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Inhalation Anthrax Investigation:Inhalation Anthrax Investigation:Palm Beach County, FloridaPalm 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 WeaponsBiological Weapons

• Organisms themselves

– Cause disease two ways:

• Direct invasion• Release of toxins

• Toxins from organisms

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Why use it as a weapon?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

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Relative costsRelative costsTo cause effective lethality over 1 kmTo cause effective lethality over 1 km22

• Conventional weapons:

• Nuclear:

• Chemical:

• Biological

$2000 +

$800

$60

$1

Proceedings of the Seminar on Responding to the Consequences of Chemical and Biological Terrorism

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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

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Learning ObjectivesLearning 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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•  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).

ASSURANCEASSURANCEAssurance 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:

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ASSURANCEASSURANCEcon’tcon’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 anthracisBacillus anthracis

• Gram positive rod

• Spore forming

• Encapsulated

• Laboratory diagnosis– non-hemolytic, non-motile

– culture and gamma phage lysis

– PCR

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AnthraxAnthrax

• Zoonotic disease

• Transmission

– contact with infected animals

– laboratory exposure

– person to person not documented

• Biological weapon

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AnthraxAnthrax

United States

• 224 cutaneous 1944 – 1994

• 18 inhalation 1900 – 1978

Florida

• 8 human cases 1927 – 1974

• Last veterinary case reported 1953

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Role of a County Health Department Role of a County Health Department rrepresentative who epresentative who reports to the scene of a bio or chemical terrorist event is that of a 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 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, credible and effective in this role, he/she must be professional, experienced, knowledgeable, and articulate. Being knowledgeable experienced, knowledgeable, and articulate. Being knowledgeable includes expertise in: includes expertise in:

Principles of epidemiologyPrinciples of epidemiology Pathology and characteristics of potential biological agents Pathology and characteristics of potential biological agents relative toxicity and relative toxicity and characteristics of potential chemical agentscharacteristics of potential chemical agents Requirements for agent sampling and safeguarding crime scene Requirements for agent sampling and safeguarding crime scene

evidenceevidenceRequirements and authority for imposing/lifting quarantineRequirements and authority for imposing/lifting quarantineRequirements for decontamination and establishing downwind Requirements for decontamination and establishing downwind

evacuation zones ) see Chemical Terrorism Manual)evacuation zones ) see Chemical Terrorism Manual)Locations and capabilities of county medical facilities, HAZMAT, Locations and capabilities of county medical facilities, HAZMAT,

fire department, and law enforcement assets fire department, and law enforcement assetsUse of and requirements for respirators and other personalUse of and requirements for respirators and other personal

protection equipment protection equipmentEmergency event notification chainEmergency event notification chain

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CutaneousCutaneous

• Vesicular lesion

• Ulceration

• Painless

• Edema

• Antibiotics highly effective

• Incubation period 1–7 days

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CutaneousCutaneous

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InhalationInhalation• 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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Alachua

BakerBay

Bradford

Brevard

Broward

Calhoun

Charlotte

Citrus

Clay

Collier

Columbia

Dade

De Soto

Dixie

Duval

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Holmes

Indian River

Jackson

Jefferson

Lafayette

Lake

Lee

Leon

Levy

Liberty

Madison

Manatee

Marion

Martin

Monroe

NassauOkaloosa

Okeechobee

Orange

Osceola

Palm Beach

Pasco

Polk

Putnam

St Johns

St Lucie

Santa Rosa

Sarasota

SeminoleSumter

Suwannee

TaylorUnion

Volusia

Wakulla

WaltonWashington

Alachua

BakerBay

Bradford

Brevard

Broward

Calhoun

Charlotte

Citrus

Clay

Collier

Columbia

Dade

De Soto

Dixie

Duval

Escambia

Flagler

Franklin

Gadsden

Gilchrist

Glades

Gulf

Hamilton

Hardee

Hendry

Hernando

Highlands

Hillsborough

Holmes

Indian River

Jackson

Jefferson

Lafayette

Lake

Lee

Leon

Levy

Liberty

Madison

Manatee

Marion

Martin

Monroe

NassauOkaloosa

Okeechobee

Orange

Osceola

P alm Beach

Pasco

Polk

Putnam

St Johns

St Lucie

Santa Rosa

Sarasota

SeminoleSumter

Suwannee

TaylorUnion

Volusia

Wakulla

WaltonWashington

Palm Beach County, Florida

• October 4, 2001– Confirmation of B. anthracis– Florida DOH team arrives– CDC team arrives– FBI arrives

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Local Public Health System Performance Local Public Health System Performance Assessment InstrumentAssessment Instrument

Essential Health Services #2Essential Health Services #2

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

DIAGNOSE AND INVESTIGATE HEALTH DIAGNOSE AND INVESTIGATE HEALTH PROBLEMS AND HEALTH HAZARDS IN THE PROBLEMS AND HEALTH HAZARDS IN THE

COMMUNITYCOMMUNITY

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Indicator 2.3: Investigate and Respond to Indicator 2.3: Investigate and Respond to Public Health EmergenciesPublic 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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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.

Indicator 2.3: Investigate and Respond to Indicator 2.3: Investigate and Respond to Public Health EmergenciesPublic Health Emergencies

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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 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?

 

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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% 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

 

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Index CaseIndex 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 CaseIndex 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 FindingsClinical Findings

• Incoherent

• Fever

• Supple neck

• Clear lung sounds

• Hypotensive

• Seizures

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Clinical FindingsClinical 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 InterviewInitial Interview

Dr. Kum arSenior Physician

DirectorEpidem iology

Barbara F JohnsonSr. Com . Health Nursing Supv.

Epidem iology

Judith M Cob bCom . Health Nursing Consultant

LeadInterview er

Dianne StrockEnv. Mgr.

Env. Health & Eng

John O 'MalleyEnv. Adm.

Env. Health & Eng.

Dr. MaleckiDirector

LeadInvestigator

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HISTORYHISTORY

• 60 Days Prior to Onset of Disease

• Daily Activities (Work and Home)

• Meals

• Hobbies & Pets

• Travel

• Recreation

• Unusual Incidents

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Early ConsiderationsEarly 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 Local Public Health System Performance Assessment InstrumentAssessment Instrument

Essential Health Services #8Essential Health Services #8

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

ASSURE A COMPETENT PUBLIC AND ASSURE A COMPETENT PUBLIC AND PERSONAL HEALTH CARE WORKFORCEPERSONAL HEALTH CARE WORKFORCE

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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.

 

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• Provide formal (e.g., educational programs, leadershipinstitutes) and informal (e.g., coaching, mentoring)opportunities for leadership development for employeesat all organizational levels. 

• Promote collaborative leadership through the creation of alocal public health system with a shared vision andparticipatory 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

To accomplish this, the organizations within the LPHS:

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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 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

 

8.4.5.1 What percent of the answer reported in question 8.4.5 is the direct contribution of the local public health agency?

 

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Response StrategyResponse Strategy

• Active surveillance

• Environmental investigation

• Clinical evaluation

• Collaboration: NC & Atlanta

• Communications

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Suspect CaseSuspect Case

EB

• 73 year old male

• AMI employee

• Respiratory illness onset Sep 28

• Hospital admission Oct 1

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Day 4: Pivotal FindingsDay 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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AMIAMI

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WORK STATIONWORK STATION

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KEYBOARDKEYBOARD

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BULK SAMPLESBULK SAMPLES

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QUARANTINEQUARANTINE

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Strategy ChangeStrategy 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 PlanningDay 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: InterventionDay 5: Intervention

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Exposure AssessmentExposure AssessmentIndex CaseIndex Case

• Observed viewing suspicious mail (9/19?)

– Contained fine white powder

– Also contained “Jewish star”

• Office cultures positive

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Anthrax Links With MailAnthrax Links With Mail

• Index case: handled “suspicious” mail

• EB: AMI mail distributor

• SD: mail sorter -- opened letter with white powder

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AMI mailroomAMI mailroom

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MAIL ROOMMAIL ROOM

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US POSTAL SERVICEUS POSTAL SERVICE

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Postal Service InvestigationPostal Service Investigation

AMI

Boca RatonMain

Substation

AMIVan

Blue Lake

West PalmMain

Branch

GreenAcres Lake

Worth

<5%

95%+

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Contaminated MailContaminated 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

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Time LineTime Line

9/11 9/18 9/25 10/2 10/9 10/16 10/23 10/30

WTC te

rroris

t acts

Epi team

s arrive

_______Index ill

ness

Index le

tter

EB illness

SD lette

r

AMI sourc

e

PO testin

g

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Insights Gained:Insights Gained: Florida Experience 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 -

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Five Guidelines For Including the Public In Five Guidelines For Including the Public In Bioterrorism Response PlanningBioterrorism Response Planning

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

“Vaccinating a city against panic”

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Other Public Health Threats During Other Public Health Threats During Anthrax InvestigationAnthrax Investigation

• Hurricane Michelle

• West Nile Virus Alert

• Death due to Legionnaires Disease

• Ciguatera Toxin Poisoning

• Over 900 Anthrax Hoaxes

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SummarySummary

• 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.

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Insights Gained:Insights Gained: Florida Experience Florida Experience

• Testing

• Laboratory logistics

• Data management

• Interagency collaboration

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Insights Gained:Insights Gained: Florida Experience 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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LeadershipLeadershipCollaborative LeadershipCollaborative 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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LeadershipLeadership

• 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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LeadershipLeadershipCollaborative LeadershipCollaborative Leadership

• Being broadly inclusive

• Creating a credible open process

• Bringing about a shared understanding

Collaborative leaders are sustained by their deeply democratic belief that people have the capacity to create their own visions and solve their own problems.

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Authentic visions and strategies for addressing the shared concerns of the organization or community will be created.

• Convene

• Energize

• Facilitate

• Sustain the process

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The only consensus that really matters

is that of the people who live

there. 

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National EnquirerNational Enquirer

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““What’s next? Anthrax What’s next? Anthrax

action figures?action figures?

Can I get a Happy Meal with Can I get a Happy Meal with

the Dr. Jean Malecki doll, the Dr. Jean Malecki doll,

please?”please?”

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