Bioterrorism: The Public Health perspective Paul Le Guerrier, M.D.

Outline 1) History 2) Why bother ? 3) Which biological agent ? 4) Who is expected to participate ? 5) What is your role in all this ?

Definitions Biological warfare: The use of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals or plants. Usually reserved for war between nations Bioterrorism: The use of microorganisms or toxins derived from living organisms to produce death or disease and terror or anxiety in humans

History Early attempts WW 1 which lead to the 1925 Geneva protocol Japan and the 731 unit WW 2 Germany vs The Allies US program The Russian program 1969 Nixon (national security decision 35) BA 1970 Nixon (national security decision 44) toxins 1972 Convention on the Prohibition of the Development,Production and Stockpiling of Bacteriological and Toxin weapons and their destruction

History 1978 Markov assasination The sverdlosvsk anthrax outbreak of 1979 The Iraqi program The 1984 salmonella outbreak in The Dalles Aum Shinrikyo The US anthrax outbreak Al Quaeda (ricin in England, January 2003)

History The first successful use of biological weapons in the US was by the Bhagwan Shree Rajneesh cult in 1984.Bhagwan Shree Rajneesh The group contaminated salad bars in 10 restaurants in The Dalles, Ore., with Salmonella Typhimurium, causing 751 people to become ill

History The second successful use of BW in the US

History

Biological weapons characterized by: low visibility, high potency, substancial accessibility relatively easy delivery There are people out there ready to use them

Why bother ? 1) The threat is low but real

Relation entre la probabilité dun événement et le nombre de victimes Nombre de victimes Probabilité delévénement Canulars Actes de bioterrorisme de faible ampleur Actes de bioterrorisme de grande ampleur

Why bother ? 1) The threat is low but real 2) Public Health has a legal mandate 3) Cost/benefit studies

Why bother ? 1) The threat is low but real 2) Public Health has a legal mandate 3) Cost/benefit studies 4) If an act of bioterrorism occurs, the response will be difficult 5) There are benefits: May help us respond to new epidemics or out of the ordinary infectious emergencies

Which biological agent ? 3 ways to identy which biological agent would be used by a terrorist : 1) Look at what was developped; 2) Assess our vulnerability; 3) Do a risk assessment.

Which biological agent ? Look at what was developped 1)World Health organisation report (1970) 2) NATO report 3) US program 4) Russian program 5) Iraqui program

Assess our vulnerability CDC + John Hopkins Center for Civilian biodefense 4 criteria: Impact on health/ infectivity Required competence Importance of the Public Health response Publics reaction/perception Groupes A, B, C Which biological agent ?

Which biological agent ? CDC s list Group A agents » Anthrax (Bacillus anthracis)Anthrax » Botulism (Clostridium botulinum toxin)Botulism » Plague (Yersinia pestis)Plague » Smallpox (variola major)Smallpox » Tularemia (Francisella tularensis)Tularemia » Viral hemorrhagic feversViral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])

Which biological agent ? CDC s list Category A Diseases/Agents The public health system and primary healthcare providers must be prepared to address these agents because they: can be easily disseminated or transmitted from person to person; result in high mortality rates and have the potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness.

Which biological agent ? CDC s list Group B agents » Brucellosis(Brucella species)Brucellosis » Epsilon toxin of Clostridium perfringens » Food safety threatsFood safety threats (e.g., Salmonella species, E coli O157:H7, Shigella) » Glanders (Burkholderia mallei) » Melioidosis (Burkholderia pseudomallei) » Psittacosis (Chlamydia psittaci) » Q fever (Coxiella burnetii)Q fever

Which biological agent ? CDC s list Group B agents » Ricin toxin from Ricinus communisRicin toxin » Staphylococcal enterotoxin B » Typhus fever (Rickettsia prowazekii) » Viral encephalitis (alphaviruses [e.g., VEE, EEE,WEE]) » Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

Which biological agent ? Category B Diseases/Agents Second highest priority agents include those that: are moderately easy to disseminate; result in moderate morbidity rates and low mortality rates; and require specific enhancements of national diagnostic capacity and enhanced disease surveillance

Which biological agent ? CDC s list Group C agents Emerging pathogens

Which biological agent ? Do a risk assessment 1) Souches densemensement 2) Culture microbienne +++ 3) Purification 4) Lyophilisation (séchage à froid) 5) Élimination de la charge statique 6) Pulvérisation 7) Stabilisation 8) Stockage 9) Mécanisme de dispersion

Which biological agent ? Le charbon: Difficulté dobtenir des souches pathogènes Spores sont très stables et résistantes Le bacille de la peste: Très difficile dobtenir des souches pathogènes Difficile de produire une arme efficace, la bactérie résiste mal aux UV et à la chaleur

Which biological agent ? Le bacille de la tularémie: Difficulté dobtenir des souches pathogéniques Résiste au froid et non à la chaleur Les toxines botuliniques: Très difficile dobtenir des souches qui soient hautement productrices de toxines Stable Pas considérées comme une arme de destruction massive

Which biological agent ? Les FHV: Difficulté dobtenir des souches virales et de les manipuler relativement instable Le virus de la variole: Très difficile dobtenir des souches Difficile de produire une arme efficace Le virus est très stable dans lenvironnement

Which biological agent ? Routes of exposure By inhalation By ingestion By cutaneaous exposition By using a vector By the subcutaneous route

Which biological agent ? The targets Difficulté +++ de produire de grands aérosols Par conséquent, les terroristes viseraient des petites cibles Établissements Stades Réseau de transport - gares, aéroports (métro de Montréal cible de choix !) Lieux de rassemblement extérieurs

Which biological agent ? The likliest perpetrators ( J Stern, EID vol.5, no ) Religious and extreme right-wing groups Groups seeking revenge who view secular rulers and the law they uphold as illegitimate They are unconstrained by fear of goverment or public backlash, since their actions are carried out to please God or themselves.

Les deux scénarios 1) Les actes annoncés Law enforcement leads 2) Les actes non annoncés Public Health leads

Who is expected to participate ? 4 levels : Local Provincial National International

Who is expected to participate ? The local level

Rôle de la santé publique (Maladies infectieuses) Notre expertise: 1.Évaluation du risque lié au mode de transmission des agents biologiques (enquête épidémiologique). 2. Prise en charge des personnes exposées (pas les blessés).

Informe les intervenants, les décideurs et le public sur les mesures à prendre pour se protéger. Évalue la pertinence dun suivi clinique et épidémiologique. Rôle de la santé publique (Maladies infectieuses)

Événement à Saint-Léonard Appel au 911 Enquête policière Conférence téléphonique CAAM

Événement à Saint-Léonard

Prises en charge des lieux SPVM Évacuation Délimitation des zones Les personnes exposées ont du se laver les mains

Événement à Saint-Léonard

Armorcé une enquête : auprès des personnes exposées auprès des lieux ( bâtiment, ventilation chauffage, machineries, etc) Identifié les personnes : exposées; potentiellement exposées; non exposées.

Événement à Saint-Léonard Offert une protection post-exposition aux personnes exposées. Noté le noms des personnes potentiellement exposées. Renseigné et répondu aux questions.

Événement à Saint-Léonard

Prélèvement dun échantillon par un policier de léquipe technique (avec laide de lunité dintervention des produits chimiques Décontamination partielle des lieux

Événement à Saint-Léonard

Fermeture des lieux (Assurer par les policiers) Réouverture des lieux lorsque les analyses se sont révélées négatives (Aviser les responsables des compagnies, aviser les personnes exposées de cesser leur médication)

Who is expected to participate ? The provincial level Régie régionale

Who is expected to participate ? The federal level

Office of Emergency preparedness, planning and training Office of public health security Office of laboratory security Office of emergency services Office of the Executive Director

What is your role ? Law enf. P.H. Medical Deterence of bioterrorism X Surveillance of unusual outbreaks X Law enforcement response X Public Health response X Medical response X Research and development X X X

What is your role ? Get to know these possible BWA How to recognize them How to treat them Be suspicious Call Public Health Could be part of mobilized teams