Biological Threats and the Importance of Preparedness

Thomas Inglesby, MDCenter for Biosecurity of UPMC

March 3, 2008

Major PointsjBiological threats remain a top problem before the country -need to keep working toward long-term resilience, the ability p g g , yto withstand bioattacks or pandemics

Building biopreparedness will help us deal with otherBuilding biopreparedness will help us deal with other catastrophes, make progress on serious health care challenges, and improve U.S. ability to help other countries

Biopreparedness funding has been invaluable in past years and will be critical in years ahead

State of H5N1 in the WorldBird Cases -- More than 200M killed or culled

59 counties affectedLast 3 months: bird outbreaks in China, Thailand, Laos, Vietnam, Indonesia,Last 3 months: bird outbreaks in China, Thailand, Laos, Vietnam, Indonesia, Bangladesh, India, Pakistan, Saudi Arabia, Egypt, Nigeria, Ukraine, Hungary, UK, Iran, Turkey, Myanmar, Romania, Benin, Poland, Russia, Israel, GermanyGeographic spread unprecedented: no past avian flu has led to global g p p p p goutbreak

Human cases since 2003 -- 360 cases, 226 have died • 63% human case fatality ratio;63% human case fatality ratio; • involving 14 countries on 3 continents

2008 so far: 11 human cases in Indonesia, Vietnam– 9 have died Source of infection unclear in ¼ cases - may be live-poultry market No sustained human to human transmission yetNo sustained human to human transmission yet

Never have so many different kinds of animals been infected with same flu virus: e.g. cats, dogs, pigs, ferrets, civets, fish, wide range of birds

H5N1 Outbreaks Humans and birds as of February 12 , 2007

U.S. Government Planning Assumptions for a Severe Pandemic Flu

Proportion of population ill: 25-30%Duration of community outbreak: 8 weeksAverage duration of illness: 10 daysAverage duration of illness: 10 daysCase/fatality ratio: 2% ?

90 illi ill90 million ill9.9 million hospitalized1.9 million U.S. deaths

[http://www.hhs.gov/pandemicflu/implementationplan/pdf/Pandemic.pdf – see pg. 18]

Influenza Outbreaks in 1957:A g tAugust

Percentage of CountiesReporting Outbreaks

0

10%

50%50%

Influenza Outbreaks in 1957:September 14September 14

Percentage of CountiesReporting Outbreaks

0

10%

50%50%

Influenza Outbreaks in 1957:September 28

Percentage of CountiesReporting Outbreaks

0

10%

50%50%

Influenza Outbreaks in 1957:October 12

Percentage of CountiesReporting Outbreaks

0

10%

50%50%

Influenza Outbreaks in 1957:October 26

Percentage of CountiesReporting Outbreaks

0

10%

50%50%

Major Migration Flows: 1960 75Major Transportation Flow: 1960-75Major Migration Flows: 1960-75j p

11Source: Population Action International 1994 Source: US CDC 11Source: US CDC

Major Migration Flows: 1990sMajor Transportation Flow: 1990sMajor Migration Flows: 1990sMajor Transportation Flow: 1990s

22

4 x increase in volume as compared to 19604 x increase in volume as compared to 1960--7575Source: Population Action International 1994 Source: US CDC 22Source: US CDC

Biological WeaponsCause disease epidemics

Proven to work• On smallest of scales: anthrax 2001 attacks, Soviet accidents • In past, large-scale field tests: U.S., UK, Former Soviet Union

Knowledge widely dispersed; not easy to detect or deterKnowledge widely dispersed; not easy to detect or deter• Materials accessible, inexpensive• Dual use, hard to track, easily hidden• Attribution difficult

Anthrax leads list, but many other “Material Threats to the Nation”:Smallpox, Botulism, Glanders, Meliodosis, Ebola, Marburg, Plague, Junin Virus, Tularemia, Drug-resistant pathogens

Based on number of analyses: large-scale bioattacks on par with nuclear terrorism in potential to cause fatalities

Previously healthy 47 year old manPreviously healthy 47 year old man…

• Develops nausea, pain in his abdomen, “flu”

• Four days later - Loses consciousness in church

• Next day intense abdominal pain goes to ER evaluated• Next day - intense abdominal pain goes to ER, evaluated, then sent home with medicines

• Becomes confused and unresponsive ambulance p

• Pt arrives to hosp in shock; placed on ventilator, dies 5 hrs later

Consider thousands of anthrax cases, or more

Discovery of first cases, only tip of the icebergPervasive uncertainties: scale of attack? location? who is at risk? Potential for “reload”: (repeated attacks over time and in differentPotential for “reload”: (repeated attacks over time and in different places); public will understand this, and everyone will feel at riskHospitals inundated with sick people and people seeking antibioticsNeed to get antibiotics to hundreds of thousands or millions ofNeed to get antibiotics to hundreds of thousands or millions of peopleSocial, economic disruption: may be severe Consequences not over quickly: timeline = weeks or moreConsequences not over quickly: timeline weeks or more

Public health and medicine central to the response

Al Qaeda Seeking Means of Large-scale Attacks

AQ h d j bi ff i Af h iAQ had major bioweapons effort in Afghanistan • WMD Commission on Intelligence, 2004 [http://www.wmd.gov/report/wmd_report.pdf]

• AQ claims “right to kill 4 million Americans, including 2 million children ”children.

Suliman Abu Ghaith, al Qaeda spokesman

2003: AQ justifies use of WMD on religious grounds in contradiction to mainstream Islamcontradiction to mainstream Islam

2006: AQ in Iraq: call for scientists to join jihad, help make WMD

• 2008: LA Times: AQ has reconstituted WMD program new R&D• 2008: LA Times: AQ has reconstituted WMD program, new R&D efforts and attempts to obtain

[See: http://www.upmc-biosecurity.org/website/biosecurity_briefing/archive/international_biosecurity/content/2006-09-29-alqaedalookingforscientists.html]

“Our greatest concern is that terrorists might acquire “Our greatest concern is that terrorists might acquire biological agents, or less likely, a nuclear device,

either of which could cause mass casualties.”either of which could cause mass casualties.

“Mapping the Global Future”: Report of the National Intelligence Council’s 2020 Project;

January 2005

Resilience to Biological ThreatsGoals

Prevention – improve international sentiment toward US morePrevention improve international sentiment toward US, more international collaboration, approbation against bioweapons; dismantle terrorist networks; ensure we can attribute

Hi hl i f d d b dl d bli b f d d i iHighly-informed and broadly prepared public - before and during crises

Info systems for health care & political leaders during crisis

Accelerate research, development, production, stockpiling of vaccines, therapies, diagnostic tests for major biological threats

Public health and medical systems that can cope with big epidemics and catastrophes• Rapidly investigate epidemics, communicate with leaders and the public,

prophylactic meds for the exposed, medical care for the sickprophylactic meds for the exposed, medical care for the sick

Big successesBig successes• National smallpox vaccine reserve • Large stockpiles of antibiotics & antivirals• Large stockpiles of antibiotics & antivirals• Substantial pandemic flu funding and program development

– Substantial pandemic vaccine development program• Stronger health departments (e.g. 2x the number ofStronger health departments (e.g. 2x the number of

epidemiologists; all on-call 24/7; better inter-heatlh dept comm.)• Improving hospital preparedness• PAHPA legislation • Federal programs consolidated under HHS ASPR• New BARDA office to develop meds, vaccines• Community resiliency now explicit policy goal

Continued global leadership in bio research and Biopharma• Continued global leadership in bio research and Biopharma industry

Serious ChallengesSerious Challenges• Small quantities of anthrax vaccine, no way to make more fast• Little funding for BARDA – long lists of unmet med, vaccine needsg g• Few tested means for mass distribution – need private sector to

engage• Hard to find and retain good public health leaders, investigators –

keep building human capital in public healthkeep building human capital in public health • Hospitals can’t cope with top national planning scenario events• Set biosurveillance strategy that makes sense • Health information systems that provide situational awarenessHealth information systems that provide situational awareness • Systems to help communities become more resilient, better cope

with disasters• Biological knowledge and technology evolving very fast

S• Stop losing ground in Bio research and global Biopharma position • Use US successes to help fight infectious disease abroad –

humanitarian assistance strongly improves attitudes toward US

“What physics was to the 20th century biology will be toWhat physics was to the 20th century, biology will be to the 21st…. Many of the big problems facing humanity are biological, or are susceptible to biological intervention…how to deal with an aging population ….climate change…the risk of a new lethal infection becoming pandemic…..the fact that such an infection g pmight itself be the result of synthetic biology only

emphasizes the biological nature of future risks….

June 2007 EconomistJu e 00 co o st