Inhalation Anthrax Investigation: Palm Beach County, Florida

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 1

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 km 2 Conventional weapons: Nuclear: Chemical: Biological $2000 + $800 $60 $1 Proceedings of the Seminar on Responding to the Consequences of Chemical and Biological Terrorism 5

Biological Agent Effective Dosage Anthrax Plague Smallpox Tularemia Ricin Botulinum Toxin 8,000 to 50,000 spores 100 to 500 organisms 10 to 100 organisms 10 to 50 organisms 3-5 mg/kg of body weight.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 7

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). 8

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. 9

Bacillus anthracis Gram positive rod Spore forming Encapsulated Laboratory diagnosis non-hemolytic, non-motile culture and gamma phage lysis PCR 11

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 14

Cutaneous Vesicular lesion Ulceration Painless Edema Antibiotics highly effective Incubation period 1 7 days 15

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 17

Inhalation 18

Palm Beach County, Florida E s c a m b i a October 4, 2001 H o l m e s H o l m e s J a c k s o n S a n t a R o s a J a c k s o n S a n t a R o s a O k a l o o s a O k a l o o s a W a l t o n W a l t o n W a s h i n g t o n N a s s a u G a d s d e n W a s h i n g t o n G a d s d e n N a s s a u H a m i l t o n C a l h o u n L e o n H a m i l t o n C a l h o u n L e o n J e f f e r s o n M a d i s o n J e f f e r s o n M a d i s o n B a y B a k e r B a y D u v a l B a k e r L i b e r t y S u w a n n e e D u v a l L i b e r t y W a k u l l a S u w a n n e e C o l u m b i a W a k u l l a T a y l o r C o l u m b i a T a y l o r U n i o n C l a y L a f a y e t t e U n i o n G u l f C l a y L a f y e t t e S t J o h n s G u l f F r a n k l i n B r a d f o r d S t J o h n s F r a n k l i n B r a d f o r d G i l c h r i s t G i l c h r i s t A l a c h u a D i x i e A l a c h u a P u t n a m D i x i e P u t n a m F l a g l e r F l a g l e r L e v y L e v y M a r i o n M a r i o n V o l u s i a V o l u s i a Confirmation of B. anthracis Florida DOH team arrives CDC team arrives FBI arrives C i t r u s L a k e C i t r u s L a k e S u m t e r S e m i n o l e S u m t e r S e m i n o l e H e r n a n d o H e r n a n d o O r a n g e O r a n g e P a s c o P a s c o H i l l s b o r o u g h H i l l s b o r o u g h P o l k P o l k O s c e o l a O s c e o l a B r e v a r d B r e v a r d I n d i a n R i v e r I n d i a n R i v e r M a n a t e e H a r d e e O k e e c h o b e e M a n a t e e H a r d e e O k e e c h o b e e S t L u c i e S t L u c i e H i g h l a n d s D e S o t o H i g h l a n d s S a r a s o t a D e S o t S a r a s o t a M a r t i n M a r t i n C h a r l o t t e G l a d e s C h a r l o t t e G l a d e s H e n d r y H e n d r y P L e e P a l m a l m B e a c h B e a c h L e e C o l l i e r B r o w a r d C o l l i e r B r o w a r d M o n r o e M o n r o e D a d e D a d e 19

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 20

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). 21

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. 22

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? 23

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? 24

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 Chemists? 2.3.4.02 Emergency management? 2.3.4.03 Environmental health scientists? 2.3.4.04 State epidemiologists? 2.3.4.05 Hazardous Material Response Teams? 2.3.4.06 Health physicists? 2.3.4.07 Industrial hygienists? 2.3.4.08 Infectious disease specialists? 2.3.4.09 Law enforcement? 2.3.4.10 Medical examiners/coroner? 2.3.4.11 Microbiologists? 2.3.4.12 National Guard? 2.3.4.13 Occupation health physicians? 2.3.4.14 State public health laboratory director? 2.3.4.15 Toxicologists? 2.3.4.16 Veterinarians? 2.3.4.17 Funeral/Mortuary Directors? 25

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% 26-50% 51-75% 76-100% 1 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% 26-50% 51-75% 76-100% 1 2 3 4 26

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 27

Index Case Illness onset September 30 Hospital admission October 2 Unexplained, non-localizing severe illness shaking chills, fever vomiting altered mental status 28

Clinical Findings Incoherent Fever Supple neck Clear lung sounds Hypotensive Seizures 29

Clinical Findings WBC count: 9400 mm 3 Chest X-ray increased perihilar density Head CT normal Cerebrospinal fluid 4570 WBC mm 3, 1375 RBC mm 3 glucose=57 mg/dl; protein=666 mg/dl 30

Cerebrospinal Fluid Gram Stain 32

Initial Interview Dr. Kumar Senior Physician Director Epidemiology Dr. Malecki Director Lead Investigator Judith M Cobb Com. Health Nursing Consultant Lead Interviewer John O'Malley Env. Adm. Env. Health & Eng. Barbara F Johnson Sr. Com. Health Nursing Supv. Epidemiology 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 34

Early Considerations Source? natural intentional Communication objectives isolated case full-scale investigation no known transmission person-to-person 35

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 36

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? 39

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? 40

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? 41

8.4.5 How much of this LPHS Model Standard is achieved by the local public System collectively? 0-25% 26-59% 51-75% 76-100% 1 2 3 4 is the 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 45

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 51

Day 4: Intervention Planning Define exposed group Anyone in AMI building >1 hour In past 60 days Assess exposure Questionnaire Nasal cultures Serology testing 52

Day 5: Intervention 54

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

MAIL ROOM 60

US POSTAL SERVICE 61

Postal Service Investigation Green Acres Lake Worth AMI West Palm Main Branch Blue Lake <5% 95%+ AMI Van Boca Raton Main Substation 62

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. Recognize that panic is rare and preventable 2. Enlist the general public as a capable partner 3. Think beyond the hospital for mass-casualty care 4. 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 67

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 71

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. 72

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. 74

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? 79