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Testimony
Before the Committee on
Governmental Affairs and Subcommittee on International Security,
Proliferation and Federal Services
United States Senate
Bioterrorism:
CDC's Public Health Response
Statement of
Mitchell L. Cohen, M.D.
Director
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Department of Health and Human Services
For Release on Delivery
Expected at 9:30
am
on Wednesday,
October 31, 2001
Good morning, Mr. Chairman
and Members of the Committee. I am Dr. Mitchell L. Cohen,
Director, Division of Bacterial and Mycotic Diseases, National
Center for Infectious Diseases, Centers for Disease Control
and Prevention (CDC). Thank you for the invitation to update
you on CDC's public health response to the threat of bioterrorism.
I will update you on CDC's response to recent anthrax exposures,
and I will discuss the status of implementing the overall
goals of our bioterrorism preparedness program.
As has been highlighted recently,
increased vigilance and preparedness for unexplained illnesses
and injuries are an essential part of the public health
effort to protect the American people against bioterrorism.
Prior to the September 11 attack on the United States, CDC
was making substantial progress toward defining, developing,
and implementing a nationwide public health response network
to increase the capacity of public health officials at all
levels-federal, state, and local-to prepare for and respond
to deliberate attacks on the health of our citizens. The
events of September 11 were a defining moment for all of
us, and since then we have dramatically increased our levels
of preparedness and are implementing plans to increase it
even further.
Recent Anthrax Exposures
As you are aware, many facilities
in communities around the country have received anthrax
threat letters. Most were received as empty envelopes; some
have contained powdery substances. However, in some cases,
actual anthrax exposures have occurred. On Wednesday, October
3, the Florida Department of Health notified CDC of a positive
anthrax laboratory test result in a Florida resident who
had recently visited North Carolina. Samples were sent overnight
to CDC for confirmatory testing, and CDC dispatched two
investigative teams-to Florida and North Carolina-on October
4. By Sunday, October 7, test results confirmed that a second
person-a coworker of the first individual-had been exposed
to anthrax and that traces of the bacteria had been found
in their workplace. A decision was made to close the building,
and additional CDC staff were sent to help the state and
local public health department manage notification, health
evaluations of other coworkers, and provision of prophylactic
antibiotics after the National Pharmaceutical Stockpile
was deployed.
As CDC was continuing to
receive clinical specimens and environmental samples from
Florida, we became aware of a possible case of cutaneous
anthrax in New York City. This person, an NBC employee in
Rockefeller Plaza, had opened envelopes containing powder
on September 18 and 25 and subsequently developed a skin
lesion. A biopsy of the lesion yielded evidence of anthrax.
The diagnosis was confirmed by immunohistochemistry on a
skin biopsy specimen in CDC's laboratory in the early morning
of October 12. The New York City Department of Health and
CDC immediately implemented appropriate public health actions,
including restricting access to two floors of 30 Rockefeller
Plaza and evaluating workers for the need for prophylactic
therapy. CDC sent additional personnel to New York, joining
the more than 30 epidemiologists and other CDC staff assisting
with worker injury and enhanced syndrome surveillance following
the September 11 terrorist attack. Laboratory studies on
the powder from the September 25 letter were negative for
the organism causing anthrax. Subsequent investigation identified
the letter that had arrived on September 18, which was found
to be contaminated with Bacillus anthracis, the
organism that causes anthrax.
On October 15, CDC was notified
of a possible anthrax exposure on Capitol Hill. A letter,
which has now been confirmed to have contained B. anthracis,
was opened by a Senate staff member. This person took appropriate
action, notifying emergency personnel, and public health
measures were promptly implemented. Certain areas of the
office building were closed, and employees were screened
by history for exposure and started on antibiotic prophylaxis
after a nasal swab was obtained to assess the extent of
the exposure zone. CDC has sent over 70 epidemiologists,
laboratorians, environmental health experts, industrial
hygienists, and other public health professionals to Washington,
DC, to assist local, state, and federal authorities in the
investigation.
Environmental specimens have
tested positive from the initial area of exposure as well
as several other locations in Congressional office buildings.
In addition, mail rooms in the U.S. Capitol complex have
had positive environmental samples. Environmental specimens
have also tested positive from mail facilities servicing
the Departments of State and Justice, the CIA, the Walter
Reed Army Institute of Research, and the U.S. Supreme Court.
Late Friday evening, October
19, enhanced regional surveillance activities-a collaborative
effort between the Washington, DC, Department of Health
(DCDOH), the Maryland Department of Health and Mental Hygiene,
and the Virginia Department of Health-identified a patient
with an acute respiratory illness who was an employee of
the U.S. Postal Service's Washington, DC, Processing and
Distribution Center (the Brentwood facility). The patient's
illness progressed, and on Sunday, October 21, the illness
was confirmed as inhalational anthrax. Between October 20
and 22, three additional postal workers at the Brentwood
facility were hospitalized for what was determined to be
inhalation anthrax. On Thursday, October 25, a mail handler
for diplomatic pouch mail at an off-site mail facility servicing
the Department of State was hospitalized and subsequently
confirmed as having inhalational anthrax. Two of these five
workers have died.
On Saturday, October 20,
CDC and DCDOH initiated an investigation of the Brentwood
facility, based on the clinical presentation of illness
in the index case. Although no specific exposure event was
identified, the contaminated tightly sealed letter that
was mailed to the Senator's office was processed at this
facility on October 12 before entering the Capitol mail
distribution system. The Brentwood facility was closed on
October 21, and antibiotic prophylaxis was recommended to
employees working there. In addition, business visitors
to nonpublic operations areas of this facility also were
offered antibiotics. Subsequently, antibiotic therapy has
been recommended to all mail handlers in facilities receiving
mail directly from the Brentwood facility pending results
of ongoing epidemiologic and environmental investigation.
The first patient also worked
at a second postal facility. On October 21, this facility
also was closed. Antimicrobial prophylaxis also was recommended
for workers at this facility pending further epidemiologic
and environmental testing.
As of this morning-October
30-2 cases of inhalational anthrax have been identified
in Florida, 5 cases of inhalational anthrax have been identified
in Washington, DC, 1 case of inhalational anthrax and 6
cases of cutaneous anthrax have been identified in New York
City, and 2 cases of inhalational anthrax and 4 cases of
cutaneous anthrax have been identified in New Jersey.
CDC is working with U.S.
Postal Service employees and managers on strategies to protect
workers in mail-handling and processing facilities from
exposure to anthrax. These strategies include administrative
controls to limit the number of workers potentially exposed,
engineering and house-keeping controls to prevent exposure,
and personal protective equipment for workers handling mail.
The best defense against
such biologic threats continues to be accurate information
regarding how to recognize a potential threat and knowledge
of appropriate actions. In the Morbidity and Mortality
Weekly Report (MMWR) and in multiple health
advisories distributed via the Health Alert Network, CDC
has issued several updates on the investigations as well
as interim guidelines for health departments with recommended
procedures for handling such incidents. These guidelines
include advice to the public and state and local health
officials dealing with suspicious incidents, as well as
guidance to clinical laboratory personnel in recognizing
Bacillus anthracis in a clinical specimen. The
guidelines also outline post-exposure prophylaxis and anthrax
treatment recommendations. In persons exposed to Bacillus
anthracis, disease can be prevented with antibiotic
treatment. Early antibiotic treatment of all forms of anthrax
is essential. The Bacillus anthracis strains in
this outbreak are susceptible to doxycycline and fluoroquinolones.
Ciprofloxacin or doxycycline is recommended as the antibiotic
for initial use for prophylaxis. Copies of the October 26,
2001, MMWR, which addresses these issues, have
been provided to the Committee.
This is the first bioterrorism-related
anthrax attack in the United States, and the public health
ramifications of this attack continue to evolve. In collaboration
with state and local health and law enforcement officials,
CDC and the FBI are continuing to conduct investigations
related to anthrax exposures. During this heightened surveillance,
cases of illness that may reasonably resemble symptoms of
anthrax will be thoroughly reviewed. The public health and
medical communities continue to be on a heightened level
of disease monitoring to ensure that any potential exposure
is recognized and that appropriate medical evaluations are
given. This is an example of the disease monitoring system
in action, and that system is working.
Public Health Leadership
The Department of Health
and Human Services' (DHHS) anti-bioterrorism efforts are
focused on improving the nation's public health surveillance
network to quickly detect and identify the biological agent
that has been released; strengthening the capacities for
medical response, especially at the local level; expanding
the stockpile of pharmaceuticals for use if needed; expanding
research on disease agents that might be released, rapid
methods for identifying biological agents, and improved
treatments and vaccines; and preventing bioterrorism by
regulation of the shipment of hazardous biological agents
or toxins.
As the nation's disease prevention
and control agency, it is CDC's responsibility on behalf
of DHHS to provide national leadership in the public health
and medical communities in a concerted effort to detect,
diagnose, respond to, and prevent illnesses, including those
that occur as a result of a deliberate release of biological
agents. This task is an integral part of CDC's overall mission
to monitor and protect the health of the U.S. population.
In 1998, CDC issued Preventing
Emerging Infectious Diseases: A Strategy for the 21st Century,
which describes CDC's plan for combating today's emerging
diseases and preventing those of tomorrow. It focuses on
four goals, each of which has direct relevance to preparedness
for bioterrorism: disease surveillance and outbreak response;
applied research to identify risk factors for disease and
to develop diagnostic tests, drugs, vaccines, and surveillance
tools; infrastructure and training; and disease prevention
and control. This plan was developed with input from state
and local health departments, disease experts, and partner
organizations such as the American Society for Microbiology,
the Association of Public Health Laboratories, the Council
of State and Territorial Epidemiologists, and the Infectious
Disease Society of America. It emphasizes the need to be
prepared for the unexpected - whether it is a naturally
occurring influenza pandemic or the deliberate release of
anthrax by a terrorist. It is within the context of these
overall goals that CDC has begun to address preparing our
nation's public health infrastructure to respond to acts
of biological terrorism. Copies of this CDC plan have been
provided previously to the Committee. In addition, CDC presented
in March a report to the Senate entitled Public Health's
Infrastructure: A Status Report. Recommendations in
this report complement the strategies outlined for emerging
infectious diseases and preparedness and response to bioterrorism.
These recommendations include training of the public health
workforce, strengthening of data and communications systems,
and improving the public health systems at the state and
local level.
CDC's Strategic Plan for
Bioterrorism
CDC outlined necessary steps
for strengthening public health and healthcare capacity
to protect the nation against bioterrorist threats in its
April 21, 2001, MMWR release of Biological
and Chemical Terrorism: Strategic Plan for Preparedness
and Response - Recommendations of the CDC Strategic Planning
Workgroup. This report reinforces the work CDC has
been contributing to this effort since 1998 and lays a framework
from which to enhance public health infrastructure. In keeping
with the message of this report, five key focus areas have
been identified which provide the foundation for local,
state, and federal planning efforts: Preparedness and Prevention,
Detection and Surveillance, Diagnosis and Characterization
of Biological and Chemical Agents, Response, and Communication.
These areas capture the goals of CDC's Bioterrorism Preparedness
and Response Program for general bioterrorism preparedness.
- Preparedness and Prevention
CDC has been working to ensure that all levels of the public
health community - federal, state, and local - are prepared
to work in coordination with the medical and emergency response
communities to address the public health consequences of
biological and chemical terrorism.
CDC is creating
diagnostic and epidemiological guidelines for state and
local health departments and will help states conduct drills
and exercises to assess local readiness for bioterrorism.
In addition, CDC, the Food and Drug Administration (FDA),
the National Institutes of Health (NIH), the Department
of Defense (DOD), and other agencies are supporting and
encouraging research to address scientific issues related
to bioterrorism. In some cases, new vaccines, antitoxins,
or innovative drug treatments need to be developed, manufactured,
and/or stocked. Moreover, we need to learn more about the
pathogenesis and epidemiology of the infectious diseases
which do not affect the U.S. population currently. We have
only limited knowledge about how artificial methods of dispersion
may affect the infection rate, range of illness, and public
health impact of these biological agents.
- Detection and Surveillance
As was evidenced in Florida, New York, and Washington, DC,
the initial detection of a biological terrorist attack occurs
at the local level. Therefore, it is essential to educate
and train members of the medical community - both public
and private - who may be the first to examine and treat
the victims. It is also necessary to upgrade the surveillance
systems of state and local health departments, as well as
within healthcare facilities such as hospitals, which will
be relied upon to spot unusual patterns of disease occurrence
and to identify any additional cases of illness. CDC is
providing terrorism-related training to epidemiologists
and laboratorians, infection control personnel, emergency
responders, emergency department personnel and other front-line
health-care providers, and health and safety personnel.
CDC is providing educational materials regarding potential
bioterrorism agents to the medical and public health communities
on its website for Public Health Emergency Preparedness
and Response at www.bt.cdc.gov.
CDC is working with partners such as the Johns Hopkins Center
for Civilian Biodefense Studies (www.hopkins-biodefense.org)
and the Infectious Diseases Society of America to develop
training and educational materials for incorporation into
medical and public health graduate and post-graduate curricula.
With public health partners, CDC is spearheading the development
of the National Electronic Disease Surveillance System,
which will facilitate automated, timely electronic capture
of data from the healthcare system.
- Diagnosis and Characterization
of Biological and Chemical Agents
To ensure that prevention and treatment measures can be
implemented quickly in the event of a biological or chemical
terrorist attack, rapid diagnosis is critical. CDC has developed
guidelines and quality assurance standards for the safe
and secure collection, storage, transport, and processing
of biologic and environmental samples. In collaboration
with other federal and non-federal partners, CDC is co-sponsoring
a series of training exercises for state public health laboratory
personnel on requirements for the safe use, containment,
and transport of dangerous biological agents and toxins.
CDC, also in cooperation with the Association of Public
Health Laboratories (APHL) and the National Laboratory Training
Network (NLTN) have sponsored a "hands-on" laboratory course
for public health microbiologists. In conjunction with the
course, CDC produced two videos that were distributed to
the participants as well as to members of the NLTN. The
participants in this course are now using these videos and
the other materials developed by CDC to train other laboratorians
in their states. CDC is also enhancing its efforts to foster
the safe design and operation of Biosafety Level 3 laboratories,
which are required for handling many highly dangerous pathogens.
Furthermore, CDC is developing a Rapid Toxic Screen to detect
people's exposure to 150 chemical agents using blood or
urine samples.
A decisive and timely response to a biological terrorist
event involves a fully documented and well rehearsed plan
of detection, epidemiologic investigation, and medical treatment
for affected persons, and the initiation of disease prevention
measures to minimize illness, injury and death. CDC is addressing
this by (1) assisting state and local health agencies in
developing their plans for investigating and responding
to unusual events and unexplained illnesses, and (2) bolstering
CDC's capacities within the overall federal bioterrorism
response effort. CDC is formalizing current draft plans
for the notification and mobilization of personnel and laboratory
resources in response to a bioterrorism emergency, as well
as overall strategies for vaccination, and development and
implementation of other potential outbreak control strategies
such as quarantine measures. In addition, CDC is developing
national standards to ensure that respirators used by first
responders and by other health care providers responding
to terrorist acts provide adequate protection against weapons
of terrorism.
Rapid and secure communications are crucial to ensure a
prompt and coordinated response to an intentional release
of a biological agent. Thus, strengthening communication
among clinicians, emergency rooms, infection control practitioners,
hospitals, pharmaceutical companies, and public health personnel
is of paramount importance. To this end, CDC is making a
significant investment in building the nation's public health
communications infrastructure through the Health Alert Network
(HAN). HAN is a nationwide program to establish the communications,
information, distance-learning, and organizational infrastructure
for a new level of defense against health threats, including
bioterrorism. Currently, 13 states are connected to all
of their local health jurisdictions; 37 states have begun
connecting to local providers as well; and CDC is also directly
connecting to groups, such as the American Medical Association,
to cast a broad net of coverage. CDC has also established
the Epidemic Information Exchange (Epi-X), a secure, Web-based
communications system that provides information sharing
capabilities to state and local health officials. CDC also
provides timely satellite broadcast and web-broadcast training
through the Public Health Training Network. For example,
CDC experts recently shared information on anthrax with
physicians, hospitals, and other healthcare providers across
the country.
Ongoing communication
of accurate and up-to-date information helps calm public
fears and limit collateral effects of the attack. CDC communicates
with the public directly through its website on emergency
preparedness and through a public inquiry telephone and
email system, which, since the recent attacks, has responded
to hundreds of questions daily. In addition, CDC communicates
to the public by releasing daily updates to the news media,
answering inquiries from the press and providing medical
experts for interviews.
The National Pharmaceutical
Stockpile
Another integral
component of public health preparedness at CDC has been
the development of a National Pharmaceutical Stockpile (NPS),
which is mobilized in response to an episode caused by a
biological or chemical agent. The role of the CDC's NPS
program is to maintain a national repository of life-saving
pharmaceuticals and medical material that can be delivered
to the site or sites of a biological or chemical terrorism
event in order to reduce morbidity and mortality in a civilian
population. The NPS is a backup and means of support to
state and local first responders, healthcare providers,
and public health officials. The NPS program consists of
a two-tier response: (1) 12-hour push packages, which are
pre-assembled arrays of pharmaceuticals and medical supplies
that can be delivered to the scene of a terrorism event
within 12 hours of the federal decision to deploy the assets
and that will make possible the treatment or prophylaxis
of disease caused by a variety of threat agents; and (2)
a Vendor-Managed Inventory (VMI) that can be tailored to
a specific threat agent. Components of the VMI will arrive
at the scene 24 to 36 hours after activation. The NPS was
mobilized for the first time on September 11, when a 12-hour
push pack was deployed to New York City, delivering 50 tons
of medical supplies to the site of the disaster in 7 hours.
In addition, substantial quantities of VMI were delivered
to New York City within 24 hours. Components of the VMI
were deployed to Palm Beach, Florida, Montgomery County,
Maryland, and Trenton, New Jersey, to provide adequate supplies
of antibiotics to provide prophylaxis to individuals who
were potentially exposed to anthrax. CDC has developed this
program in collaboration with federal and private sector
partners and with input from the states.
Core Capacities for State
and Local Health Bioterrorism Preparedness and Response
CDC has been
working with partners at all levels to develop core capacities
needed to respond to pubic health threats and emergencies.
CDC is also developing specific guidelines to assist public
health agencies in their efforts to build comprehensive
bioterrorism preparedness and response programs. This collaborative
effort engages federal, state, and local partners in determining
what is needed for state and local public health agencies
to improve their preparedness and response to bioterrorism.
This process enables health departments to more effectively
target specific improvements to protect the public's health
in the event of a biological or chemical terrorist event
and will provide the framework for future program efforts.
The core capacities effort is for dual purpose. While these
capacities focus on bioterrorism events, they are also relevant
to naturally occurring infectious disease outbreaks and
natural disasters.
Challenges
CDC has been
addressing issues of detection, epidemiologic investigation,
diagnostics, and enhanced infrastructure and communications
as part of its overall bioterrorism preparedness strategies.
Based on federal, state, and local response in the weeks
following the events of September 11, and on recent training
experiences, such as the National TOPOFF event and the Dark
Winter exercise, CDC has learned valuable lessons and identified
gaps that exist in bioterrorism preparedness and response
at federal, state, and local levels. CDC will continue to
work with partners to address challenges such as improving
coordination among other federal agencies during a response
and understanding the necessary relationship needed between
conducting a criminal investigation versus an epidemiologic
case investigation. These issues, as well as overall preparedness
planning at federal, state, and local levels, require additional
action to ensure that the nation is fully prepared to respond
to acts of biological and chemical terrorism.
Disease experts
at CDC are working with partners at other federal agencies
and in state and local health departments to develop strategies
to prevent the spread of disease during and after bioterrorist
attacks. Specific components include (1) creating protocols
for immunizing at-risk populations subject to the availability
of suitable vaccines; (2) isolating large numbers of exposed
individuals when there is risk that the disease can be spread
from person to person; (3) reducing occupational exposures;
(4) assessing methods of safeguarding food and water from
deliberate contamination; and (5) exploring ways to improve
linkages between animal and human disease surveillance networks
since threat agents that affect both humans and animals
may first be detected in animals.
Conclusion
In conclusion,
CDC is committed to working with other federal agencies
and partners as well as state and local public health departments
to ensure the health and medical care of our citizens. We
have made substantial progress to date in enhancing the
nation's capability to prepare for and respond to a bioterrorist
event. The best public health strategy to protect the health
of civilians against a biological attack is the development,
organization, and enhancement of public health prevention
systems and tools. Priorities include strengthened public
health laboratory capacity, increased surveillance and outbreak
investigation capacity, and health communications, education,
and training at the federal, state, and local levels. Not
only will this approach ensure that we are prepared for
deliberate bioterrorist threats, but it will also ensure
that we will be able to recognize and control naturally
occurring new or re-emerging infectious diseases. A strong
and flexible public health infrastructure is the best defense
against any disease outbreak.
Thank you very
much for your attention. I will be happy to answer any questions
you may have.
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Last revised: November 1, 2001