Homeland Security

The following abstract outlines the bioterrorism preparedness and response focus areas for which the Connecticut Department of Public Health is applying for funding with this application. In addition, current activities in all five focus areas will be described together with the outstanding Connecticut-specific bioterrorism preparedness-specific needs and opportunities this application will address.

Support is being requested in the following focus areas:

1. Preparedness Planning and Readiness Assessment $188,586

2.a. Surveillance and Epidemiologic Capacity - Core Activities $436,331

2.b. Surveillance and Epidemiologic Capacity - Special Activities $248,009

3. Laboratory Capacity - Biologic Agents $ 58,755

5. Health Alert Network/Training $727,944

Connecticut (CT) has a number of specific governmental, demographic, health care delivery, geographic and economic-developmental features that need to be considered in planning for health-related emergencies, including bioterrorism and chemical terrorism. These are described below.

CT is a densely populated state with approximately 3.3 million inhabitants compressed into 5009 square miles. The unit of local government in CT is the town. Although the state map is divided into 8 counties, there is no county government. There are 169 independent towns, each with their own government (mayor or selectman), police, local tax, school and public health structure. Overall, there are five towns with populations of at least 100,000 persons. Their metropolitan areas including surrounding but independent towns range from 200,000 to 700,000 persons.

In the case of public health, some towns have joined together to form health districts, so that there are currently 112 independent local health departments, each with their own health director who serves under the local municipal governing body. Towns with at least 40,000 population are required to have a full time health director. Currently, there are 45 full time health directors, serving 82% of the CT population, largely urban or suburban, and 66 part time health directors, serving the remaining 18%, largely suburban or rural.

The state government is the main bridge between these independent towns. The role of the Department of Public Health (DPH) is to provide guidance, assistance and oversight to the local health departments. The local health departments have the direct authority and primary responsibility for investigating and responding to local public health problems. However, given that many local health departments are very small, their real capacity to independently respond to many problems, especially complex ones, is limited. Thus, the DPH is usually intimately involved in providing technical and manpower support and oversight for any sizable or unusual disease investigation or response needs.

This broad organizational structure has several implications for bioterrorism-related planning and response. First, it means that each of the 112 health departments and 169 municipalities (e.g., police departments, school systems) needs to be prepared to manage discrete exposure incidents (e.g., anthrax threats in schools or workplace sites). Second, it means that the CT DPH has a pivotal role in bioterrorism planning and response. Given the minimal public health capacity at the town level, DPH needs to be able to supply technical support to all towns and will likely take the lead investigatory and coordinating role whenever there is a larger-scale threat. This also means that an effective DPH-based and coordinated communication system needs to be in place for standard information to be readily available to all 112 health departments in the event of a broader public health emergency/concern.

The organization of the health care delivery system in CT is also relevant to bioterrorism planning and preparedness. In general, most health care delivery is done through the private sector. The State is generally not involved in direct provision of public health services, this being a local health responsibility. At the local level, most local health departments work through the Visiting Nurses Association or private providers to provide special public health services. In the event of a public health emergency that involves provision of medical services (e.g., pandemic influenza, large scale need for anthrax prophylaxis), the main role of the local health departments will be organizational: working with local health care providers to organize special clinics. This relative lack of public sector capacity further highlights the need for local level response planning.

There are 35 acute-care hospitals in CT. Most of these hospitals are fully independent of each other and the State and serve catchment areas that include many towns. All of these hospitals have intensive care units, and most have laboratory, outpatient and emergency services attached to them. As part of a surveillance and response preparedness, these hospitals need to be fully integrated into a unified surveillance and communication system run by DPH.

The disease reporting system in CT has several features that facilitate bioterrorism preparedness. Health care providers, hospitals and laboratories are all required to report selected infectious diseases or associated laboratory findings and suspected outbreaks to both DPH and to the local director of health in the town in which the affected individual resides. The dual reporting system, while cumbersome to reporting sources on one hand, assures that DPH gets relevant information as quickly as it is reported and can rapidly identify and examine disease clusters that occur in persons residing in different towns. In a state with so many different health departments in a small geographic area, this is an important feature. On the negative side, reporting by laboratories and health care providers is largely done by paper and mail with a telephone option, and is often slow. As part of enhancing surveillance, it is critical to find more efficient means of reporting routine surveillance information.

As a result of its geographic location and economic developmental status, CT has some specific as well as general bioterrorism concerns that need to be addressed in its preparedness and response planning. Significantly, parts of CT, especially Fairfield County (population, 800,000), the county closest to New York City (NYC), are in many ways suburbs of NYC. CT towns from Greenwich to New Haven are part of a 60-mile long urban corridor carrying traffic to and from NYC. Each day, more than 24,000 CT residents take hourly commuter trains or drive to NYC. Thus, any major bioterrorist or chemical exposure in NYC is apt to affect a significant number of CT residents. Any exposure with a latent period to onset of symptoms (e.g., anthrax, smallpox) may first be detected in CT residents in CT.

CT has a number of other specific developmental features that need to be considered in preparedness and response. These include: two nuclear power plants, a Navy submarine base (Groton-New London), the US Coast Guard Academy, one international (Hartford-Springfield) and several domestic airports, commuter rail lines to and from NYC, a federal building in Hartford, a number of military-industrial contractors (Pratt and Whitney Aircraft, Sikorsky Aircraft, General Dynamics-Electric Boat Naval Shipyard), several international corporations (Pfizer Chemical, General Electric and Union Carbide world headquarters) and family planning clinics, which have been the sites of anti-abortion demonstrations.

Finally, at the State planning level, there are a number of different DPH components and partners which are and/or will need to be involved in planning the State-level response. Within DPH, the Infectious Diseases Division (the lead coordinating unit for this application and bioterrorism response planning), the Local Health Administration Unit (main liaison unit with local health departments on developmental and communications issues), the Office of Emergency Medical Services (OEMS), the DPH Laboratory, the Data Processing Unit and the Division of Environmental Epidemiology are involved in developing different components of this application. Outside of DPH, the Connecticut Association of Directors of Health (CADH), an incorporated group of full time local health directors, is the main group that represents local health planning and coordinating needs. It has been directly involved in preparing the HAN portion of this application. Other state agencies which have been or will be involved include: the local FBI unit, the Connecticut State Police, the CT Department of Environmental Protection, the CT Fire Training Academy, and the state Office of Emergency Management (OEM).

With this more general background in mind, the following is a description of current/existing activities and resources for each of the five focus areas with needs to progress further in each area.

There has been considerable progress in raising awareness of bioterrorism, but less in the planning and coordination areas to date. DPH and OEM do have considerable experience in planning for nuclear disasters and in planning for pandemic influenza. With two nuclear power plants, there is a long-standing planning and disaster drill experience. In addition, several years ago, CT was host to the International Special Olympics, an event that required considerable public health planning and preparation for surveillance and response. It was coordinated by DPH OEMS staff with input and readiness on the part of many other organizations, including the DPH Infectious Diseases Division and CADH. Furthermore, last year, CT was one of 4 states that participated in evaluation of a national pandemic influenza preparedness and response guidance document for states.

To date, a number of state agencies have independently pursued training and organizational activities in preparedness planning and readiness assessment. These are listed in the narrative and include formation of independent planning groups in a number of towns. Within DPH, a DPH bioterrorism coordinator has been named. The DPH Bioterrorism response coordinator, a member of the DPH Infectious Diseases Division, has taken all available chemical and biological training courses from USAMRID and has participated in at least 4 of the local town planning groups. From the broader state perspective, it is an OEM objective to add a bioterrorism module to the State Catastrophic Disaster Plan.

Given the high level of concern with bioterrorism preparedness, the initial training that key individuals in many agencies have already had, and the experience with nuclear disaster, Special Olympic and pandemic influenza planning, Connecticut is in good position and is ready as a next step to conduct a comprehensive assessment of the current status of preparedness, to develop a comprehensive State Public Health Plan for Preparedness and Response to Bioterrorism and to develop and initiate broad training in this area. The OEMS (Office of Emergency Medical Services) unit within DPH will take the lead on this and coordinate it with the Bioterrorism Coordinator within the Epidemiology Program.

The Epidemiology Program within the Infectious Diseases Division is the unit which will conduct bioterrorism-related surveillance and epidemiologic response and which will provide medical-epidemiologic leadership for the public response. Considerable core surveillance and epidemiologic capacity and experience already exist within this program, and some bioterrorism-specific surveillance activities have already been initiated and integrated into this unit's activities.

The Epidemiology Program is responsible for surveillance for most communicable diseases including outbreak investigations, and is the program base of the CT Emerging Infections Program (EIP), one of 8 state-based Emerging Infections programs funded by CDC. It has 11 staff epidemiologists with MPH training, includes medical and veterinary expertise, and is the base of the CT EIS officer. These staff work as a coordinated unit and are all available to assist in any investigation as the need arises. Program staff have considerable collective experience in responding on an ad hoc basis to widely publicized public health events on short notice and in public health planning (see narrative for elaboration). Thus, the capacity currently exists to respond to most public health emergencies. In addition, the reportable disease and reportable laboratory findings lists have already been modified so that beginning in 1999, they include special sections listing reportable diseases with bioterrorism-specific surveillance implications.

As previously mentioned, the DPH Bioterrorism Coordinator (including for bioterrorism surveillance and epidemiologic activities) is a current Epidemiology Program staff member who has already had considerable personal training. This person will continue to be located in the Epidemiology Program. There is already initial relevant planning experience within the Epidemiology Program. In 1998, the CT Epidemiology Program evaluated the draft national guidelines for state planning for pandemic influenza.

In spite of having some established surveillance and epidemiologic response capacity, additional personnel are needed. In giving up a state-funded position to bioterrorism coordination, staff capacity and flexibility to respond to all emergent issues is diminished. Thus, the personnel applied for in this section of the application are needed to maintain that capacity and to provide support to the Coordinator to enable development of a statewide plan, provision of assistance in development of local response plans; to enable detailed follow-up of suspect cases and clusters of disease that might be bioterrorism-related; and to organize and maintain ongoing communication networks with hospitals, emergency departments and infectious disease specialists.

Finally, given the long-term need to improve timeliness and ease of reporting from laboratories to enhance early recognition of clusters of reportable diseases, as outlined in the Background section, it is critical to develop electronic laboratory reporting capability. This need is further elaborated upon in the detailed application.

Given the current epidemiologic capacity and status as an EIP site, CT is in a unique position to pilot a model intensive care unit (ICU) based syndromic surveillance system to identify possible bio- or chemical terrorist events with significant personal health impact.

One of the core activities of the CT Emerging Infections program is the Unexplained Deaths and Lifethreatening Illness project. This project is run by the Yale Department of Epidemiology and Public Health component of the CT EIP in collaboration with DPH. It is a medical ICU-centered, syndrome-based surveillance system in which daily to monthly contact is made with all 7 acute care hospital medical ICUs in New Haven County. This surveillance system can be easily adapted to determine rates of admission of all syndromes daily in all New Haven County Hospitals.

As part of this application, it is proposed to expand the medical ICU-based surveillance system to all acute-care hospitals in Fairfield County (population 800,000) to include the part of CT that houses the urban commuter corridor to New York City. There is enthusiasm on the part of both the New York City Health Department and the hospitals in this area to participate in such a surveillance system that would be an early warning and monitoring system of a possible bio- or chemical terrorist event in their catchment area or New York City. We are collaborating with NYC, NY State and New Jersey in the design of the system and would work with them on the investigation of increases in admissions due to any particular syndrome. If this system is successful and feasible, it could be a model for expansion statewide and for other states to consider.

The needs to enable this project include: personnel resources to organize ICU surveillance, establish thresholds for response, evaluate the system (sensitivity, timeliness), integrate it with the Unexplained Deaths Project, and to pay hospitals for extra time to collect the required information in a specified format on a daily basis. This project would be developed by the Yale EIP, but would be jointly evaluated. Increases in admissions would be investigated by DPH staff.

The DPH laboratory already has the technical staff capacity to perform diagnostic work with the priority possible bioterrorism agents. With additional training and with opportunities to participate in response exercises, the DPH laboratory should be technically prepared to provide much of the laboratory support needed to participate in surveillance and response. Currently, there are two BSL-3 safety areas in the laboratory. These are dedicated to working with tuberculosis and with rabies diagnostic specimens. These areas are each operating at capacity, CT being a state heavily affected by the raccoon rabies epizootic. The main initial resource-dependent need is to renovate another area of the laboratory to bring it up to the BSL-3 safety level, so that the capacity exists to handle large numbers of specimens in case there is an event involving large numbers of people or a need for environmental monitoring that is too large for the FBI laboratory to manage or to provide assistance to surrounding states who could need it.

The CT chemistry laboratory is fully certified and tests for asbestos, organics, inorganics and radiation in a wide variety of samples. It is not particularly well prepared to deal with toxic gas exposures. While planning, training and response exercises are needed to determine how the DPH laboratory would respond to a potential chemical exposure event, environmental and diagnostic specimens would be best handled at a a regional laboratory with appropriate capacity. We are aware that both Massachusetts and New York intend to apply to develop that capacity.

5. Health Alert Network/Training

An informal, ad hoc HAN already exists in CT. It has been used effectively in many of the situations described in the Core Surveillance and Epidemiologic Capacity section above. Urgent confidential communications with local health departments are made via broadcast fax using an Internet service provider. Less urgent communications are made via mailings, telephone, monthly CADH meetings and required semi-annual meetings with all directors of health. In addition, a listing of contact telephone and fax numbers with acute care hospitals, particularly with hospital epidemiologists, and infectious disease physicians is maintained, and an informal listing of e-mail addresses of all Northeastern state State Epidemiologists and other key contact staff in their states plus CT ID Society members with e-mail addresses is kept and used as needed.

Nonetheless, there are substantial limitations to the current HAN. Few local health departments regularly use the Internet and Internet communication is not yet a reliable means of communication with all local health departments. At the state end, the DPH web page is understaffed and underdeveloped and not yet a reliable site for the most up-to-date information. Other than fax or telephone, there is no secure means of two-way communication with local health departments or hospitals. Other than mailing, there is no ready way to communicate with emergency care providers.

There is an infrastructure, however, on which secure electronic communications with all of these groups can be developed. The Connecticut Immunization Registry and Tracking System is based on a secure Virtual Private Network and it gives health care providers in remote clinic sites direct electronic access to immunization information and allows them to enter updated information. With an additional server, T1 line, ports, technical data processing staff capacity, and staffing to put information on the system, this infrastructure can be developed to become the future HAN in CT. It would ultimately serve local health departments, clinical laboratories (it would be used as part of the proposed electronic laboratory surveillance, see above), hospitals and emergency care providers.

There is substantial distance learning capacity in CT. Although not yet fully enumerated, satellite downlink sites are available in all parts of the state through universities, hospitals and businesses. Together with several limited-seating DPH satellite downlink sites in Hartford, these have been used for many of the CDC-sponsored courses. However, the distance learning capacity has been greatly underused by local health departments, due to lack of dedicated resources to publicize opportunities and to arrange for use of downlink sites in geographically convenient parts of the state. As part of the HAN proposal, a distance learning coordinator position is requested.