Dallas County Bioterrorism Program:
Overview and Highlights
David Buhner MD MS
Epidemiologist
Dallas County Department of Health and Human Services

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1993—World Trade Center bombing
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1996—Alfred P. Murrah Federal
Building bombing in Oklahoma City
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2001—Destruction of the World Trade
Center

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1978—Deliberate contamination of
Israeli citrus exports with mercury
1982—Deliberate contamination of
Tylenol with cyanide
1984—Deliberate contamination of salad bars with Salmonella in Oregon
1995—Tokyo Sarin gas attack
2001—The US anthrax attacks

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Office of Technology Assessment:
Used under optimal conditions biological weapons could have an impact similar to a small nuclear device.

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C. botulinum lives in the soil .
Evenly dispersed and inhaled 1 gram of botulinum toxin could kill 1 million people.
After the 1991 war, Iraq admitted to the possession of 19,000 liters of concentrated toxin, 10,000 liters loaded into military weapons.

Potential Agents of Bioterrorism

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361 cases reported between 2/23/03 and 6/7/03, with 33 (9%) deaths
Some control measures used:
-over 18,000 people quarantined
-closure of businesses
-closure of schools
Economic losses projected at
1,000,000,000 dollars

The Latest in Feline Fashion

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The European Black Death (bubonic plague) of the 1300’s is estimated to have killed 1/3 of the European populace within 2 years.
Epidemics due to Old World diseases introduced into the New World with the arrival of Europeans are estimated to have killed 90% of the native inhabitants.

Public Health:
Epidemic Disease Defense
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Traditional role: control of infectious, communicable diseases of “natural” origin in the local populace.
There is little debate about the decades-long deterioration that has been allowed to take place in the local public health infrastructure in the US.

Unique Features of Bioterrorism
Unlike other forms of terrorism:
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Public health system is THE crucial factor in an effective response.
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Bioterrorism may be covert, with a delay, due to the incubation period of the illness, in the appearance of the problem.
Bioterrorism can be self-propagating due to person-to-person spread; early identification and institution of effective public health measures can limit what otherwise might be a catastrophic outbreak of disease.

New Role for Public Health:
Watchdog for Bioterrorism
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Good news: the skill set, personnel, and physical resources required for this role are little different from those required for traditional public health functions
Bad news: public health infrastructure deterioration and failure to keep up with the modern pace of technological change critically compromise local public health’s ability to respond with the speed and efficacy required to limit the damage from a large-scale attack of bioterrorism

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In 1999 The Centers for Disease
Control and Prevention (CDC) first received congressionally appropriated funds to enter into multi-year cooperative agreements aimed at upgrading state and local health department preparedness and response capabilities relative to bioterrorism.

1. Preparedness Planning and Readiness Assessment
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The worst time to determine how to respond to an emergency situation is during the emergency.
Need adequate planning and preparation
Need training exercises to assess the adequacy of the plans and preparation

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Rapid disease detection requires a sensitive surveillance system.
Detected cases must be investigated by epidemiologists to:
1) discriminate sporadic cases from outbreaks of disease
2) discriminate natural from intentional
3) identify the population at risk so they may be treated
4) identify appropriate control measures to limit spread to the unaffected

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Rapid and correct identification of the particular biological agent in an outbreak is of fundamental importance because
1) public health consequences differ
2) control measures differ
A well-equipped lab with highly trained personnel is a critical necessity.

4. Communications and
Information Technology
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Public health surveillance and outbreak response require that large amounts of real-time data must be collected, stored, sorted, integrated, analyzed, and interpreted and the results communicated to the appropriate person(s).
Effective communications systems must link public health officials, first responders, government officials, physicians, and all other agencies and organizations likely to be involved in a large-scale outbreak of illness.

5. Risk Communication and Health
Information Dissemination
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The importance of informed, timely , and effective communication with the public and the media, especially during a public health crisis, cannot be overstressed.

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All individuals involved in a response to bioterrorism must possess the up-to-date skills and knowledge necessary to carry out their responsibilities.

Highlight I

The Importance of a Regional
Approach
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Substantial population flow takes place daily between Collin, Dallas,
Denton, and Tarrant counties, as well as to and from more distant counties.
The effects of bioterrorism are unlikely to respect jurisdictional boundaries.

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Hospitals lack the empty beds and staff to manage a sudden influx of large numbers of patients (no surge capacity). This is a nationwide problem.
No hospital wishes to accept the role of epidemic disease hospital in the event of an outbreak.
Where will large numbers of suddenly ill patients be cared for in the event of an outbreak?

A Regional Quarantine and
Treatment Facility
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Representatives of the four counties
(public health and government),
DFWHC, PMH, JPS, the VA, NTCOG, local medical societies, and others have been meeting regularly for more than a year to address this problem.

Highlight II

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DCHHS Bioterrorism Preparedness and Response Laboratory
A state-of-the-art, CDC-sanctioned, LRN laboratory (operating at BSL-3) capable of conducting CDC-validated confirmatory testing for a wide variety of organisms (a
Confirmatory lab)
Provides services to all of North Texas including Collin, Dallas, Denton, Tarrant counties, and TDH Region 2/3
Provides critical training and support to local hospital and clinical laboratories
(Sentinel labs)

Highlight III

The Benefits of Public Health
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Institution of effective treatment as soon as possible after exposure can save the lives of individuals epidemiologically identified as having been exposed to infectious diseases and/or toxins.
Implementation of effective control measures can prevent the spread of communicable illnesses from exposed, infected individuals to the previously unexposed and uninfected.

Epidemiologic Response Teams
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Rapid investigation of reported cases can take maximum advantage of the lag time
(incubation period) between exposure and the onset of illness.
Dallas County has provided for a rapid and flexible response to outbreaks of illness by forming response teams consisting of, as necessary, physicians, epidemiologists, nurses, laboratorians, and the appropriate equipment and supplies.
These teams are available 24/7 and capable of managing multiple, simultaneous outbreak investigations.