EIIP Virtual Forum Presentation – December 01, 2004

An Overview of Bioterrorism
Priorities for Public Health Preparedness

Dr. Nelson Arboleda,
Bioterrorism Preparedness and Response Program
National Center for Infectious Diseases (NCID)
Centers for Disease Control and Prevention (CDC)

Avagene Moore
EIIP Moderator

The following version of the transcript has been edited for easier reading and comprehension. A raw, unedited transcript is available from our archives. See our home page at http://www.emforum.org

[Welcome / Introduction]

Avagene Moore: Welcome to the EIIP Virtual Forum! Amy Sebring, my partner/associate, and I are pleased to see you in our audience today. Today's topic is "An Overview of Bioterrorism: Priorities for Public Health Preparedness." If you have not read the background materials, including our speaker's bio, please do so after today's session.

Now, it is my pleasure to introduce today's guest speaker. Dr. Nelson Arboleda is an Epidemic Intelligence Service Officer in the Centers for Disease Control and Prevention. His specific assignment is with the National Center for Infectious Diseases, Bioterrorism Preparedness and Response Program. He received his Bachelor of Science Degree from St. Edward's University in Austin, Texas and his Medical Degree from Universidad del Valle in Cali, Colombia. He conducted his medical internship and his Masters of Public Health at the University of Miami/Jackson Memorial Hospital in Miami, FL. While in Miami, he served as the Project Coordinator of the National Violent Death Reporting System of Miami Dade County.

Nelson, we welcome you to the EIIP Virtual Forum to discuss this important topic with our audience. I now turn the floor to you, Nelson.


Nelson Arboleda: Thank you, Avagene, and hello to everyone in the Virtual Forum audience. It is a pleasure to be here today.

The Centers for Disease Control and Prevention (CDC) has been responding to public health emergencies for decades. In 1998 a program was created in the National Center for Infectious Diseases specifically to prepare for and respond to bioterrorism. More recently CDC created the Office of Terrorism Preparedness and Emergency Response. In recent years, CDC has been actively engaged in preparedness efforts, designing and implementing surveillance and detection programs and providing guidance to state and local stakeholders.

The Anthrax attacks through the US mail system in the fall of 2001 highlighted the importance for rapid biological agent detection and identification. Detection and identification is essential for ensuring rapid and appropriate response to bioterrorism and naturally occurring outbreaks so that exposures can be mitigated and those exposed can be isolated and treated.

The Laboratory Response Network was designed to network federal, state and specific local laboratories to strengthen their capacity to detect different biological and chemical agents through the sharing of standardized reagents and testing protocols and referral and reporting mechanisms. Similarly, CDC's Health Alert Network has upgraded the capacity of state and local health agencies to communicate different health threats--including bioterrorism, emerging infectious diseases, and environmental hazards.

CDC has worked with pharmaceutical companies and other partners to create a Strategic National Stockpile of medicines and emergency supplies that will be rapidly deployed anywhere in the United States within 12 hours to respond to outbreaks of anthrax, plague, tularemia, or other diseases, whether caused by bioterrorism or naturally occurring. The Stockpile was essential in responding to the terrorist attacks of September 11, 2001, as well as to the ensuing anthrax outbreak.

Collectively, these measures strengthen the existing public health system while preparing for bioterrorism, infectious disease outbreaks, and other public health threats and emergencies.

The U.S. public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States.

High-priority agents, referred to as the category A agents, include organisms that pose a risk to national security 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.

These agents include: Anthrax, Botulism, Plague, Smallpox, Tularemia, and Viral Hemorrhagic Fevers (Filoviruses: Ebola, Marburg and Arenaviruses: Lassa, Machupo).

The category B agents include those that:

  • are moderately easy to disseminate;
  • result in moderate morbidity rates and low mortality rates; and require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance.

The category C agents include emerging pathogens that could be engineered for mass dissemination in the future because of:

  • availability;
  • ease of production and dissemination; and
  • potential for high morbidity and mortality rates and major health impact.

For terrorism and naturally occurring public health emergencies, preparedness at all levels from the local to the state to the federal level are essential. As the lead federal agency for public health, CDC assists state and local health departments in preparations to respond to terrorism, infectious disease outbreaks, and other public health emergencies. A well-planned, rapid, and effective response is critical to saving lives.

Across the country, state and local officials are assessing their capabilities and capacity to respond to a biological, chemical, radiological, or a conventional weapons terrorism incident. In the post 9/11 era, state and local health departments are now expanding their roles to include responding effectively to terrorism.

Since 1999, CDC has provided funding and support for the State and Local Preparedness Cooperative Agreement Program. The purpose of this program is to upgrade state and local public health jurisdictions' preparedness for a response to terrorism, infectious disease outbreaks, and other public health threats and emergencies. These cooperative agreements comprise the largest public health program outside of Medicare.

Since its inception, planning activities for the State and Local Preparedness Program have spread from 5 states or localities to the current 50 states, 4 localities, and 8 U.S. territories. Specific accomplishments achieved by the state and local jurisdictions include:

  • 100% of participants have identified a state-wide Director of Bioterrorism.
  • 98% have established a Bioterrorism Advisory Committee.
  • 91% can initiate a field investigation within 6 hours of an urgent disease report from all parts of a jurisdiction on a 24/7 basis.
  • 100% established a timeline for a state-wide plan.
  • 95% indicate a 24/7 system is in place to activate the response plans.
  • 82% have systems established to rapidly detect a terrorist event through mandatory disease reporting.

CDC also initiated the current Public Health Preparedness Project. Working with subject matter experts within CDC and across public health, this project will define public health preparedness indicators. These indicators will improve strategic planning and management of CDC's cooperative agreements. By providing an evaluation framework, the indicators will also link preparedness levels to measurement of progress toward the long-term goals and measures of CDC's terrorism program.

Next Steps: Because a chemical, biological, radiological or nuclear (CBRN) attack will most likely occur locally, disease-tracking systems at state and local health agencies must be ready to detect unusual patterns of disease and injury, and epidemiologists at these agencies must have expertise and resources for responding to reports of rare, unusual, or unexplained illnesses or deaths.

CDC is also developing new methods to rapidly detect, evaluate, and report suspicious health events that might indicate natural or intentional CBRN releases for all state health departments and selected major metropolitan cities and territories.

The role of our public health system is changing to include new areas, such as public health law, forensic epidemiology, and national security. This expansion has reshaped public health practice, and requires public health preparation for and response to emergencies in a more effective, efficient, and coordinated way. While embracing this new role, public health's cardinal responsibility remains the same--to protect people's health.

CDC is committed to enhancing preparedness and emergency response expertise. Core competencies, such as detection; investigation and response; control, containment and recovery; laboratory science; and research have driven past successes and will now provide the foundation for renewed efforts to protect the public from ever changing health threats.

These renewed efforts have:

  • Facilitated the enrollment of 25 new laboratories into the national Laboratory Response Network, bringing the total to 121.

  • Continued to manage the State and Local Preparedness Cooperative Agreement and provided updated guidance to all 62 grantees.

  • Successfully maintained the Strategic National Stockpile (SNS) with 12-hour push packages, ensuring onsite delivery within 12 hours.

  • Established an agency-wide public health strategy for terrorism preparedness and response.

  • Recently Published 'Public Health Emergency Guide for State, Local, & Tribal Public Health Directors'' - (Available on CDC Website October 29, 2004) http://www.bt.cdc.gov/planning/responseguide.asp. Note: A pocket-sized field version of the guide will be available to state, local, and tribal public health departments in January 2005.

  • Increased the availability of respirators certified against CBRN agents for first responders based on rigorous laboratory tests, evaluation of product specifications, and assessment of the manufacturer's quality control procedures.

  • Issued criteria for testing/certifying CBRN Escape Respirators intended to reduce toxic exposures in the workplace.

  • Participated in exercises such as TopOff 2, Global Mercury, and Unified Defense 2003 to improve coordinated emergency response.

  • Posted over 1,200 notifications on reports of outbreaks on the Epidemic Information Exchange (Epi-X), CDC's nationwide secure communications system. Epi-X connects more than 1,800 public health officials, fills requests for epidemiologic assistance, and announces terrorist threats or acts.

CDC is committed to strengthening the nation's public health system. CDC will continue providing technical assistance to states, improving laboratory capacity to detect biological and chemical agents, detecting emerging threats through a local/national data collection system, developing personal protective equipment technologies, and ensuring health information reaches all clinicians through a comprehensive network of satellite and other communication capacities.

That concludes my formal remarks. I am available for questions and now turn you back to our Moderator.

Avagene Moore: Thank you very much, Nelson, for your remarks. I am sure our audience has questions for you.

[Audience Questions & Answers]

Marquita M Johnson: I am a Bioterrorism (BT) Training Coordinator for Public Health and one of the issues I run into with training is keeping the Public Health focus of BT a priority. How can I do this?

Nelson Arboleda: That is a great question Marquita. The topic seems to be driven by the recent acts or threats and so does interest. For those of us that do work in this field everyday, we know how important it is that individuals, law enforcement agencies and Health Care providers are trained to respond to a BT event. Here at CDC we utilize a variety of folks with different backgrounds to conduct and prepare our trainings. We have seen how important it may be to utilize audiovisual tools that will engage your audience and those individuals which specialize in Graphic Design, Health Communications, etc.

Jennifer Vuitel: Are there any plans for grants that would specifically help states and/or municipalities reach non-English speakers with critical/emergency related public health information?

Nelson Arboleda: When agreements and grants are prepared the entire population is taken into account specifically in areas where other racial groups or languages are considered. If you have a specific interest I can get back with you with that information.

Isabel McCurdy: Nelson, was the Epi-X used during your recent flu vaccine incident?

Nelson Arboleda: Epi-X is utilized on a number of cases for various events and for the dissemination of information of Public Health importance. Our Directors Emergency Operations Center (DEOC) has been activated to deal with citizen and physician calls.

For the flu, there have been various teams formed to tackle distribution and our Emergency Operations Center is activated with phone access 24/7.

Mark Drummey: Do you have a national data repository (and supercomputer to crunch this information) for your local/national data collection system?

Nelson Arboleda: No. There are various surveillance systems in place gathering data on different agents on a daily basis. We have been able to fund and assist States to develop their own systems at their local and/or state health Departments.

In addition, many states are currently using free software that we offer called EARS — Early Aberration Reporting System. The EARS System is a software package that has traditionally been used in the developing field of syndromic surveillance

Burt Wallrich: There are people in our communities who are not reached through usual channels, such as mass media, aside from the issue of language. These include homeless people living on the streets and some undocumented immigrants. Does CDC assist local emergency management agencies and health departments with planning to ensure that everyone gets effective warnings, quarantine information, etc.?

Nelson Arboleda: CDC would assist State Health Departments to do this upon the request of the State.

Patricia Townley: In our county we have contacted the local homeless shelters, the soup kitchens and the Salvation Army to set up training for their staff and volunteers surrounding emergency preparedness. Since this group has a relationship with most of our homeless, they will work with us in assuring information gets to them and they are transported to PH for medication, etc.

Amy Sebring: I can understand the usefulness of preparedness indicators, however, in our discipline we use exercises to test plans and evaluate training, etc. Is there any requirement for exercising in the cooperative agreements?

Nelson Arboleda: That's also a great question. Let me confer with other subject matter experts in the branch and I will be happy to get back to you.

Avagene Moore: Nelson, I am sure you are pleased as we all are to see the emphasis now placed on public health. What is the most important thing the individual citizen and family can do to be prepared for bioterrorism?

Nelson Arboleda: That is a question that we get asked quite a bit. I would say that individuals should continue their daily lives as normal as possible and make sure the entire family knows who and how to contact in case of a bioterrism event.

Know the numbers to local law enforcement agencies and health care providers as well as alarming local health departments of any unusual events. Public health starts at the local level.

Isabel McCurdy: Nelson, what is your email for follow up questions?

Nelson Arboleda: [email protected]

Amy Sebring: You mentioned the state level bioterrorism advisory committees. Are there any requirements for local level committees that you are aware of?

Nelson Arboleda: That is really a State issue. There are no national guidelines or requirements from CDC.

Amy Sebring: What is the status of the National Disease Surveillance System implementation? NNEDSS I believe. Will that coordinate all these local systems?

Nelson Arboleda: That system is not run out of our group of Bioterrorism Preparedness and Response - you can consult the CDC website at www.cdc.gov.


Dee Beaugez: Does the CDC have a plan to help support rural county public health departments in the event of a bioterrorism incident that could impact their county?

Nelson Arboleda: The State has response plans for county level events. CDC assists on requests of state health departments.


Avagene Moore: Thank you, Nelson. We greatly appreciate your effort and time on our behalf today.Please stand by a moment while we make some quick announcements.

If you are not currently on our mailing list, and would like to get program announcements and notices of transcript availability, please see the Subscribe link on our home page.

We welcome three new Partners this week:

EGOware http://www.egoware.com with Joel Mottinger, Vice President of Sales, serving as the Point of Contact to the EIIP;

NC4 http://www.NC4.us with Merrily Powell, Regional Account Manager, as our POC; and

Centro Internacional Antiterrorista-Desastres Naturales (Web site is under construction) with Dr. Demetrio Wazar Gomez, Director, as the EIIP POC.

Glad to have all three new Partners! If you are interested in becoming an EIIP Partner, please see the "Partnership for You" link on the EIIP Virtual Forum homepage http://www.emforum.org .

Again, the transcript of today's session will be posted later today and you will be able to access it from our home page. An announcement will be sent to our Mail Lists when the transcript is available.

Our next Virtual Forum session is Wednesday, December 15, 12:00 Noon Eastern. Our topic is the new DHS/FEMA Catastrophic Plan. You don't want to miss that one!

Thanks to everyone for participating today. We appreciate you, the audience! Before you go, please help me show our appreciation to Dr. Nelson Arboleda for a fine job. Thank you, Nelson!

The EIIP Virtual Forum is adjourned!