| Home > Events > 2nd National Symposium > Jeffrey Koplan CDC's Strategic Plan for Bioterrorism
Jeffrey Koplan, MD, MPH DR. HENDERSON: For our first presentation this afternoon or this morning, the second part of the morning, we're pleased to welcome Dr. Jeff Koplan. Dr. Koplan is Director of the Centers for Disease Control, and he's an Assistant Surgeon General in the Public Health Service. Jeff joined CDC in 1972 and had a 22-year distinguished career with leadership roles, I would say, in virtually every major program of the center, including I am happy to say some experience with smallpox, which I'm sure had a great deal to do with his future career. He left CDC in 1994 to become President of the Prudential Center for Health Care Research, but they recruited him back to CDC two years ago to assume the position of Director. He's a graduate of Yale and the Harvard Schools of Medicine and Public Health. Two years ago CDC was charged with taking a lead role in the civilian bioterrorism preparedness, and since that time, remarkable strides have been made. It is a special pleasure to have Jeff with us to discuss CDC's strategic plan for bioterrorism. Jeff Koplan. (Applause.) DR. KOPLAN: Thank you, D.A. It's a pleasure to be here with you today, a challenging subject, a challenging topic.
I was sitting here this morning, and it crossed my mind that probably over half this audience are writers keen on writing the next bio horror disaster thriller and here to get material. (Laughter.) As D.A. said, based on a charge from Secretary Donna Shalala in 1998, CDC has been given a lead public health role in efforts to strengthen the nation's capacity to detect and respond to a bioterrorist threat. The mission in responding to bioterrorism is not that much different from our overall mission, and indeed, I view what we're doing as an extension of longstanding roles and responsibilities in public health. Over the past 50 years, CDC has seen a decline in the instance of some diseases, an increase in some others, and many new diseases. In the last 30 years, we've had 30 new infectious diseases that we've been confronted with, some of whom have become fixtures in our battles: HIV, hanta virus, Legionnaires, toxic shock syndrome, Lyme disease, and others that have waned and waxed over the years. We estimate that CDC is involved in 800 to 1,000 field investigations every year, and these days our new focus of activity is on both emerging infectious diseases and bioterrorism in the infectious disease realm. What are we doing to address this challenge? Well, for one, I'd like to make it clear that we don't think we have finished addressing it. We're barely getting started. We're not there yet, but we do feel we've made significant and substantial gains even in the past year, and that's what I'm going to share with you today. But I think as you've heard from this morning's earlier speakers, the immensity and the depth, the range of the challenges before us are so great that there will be no point in this process where we can sit back and say, "Well, we've done it. We're prepared, and we're ready to go." That's not going to be a feature of the challenge of bioterrorism. We've developed a broad based strategy that has complementary and coordinated improvements in bioterrorism related preparedness as our goal, and this is going to take place at federal, state, and local levels, and we've involved a large number of consultations and partners in this to put this together. Many of the groups are outlined before you, but they include the Association of State and Territorial Health Officials, Association of Public Health Labs, Council of State and Territorial Epidemiologists, American Society of Microbiology, Infectious Disease Society of America, and the Center for Civilian Biodefense Studies at Johns Hopkins, as well as a number of others. The plan addresses a variety of issues, but there's an emphasis on enhancing capacity for detection, diagnosis, and management of disease outbreaks; improving the characterization and identification of causative pathogens, toxins, and selected chemical exposures; strengthening public health response capacities to control and contain such emergencies; and improving our information technology infrastructure so that we can rapidly transfer data and information needed to prepare and respond to these events. First and foremost in our minds is to insure that we have the appropriate level of preparedness and response capacities at local and state levels in both the public and private health care systems. The first signs of a bioterrorist event will be observed at this level, and it makes sense that we place our greatest efforts there as our first lines of defense. However, preparing communities to address the dangers of bioterrorism is a major challenge. A critical step in meeting these challenges is to reexamine the core public health infrastructure in the United States. This term gets used a lot, and for those of you who are not in the public health community, it involves disease surveillance, detection, monitoring, and reaction to health events, a wide range of health events, training of health personnel, and a wide range of disciplines, health communications, and laboratory capacity. Enhancing this core public health infrastructure will enable public health agencies and primary health care providers who are the front lines of response to detect and respond rapidly when an incident occurs. Indeed, when that magical ship is available that does the ten to the sixth, ten to the seventh test and gives us that information that George referred to in the presentation earlier, it will still require these laboratories, these individuals to get those specimens and use these chips and put them into place so that there is a good meshing of this improved biotechnology that we'll have available to us as a tool with people and skills and responsibilities that exist now at local and state levels. We have gained some additional resources for this effort in the year 1999 and the year 2000. Over $275 million have been appropriated to CDC to help insure efforts occur associated with bioterrorism preparedness and response. Apart from the pharmaceutical stockpile and some other congressional earmarks, the major share of these funds are awarded extramurally to state and local bioterrorism efforts. And with these funds, public health agencies have begun to develop capacities and enhance existing public health infrastructure in ways not possible without the infusion of such monies. Specific activities include development and implementation of information systems used to monitor disease trends, detect outbreaks, and improve public health decisions, such as the National Electronic Disease Surveillance system, NEDS, and the Health Alert Network, HAN. I remind some of you who haven't worked in state and local health departments that our public health communications surveillance network, computational network, has lagged that of many other sectors of our society. Many of my public health colleagues, particularly at the community, county, city level are still working on technologies that involve paper and pen, telephones, while their kids are at home using the Web and Internet to order from Lands End and Toys R Us. (Laughter.) We would like to correct that gap. One of the things we have been working on is improving local capacity to assess what their characteristics are and what their needs are and to provide some standards. We work with the Department of Justice to implement an assessment tool for local public health agencies, and this has already begun to reveal important pieces of information useful to them and to us nationally. Since the inception of the bioterrorism initiative, CDC has worked hard to improve our own capacity, and a number of our staff are here today and I'm sure will interact with you. Dr. Jim Hughes, who is Director of our National Center for Infectious Diseases, and Scott Lillibridge and his colleagues who are in the bioterrorism and preparedness program. One of the things we have emphasized is improving our laboratory capacity. Prior to the inception of the bioterrorism initiative, we had limited capacities for many bioterrorist agents, which some of them we had had at one time and lapsed over the years. We've improved on our in-house ability to test for five of the six pathogens listed on the critical biological agents Category A list, plague, tularemia, botulinum toxin, small pox, and viral hemorrhagic fevers, and have added the ability to test for anthrax. These six critical agents represent diseases that can be easily transmitted person to person, cause high mortality, and might cause public panic and social disruption. They require special action for public health preparedness. Rapid identification, triage strategies, new labs, and staff provide increased national capacity to respond to such events, and we continue to work with state and local partners to insure that they develop capacities to test for other critical agents as well, such as Q fever, Glanders, brucellosis, alpha viruses, Staph. enterotoxin, et cetera, et cetera. And many of the state health labs have improved their capacity even over the past year. So there's been a marked increase in capability with more improvement to go in state laboratories around the country.
One of the other areas for progress and improvement has been developing a new, rapid response in advanced laboratory at CDC for bioterrorism, which specimens come into the lab, are triaged, and initially process samples are processed for both chemical and biological agents, and then there's linkage with around-the-clock, rapid response teams to provide an assistance. Chain of custody is maintained throughout this process, and we're using new, rapid diagnostic assays that can then be transferred more broadly around the country. To date over 600 specimens have been logged into the rapid response and advanced technology laboratory, and they themselves tell a story of threats going on around the country that are as recent as the last few days and involve a wide range of threatened agents. Thankfully they have remained threats. Approximately two years ago CDC recognized the need to assure that appropriate laboratory testing capacities for critical agents existed throughout laboratories throughout all of the states, and we've worked with associations, state, and territorial public health labs, Department of Justice, and the FBI, the Department of Defense, and developed a national response, national laboratory response network. This secure network provides standardized diagnostic protocols and reagents needed by state public health labs for plague, tularemia, anthrax and botulinum, and it also offers help in to test for specific agents, other agents on the critical agent list. This function helps to share information and communicate best practices, and we are increasing the number of people trained in it and laboratories that are participating and hope to increase that further in the year 2001. We're looking also to develop standard methodologies for laboratory testing and developing techniques to rule out potential bioterrorism agents. Another important area is epidemiology and surveillance. Critical to CDC's bioterrorism preparedness effort is early detection of an event coupled with effective and timely response, and you'll hear that theme over and over. You've heard it earlier this morning. You'll hear it over and over again. A key issue is early detection. Because that early detection and initial response will be at the local level, we are working with epidemiologists at state and local health departments to acquire and develop and maintain the resources and expertise necessary to respond to rare, unusual, unexplained illnesses. The zebra was alluded to earlier.
As of now, all 50 states, the District of Columbia, and New York City, Chicago, and L.A. are supported by funds to enhance their epidemiologic and surveillance capacities. These funds are being used to hire surveillance coordinators, epidemiologists, support specific local events in training, rapid reporting and response teams. In keeping with the lessons learned from the West Nile outbreak in the Northeast, some states are also developing reporting mechanisms with medical examiners, poison control centers, hospitals, EMS units, animal health care providers, and other nontraditional partners to enable early detection. Working with state and local partners, CDC has also developed disease specific information for health care providers, emergency first responders in the public that will instruct them in what to do during an actual bioterrorism event. Working with the U.S. Army Medical Research Institute of infectious Diseases, CDC has trained over 15,000 health care providers, including emergency room physicians and infectious disease practitioners via satellite training. Some medical schools have even included bioterrorism lectures in their curriculum, which is certainly a sign of progress and difficult in a competing medical school curriculum where all new subjects are viewed with question and if not disdain. In addition, CDC is working with the Infectious Disease Society and other infectious disease groups to develop training materials targeted at these medical specialties to help them detect, recognize, and respond to bioterrorist events. The West Nile encephalitis outbreak, which I believe you'll hear more about this afternoon from Marcie Layton, typifies how improved public health infrastructure is vitally needed to deal with ongoing outbreaks of both naturally occurring infections, as well as bioterrorism. Improved laboratory and surveillance capacities make a big difference in rapid response and appropriate outbreak control, and as the term has been used already, needed surge capacity, whether it's in hospitals, in pharmaceutical companies, in laboratories, in health departments, has to be there to deal with these unforeseen events. In the research area, CD, along with the National Institutes of Health continues to make investments in research and development associated with vaccines. To better prepare the U.S. against the possible use of small pox virus, CDC has awarded a contract this year to Ora Vax of Cambridge, Mass., to produce small pox vaccine. Approximately 40 million doses of vaccine will be produced initially with anticipated delivery of the first full scale production lots in 2004. The contract allows for increased production of the vaccine should the need arise.
To address overall vaccine issues associated with bioterrorism, a working group of representatives from the Department of Health and Human Services, many different parts of the department, the Department of Defense, USAMRIID and the U.S. Department of Agriculture was recently formed to address and evaluate vaccines that are both currently available and what others may need to be developed. In addition, a variety of academic institutions have been funded to support bioterrorism preparedness and response, and these institutions are performing work that is associated with development of national policies and structures to prevent civilian populations from experiencing bioterrorism, improving computer based surveillance systems, establishing a center for research and education, and conducting studies of viral hemorrhagic fevers. Each of these research activities we hope will provide insights helpful to us in the governmental agencies at all levels. There's also been progress made in the national pharmaceutical stockpile. Our strategy is to have both preparedness and response efforts in place, and in this case, it involves having a key component of that preparedness be a national pharmaceutical stockpile. It's organized into two pieces. The first component includes eight identical push packages. CDC has these placed strategically at distribution centers around the country. These are 12-hour push packages, meaning that within 12 hours of release, they can be on site anywhere in the United States. They're made of 109 palletized air cargo containers. It takes two airplanes to deliver them, and they comprise pharmaceuticals, IV fluids, airway supplies, emergency medications, bandages, and dressings. These items are necessary to enhance state and local capacity to provide therapeutic treatment and prophylaxis of a large population. In addition to the 12 hour push packages, CDC will also use VMI, vendor managed inventory, to provide specific quantities of antibiotics and other medical materials to the requesting agency within 24 to 36 hours after the decision to deploy. This is in partnership with the Department of Defense, rather, the Department of Veterans Affairs. We're also doing extensive training of staff. We recognize that local expertise needs increased experience and training in these areas, and recent experience in the top off exercise indicated that we quickly exhaust our resources and personnel both nationally and locally and need to develop some other contingency plans to have more staff available for this. Other key areas that we've invested in are information technology, improving both accuracy and timeliness in data, and doing this at levels including national and local and state, and have begun to test in field responses at the World Trade Organization meeting in Seattle in late '99, and at the two national conventions for the political parties this year we used some new, more creative approaches to rapid and accurate data response systems. We're also trying to improve the moving away from paper and pencil and telephones to a true national electronic disease surveillance system and have made considerable progress in this in a number of states around the country with grants. That includes improving security, having some common standards, and developing some software packages that all states can use in this. And two states are doing this particularly intensively: New York State and Oregon. And we hope the best practices from these states will then be used in other locales. We are also trying to meet a need that state epidemiologists have asked for for some time, which is to create a national clearing house for outbreaks and investigations ongoing. We have created a new program called Epi-eXchange, in which states can enter these processes with all of the information in real time, and then they're shared with other state epidemiologists who have access to this information via the Web, a secure Web site. Many of you have heard of the exercise performed in May of 2000 called top off, referring to top officials in which a mock exercise was done in three cities simulating a biological threat of a plague outbreak in Denver, a mustard gas release in Portsmouth, New Hampshire, and a simulated radiologic incident in Washington. This was a relatively expensive exercise engineered and run by the Department of Justice, but I think it was highly worthwhile for all of us. Most of our staff were heavily involved in this for the several days of the event, and I can tell you from being an active participant that this same level of gastric upset and need for frequent changes of clothes occur; even though you were saying to yourself, "But this was an exercise," it was an exercise that took on real meaning for the participants, and many of our folks who were here spent day and night working on this for several days. It indicated a number of lessons and challenges that we need to pay attention to. There were difficulties in implementing and exercising federal, state, and local quarantine authorities. There were complications in local distribution of the national pharmaceutical stockpile once it got to the state. There was a complexity in providing support for expanded health care delivery. There was limited hospital capacity, limited clinical care capabilities. Long-term outbreak control strategies were not well in place, and there were chain of command issues present. This is all well described, and I'd urge those of you who haven't read it in the recent newsletter of the Johns Hopkins center, a very nice description there in 12 pages, and I'd urge you to take a look at it. We are addressing all of these challenges and trying to correct them one by one as part of what we're doing. In summary, dealing with these issues involves looking at things from a federal level, from a state level, from a local level. All of those areas have to be improved. Academia has to be brought into it and develop the capacities that currently don't exist in most public health schools, management schools, medical centers. The wide variety of federal partners have to be better linked to each other, and the traditional first responders have got to be linked to the public health system, and in addition, linkage between our national effort and international efforts for our partners at WHO have to be further improved. All of this has to be done via obviously a need for increased resources to do it, partnerships with other groups, the systems to put it into place, research training and technical support. We will get there, but it requires a lot more work. In parallel to the "be paranoid" slide, I have a picture of our moderator at an earlier stage of his career. (Laughter.) And I think that's the tack we all have to take no matter what our roles in this effort are. If we do what we need to do, we can minimize the consequences of untoward events that we've heard described earlier. We can improve the nation's public health infrastructure not just for bioterrorism, but for emerging infections and a wide variety of health issues, and we'll end up with a safer, healthier population. Thank you.
(Applause.)
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