Biological Threats Outbreaks, Attacks and Accidents

Biological Threats Outbreaks, Attacks and Accidents Prevent, Detect and Respond A Global Health and National Security Imperative Gerald W Parker, DVM, PhD Associate Vice President Public Health Preparedness and Response Texas A&M Health Science Center Interim Director, Institute for Infectious Animal Diseases Texas A&M AgriLife Research

Topics Evolving Biological Threats and Policy Lessons observed: 2 Cases 2001 Anthrax 2014 Ebola response National Security Strategy Global Health Security Agenda

Evolving Biological Threats Threat Agents Traditional threats remain Engineered and advanced threats Emerging infectious diseases Threat Events Accidental release Deliberate elicit use by offensive weapons programs State Non-state Lone actor Naturally-occurring, emerging trans-boundary infectious diseases (zoonotic) Therapeutic resistance DURC Emerging Threats Traditional Threats Advanced Threats

Popular Biology ~2025

Emerging Infectious Diseases Pathogenic microbes can be resilient, dangerous foes. Although it is impossible to predict their individual emergence in time and place, we can be confident that new microbial diseases will emerge. IOM, 1992

Biodefense & Emerging Infectious Disease Highlights 1972 1995 1997 1999 2001 2003 2004 2005 2006 2009 2012 2014 2016 Biological & Toxin Weapons Convention Sarin attack in Tokyo by Aum Shinrikyo H5N1 Pandemic potential Al Qaeda 911 & Anthrax letter attacks CDC Laboratory Response Network & Strategic National Stockpile SARS H5N1 Pandemic potential CDC and NIH Biodefense preparedness programs expand rapidly Hurricanes H5N1 Pandemic Influenza Emergency Supplemental Appropriations Project BioShield H1N1 Pandemic Ebola Middle East Coronavirus Pandemic & All Hazards Preparedness Act

ANTHRAX ATTACKS OF 2001

2001 Anthrax Attack Observations The 2001 attacks may be easiest type of bioterrorist strike to confront even so their impact was far-reaching: Two branches of the Federal Government were temporarily shut down & U.S. Postal operations significantly disrupted Only 22 individuals contracted anthrax (11 inhalational & 11 cutaneous) More than 33,000 required post-exposure antibiotics Direct economic cost (losses) ~ $3 Billion Decontamination of Senate office building, Postal Process plant and AMI building cost ~$320 Million

Observations (Continued) The response from medical, public health & law enforcement communities was massive. 1000 physicians, epidemiologists, public health official & medical practitioners. U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) performed 30,000 tests on 10,000 samples. 400 contractors & as many 400 government workers needed to decontaminate just the Hart U.S. Senate Office Building. These attacks revealed weaknesses in almost every aspect of U.S. biopreparedness. The failure to communicate a clear message to the public was on of the greatest problems.

Key Lessons Learned Establish clear chain of command for incident response 1. Develop check list of key immediate actions 2. Expand cooperation between medical, public health & law enforcement communities 3. Establish reliable 1st responder communications 4. Exchange liaisons, increase 1st responder training & joint exercises

Key Lessons Learned Continued Develop comprehensive communication strategies 1. Develop coordinated media strategy 2. Prepare public messages in advance 3. Establish joint information center for sharing data Improve ability to detect a biological attack early 1. Expand environmental detection systems 2. Improve clinical & forensic diagnostic capabilities 3. Alert medical community immediately

Key Lessons Learned Continued Develop local distribution plans for antibiotics, vaccine administration & provision of treatment of mass casualties 1. Develop stockpile and mass delivery strategies 2. Incorporate mental health needs into response plans 3. Strengthen civil defense 4. Need Anthrax Vaccine and surge capability Expand local & regional surge capacities for mass-casualty care. Improve large-area decontamination capabilities

Percent We Can Save with Oral Antibiotics Saving Lives Requires Fast, Effective Response 100 Percent Infected in Incubation 80 60 40 20 Detect Decide Distribute Dispense 0 0 1 2 3 4 5 6 7 8 Time after Attack (days) Baccam, P. & Boechler, M, Public Health Response to an Anthrax Attack: An Evaluation of Vaccination Policy Options, Biosecuirty and Bioterrorism: Biodefense Strategy, Practice and Science Vol 5, #1, 2007 pp. 26-34.

Summary 2001 anthrax letter attacks demonstrated biological risk is real Even small scale attacks can have national & international impacts; Defense against biological attacks requires extensive preparation, coordination & vigilance; Must be underpinned by robust research foundation Saving lives after an attack requires effective response that is fast with robust logistics to deliver medical countermeasures Microbial forensics established as a new science Laboratory biosecurity, personal reliability, and biosafety

The Simplest Versus the Most Realistic Attack Scenario Past Experience: 2001 Anthrax Attacks Current Concern: Aerosol Release 1 gm via letters Number that received 30,000 antibiotic treatment Number of illnesses 22 Number of deaths 5 1-2 kg via cropduster Number that will need antibiotic treatment 1.9-3.4 M Number of illnesses ~450,000 Number of deaths ~380,000 Decontamination 3 Buildings ~$320 M Decontamination City wide Direct Economic Cost >$1 B Projected Economic Cost >$1.8 T

Comprehensive Biodefense Strategy HSPD-10 THREAT AWARENESS PREVENTION AND PROTECTION SURVEILLANCE AND DETECTION RESPONSE AND RECOVERY Response planning BW related intelligence Proactive prevention (vaccination) Critical infrastructure protection (collective protection) Attack warning (biosurveillance) Attribution (forensics) Mass casualty care (surge medical care) (rapid distribution of medical countermeasures) Risk communication Medical countermeasure development Decontamination

A Common Comprehensive Resilience Framework PRE-EVENT POST-EVENT PREVENTION PROTECTION SURVEILLANCE AND DETECTION RESPONSE AND RECOVERY THREAT ASSESSMENT AND AWARENESS TRAINED, EQUIPPED &PROTECTED RESPONDERS RESEARCH, DEVELOPMENT, AND ACQUISITION INFORMATION MANAGEMENT AND COMMUNICATIONS ANTICIPATION OF FUTURE THREATS PUBLIC PREPAREDNESS

Filovirus Emergence Since 1976 Martines RB, et al. J Pathol 10-9- 2014 E-pub ahead of print

WHO Sit Rep Guinea Liberia Sierra Leone 01/06/2016

Current Outbreak In West Africa Dec 2013 March 2014 Aug 2014 Oct 2014 Jan 2015 Nov / Dec 2015 Jan 2016 Epidemic began in Guinea - index patient thought to be a 2 year old child WHO notified of rapidly evolving situation. MSF - unprecedented and warned of difficulties combating EVD WHO declares public health emergency of international concern Outbreak spreads to include Guinea, Liberia, Sierra Leone, Senegal, Nigeria, and Mali Senegal & Nigeria declared EVD free Mali declared EVD free Sierra Leone declared EVD free Guinea declared EVD free Liberia declared EVD free

2013-2016 Ebola epidemic is the largest in history > 28,000 cases, >11,000 deaths Why was this outbreak so bad?

Contributing factors Delayed recognition, diagnosis, and public health response Epicenter located on a 3 border region First cases: Gueckedou and Macenta Highly interconnected populations Easy connections by roads: rural and urban areas EVD spread to cities Overcrowding and poor sanitation Cultural and social factors Distrust of government authorities Inadequate health care infrastructure N Engl J Med Oct 16, 2014; 371(16):1481-1495

From Liberia to Dallas Arrive Dallas 20 September Depart Liberia 19 September

Ebola Virus In Texas First case to be diagnosed in U.S. Sept 20: Mr. Thomas Eric Duncan arrives in U.S. from Liberia First cases of secondary transmission Oct 10: Nurse (Nina Pham) who provided care to index patient developed fever and tested positive for EVD Oct 15: 2nd nurse (Amber Vinson) who provided care for index patient reported with fever and tested positive for EVD after traveling to Ohio

First Ebola Virus Disease Diagnosis in U.S. Occurs in Texas Texas has sophisticated and one of the nation s best emergency management system, but Texas faced unique public health emergency that required extraordinary efforts from public health experts, health care workers, emergency responders, and private sector partners, as well as local, state, and federal leaders Disaster response requires coordinated response among state and local governments, community support organizations, and multidisciplinary responders Emergency management, public health, search & rescue, law enforcement, transportation oversight, environmental controls, communications, and logistics Public health is a team sport

Forensics of the Ebola Response Decision Making: Who s in charge? Irrational, but legitimate public fear HazMat: How clean is clean? Laboratory testing The lack of vaccines and therapies Communications: media, media, media Contact tracing & monitoring Health care worker protection Ethics: individual, local, national, global Hospital surge capability & capacity

Disasters Are Managed Locally Trial By Ebola. Vanity Fair; February 2015

Texas Task Force Infectious Disease Preparedness & Response 1. Hospital care 2. Identification and isolation triage 3. Hospital Preparedness Program 4. Education and training 5. Hospital care experimental drugs 6. Personal protective equipment 7. Control order authority 8. Epi monitoring and contact tracing 9. Disposition of deceased 10. Housing and social services 11. Laboratory testing and sample transport 12. Guidelines for monitoring HCW 13. Incident command 14. Decontamination and waste removal 15. Communications 16. Care of domestic animals 17. Task Force future role

The Modern Reality of Emerging Infectious Diseases The Natural Threat Emergence of new, virulent pathogens (50 appeared since 1973) August 16, 2012 West Nile virus: Dallas declares state of emergency H7N9 SARS May 29, 2013 WHO calls Middle Eastern virus, MERS, threat to the entire world Transportation assures rapid global spread of emerging diseases 31

: Figure 1 From Sands, et al., The Neglected Dimension of Global Security A Framework for Countering Infectious Disease Crises, NEW ENGLAND J. OF MEDICINE (Jan. 13, 2016) Major Emerging and Reemerging Infectious-Disease Outbreaks, Epidemics, and Pandemics, 2002 through 2015.

The Escalating Threat of CBRN Attack Syria, North Korea, Iran, Egypt, etc. Bioterrorism Report Card: U.S. unprepared Iraq arrests five in 'al-qaeda chemical weapons plot Al-Qaeda planned to strike targets in Iraq, Europe and North America with chemical weapons October 12, 2011 June 2, 2013 33

National Security Strategy 2010 The effective dissemination of a lethal biological agent within a population center would endanger the lives of hundreds of thousands of people and have unprecedented economic, societal, and political consequences. We must continue to work at home with first responders and health officials to reduce the risk associated with unintentional or deliberate outbreaks of infectious disease and to strengthen our resilience across the spectrum of highconsequence biological threats.

Global Health Security Agenda 2014

A NATIONAL BLUEPRINT FOR BIODEFENSE: LEADERSHIP AND REFORM NEEDED TO OPTIMIZE EFFORTS BIPARTISAN REPORT OF THE BLUE RIBBON STUDY PANEL AND BIODEFENSE OCTOBER 2015 Institute Sponsors: Hudson Institute Inter University Center For Terrorism Studies

Essential Tasks in Responding to a Biological Incident of Potential National Significance: Priority Considerations, Decisions & Actions Save Lives Ensuring rapid identification of attack, diagnosis and confirmation Providing medical care Distributing & administrating medical countermeasures as needed and in time Maintain Order and Continuity of Operations Ensuring coordinated multi-disciplinary response Ensuring security of assets Ensuring security and operation of critical infrastructure Manage the Crises and Prepare for Future Incident Sharing essential information and intelligence Enhancing protection Increasing detection capabilities

Local Public Health and Emergency Management Are On the Frontline of Global Biologial Threats Source: Kilpatrick AM, et al. Drivers, dynamics, and control of emerging vector-borne zoonotic diseases. The Lancet 380:9857, 1-7 Dec 2012, pp. 1946-55. www.sciencedirect.com/science/article/pii/s0140673612611519 Note: Air traffic to most places in Africa, regions of South America, and parts of central Asia is low. If travel increases in these regions, additional introductions of vector-borne pathogens are probable.