So is this in use now or when can we expect us to have this on the battlefield? This particular system has been the first three have been fielded they were fielded in 1997 we have a newer system coming out in FY-01 Sir you mentioned a system that the Navy has they're using I guess is the IBADS can you tell us about that one? Well the Navy's IBAD is a rapid prototype that was developed for primarily ship board operations and it's a fairly simple system what it does is it constantly samples the air counting particles and looks for a rise in the background threshold once it exceeds that threshold it will come from the ship and allow it to go into collective protection at that point what they'll do is the system takes a liquid sample one of the medical personnel will come out and do a manual identification process on that sample using column metric immuno assay strips or what we prefer to is handheld assays and it can do its identification in under 15 minutes I've never seen one of these IBADS so I'm having a little difficulty envisioning how this works in an air base or a port or a fixed facility and use it that way Realistically now this system is designed for blue water operations once you get into littoral operations or into a more complex land based environment that particular particle counter would be giving you a lot of false positives so it's really not appropriate Okay so do you have anything that could be used in ports, in air bases things like that? Well what we currently have got as I mentioned earlier is a concept technology demonstration that the JPO put together and it's called the portal shield and it's the first fully automated system biodetection system we've developed and it was again primarily designed for fixed sites ports and airfields it uses a smart network of sensors that are integrated with an advanced decision algorithm that allows it to automatically detect identify track the cloud as well as warn the biological event and it's able to do identify its eight agents in less than approximately 20 minutes so we've continued to slice that identification cycle time down as we go So sir, you've mentioned a couple systems and some of them sound like they're fairly new do you have anything else that's coming up down the pipeline? Well currently what we're working on right now is the joint biological point detection system and it's the first DOD joint biosuite that's under development and what we're doing is developing a common biosuite that is applicable or mountable in different variations the Army will put it on a Humvee the Navy will have it shipboard and the Air Force will be able to have a fixed site variant of it to protect its air bases the Marine Corps will also get a man-portable variant of this particular system and it has some and we continue to make improvements in these this particular system will be able to identify 10 agents and we'll do it right now in less than 15 minutes Ok well this is all good it sounds like it's a great advance forward from where we were a few years ago and it sounds like it's critically needed but what can we do for the tactical unit? Can we provide early warning for bio for the guys down in the mud like we can for the chem agents with for example the M8 detection system Well we're working on our first attempt at a true tactical detector-worn system and that's called the Joint Biological Remote Early Warning System or J. Bruce and again trying to leverage earlier portal shield work what this is is again a smart network of low-cost lightweight generic detection sensors integrated with a central command and control facility and a central identification unit so what we're looking at is being having this complex system do that automatic detection of the cloud in less than a 5-minute time period currently we're still working on getting it out to real-time data we haven't quite achieved that yet but this is a significant step towards that Ok well great now I believe we have a video segment of Major Woolen who is works at USAMRID he works with also with the 520th Theatre Army Medical Laboratory also known as the TAML and he's going to discuss what happens with this positive sample BW agent identification in field environment is an integrated process it starts with the high volume air sampling capabilities being either a bids or a portal shield those capabilities have multiple systems within them that tell them there's something unusual there and they also have the ability to screen for various different BW agent types once they come up with a presumptive identification that there is something unusual in the air and they possibly will have an presumptive idea of that agent as well they would hand that sample off then to a sample collection and transport team to bring that sample back to the med lab once the sample arrives at the medical laboratory component it will be analyzed again by various technologies right now the TAML currently has the ability to culture to PCR, dualize to do immunohistochemistry and fluorescent antibody type of analyses no less than two of the technologies will be utilized to analyze for any one agent the reason that we do that is because we want the analysis at the level of the medical laboratory to be able to add confidence to the presumptive agent identification so in order to add that confidence level we feel like we need to analyze the sample by multiple technologies also by technologies that are mature not technologies that are still on the cutting edge of development and have not yet reached the maturation level where you would consider them validated right now the technological packages that are available give us an opportunity to within a 10 to 11 hour time period after receiving a sample have the first level of testing completed by the end of a 27 28 hour time period we will have been able to not only do our preliminary analysis of that sample also to have identified whether or not there are any PCR inhibitors that would potentially give us a false negative with PCR be able to sort those inhibitors out with regards to doing a dilution series to be able to bypass the effects of the inhibitors and then to have run a full panel BW agent test once the analyses are completed at the med lab the forward deployed med lab that sample then needs to be evacuated back to a reference laboratory for definitive testing so what's happening in a field environment is you have a presumptive agent ID you then would have a confirmatory level of agent identification in the med lab you then would have definitive level of identification being conducted at the reference laboratory well as major woolen highlighted the most reliable way then to evaluate the suspected use of a biological warfare agent is probably going to be through sample collection and proper lab analysis question is though what happens if a system alarms you think something's out there but you can't get a positive identification does this mean you don't have a biological warfare event and colonel buley I'll let you answer that as I mentioned previously with a limited number of agents we can do we can't positively identify all the possible variations of the agents out there so what we do is we train the operators to take into account all the information provided by the network or the array of systems when doing their operational analysis when they sit down and have done that if they still have a suspicion that in fact something may have occurred in the sections that have happened then they've identified then we provide again that liquid sample to the appropriate medical folks to do their analysis for a confirmatory of our suspicions well great now I think this moves us on then to our follow up issue what is the medical response when we get a confirmed sample in theater now once again we have major woolen who's going to talk about this issue just as the agent identification process is an integrated process in the battlefield the decision of what to do with that information is also an integrated process when the environmental detectors warn us that there is a potential problem that information is relayed back to the central headquarters we are alerted at the med lab level that a sample is coming in by our by the factor that we have been alerted that the surgeon has also been alerted that the sample is coming in once we have analyzed the sample at the med lab level and have our results we would then relay that information back to the surgeon for the surgeon to factor into any decisions that he needs to make with regards to medical counter measures so the information is kind of a the flow of it is very similar to the flow of the samples within the various communities from a military standpoint both the NBC cell and the surgeon cell will be involved in the process ok well what we'd like to do now is offer our audience members out there in television land the opportunity to ask us questions so the phone lines are open you should have the number and anyone who wants to ask a live question anyone who dares ask a live question can certainly phone them in right now though we have many many faxes the faxes have been coming in all night I understand so let's go to some of the faxes now first question here comes from Fort Dietrich I thought they were supposed to know all the answers to these questions but would you comment on the frequency of meningitis in human cases of inhalational anthrax I see this condition in our non-human primates experimental anthrax and Major Court of Peterson's I outrank you that's a good question Ted and we don't have a lot of data about human anthrax and because of that we have to rely on the little data we have and one of the largest number of cases we are aware of that's been published is related to the spherilosc outbreak of inhalation anthrax and the pathological study that was done published I believe they are about of those 42 cases they looked at there are about 21 that had hemorrhagic meningitis so we are talking about 50% but once again it's unlimited amounts of data with humans the next question comes to us from Kalamazoo, Michigan and the Kalamazoo asks is the anthrax vaccine inactivated or is it a live attenuated vaccine well Major Court of Peter being the low man on the totem pole rank wise has been the one who has had to deal with all the nuts and bolts of the anthrax vaccine issues so again Mark well basically the anthrax vaccine is neither live nor dead it pretty much in other words it has no live or dead bacterial products in it what it has in it is what's called protective antigen and that is a protein that the anthrax bacteria makes and that protein is required for the toxins to exert their effects on the body so basically it's got this protein protective antigen okay thanks next question comes to us not sure where this is from but they ask I guess it's from Lichfield, Minnesota and the Meeker County Public Health authorities why should textile workers be vaccinated against anthrax well textile workers traditionally have been at higher risk of contracting anthrax and specifically those textile workers who work with goat hides or goat hair products goats are one of the herbivorous species that customarily have been more prone to anthrax and so if you work with processing goat hair or goat products you are at theoretical risk at least of contracting anthrax now many decades ago that risk was much much much higher nowadays safety standards are better hides are processed in different manners and so textile workers are at very low risk so I suspect that in many areas of the country or at many mills they are probably no longer immunizing but there is again a theoretical risk that textile workers especially goat hair workers are at increased risk for anthrax next question comes to us from Montreal, Quebec and they ask basically what is the vaccination schedule for anthrax well just to climb back up on my soap box for a minute yesterday I think all of us at USAMRAD and in the medical command in the military think that the anthrax vaccine is a very safe vaccine we also think based on a lot of animal data and a limited amount of human data that it's a pretty efficacious vaccine but no question there is a drawback and that drawback is its logistics this is not the most user friendly vaccine out there so the vaccine series is unfortunately a six dose series it's given at time zero two weeks after that, four weeks after that and then six, twelve and eighteen months after that and then after those six doses you're fully immunized but you still need a booster every year if you're at continuing risk so if you get out of the military obviously you don't need your boosters anymore but if you're going to stay on active duty you need a booster every year and again that's the big drawback for the anthrax vaccine so I understand that we have a caller on the air from Atlanta, Georgia so if we could go to you Atlanta you had a question? come in Atlanta I don't hear Atlanta so Mark did you have some comments? I was just going to make a comment sometimes people get confused about the interval between the third and the fourth dose of the anthrax vaccine you're talking about vaccine at day zero two weeks later, four weeks later and six months after the day zero vaccine now you can translate that into say after that third shot it's really five months after that third shot that the fourth dose comes and then six months and then six months again I understand that Atlanta is here now can we go to Atlanta? Atlanta you had a question? yes I do thank you my question is if a civilian suspects that there's an anthrax attack should we call the army, the police or the health department first who should we call first? that's an excellent question we should be called first I think you have to remember one of the key differences between dealing with biological warfare and biological terrorism in the United States is that events in the United States in addition to being terrorist events are also criminal events so there are criminal concerns there are chain of custody concerns there are evidence gathering concerns and for that reason law enforcement officials need to be involved very very early on so it is useful and in fact it is recommended that the FBI be alerted very very early on because they will come they can handle the specimen appropriately safely establish a chain of custody and maintain that chain of custody so you definitely want to call the FBI it also would be good to call your local health department and then the local health department would start to analyze the threat if they felt they were in over their head they would federalize they would go to the CDC and or use SAMR and all of that sounds like a pretty cumbersome procedure but in reality that stuff would happen very quickly if this were really an anthrax event so I think going to the FBI would be appropriate going to your local police people would be appropriate and going to your local health department would also be appropriate thank you I don't know the answer to that and it's one of the advantages of being the host the next question comes to us from New York City and New York understands that the Germans have a unit called the Fox vehicle and they ask do we have something similar to this in the military? Well, Colonel Beaulieu I think that feeds right into your shtick yes thank you we have fielded approximately 210 of the Fox systems that were purchased directly from from Germany what those are though is they are chemical reconnaissance systems designed for the battlefield they will not do biological detection or identification to correct that problem we have an ongoing program within DoD called the Joint Lightweight NBC reconnaissance system this is an update in essence to the Fox in terms of its reconnaissance capability and this system will be able to do both chemical and biological detection and identification okay, I understand we have a caller on the line from Baton Rouge Louisiana, Baton Rouge, go ahead yes sir, my question had to do with the PCR inhibitors that your colonel was describing earlier for biological sample processing I was wondering how do those inhibitors function no idea I'm a blue-collar pediatrician I'm going to have to get that question to people now, Colonel Eric Henshel will be on the show later on today he's kind of our lab expert at Fort Detrick and I'm going to let that question ride until he's on and we'll have him tackle that so Colonel Henshel you're on the spot later okay, next fax comes to us from McDill Air Force Base in Florida and they point out that Lieutenant Colonel Randy Randolph on yesterday's broadcast stated that the antibody response I think to anthrax vaccine was 91% after the second shot 95% after the third shot and 100% after the fourth immunization so they ask are there any plans or studies to reduce the number of shots in the series and yes there are I'm pleased to report and I think some of you out there probably understand how scientific research goes if I develop a new vaccine I want to write about it for the medical literature I want to become famous and I'm more likely to get published if my vaccine works then if it doesn't so jeez if two doses of vaccine works then three doses ought to really work and boy six doses ought to be great so it was initially studied as a six dose series in laboratory animals and fortunately or unfortunately that's the way the FDA chose to license it but we don't have good information that says that less doses wouldn't work as well and it's exactly what we're looking at at Fort Detrick right now so and unfortunately this is a very slow process the wheels of science turn slowly but what we've done so far is we've taken that initial three dose series the zero two and four week doses and we've tried to see could you get the same antibody response by omitting that middle dose that two week dose and it looks in preliminary studies like perhaps you can do that so maybe zero and four weeks are as good as zero two and four weeks now that would allow us to get from six doses to five if the FDA approves that if it pans out in larger studies and then it would be another step to take it further but that's exactly what we're trying to do now I understand we have a caller on the line from Hartford Connecticut so Hartford if you can hear me go ahead yes Colonel C. Slack my question is that say there was a terrorist incident of a biological nature where they claimed to be using anthrax where there was say 20,000 or more people where would the antibiotics come from to provide the prophylaxis in the treatment are they being stockpiled somewhere and if so how much stockpiling how are you determining how much the stockpile and how would we get them well Hartford that is an excellent question and I'm going to give you a fairly brief answer because tomorrow the Centers for Disease Control folks are actually going to discuss stockpile issues at length but in a nutshell yes Uncle Sam feels your pain we are aware of this problem of the need to stockpile these antibiotics and people at the Centers for Disease Control the various health departments and other government agencies have been exploring the best way to answer this question and I'm not sure what that best way is but I think all of us understand that some of these drugs Cyprophyloxacin for example are extraordinarily expensive drugs and they have shelf lives so it's difficult to stockpile huge amounts of drugs without creating an economic problem of vast magnitude so we've explored the possibility for example of buying an insurance policy with they would maintain a larger rotating stock in their warehouse and then if it's ever needed it would be pushed forward but again negotiations are still going on the CDC has come up with a plan to have various stockpile sites at regions throughout the country and again I think I will let them talk to the specifics of that but we are hoping to stockpile drugs now I understand I have another caller on the line from St. Mary's Hospital in Wisconsin in Madison Wisconsin St. Mary's go ahead if you can hear me I am one of those former active duty people that has been vaccinated for plague and smallpox the question is since the book indicates that the plague vaccine isn't really effective and you had mentioned yesterday that smallpox effectiveness is wearing off would having those vaccinations be a relevant factor in determining the epidemiology of a potential incident and if it is are shot records typically available in theater for people that could be affected by a biological attack I think those are great questions knowing that you had the plague vaccine or the smallpox vaccine might be of some use epidemiologically but by and large the fact that you had those two specific vaccines early on in your medical or military career probably has no benefit remaining to you the plague vaccine that we used in the military for many many decades was designed to protect soldiers against endemic bubonic plague it was never designed to protect against sinisterly delivered aerosolized pneumonic plague and it did protect our soldiers during the Vietnam War very very well we saw virtually no bubonic plague cases in Vietnam in American troops despite the fact that the South Vietnamese who didn't vaccinate were seeing plenty of them so it did what it was supposed to do but its immunity was very short lived you needed boosters pretty frequently so you're probably not even protected against bubonic plague anymore and you definitely aren't protected against pneumonic plague similar story with smallpox the smallpox vaccine in some respects was one of the greatest vaccines in medical history hard to argue with success it eradicated smallpox one of protection was 10 years at the outset or at the outlying and probably closer to 3-5 years so if you haven't been immunized in the last 3-5 years against smallpox probably not protected against that disease as well now if you had a vaccine against smallpox 20 years ago and you got smallpox today you would probably we think and I'm making this up to a degree but you might be protected from dying you probably wouldn't be protected from getting smallpox but in general I don't think those vaccines are going to help you anymore okay let's do a couple more faxes next fax comes to us from the Texas Department of Health in Austin, Texas and Austin has a question on decontamination they've received conflicting information on the use of chlorine bleach to decon anthrax and they ask that we please discuss that I think we could get off on a very long discussion about this and again I appreciate the problems because I too have heard many many various and different recommendations regarding decon and I think to get around this or to answer this question I think you have to have some appreciation for the history in the military traditionally when we've talked about decon most of our doctrine and dogma decon was derived from the chemical warfare field and so many of these recommendations that one use bleach for decontamination