Inhalation Anthrax Investigation:
Palm Beach County, Florida
Jean M. Malecki, MD, MPH, FACPM
Director, Department of Public Health
Chair, Department of Preventive Medicine
Nova Southeastern College of Osteopathic Medicine
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Biological Weapons
• Organisms themselves
– Cause disease two ways:
• Direct invasion
• Release of toxins
• Toxins from organisms
3
Why use it as a weapon?
•
•
•
•
•
•
Easy storage
Can be aerosolized
Potentially undetectable
Affects both animals and man
Vaccine protects the aggressor
“Poisons” the land
4
Relative costs
To cause effective lethality over 1 km2
• Conventional weapons:
$2000 +
• Nuclear:
$800
• Chemical:
$60
• Biological
$1
Proceedings of the Seminar on Responding
to the Consequences of Chemical and
5
Biological Terrorism
Biological Agent
Effective Dosage
Anthrax
8,000 to 50,000 spores
Plague
100 to 500 organisms
Smallpox
10 to 100 organisms
Tularemia
10 to 50 organisms
Ricin
3-5 mg/kg of body weight
Botulinum Toxin
.00001 mg/kg of body weight
6
Learning Objectives
1.
The participant will be able to evaluate the assurance role of public
health and the value of the ten (10) Essential Services of Public Health
(Essential Services) related to emergency responses to threats to public
health.
2.
The participant will be able to recognize the value of the Center for
Disease Control and prevention (CDC), Local Public Health System
Performance Standards (Performance Standards) in preparing for and
dealing with potential bioterrorism issues.
3.
The participant will be able to recognize and analyze the complexities of
working with multiple agencies involved in complex public health issues,
such as dealing with potential bioterrorism incidents.
4.
The participants will be able to analyze leadership issues crucial to
developing effective potential lines of action to deal with potential
bioterrorism threats.
JMM/ff: 10/02
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ASSURANCE
Assurance activities represent actions to intervene in disease or care
processes to prevent the spread of disease through populations,
promote healthy conditions, and ensure the quality of medical care
available to treat disease in individuals. Assurance activities include
the following:
•
Licensing, inspecting, and regulating food service, recreation, day
care, housing, and health care facilities to ensure compliance with
standards.
• Providing education and training to make people aware of health
risks and to communicate strategies to avoid these risks.
Monitoring and managing environmental conditions (for example,
air quality, occupational safety, radiation control, solid waste
management, hazardous waste management, water safety, and
sewage disposal).
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ASSURANCE
con’t
• Controlling disease vectors (for example, mosquito spraying) and
animal reservoirs (for example, rodent control and finding the
perpetrator).
• Providing personal health care services (for example,
immunizations, TB/STD clinics, maternal and child health clinics,
home health, mental health, dental care, and substance abuse
treatment and intervention clinics for bioterrorism in events.
• Facilitating enrollment in public insurance programs.
• Instituting isolation and quarantine protocols, when necessary.
• Advocating for additional resources (for example, the National
Pharmaceutical stockpile).
• Providing technical assistance to health care providers and
businesses (for example, providing guidance to pharmacies on
appropriate inventories of antibiotics).
• Mobilizing community partnerships to improve capacities and
encourage coordination.
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Bacillus anthracis
• Gram positive rod
• Spore forming
• Encapsulated
• Laboratory diagnosis
– non-hemolytic, non-motile
– culture and gamma phage lysis
– PCR
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Anthrax
• Zoonotic disease
• Transmission
– contact with infected animals
– laboratory exposure
– person to person not documented
• Biological weapon
12
Anthrax
United States
• 224 cutaneous 1944 – 1994
• 18 inhalation 1900 – 1978
Florida
• 8 human cases 1927 – 1974
• Last veterinary case reported 1953
13
Role of a County Health Department representative who
reports to the scene of a bio or chemical terrorist event is that of a
public health advisor/consultant to the incident commander. To be
public health advisor/consultant to the incident commander. To be
credible and effective in this role, he/she must be professional,
experienced, knowledgeable, and articulate. Being knowledgeable
includes expertise in:
Principles of epidemiology
Pathology and characteristics of potential biological agents
relative toxicity and characteristics of potential chemical agents
Requirements for agent sampling and safeguarding crime scene
evidence
Requirements and authority for imposing/lifting quarantine
Requirements for decontamination and establishing downwind
evacuation zones ) see Chemical Terrorism Manual)
Locations and capabilities of county medical facilities, HAZMAT,
fire department, and law enforcement assets
Use of and requirements for respirators and other personal
protection equipment
Emergency event notification chain
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Cutaneous
• Vesicular lesion
• Ulceration
• Painless
• Edema
• Antibiotics highly effective
• Incubation period 1–7 days
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Cutaneous
16
Inhalation
• Flu-like symptoms
• Progresses to shock, death
• Incubation period 1-60 days
Mechanism
• Spores inhaled
• Carried to lymph nodes
• Hemorrhage, edema, necrosis
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Inhalation
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Palm Beach County, Florida
Escambia
Santa Rosa Okaloosa
Santa Rosa Okaloosa
Walton
Walton
Holmes
Holmes
Jackson
Jackson
Washington
Washington
Bay
Bay
Nassau
Nassau
Gadsden
Gadsden
Leon
Madison
Jefferson Madison
Leon
Jefferson
Calhoun
Calhoun
Liberty
Liberty
Gulf
Gulf
Wakulla
Wakulla
Taylor
Taylor
Franklin
Franklin
Hamilton
Hamilton
Baker
Duval
Baker
Duval
Suwannee
Suwannee Columbia
Columbia
Union
Clay
Lafayette
Union
Clay
St Johns
Lafayette
Bradford
St Johns
Bradford
Gilchrist
Gilchrist
Alachua
Putnam
Dixie
Alachua
Putnam
Dixie
Flagler
Flagler
• October 4, 2001
– Confirmation of B. anthracis
– Florida DOH team arrives
– CDC team arrives
– FBI arrives
Levy
Levy
Marion
Marion
Volusia
Volusia
Citrus
Citrus
Lake
Lake
Seminole
Seminole
Sumter
Sumter
Hernando
Hernando
Orange
Orange
Brevard
Brevard
Pasco
Pasco
Hillsborough
Hillsborough
Polk
Polk
Osceola
Osceola
Indian River
Indian River
Hardee
Manatee Hardee
Manatee
Sarasota
Sarasota
De Soto
De Soto
Charlotte
Charlotte
Lee
Lee
Okeechobee
Okeechobee
Highlands
Highlands
St Lucie
St Lucie
Martin
Martin
Glades
Glades
Hendry
Hendry
Collier
Collier
P alm Beach
Palm
Beach
Broward
Broward
Monroe
Monroe
Dade
Dade
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Local Public Health System Performance
Assessment Instrument
Essential Health Services #2
DIAGNOSE AND INVESTIGATE HEALTH
PROBLEMS AND HEALTH HAZARDS IN THE
COMMUNITY
2.1 Identification and Surveillance of Health Threats
2.2 Plan for Public Health Emergencies
2.3 Investigate and Respond to Public Health Emergencies
2.4 Laboratory Support for Investigation of Health Threats
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Indicator 2.3: Investigate and Respond to Public
Health Emergencies
LPHS Model Standard:
Local public health systems must respond rapidly and effectively to investigate
public health emergencies which involve communicable disease outbreaks or
biological, radiological or chemical agents. With the occurrence of an adverse
public health event or potential threat, a collaborative team of health professionals
participates in the collection and analysis of relevant data. A network of support
and communication relationships exists in the LPHS, which includes health-related
organizations, public safety and rapid response teams, the media, and the general
public. Timely investigation of public health emergencies is coordinated through
an Emergency Response Coordinator, who leads the local effort in the event of a
public health emergency (e.g., health officer, environmental health director).
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Indicator 2.3: Investigate and Respond to
Public Health Emergencies
In order to investigate public health emergencies, the LPHS:
 Designates an Emergency Response Coordinator.
 Develops written epidemiological case investigation protocols for
immediate investigation of:
-communicable disease outbreaks,
-environmental health hazards,
-potential chemical and biological agent threats,
-radiological threats,
-and large scale disasters.
 Maintains written protocols to implement a program of source and contact tracing
for communicable diseases or toxic exposures.
 Maintains a roster of personnel with the technical expertise to respond to
potential biological, chemical, or radiological public health emergencies.
 Evaluates past incidents for effectiveness and opportunities for improvement.
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Please answer the following questions related to Indicator 2.3:
2.3.1 Has the LPHS designated an Emergency Response Coordinator?
If so,
2.3.1.1
Is there coordination with the local public health agency’s
Emergency Response Coordinator?
2.3.2 Does the LPHS have current epidemiological case investigation
protocols to guide immediate investigations of public health emergencies?
If so, do these protocols address:
2.3.2.1
Communicable disease outbreaks?
2.3.2.2
Environmental health hazards?
2.3.2.3
Chemical threats?
2.3.2.4
Biological agent threats?
2.3.2.5
Radiological threats?
2.3.2.6
Large-scale natural disasters ?
2.3.2.7
Possible terrorist incidents?
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2.3.3
Does the LPHS maintain written protocols for implementing a
program off source and contact tracing for communicable
diseases or toxic exposures?
If so, are protocols in place for:
2.3.3.1
Animal and vector control?
2.3.3.2
Exposure to food-borne illness?
2.3.3.3
Exposure to water-borne illness?
2.3.3.4
Excessive lead levels?
2.3.3.5
Exposure to asbestos?
2.3.3.6
Exposure to other toxic chemicals?
2.3.3.7
Communicable diseases?
2.3.3.8
Radiological health threats?
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2.3.4
Does the LPHS maintain a roster of personnel with the technical expertise
to respond to potential biological, chemical, or radiological public health
emergencies?
If so, does the LPHS have access to the following personnel within one hour?
2.3.4.01
2.3.4.02
2.3.4.03
2.3.4.04
2.3.4.05
2.3.4.06
2.3.4.07
2.3.4.08
2.3.4.09
2.3.4.10
2.3.4.11
2.3.4.12
2.3.4.13
2.3.4.14
2.3.4.15
2.3.4.16
2.3.4.17
Chemists?
Emergency management?
Environmental health scientists?
State epidemiologists?
Hazardous Material Response Teams?
Health physicists?
Industrial hygienists?
Infectious disease specialists?
Law enforcement?
Medical examiners/coroner?
Microbiologists?
National Guard?
Occupation health physicians?
State public health laboratory director?
Toxicologists?
Veterinarians?
Funeral/Mortuary Directors?
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2.3.5 Does the LPHS evaluate public health emergency response incidents
for effectiveness and opportunities for improvement?
2.3.6 How much of this LPHS Model Standard is achieved by the local public
health system collectively?
0-25%
1
26-50%
51-75%
76-100%
2
3
4
2.3.6.1 What percent of the answer reported in question 2.3.6 is the
direct contribution of the local public health agency?
0-25%
1
26-50%
51-75%
2
3
76-100%
4
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Index Case
• 63 year-old male
– London native; in U.S. since 1974
– Photo editor, American Media Inc (AMI)
Exposure history
– Cyclist, fisherman
– Travel: North Carolina only
– No livestock exposure
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Index Case
• Illness onset September 30
• Hospital admission October 2
• Unexplained, non-localizing
severe illness
– shaking chills, fever
– vomiting
–altered mental status
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Clinical Findings
• Incoherent
• Fever
• Supple neck
• Clear lung sounds
• Hypotensive
• Seizures
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Clinical Findings
• WBC count: 9400 mm3
• Chest X-ray increased perihilar density
• Head CT normal
Cerebrospinal fluid
– 4570 WBC mm3, 1375 RBC mm3
– glucose=57 mg/dl; protein=666 mg/dl
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Cerebrospinal Fluid
Gram Stain
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Initial Interview
Dr. Malecki
Director
Lead
Investigator
Dr. Kumar
Senior Physician
Director
Epidemiology
Judith M Cobb
Com. Health Nursing Consultant
Lead
Interviewer
Barbara F Johnson
Sr. Com. Health Nursing Supv.
Epidemiology
John O'Malley
Env. Adm.
Env. Health & Eng.
Dianne Strock
Env. Mgr.
Env. Health & Eng
33
HISTORY
•
•
•
•
•
•
•
60 Days Prior to Onset of Disease
Daily Activities (Work and Home)
Meals
Hobbies & Pets
Travel
Recreation
Unusual Incidents
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Early Considerations
• Source?
– natural
– intentional
• Communication objectives
– isolated case
– “full-scale” investigation
– no known transmission person-to-person
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Local Public Health System Performance
Assessment Instrument
Essential Health Services #8
ASSURE A COMPETENT PUBLIC AND
PERSONAL HEALTH CARE WORKFORCE
8.1
Workforce Assessment
8.2
Public health workforce standards
8.3
Life-long learning through continuing education, training and
mentoring
8.4
Public health leadership development
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Indicator 8.4: Public Health Leadership Development
LPHS Model Standard:
Public health leadership is demonstrated by both individuals
and organizations that are committed to improving the health of the
community. Leaders play a vital role in assuring the creation of a public
health system, the implementation of the Essential Public Health
Services, and the creation and achievement of a shared vision of
community health and well-being. LPHS leadership may be provided
by the local governmental public health entity, may emerge from the
public and private sectors or the community. Or may be shared by
multiple stakeholders. The LPHS encourages the development of
leadership capacity that is inclusive, representative of community
diversity and respectful of the community’s perspective.
37
To accomplish this, the organizations
within the LPHS:
•
•
Provide formal (e.g., educational programs, leadership
institutes) and informal (e.g., coaching, mentoring)
opportunities for leadership development for employees
at all organizational levels.
Promote collaborative leadership through the creation of a
local public health system with a shared vision and
participatory decision-making
•
Assure that organizations and/or individuals have opportunities to
provide leadership in areas where their expertise or experience
can provide insight, direction, or resources.
•
Provide opportunities for development of diverse community
leadership to assure sustainability of public health initiatives
38
Please answer the following questions related to Indictor 8.4:
8.4.1
Do organizations within the LPHS promote the
development of leadership skills?
If so, is leadership skill development promoted by:
8.4.1.1 Encouraging potential leaders to attend
formal leadership training?
If so, do members of the LPHS workforce
participate in the following:
8.4.1.1 National Public Health Leadership
Institute?
8.4.1.2 Regional or state public health leadership
institutes?
8.4.1.3 Executive management seminars or
programs?
8.4.1.4 Graduate programs in
leadership / management?
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8.4.1.2 Mentoring personnel in middle management /
supervisory positions?
8.4.1.3 Promoting leadership at all levels within organizations
that comprise the LPHS?
If so,
8.4.1.3.1 Within in LPHS organizations, are
communication mechanisms that encourage
informed participation indecision-making
(e.g., staff meetings, listserve) established?
8.4.1.4 Using performance evaluation plans to establish
leadership expectations and to recognize leadership
competence both individual and collaborative- in team,
unit, and other internal and external settings?
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8.4.2
Do organizations within the LPHS promote collaborative
leadership through the creation of a shared vision and
participatory decision-making?
If so,
8.4.2.1 Across LPHS organizations, are communication
mechanisms that encourage informed
Participation in decision-making (e.g., forums,
listserve) established?
8.4.3
Does the LPHS assure that organizations and/or individuals
have opportunities to provide leadership in areas where their
expertise can provide insight, direction, or resources?
8.4.4
Does the LPHS provide opportunities to develop community
leadership through coaching and mentoring?
If so,
8.4.4.1 Does the LPHS recruit new leaders who are
representative of the diversity within the community?
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8.4.5
local
is the
How much of this LPHS Model Standard is achieved by the
public System collectively?
0-25%
26-59%
51-75%
76-100%
1
2
3
4
8.4.5.1 What percent of the answer reported in question 8.4.5
direct contribution of the local public health agency?
42
Response Strategy
• Active surveillance
• Environmental investigation
• Clinical evaluation
• Collaboration: NC & Atlanta
• Communications
43
Suspect Case
EB
• 73 year old male
• AMI employee
• Respiratory illness onset Sep 28
• Hospital admission Oct 1
44
Day 4: Pivotal Findings
• B. anthracis isolated from
– Office keyboard used by index case
– Nasal swab of ill AMI employee (EB)
• Conclusions
– Source AMI building
– Mechanism: intentional release
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AMI
46
WORK STATION
47
KEYBOARD
48
BULK SAMPLES
49
QUARANTINE
50
Strategy Change
• FBI directs investigation
– Building secured
– Collected work site samples
– NIOSH, NCEH consulted
– Swabs, vacuum & air samples
•Public Health investigation team
– Assisted, processed samples
– Unable to enter building
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Day 4: Intervention Planning
• Define exposed group
– Anyone in AMI building >1 hour
– In past 60 days
• Assess exposure
– Questionnaire
– Nasal cultures
– Serology testing
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Day 5: Intervention
54
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Exposure Assessment
Index Case
• Observed viewing suspicious mail (9/19?)
– Contained fine white powder
– Also contained “Jewish star”
• Office cultures positive
56
Anthrax Links With Mail
• Index case: handled “suspicious” mail
• EB: AMI mail distributor
• SD: mail sorter -- opened letter with
white powder
57
AMI mailroom
58
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MAIL ROOM
60
US POSTAL SERVICE
61
Postal Service Investigation
Green
Acres
West Palm
Main
Branch
Lake
Worth
<5%
AMI
AMI
Van
Boca Raton
Blue
Main
Lake 95%+ Substation
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Contaminated Mail
• Letter handled by index case ~ 9/19
• Letter opened by SD ~9/25
• 2 contaminated mail routes to AMI
• Conclusion: At least 2 contaminated
AMI letters
63
Time Line
9/11
9/18
9/25
10/2
10/9
10/16
10/23
10/30
64
Insights Gained:
Florida Experience
• Convincing Data-both to self and others • Tell patient/community-communicate
information effectively to internal and external
customers • Bear the news-listen to fears, allow for venting • Put into perspective 65
Five Guidelines For Including the Public In
Bioterrorism Response Planning
“Vaccinating a city against panic”
1.
2.
3.
4.
Recognize that panic is rare and preventable
Enlist the general public as a capable partner
Think beyond the hospital for mass-casualty care
Provide information, which is as important as
providing medicine
5. The public will not take the pill if it does not trust the
doctor
66
Other Public Health Threats During
Anthrax Investigation
• Hurricane Michelle
• West Nile Virus Alert
• Death due to Legionnaires Disease
• Ciguatera Toxin Poisoning
• Over 900 Anthrax Hoaxes
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Summary
• 2 cases inhalation anthrax
• Source: AMI via mail
• Cultures at postal facilities positive
• No cases in postal workers
• Nasal cultures positive in <0.1%
• Serology data inconclusive
• Medication side effect data.
69
Insights Gained:
Florida Experience
• Testing
• Laboratory logistics
• Data management
• Interagency collaboration
70
Insights Gained:
Florida Experience
• Interagency collaboration
– Multiple agencies involved
– Chain of command and
responsibilities
– Cross-training for all disciplines
– Finding perpetrators - most
important prevention strategy
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Leadership
Collaborative Leadership
Collaborative leaders are sustained by their deeply democratic belief that
people have the capacity to create their own visions and solve their own
problems.
• Being broadly inclusive
• Creating a credible open process
• Bringing about a shared understanding
Authentic visions and strategies for addressing the shared concerns of the
organization or community will be created.
• Convene
• Energize
• Facilitate
• Sustain the Process
The only consensus that really matters is that of the people who
live there.
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Leadership
• The role of leadership in collaboration is to engage
others by designing constructive processes for working
together, convene appropriate stakeholders, and
facilitate and sustain their interaction.
• Leaders promote and safeguard the collaborative
process rather than take unilateral, decisive action.
• Those who lead collaborative efforts – transforming,
facilitative, “servant” leaders – rely on both a new
vision of leadership and new skills and behaviors to
help communities and organizations realize their
visions, solve problems, and get results.
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Leadership
Collaborative Leadership
Collaborative leaders are sustained by their deeply democratic
belief that people have the capacity to create their own visions and
solve their own problems.
•
Being broadly inclusive
•
Creating a credible open process
•
Bringing about a shared understanding
75
Authentic visions and strategies for addressing the
shared concerns of the organization or community
will be created.
• Convene
• Energize
• Facilitate
• Sustain the process
76
The only consensus
that really matters is
that of the people who
live there.
77
National Enquirer
78
“What’s next? Anthrax
action figures?
Can I get a Happy Meal with
the Dr. Jean Malecki doll,
please?”
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