Bioterrorism.ppt

IAEM 48th Annual Conference - R. J. Coullahan 1

Bioterrorism & Public Health Surveillance Systems:Integrating the Medical Incident Commander,

Public Health, and Emergency Management

Robert J. Coullahan, CEMRobert J. Coullahan, CEM®®

Assistant Vice PresidentAssistant Vice PresidentDisaster Preparedness & Consequence Management ProgramsDisaster Preparedness & Consequence Management Programs

Science Applications International CorporationScience Applications International [email protected]@saic.com


FOCUS

• Review the Threat and Effects of Bioterrorism

• Examine Scenarios of Biological Attack

• Early Warning, Recognition & Reporting Needs

• Medical, Public Health & Emergency Management Linkages

• Surveillance Systems – Initiatives & Pilot Programs

• Building on Lessons Learned

• Roadmap toward Enhancing Linkages

• Exploring the Role of IAEM


THREAT AND EFFECTS

• Review the Asymmetric Threat

• Illustrative Bioincident Timeline

• Defining Biological Warfare & Biological Terrorism

• Agents and Factors for Successful Bioagent Release


BIOLOGICAL WEAPONS - HISTORY

• Oldest of the NBC triad of weapons

• Used for > 2,000 years:– 6th Century B.C.: Assyrians poison

the wells of their enemies with rye ergot.

– 1767: Sir Jeffrey Amherst gives blankets laced with smallpox to Native Americans.

– World War I: Germany allegedlyreleases Cholera in Italy; plague in St. Petersburg.

– World War II: Oct 4, 1940 Japanese release plague bacteria at Chuhsien resulting in 99 deaths.


THE THREAT OF BIOTERRORISM


Generalized Bioincident Timeline


SBCCOM BW RESPONSE TEMPLATE

From: “Improving Local and State Agency Response to Terrorist Incidents Involving Biological Weapons”, US Army SBCCOM, Final Draft, 1 Aug 2000


BIOLOGICAL WARFARE AND TERRORISM DEFINITIONS

The intentional use of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants.

The threat or use of biological agents by individuals or groups motivated by political, religious, ecological or other ideological objectives.

Biological Terrorism

Biological Warfare


BIOLOGICAL WEAPONS

• Availability, lethality, stability in storage.

• Large quantities can be produced.

• Can be disseminated as an infective aerosol with modifiable decay.


BW/BT EDUCATION

• Detection of an attack is difficult because bio

agents have no immediate warning properties and

clinical symptoms take hours (or days) to develop.

• Reliable bioagent air monitoring equipment is

lacking.

• Difficult to delineate the extent of a BW attack.

• A high index of suspicion needs to be present.


MEDICAL BW DEFENSE

Pre-exposure

Immunization(active)

DrugProphylaxis

Training

Incubation period(minutes - 3 weeks)

Diagnosis(class or agent

specific)

Passive Immunization(immune serum)

Pre-treatment(drugs)

Overt Disease

Diagnosis

Treatment

Communication

ATTACKATTACK ONSET OF ILLNESS


INITIAL SIGNS OF A BW ATTACK

• Many patients with the same illness

• Compressed epidemic curve with dominant respiratory signs

• High exposures may present early

• Pre-existing chronic disease may also present early

• Symptoms may be unusual for age

• Non-endemic infection

• Multiple, simultaneous outbreaks

• Dead animals before humans


KINETICS OF A BIOLOGICAL AGENT ATTACK

Onset of Symptoms Range (days)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 30 60 90 120

SEB (Staph Enterotoxin B)

RICIN

BOT AXXXXX

XXXXX

XXXXX

X = deathsX = deaths

X X SMALLPOX

EBOLA

TRANSMISSION SECONDARY INFECTIONSTRANSMISSION SECONDARY INFECTIONS

X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X X

MARBURG

VEE X

X X X X X

SequelaeSequelae

2nd TRANSMISSION

2nd TRANSMISSION

ANTHRAX

PLAGUE

TULAREMIA

XXXXXXX

XXXXXX

X X X

2nd TRANSMISSION

Q FEVERQ FEVER X


BACTERIA AND RICKETTSIABacillus anthracis

Brucellaabortis, suis, melitensis

Clostridium botulinumVibrio choleraBurkholderia

malleipseudomallei

Yersinia pestisShigella dysenteriaeFrancisella tularensisSalmonella typhiCoxiella burnetiiRickettsia

rickettsiiprowazekii

• Complete congruence of bacteria and rickettsia on AMEDD P8 list (DoD) and Select Agents List (CDC)


TOXINS

Toxins on AMEDD P8 (DoD) list; also found on Select Agent List (CDC)

BotulinumPerfringensT2 MycotoxinsPalytoxinRicinSaxitoxinStaphylococcal

enterotoxinsTetrodotoxin

Additional agents found on CDC Restricted Agents List

(42 CFR Part 72 / RIN 0905-AE 70)

AbrinAflatoxinConotoxinsDiacetoxyscripenolShigatoxin

Also:

Palytoxin


AEROSOL / INFECTIVITY RELATIONSHIP

The ideal aerosol contains a homogeneous population

of 1 to 5 micron particulates that contain viable organisms

Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size

18-20

15-18

7-12

4-6(bronchioles)

1-3 (alveoli)

Infection Severity

Particle Size (Micron, Mass

Median Diameter)

Less Severe

More Severe


FIRST BREAKTHROUGH IN BW DEVELOPMENT OF VIRAL BW AGENTS

• Arena viruses Argentinian HF, Bolivian

HF, Lassa

• Alphaviruses– Chikungunya Eastern, Venezuelan,

and Western Equine Encephalitis

• Flaviviruses– Dengue, Omsk HF Tick-borne Encephalitis,

Yellow Fever

• Orthopoxviruses Smallpox / Monkeypox

• Orthomyxovirus– Influenza

• Hantaviruses– Korean HF

• Phlebovirus Rift Valley Fever

• Nairovirus Congo-Crimean HF

• Filovirus Marburg, Ebola


SECOND MAJOR BREAKTHROUGH IN BW

• Dry agent preparations for:– Anthrax– Tularemia– Q fever– VEE– SEB– BOT

• Additives– Electrostatic inhibitors– Stabilizers


4 KEY FACTORS FOR SUCCESS OF A BIOLOGICAL ATTACK

1. Agent

2. Delivery

3. Agent / Munition Dissemination Systems

4. Meteorological Conditions


FACTOR 1. THE BIOLOGICAL AGENT

Lethal Incapacitating

Bacillus anthracis VEE Virus

Botulinum toxin Q Fever

Francisella tularensis Staph Enterotoxin B (SEB)

Yersinia pestis

Smallpox (variola)

Ricin toxin


FACTOR 2. DELIVERY OF THE BW AGENT

The ideal aerosol contains a homogeneous population of 1 to 5 micron particles that contain a maximum concentration of viable organisms

Less Severe

More Severe

18-20

15-18

7-12

4-6

(bronchioles)

1-3 (alveoli)

Infection Severity

Particle Size (Micron, Mass Median

Diameter)


TECHNIQUES FOR AEROSOL GENERATION

• Explosive (99.9% of agent killed)• Attenuated Explosive• Gas Pressurization• Mechanical Atomization

HIGH SHOCK NO SHOCK HIGH SHOCK NO SHOCK

High Explosive

Attenuated Explosive

Gas

PressurizationMechanical

Atomization

Common, Simple Hostile Environment

Complex More Efficient


FACTOR 3. THE BW MUNITION

For 1,000 organisms available with a munition efficiency of 1%, only 10 organisms are available in the aerosol to cause infection. The other 990 are killed by dissemination or by dropping out of the aerosol as a large particle.

Line Source

Point Source

Dry

Liquid(Double nozzle)

Liquid(Single nozzle)

Non-Explosive Bomblet

Explosive Bomblet

0 20 40 60 80 Percent Efficiency


DISSEMINATION OF DRY BW AGENTS


FORMATION OF THE PRIMARY AEROSOL

• initially visible• large particles fall out• later invisible, behaving like a gas• can penetrate HVAC without HEPA filtration


FACTOR 4. METEOROLOGICAL CONDITIONS

Downwind Travel with 50% Casualties

Strong 36 km

Moderate 30 km

Slight 28 km

Neutral 19 km

Lapse/Bad 2 kmRelease at 100 feet in 10 mph wind

Inversion

Non-Inversion

(Based upon Caulder’s Equations of a given amount of Anthrax)


CONSTRAINTS ON SUCCESSFUL BIOLOGICAL

ATTACK

• Agent concentration

– Must be matched to volume of target area

• Munitions efficiency

• Biological Decay Rate

– Ultraviolet light, humidity stress, oxidation

• Meteorological conditions

– Wind speed

– Inversion layer


RESPONSE OPERATIONS: National Pharmaceutical

Stockpile (NPSP)

“to maintain a national repository of life-saving pharmaceuticals and medical materiel that will be delivered to the site of a bioterrorism event in order to reduce morbidity and mortality in civilian populations.”

From: Stephen Bice, CDC,NPSP briefing before the NACCHO Bioterrorism & Emergency Response Advisory Committee, Kissimmee, FL, Feb 2000


NPSP continued• Members include pharmacists, public health

experts, and emergency response specialists.

• Arrive on-scene ahead of the 12-Hour push packages.

• Hand-off materiel to authorized state representative.

• Provide technical assistance.

• Coordinate closely with incident command structure (State and Federal EOCs).

• Maintain continuous contact with the CDC NPSP Operations Center.


ANTIBIOTICS-

CIPROFLOXACIN- DOXYCYCLINE

VACCINE

NPSP SUPPLIED CHEMOPROPHYLAXIS


MASS PROPHYLAXIS• distribution and medical application of appropriate antibiotics, vaccines, or other medications in order to prevent disease and death in exposed victims.

• identify populations at risk – a much greater number than those actually exposed.

• activate prophylaxis distribution (and follow up) plan through Neighborhood Emergency Health Centers (NEHC), optimize use of local pharmacists in the planning.

• priority emergency antibiotic prophylaxis for use by “essential” emergency personnel – independent stockpile, publicly acknowledged.


SCENARIOS

• Background of Scenario Development and Use

• Examine Scenarios of Biological Attacks- Aerial Anthrax Release- Smallpox Release


Example Scenarios

Biological Attack in Major AirportBiological Attack in Major Airport

Line of FlightAltitude: 1,000 ftRelease: 5km

50% infected20%infected

Biological Aerial AttackBiological Aerial Attack

Bombing + Chemical Attacks

Bombing + Chemical Attacks

Chemical Attacks in SubwayChemical Attacks in Subway


Scenario Analysis

Scenario Analysis• Start with Threat Scenarios • Enlist domain experts• Use computational simulation

tools to assess impact on target• physical models• GIS databases (demo- graphics,

emergency assets, street maps, …)

ScenarioEvolution

Predict Impact

Casualties

Property Damage

Economic Impact

ScenarioOutcome

Analyze appropriate threat scenarios;

overlay on conventional

response capabilities

Objective


Conventional Response Overview

Event

GovernorGovernorActivatesActivates

National GuardNational Guard

FederalFederalAssistanceAssistanceProvidedProvided

FederalFederalAssistanceAssistance

DeniedDenied

ExtraordinaryExtraordinaryStateState

ResponseResponse

LocalResponseSufficient

LocalResponseSufficient

LocalResponse

LocalResponse

State Monitors& Assesses

State Monitors& Assesses

No AssistanceNo AssistanceRequiredRequired

Request forState/Federal

Assistance

Request forState/Federal

Assistance

StateStateAssistanceAssistanceRequiredRequired

Routine StateRoutine StateResponseResponse

No StateNo StateDeclarationDeclaration

GovernorGovernorDeclaresDeclares

EmergencyEmergency

StateStateResponse Response SufficientSufficient

GovernorGovernor RequestsRequests

PresidentialPresidential DeclarationDeclaration

AppealAppeal


Days

Biological Incident Life CycleWithout Preparedness

Biological Incident Life CycleWithout Preparedness

CHAOSCHAOS IncidentIncidentExposure ofExposure ofPopulationPopulation

RecognitionRecognitionEMSEMS

Private PhysiciansPrivate PhysiciansUrgent CareUrgent Care

Hospitals / MCOsHospitals / MCOsPharmaciesPharmacies

PHSPHS

State PHS, CDC & DoD State PHS, CDC & DoD provide expertise &provide expertise &

confirmation of pathogenconfirmation of pathogen

Medical TreatmentMedical Treatment

Slow InterventionSlow InterventionSymptomatic victims Symptomatic victims

treated with antibioticstreated with antibioticsThose suspected of Those suspected of

exposure treatedexposure treated with Ciprofloxacinwith Ciprofloxacin

Limited ResponseLimited Response

Insufficient medical suppliesInsufficient medical suppliesLarge number of deathsLarge number of deaths

Public PanicPublic PanicMass Self-evacuationMass Self-evacuation

Public services collapsePublic services collapse


The Incident BeginsFlig

ht

Path

Prevailing Wind

Crop duster flies at 1000’ AGL in uncontrolled airspace releasing Anthrax along a 5km cross wind flight path

Anthrax cloud has grown to encompass a 5 km x 20 km footprint. Within this region reside 1.5 million people

20 km

5 k

m

00 77 00 00

11 22 00 00


The Population is Exposed

20% exposed contract Anthrax50% exposed contract Anthrax

5% exposed contract Anthrax

Civilian PostureCivilian Posturein the openin the openin vehiclesin vehiclesin buildingsin buildings

RiskRiskhighhigh

moderatemoderatelowlow

250,000 Exposed250,000 Exposed


0 24 48 72 96 120 144 168

EMERGENCY RESPONSE

•12,500 people are in the initial phase of illness.

Epidemiology

1 2 3 4 5 6 7 8 9

100

80

60

40

20

0

Days Post Exposure

% o

f A

ll C

ases

Initial Phase

Early Acute

Late Acute

Progressionof Illness

Day 2 - The Incident Goes Unnoticed

Day 2 - The Incident Goes Unnoticed

NoneNone

Non-specific symptomsnot likely to be attributed to Anthrax unless other

information was available.


Epidemiology

1 2 3 4 5 6 7 8 9

100

80

60

40

20

0

Days Post Exposure

% o

f A

ll C

ases

Initial Phase

Early Acute

Late Acute


• 7500 people are in the early acute phase and are exhibiting moderate flu-like symptoms

• 5000 people are in late acute phase and are experiencing severe respiratory distress

Day 3 - The Outbreak

0 24 48 72 96 120 144 168

EMERGENCY RESPONSE

NoneNone

•EMS, ERs, & private physicians experience a rapid rise in emergency patients.•Tests for common pathogens concurrent with symptom-based treatment. •Large number of patients requiring ventilators rapidly exhaust local supply.•The state health department laboratory & epidemiologist will be involved. •If anthrax is suspected an enzyme-linked immunosorbent assay (ELISA) could be requested, though it is unlikely that such a test would be performed rapidly.

1st Chance1st Chanceto Detectto Detect


Epidemiology

1 2 3 4 5 6 7 8 9

100

80

60

40

20

0

Days Post Exposure

% o

f A

ll C

ases

Initial Phase

Early Acute

Late Acute


• 30,000 people are in the early acute phase

• 26,000 people are in late acute phase

• 4,000 people are dead

Once symptoms begin, pulmonary and meningeal anthrax are usually

(90%) fatal despite antibiotic therapy and intensive care.

Day 4 - Anthrax is Strongly Suspected

0 24 48 72 96 120 144 168

EMERGENCY RESPONSE

NoneNone1st Chance1st Chanceto Detectto Detect

• Without a rapid monitoring system time is lost in identifying the Anthrax outbreak.• Further time is lost by clinicians’ unfamiliarity with this disease, preventing rapid identification and accurate diagnosis. • Large number of cases makes it likely that samples will be sent to both the State health department lab and CDC.• Poison Control Center will coordinate community medical resource needs (ventilators, antidotes, …)• Public service announcements will commence.

SamplesSamplesto CDCto CDC


Epidemiology

1 2 3 4 5 6 7 8 9

100

80

60

40

20

0

Days Post Exposure

% o

f A

ll C

ases

Initial Phase

Early Acute

Late Acute


• 162,500 people showing symptoms


Day 5 - Anthrax is ConfirmedDay 5 - Anthrax is Confirmed

0 24 48 72 96 120 144 168

EMERGENCY RESPONSE



• CDC confirms pathogen is anthrax - dispatches Epidemic Investigative Service (EIS) officers to assist state and local health officials• The rapid rise in patient load overwhelms all local response capability• Mortuary services cannot cope with the number of dead• Governor calls up National Guard and asks for additional Federal assistance • Local health authorities request 100,000’s Anthrax test kits• Treatment requires penicillin, tetracycline, erythromycin, or ciprofloxacin • Growing panic among the populace, many attempt to flee the area.• Public bulletins are aimed at reducing panic and preventing full scale evacuation.

TreatmentTreatmentInadequateInadequate


Epidemiology

1 2 3 4 5 6 7 8 9

100

80

60

40

20

0

Days Post Exposure

% o

f A

ll C

ases

Initial Phase

Early Acute

Late Acute


• 200,000 people are showing symptoms


Day 6 - The Toll Continues to Mount

Day 6 - The Toll Continues to Mount

0 24 48 72 96 120 144 168

EMERGENCY RESPONSE



TreatmentTreatmentInadequateInadequate

• 100,000’s of doses of ciprofloxacin are needed to treat the community• The vaccination series should also be administered to victims• Response effectiveness is severely limited because prophylaxis, vaccines, ventilators, …, are in short supply.• Whole scale self-evacuation of the city is underway.• The emergency response ranks have been reduced as they too become victims .• National Guard units begin to enter the region.• FEMA, Public Health Service and the FBI have activated the Joint Operations Command (JOC) and begin to organize the Federal response.

NoNoResourcesResources


How Can Lives Be Saved ?Reducing DeathsReducing Deaths

1 2 3 4 5 6 7 8 9

100

90

80

70

60

50

40

30

20

10

0

Start of Intervention (days)

De

ath

s (x

10

00)

250,000250,000ExposedExposed

A quick look patient information template containing questions like

Where do you work ?Where do you live ?How do you commute ?

Would provide enough information to develop exposure patterns.

Awareness and specialist training for the medical community would assist in early detection.Strategically placed medical supplies sufficient to treat thousands of victims is required

Early intervention could save tens-of-thousands of lives.

National Surveillance System linkinghospitals, public health agencies, and the FSL consequence management community.


Smallpox Scenario

Terrorist nation-Terrorist nation-state with ties to state with ties to

former Soviet former Soviet Union has bio Union has bio

weapons program weapons program focused on focused on

smallpox and smallpox and other diseasesother diseases


Smallpox ScenarioTerminal C

Terminal D

Terminal E

Terminal A

Terminal B

Parking

Parki

ng

Major Airport

Thanksgiving Day Terrorists begin releasing smallpox from concealed sprayers in Terminals C & D

IAEM 48th Annual Conference - R. J. Coullahan 47Event is unnoticed, no claims of responsibility

Smallpox Released in Terminal

Terminal C

Smallpox discharge lasts 10 minutes

Particles are invisible & have a long dwell time

(@ 7 hours 3.4% of 3 micron particles remain aloft)

Tens of thousands of passengers and workers pass through contaminated area of whom 2,500

become infected

Tens of thousands of passengers and workers pass through contaminated area of whom 2,500

become infected

Terrorists are vaccinated and do not retrace

their steps


2,500 Infected People Disperse

Infected board flights to thirty eight US citiesInfected board flights to thirty eight US cities


Pro

dro

me

3daysavg.

Final Phase

20 days avg.

Smallpox Prognosis

Incubation

12 days avg.A

nan

thu

m5

daysavg.

Exan

thu

m

10daysavg.

2010 30 40 50

SymptomsLargely Asymptomatic

SymptomsFever, severe headache

& backache

SymptomsLesions in oral cavityCritically Contagious

SymptomsLesions obvious on

skin

SymptomsScabbing &

scab separation

Exp

osu

re

Days

IAEM 48th Annual Conference - R. J. Coullahan 50Days2010 30 40 50

400

300

200

100

Infe

cte

d (

x 1

000)

0

AssumptionEach victim infects

~12 new victims duringcontagious period

Response Timeline

1st Generation

2nd Generation3rd Generation

390,000Victims

Non-specific symptomslikely to be attributed to

fluEruptive phase initial

caseslikely to be

misdiagnosed aschicken pox

........ .

A rapid rise in emergency patients arouses suspicion

Reporting Network Issues- no rapid monitoring system- unfamiliarity with disease

prevents immediate diagnosis

State Health Department laboratory &

epidemiologist become involved.

CDC contacted

Terrorist incident presumed•FBI WMD coordinator initiates Federal involvement

•Governor activates NG

Bulletin

Public Notification commences

Medical facilities overwhelmed

Law enforcement needed to keep order

Poison Control Center will coordinate

community medical resource needs

Growing panic among the populace.

Public bulletins issued to reduce panic & prevent full scale evacuation from cities

Vaccination of selected personnel begin

(There are only 4.9M doses stockpiled)

Local Infrastructure badly weakenedState & Federal

resourcesrequired to provide local

community needs


Actions to be Taken• Identify infected population and their contacts.

(Massive undertaking-will require tracking all infected persons whereabouts since prodrome).

• Keep public informed through special media programming. Teach good public health techniques using mass media.

• Set up screening centers to triage concerned people.

• Establish acceptable method and level of isolation.

• Maintain security at treatment and supply facilities.

• Provide State and Federal resources to replace losses in local capabilities.

• Notify drug companies of the likely requirements for over-the-counter medicine.


CONSEQUENCES OF THE SMALLPOX RELEASE

• By the 50th day after the airport spraying as many as 400,000 people could be infected with up to 100,000 dead or dying.

• Without vaccine the epidemic will continue to grow geometrically, though an effective quarantine will slow the growth.

• Facilities to treat terminally ill will need to be created• Other temporary treatment facilities will have to be stood up

to handle the large number of casualties.• Transportation to secondary treatment centers will be

required.• Mortuary facilities will be overwhelmed and strict sanitation

rules will have to be reinforced.• Re-establishment of vaccine production (2-3 yrs) will be

needed to re-eradicate smallpox


Special ConsiderationsSpecial Considerations• Active role of civilian healthcare organizations in surveillance,

response operations, and preparedness is crucial.

• A national surveillance system enables early intervention, thelinkage to the emergency management system is vital.

• Recognize the unique C/B WMD impacts on critical infrastructure/key assets – decon, reoccupancy.

• Facility re-occupancy criteria must be defined and enforced to assure public confidence, essential to continuity of operations.

• Private sector contingency planning for C/B incidents: re-occupancy, liability, critical incident stress management.

• Alert & Warning Systems: NWR & EAS (SAME); civil emergency messages; public health/EMA decision protocols.

• Avoiding stovepipe design and implementation of emerging public health surveillance systems – integrate with EM enterprise.

• Active role of civilian healthcare organizations in surveillance, response operations, and preparedness is crucial.

• A national surveillance system enables early intervention, thelinkage to the emergency management system is vital.

• Recognize the unique C/B WMD impacts on critical infrastructure/key assets – decon, reoccupancy.

• Facility re-occupancy criteria must be defined and enforced to assure public confidence, essential to continuity of operations.

• Private sector contingency planning for C/B incidents: re-occupancy, liability, critical incident stress management.

• Alert & Warning Systems: NWR & EAS (SAME); civil emergency messages; public health/EMA decision protocols.

• Avoiding stovepipe design and implementation of emerging public health surveillance systems – integrate with EM enterprise.


UNFOLDING OF BIO INCIDENT+

Public HealthMonitoring &Surveillance

•911 Calls Increase•Hospital Admissions Up

•Dead Animals of Multiple Types

National/LocalData Collection

& Analysis•Unexplained Infection Outbreak

•Data Assessment•Investigation of Origins & Nature of Outbreak

FederalResponse

Operations

•Pharmaceuticals•Medical Treatment•Mass Care•Emergency Public Information

•Structure Decontamination

•Food

Bio AgentDispersal

Public HealthEmergency

Presidential EmergencyDeclaration (Stafford Act)

Bio Agent Determined to beResult of Terrorist Attack (PDD-39 Policy Applies)

+ FEMA F64-Cc

SymptomaticPatients

Mortality

Nu

mb

er

of

Aff

ecte

d P

ers

on

s

Time


MEDICAL, PUBLIC HEALTH & EMERGENCY

MANAGEMENT LINKAGES

• Review Medical and Public Health Interface

• Training and Decision Support

• Clinician as Medical Incident Commander

• Hospitals

• Role of Laboratories


The Response Community• Emergency Medical Services

- EMTs, Paramedics• Emergency Medicine

- Physicians, Physicians Assistants- Emergency Depts., ICUs, Labs

• Hospitals and Managed Care Organizations• Private Practitioners• Medical Examiners/Coroners• Veterinary Medicine, Animal Control• Public Health Services• Emergency Management• Law Enforcement/Crisis Management• Fire/HAZMAT


Medical & Public Health Interface

Index of Suspicion…


Clinicians: The Medical Incident

Commanders • Medical Surveillance

• Medical Diagnosis

• Clinical Laboratory Tests

• Triage and Treatment

• ICU

• Recognition & Reporting


Clinician Training: Incentives?


Challenges for Hospitals & MCOs


HOSPITALSNumber of Hospitals in U.S. (AHA, 1998): 6,021

- 5,015 non-federal, short-term general or other specialty hospitals- 1,006 Federal, long-term care, and

hospitals for the mentally retarded.

Hospital Ownership- 3,026 non-government, not-for-profit - 771 investor-owned- 1,218 State and Local Government

JCAHO and HCFA are addressing MCI preparedness; recent AHA forum on MCI finding: there is no financial framework for funding hospital preparedness.


Classification of Bioterrorism Response Labs

Level-A Lab

A - Ability to rule-out diagnosis of key agents and forward organisms to next level

Level B Lab

B - Ability to confirm & characterize agents and perform antimicrobial susceptibility

Level C Lab BSL-3

C - Molecular methods - PCR, etc. and toxigenicity testing

D - High level characterization and secure banking of isolates

Level D Lab

BSL-4

ROLE OF THE LABORATORY IS VITAL


BIOSAFETY LEVEL - 4 (BSL-4)

HEPA Air Filter

Suited Ops

Autoclave

Suit disinfectant shower, UV airlock,

Glove cabinetDisinfectant

dunk bath

UV airlock

Special sewage

treatment

Shower out

Change in

• CDC• USAMRIID• Others


PUBLIC HEALTH SYSTEM

Included in the Local Public Health System:

Public Health Professionals Primary Care Personnel Hospital Staff EMS Personnel Laboratory Personnel

Defined by CDC


PUBLIC HEALTH SURVEILLANCE SYSTEMS

• Surveillance Systems

• Initiatives and Pilot Programs- Syndromic- Data-based

• Relevance to Emergency Management information systems and decision support


PUBLIC HEALTH SURVEILLANCE

Public Health Surveillance is defined by the CDC as “the ongoing, systematic collection, analysis,

and interpretation of data (e.g., regarding agent/hazard, risk factor, exposure, health event)

essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of

these data to those responsible for prevention and control.”

IAEM 48th Annual Conference - R. J. Coullahan

Bioterrorism: Examples of Potential Surveillance Data

Sources• Laboratories• Infectious disease

specialists• Hospitals• Infection control• Physician’s

offices• Poison control

centers• DNR - Fish &

Game

• Veterinarians• Medical examiners• Death certificates• Police/Fire/EMS • Quarantine• EPA• Pharmacy data• County

Agriculture Extension


Early WarningSurveillance and Reporting

• data capture and normalized baseline data:

“monitoring the pulse of the city”.• local/regional data aggregation. • incident recognition and rapid confirmation.• initial incident size-up and rapid screen of surrounding geographical areas.


STATE HEALTH LAB

CITY or COUNTY HEALTH DEPT.

CDC CONFIRMATIONHEALTH-CARE PROVIDERS

NETSS

NO NETWORK CONNECTIVITY...

… NO DATACOLLECTIONAND REPORTING

LIMITED NETWORK

CONNECTIVITY(HANs)

Gaps in F-S-L PH Communications

NEDSSLIMITED


Telephonic ReportingManual

Transcription

Aggregation of Multi-sourceData at

Public Health DepartmentsData PUSH and PULL Roles

NETWORK COMPLEXITY

DA

TA

CO

VE

RA

GE

& T

IME

LIN

ES

S

Derived Graphical Products forBioincident

Decision Support

Manual Data EntryAutomatic Upload

Data PUSH from Source

Automated Data SearchData PULL from

All Sources

BIOINCIDENT DATA MANAGEMENT MODES

Bioincident Data Management


Surveillance Data Capture Surveillance Data Capture ContinuumContinuum

City/CountyPublic HealthDepartments

(DBMSServers)

Hospitals &

Clinics

State Public Health DBMS &Consequence Assessment

Tools

PhysiciansOffices

SEMI-AUTOMATEDDATA CAPTURE

AUTOMATEDDATA EXTRACTION

Data ExtractorApplication

PatientRecords

Database

Evolutionary Capability

Manual entry/automated upload Automated extraction & upload

Offices

Veterinary

ManagedCare

Pre-Admission

Based uponICD-9 Codes

SY

ND

RO

MIC

SU

RV

EIL

LA

NC

E

DA

TA

-BA

SED

SU

RV

EIL

LA

NC

E


Hospital Emergency Departments:# of medical (non-trauma) ER visits.**# of hospital non-trauma admissions.# of infectious disease patients reported.

Hospital Intensive Care Units

911 Emergency Medical Services runs:# of non-trauma EMS responses.in the past 24-hour period.

Deaths reported to Medical Examiner/Coroner:# of deaths reported.# of medical examiner cases pending.

Sentinel Pharmacies:# of over-the-counter (OTC) flu meds and anti-diarrheals.

Unusual # of animal deaths.

Essential Information Elements

for Syndromic Surveillance

Essential Information Elements

for Syndromic Surveillance

HOSPITALS

EMS

MEDICAL EXAMINER

PHARMACIES

ANIMAL CONTROL

MANAGED CARE

Pre-admission clearances


Data Elements (cont’d.)Data Elements (cont’d.)

**Hospital Emergency Department Reporting:

• Medical non-trauma ER visits including:

a. gastrointestinal disorders;b. respiratory disorders;c. rash/fever;d. all other visits.

• Hospital non-trauma admissions.

• Number of infectious disease patients reported.


Syndromic Surveillance Prototype

Rapid Syndrome Validation Project(RSVP)

• Sandia National Laboratories Alan Zelicoff, MDSenior ScientistCenter for National Security and Arms Control, SNL

• University of New Mexico School of Medicine

• New Mexico Department of Health


Data-basedSurveillance Initiatives


Data-based Surveillance Initiatives

• CDC-sponsored grantees

• DoD GEIS (Tricare)

• Other

Early Detection System for Bioterrorist and Natural Disease

Threats Using Syndromic Surveillance in the

Greater Washington, DC, Area

From: Julie Pavlin, MD, MPH, Chief, Strategic Surveillance, DoD-GEIS

Early Detection System for Bioterrorist and Natural Disease

Threats Using Syndromic Surveillance in the

Greater Washington, DC, Area

From: Julie Pavlin, MD, MPH, Chief, Strategic Surveillance, DoD-GEIS


ESSENCE: An Electronic Surveillance System for the

Early Notification of Community-based Epidemics

• Earlier detection of aberrant clinical patterns at the community level to jump-start response

• Rapid epidemiology-based targeting of limited response assets (e.g., personnel and drugs)

• Rapidly equipping civil government leaders with outcome-based “exposure” estimates

• Risk communication to reduce the spread of panic and civil unrest


Proposed Evolution of ESSENCE:

CivilianSurveillance

System

NOAAWeather

CivilianPharmData

EMSCallData

CivilianEmergency

Rooms

ManagedCareData

PoisonControlCenter

EntomologyData

MHSOutpatient

Data

MHSLab, Rad,

Pharm

MHSSurveillance

System


City/County Health Department

State Health Department

TIMSSTD*MISHARS

HARS STD*MIS TIMS NETSS EIP Systems

NETSS

STD*MIS (Optional at the Clinic)

TIMS (Optional

at the Clinic)

PHLISEIP Systems*

PHLIS

HARS STD*MIS TIMS NNDSS EIP Systems PHLIS

*EIP Systems (ABC, UD, Foodnet)

CDC

Data Sources

Physicians

Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc.

Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc.

Chart Review

MMWR Weekly Tables MMWR Annual SummariesProgram Specific Reports and Summaries

Lab Reports

Reporting by Paper Form, Telephone and Fax

Current Situation

Statistical Surveys for Chronic Diseases,

Injuries and Other Public Health Problems

Integration Project

Courtesy: R. Spiegel, CDC

From: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.

CDC


City/County Health Department

State Health Department

HIV/AIDS

HIV/AIDS

STD Clinics TB Clinics

HIV/AIDS

STDs

TB Notifiable Disease Reports

EIP Systems

Lab Surveillance

CDCData

Sources

Physicians

Electronic data interchange (EDI) using HL7 or other standardized format

Chart Review

Lab Reports

Secure Internet

Secure InternetElectronic data interchange (EDI) using HL7 or other standardized

format

Shared Facilities and Services, e.g. common

interface, software components,

terminologies and data files

Shared Facilities and Services, e.g. common

interface, software components,

terminologies, and data files

Secure Server

Vital Statistics

Emergency Departments

Medicaid, Medicare

Encounters

Hospital Discharge

Data

Secure electronic reporting

Paper Forms, Telephone and FAX

Proposed Integrated Surveillance Systems

Solution

Courtesy: R. Spiegel, CDC


CDC


Other Related Projects:National Electronic Disease

Surveillance System

• Electronic Laboratory Reporting pilots

• Data Elements for Emergency Departments pilot project

• Bioterrorism cooperative agreements

• Standards Development Organizations activities – HL7, SNOMED, LOINC

• State integration activitiesIntegration Project



The “NEDSS” Solution• A common “framework” for

surveillance information systems:– Common data architecture (model,

definitions, coding)– Automated electronic reporting of

data, e.g. electronic laboratory reporting

– Consistent user interface– Secure Internet pipeline for reporting

to CDC– Reusable software components– Shared analysis and dissemination

methodsIntegration

ProjectFrom: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.


Some Requirements for Integrated Systems

• Patient registry matching• Rapid development and

deployment of data entry screens

• Internet data entry• Pyramid reporting and

synchronization (clinic to local to state to CDC)

• HL7 import and export Integration Project



Data Flow for Decision SupportData Flow for Decision SupportData Flow for Decision SupportData Flow for Decision Support

State Public Health Agency

City/County Public Health Dept.

Emergency Depts./ICUs:

Hospitals

MCOs

Veterinary Medical Offices

Private Physicians

Offices

National Command Authority

Public Health Assessment Tool Set

DATA CAPTURE & UPLOAD

DATA AGGREGATION & ANALYSIS

DATA FUSION & VISUALIZATION

DATA AGGREGATION & ANALYSIS

COURSES OF ACTION

LPHSLPHS

OEPOEP

CDCCDC

SPHSSPHS

NCANCA


Bioincident Health Emergency Response,

Assessment, Logistics and Decision Support


City/County “B”Emergency

Management

City/County “B”Emergency

Management

City/County “B”Public HealthDepartments

City/County “B”Public HealthDepartments

BIOHERALD…a conceptual End-to-End ArchitectureBIOHERALD…a conceptual End-to-End Architecture

Federal Response Level

City or County Response Level

State Response Level

serverserver

“A”OEM /EOC

“A”OEM /EOC

“A”State Public Health

Dept.

“A”State Public Health

Dept.

City/County “A”Emergency

Management

City/County “A”Emergency

Management

City/County “A”Public HealthDepartments.

City/County “A”Public HealthDepartments.

Bioterrorism C2 Environment

Biocon 1Biocon 1

Biocon 2Biocon 2

Biocon 3Biocon 3

Biocon 4Biocon 4

Biocon 5Biocon 5

Hos

pita

l

911

EM

S

Medical E

xaminerAnimal Control

Pharmacy

HOURGLASSHOURGLASS

HOURGLASSHOURGLASS

HOURGLASSHOURGLASSHOURGLASSHOURGLASS

HOURGLASSHOURGLASS

“B”OEM /EOC

“B”OEM /EOC

“B”State Public Health

Dept.

“B”State Public Health

Dept.

serverserverserverserver

serverserver serverserver

Tally/County A RulesTally/County A Rules



Tally/County B RulesTally/County B Rules

Tally/State A RulesTally/State A Rules

Federal AgenciesFederal Agencies

Tally/State A RulesTally/State A Rules

Hos

pita

l

911

EM

SMedica

l Exam

inerAnimal Control

Pharmacy

HOURGLASSHOURGLASS

HOURGLASSHOURGLASS

HOURGLASSHOURGLASSHOURGLASSHOURGLASS

HOURGLASSHOURGLASSResponse Operations

Response OperationsResponse Operations

Response Operations

BIOCON Levels

based upon

pre-established

thresholds of

reported data.

Thresholds

based on rules.


BUILDING ON LESSONS LEARNED

National Y2K Information Coordination Center (ICC)

Established by Executive Order 13073 (As Amended 15 June 99)

“Information sharing and coordination within Federal government and key components of public and private sectors (including international).”

“…assist federal agencies and the Chair in reconstitution processes where appropriate.”

“…to assure that Federal efforts to restore critical systems are coordinated with efforts managed by Federal agencies acting under existing emergency response authorities.”


Mission and CONOPSInformation Inputs

Types of Info.• Original -- from incident • Assessed, reviewed by other than originator• Summarized reports by intermediate levels

Sources• Depts. / Agencies• State/Local/Tribal via States & FEMA• International

Format• D/B ready

• Not D/B ready

Spectrum of Information Transmission and Interchange MeansMedia; In-Person; Telephone; Secure; FAX; VTC; Collaborative S/W; e-mail; Cables; ICRS; Internet

Customers

White House

President’s Council on Y2K

IIWG/DIWG

CDRG

D/A

Congress

S/L/T

Public

International

Industry

Business

Rules

Direct

Via Database

• Display• Info Matrix• Incident Report• Other Report

• Media Article• Media Image• Internet Page• e-mail• Reference Material

Sector Desk Display

Business

Rules

Coordination & Analysis

• Individual Analysis• Coordination: D/A;Domestic - International; Another Sector; Vital Interest; Another Vital Interest; JPIC; External Other

Resolution

Products

• Report• Sector Summary • V/I Summary• Overall Summary• Graphics• Multimedia

Business Rules Defined and Implemented in the Database Permissions

ENTRY ROUTING REVIEW AND COORDINATION PRODUCTION

National Y2K ICC Operations Model


InformationInformationCoordinationCoordinationCenterCenter


Information Coordination & Reporting System

(ICRS) • Data base autofill information from D/As,

States, and infrastructure owner/operators in agreed-on templates.

• Cyber Reporting System (Green-Yellow-Red).

• Other Dept./Agency reports and data – SITREPs.

• GIS, images, display and briefing materials

Significant Reduced Capacity

Reduced Capacity, Capability or Service

Normal RemarksPlease describe reason for reduced capability

Y2K Related Yes/ No/ UNK

Reduced Services Significant Outages

G

Reduced CapacityG

G

G

G

Reduced Capacity

G

Loss of Services

Reduced Capacity

< 24 Hours

Need Backup

Serious Threat to HealthTemporary Failure

Heavily Engaged Committed

Reduced Capability

Reduced FoodAvailability

Reduced Capacity

Significant Loss of Service

Significant Outages

FinancialServices

Public Works& Engineering

Communications

Transportation

Fire Fighting

Energy

CorrectionalFacilities

Mass Care

HazardousMaterials

Urban Searchand Rescue

Health andMedical Services

Food

EmergencyServices

Additional remarks (please be brief) SEND

Significant Shortages

G

G

G

Heavy Usage Significant Backlog

Reduced Services Significant Disruptions

G

GovernmentServices

Reduced Capacity


Law Enforcement Heavily Engaged Committed

Need Additional Resources

State Status Report

Overall Assessment G

Reporting Station: Newark, NJ City/County ReportSignificant Reduced Capacity

Reduced Capacity, Capability or ServiceNormal

Finance

Power/Fuel

Water

Communications

Transportation

G Reduced Capacity/Minor Outages Significant Outages

G

Reduced Capacity

GG

G

G

G

G

Reduced Capacity

Correctional Facilities

Martland Medical Center and Newark Beth Israel Medical Centeron diversion; EDs, ICUs at capacity

Overall Assessment

G

G

G

Manual Operations Security Compromised


Reduced Capacity < 24 Hours

EmergencyServices

Law Enforcement

Sewage

Need Backup

Serious Threat to Health

Heavily Engaged Committed

NursingHome Reduced Capacity Life Threatening

Health/Hospital Reduced ServiceSignificantLoss of Services

Food Reduced FoodAvailability

Need Backup

Significant Shortages

Heavy UsageHeavy Usage YY

All Air traffic halted

RemarksPlease describe reason for reduced capability

Temporary Failure

Reduced Capacity

Government Services


Total ATC Failure at Newark International Airport

YY

RR


Decision Support System (DSS)


ICC Legacy andPublic Health Information

Infrastructure• ICC software applications are government off-the- shelf capabilities – F, S, L access could be readily authorized.

• CDC has challenged States & local jurisdictions – develop an integrated architecture (NEDSS, BPRP…)

• ICC ICRS and DSS lessons learned can be leveraged to define feasible PH/EM implementation options.

• Expand business rules to include private healthcare providers as reporting entities.

• Evaluate utility in FY01-02 bio WMD exercises such as TOP OFF II.


COORDINATING INITIATIVES


ENHANCING LINKAGES

• CDC Bioterrorism Preparedness & Response Program.

• FY01 Public Health Improvement Act (a.k.a. “Public Health Threats and Emergencies Act”)

• Agency for Healthcare Research & Quality (AHRQ) Bioterrorism Initiative.


CDC BIOTERRORISM PREPAREDNESS AND

RESPONSE PROGRAM (BPRP)

• Facilitate and Support State and Local Bioterrorism Preparedness and Response Planning

• Create a National Health Alert Network

• Strengthen State and Local Surveillance, Epidemiology, and Laboratory Diagnostics Capabilities to Rapidly Identify and Address Infectious Disease Outbreaks Related to Terrorism


CDC FY 2000 PRIORITIES• Enhance Outbreak Response, Coordination, and

Support

• Focus on Decreasing the Population’s Vulnerability

to Biological Agents

• Improve Laboratory Readiness

• Enhance Local-level Epidemiology and Surveillance

• Improve Use of Information Technology in Preparedness process

• Improve Response to a Smallpox Emergency

• Enhance Public Health Preparedness at the Local Level.


BIOTERRORISM READINESS ASSESSMENT TOOL

Essential Service #1: Monitor health status to rapidly detect and identify an event due to hazardousbiological, chemical or radiological agents (e.g., community health profile prior to an event, vitalstatistics, and baseline health status of the community)1.1 Indicator: Monitoring for Rapid detection1.1.1 Does the LPHS monitor community and health indicators which may signal

biological, chemical and radiological incidents? Yes No DK

DK = Don’t know

If yes, how frequently are the followingrates monitored:

Daily(D)

Weekly(W)

Monthly(M)

OtherFreq(O)

Not atall

(No)

Don’tKnow(DK)

1.1.1.1 Hospital admission D W M O No DK1.1.1.2 ICU occupancy D W M O No DK1.1.1.3 Unexplained deaths (Medical

Examiners/Coroner cases)D W M O No DK

1.1.1.4 Unusual syndromes in ambulatory patients D W M O No DK1.1.1.5 Influenza-like illness D W M O No DK1.1.1.6 Ambulance runs D W M O No DK1.1.1.7 911 calls D W M O No DK1.1.1.8 Poison control centers calls D W M O No DK1.1.1.9 Pharmaceutical demand (antimicrobial

agent usage, etc.)D W M O No DK

1.1.1.10 Emergency department utilization D W M O No DK1.1.1.11 Outpatient department utilization D W M O No DK1.1.1.12 Absenteeism in large worksites D W M O No DK1.1.1.13 Absenteeism in schools D W M O No DK1.1.1.14 Others (specify)

1.2 Indicator: Hazard Analysis and Risk Assessment1.2.1 Does the LPHS perform, or have access to, hazard assessments of the

facilities within its jurisdiction? If yes, are hazards at the following facilities assessed:

Yes No DK

1.2.1.1 Academic institution and other laboratories Yes No DK NA 1.2.1.2 Agriculture co-op facilities Yes No DK NA 1.2.1.3 Chemical manufacturing and storage Yes No DK NA 1.2.1.4 Dams, levies, and other flood control mechanisms Yes No DK NA 1.2.1.5 Facilities for storage of infectious waste Yes No DK NA 1.2.1.6 Firework factories Yes No DK NA 1.2.1.7 Food production/storage plants Yes No DK NA 1.2.1.8 Military installations (includes National Guard units & Reserves) Yes No DK NA 1.2.1.9 Munitions manufacturers or storage depot Yes No DK NA

1.2.1.10 Pesticide manufacturing/storage Yes No DK NA 1.2.1.11 Petrochemical refinery/storage facility Yes No DK NA 1.2.1.12 Pharmaceutical companies Yes No DK NA 1.2.1.13 Radiological power plants or radiological fuel processing facilities Yes No DK NA 1.2.1.14 Reproductive health clinics Yes No DK NA 1.2.1.15 Ventilation systems for high occupancy buildings Yes No DK NA 1.2.1.16 Water treatment and distribution centers Yes No DK NA 1.2.1.17 Others (Specify)

Target of this DOJ/CDC Survey: Public Health Responders

Coordination by Local Public Health Agency (Director), with the survey to include the entire local public health system:

• Public Health Professionals

• Primary Care Personnel

• Hospital Staff

• EMS Personnel

• Laboratory Personnel


PUBLIC HEALTH THREATS & EMERGENCIES

ACT • Passed Senate on 27 October 2000

• Authorizes bioterrorism program initiatives

• Establishes Working Group on the Public Health and Medical Consequences of Bioterrorism (DHHS Secretary; FEMA Director; AG; Secretary USDA)

• $215M authorized for public health countermeasures

• $6M authorized for demonstration program to enhance training, coordination, and readiness.


AGENCY FOR HEALTHCARE RESEARCH &

QUALITY (AHRQ)• Agency for Health Care Policy Research reauthorized December 1999.

• Congressional direction to execute a Bioterrorism Initiative.

• Research and studies to improve healthcare outcomes (reducing morbidity and mortality) and cost-effectiveness.

• Examine role of private healthcare providers in bioterrorism readiness.


AHRQ BIOTERRORISM INITIATIVE

• Bioterrorism Initiative launched 29 September 2000

• FY00 Congressional mandate; $5M appropriated• Competitive ID/IQ task order procurement; 6

teams.• Study & Analysis Task Areas:

• Task Order #1 - “to assess the linkages among the medical care, public health, and emergency preparedness systems to improve detection and response to bioterrorist events”.

Surveillance & Detection Decision Support Systems Clinician Training Hospital Capacity Assessment


SO WHAT DOES THIS MEAN TO EMERGENCY

MANAGEMENT ?• without active technical exchange among the emergency management and public health leadership we risk development of another generation of independent stovepipe systems.

• there is an opportunity to consider systems interoperability to optimize the integrated emergency response.

• we need to actively engage the public health and healthcare provider communities as they develop & implement new decision support systems.


HELP DEVELOP ROADMAP FOR ENHANCED LINKAGES

1. What are and how effective are the current linkages among involved entities?

2. How can the involved entities centrally plan, train, and work collaboratively before, during, and after a bioterrorist event?

3. How can inter-organizational cooperation be enhanced?4. What is the current communication capacity among

these entities?5. How can communication of vital information to

responders and the public be improved?6. How can advanced information technology be used to

provide access to real-time, dynamic data for involved entities?

7. How can effective communication and collaboration be established with primary care physicians in physician offices, clinics, and managed care organizations?


OPPORTUNITIES FOR IAEM

• Participation in AHRQ Bioterrorism Initiative.

• Solicitation of IAEM membership on options for enhancing linkages.

• Engage the private healthcare enterprise and public health system on architecture.

• Shape input to a roadmap for bioterrorism preparedness and response improvement.


Attribution• National Guard• Local Emergency Responders• National Research Council• Metropolitan Medical Response System• CDC• FEMA• FBI• SBCCOM• State Emergency Management

Agencies


Further Information:

Robert J. Coullahan, CEM®

Assistant Vice PresidentDisaster Preparedness & Consequence Mgmt PgmsDirector, Readiness & Response DivisionScience Applications International Corporation1410 Spring Hill Road - Suite 400 M/S SH-4-4McLean, Virginia 22102 USAT (703) 288-5325 or (703) 288-6325F (703) 288-5426 or (703) 744-7550E [email protected]

Special Thanks to: Dr. Steven Hatfill, SAICMr. Bill Patrick, BioThreats AssessmentMr. Gary T. Phillips, SAICDr. D.A. Henderson, Johns Hopkins UniversityDr. Joshua Lederberg, Rockefeller UniversityDr. John Parachini, Monterey Institute of

International StudiesDr. Richard Spiegel, BPRP/NCID, CDC

Bioterrorism.ppt

Documents

annual conference

role of iaem iaem

biological agents

coullahanbiological

bw attackmany patients

world war

emergency managementrobert

bio agents