Goal 4: Rapidly Respond to Limit the Impacts of Bioincidents
Biodefense Summit Transcript
Panel Moderator: Mr. Lance Brooks, Chief of the Biological Threat Reduction Department, Defense Threat Reduction, Department of Defense
Panelists: John Benitez, Medical Director, Emergency Preparedness Department, Tennessee Department of Health and Lieutenant Colonel, Army Reserves and Preventative Medicine; Dr. Chris Kratochvil, Associate Vice Chancellor for Clinical Research, University of Nebraska Medical Center and Vice President for Research of the Nebraska Medicine and Chief Medical Officer at UNeHealth.
>> CICELY WATERS: Thank you, Dr. Bright and our panelists for that engaging discussion. And again, please feel free to submit your written comments and feedback to ASPR bio@HHS.gov. We will continue our program today with panel four. Panel four will focus on rapid responses to limit the impacts from bio incidents. The moderator for panel four is Mr. Lance Brooks, who serves as chief of the biological threat reduction department at the Defense threat reduction agency within the Department of Defense. Mr. Brooks?
>> LANCE BROOKS: Thank you. So, this continues on the spectrum. So we saw the risk analysis, we saw prevention efforts. We know in our best efforts in trying to prevent that we heard the likelihood we won't prevent all types of bio incidents as outlined in the strategy. Then we heard a number of preparedness activities and there's certainly a wide range of preparedness activities that have been going on for let's say many decades now as we've seen and there's no shortage of preparedness to do. But to me, the rubber really hits the road in early response. Bio is really an interesting problem set. What we have seen in the strategy and what we've heard from the panels is quite complex. Bio, we not only have to think of it as an infectious disease and just using infectious control measures, but it can also be used as an environmental contaminant. We have not heard too much of that. Paula mentioned a little bit about decontamination. So, when you think about the spectrum of bio, you've got to think across the complexity of it, which now brings into diverse multisectoral type of response. We do have a wide-ranging audience here, and hopefully a number of folks on the webcast who are paying attention and from a various number of sectors that are outlined. When you are talking about terrorist attacks, accidental release and natural outbreaks it is really a complex problem set, and as we know in bio, unlike RAT and KIM and MOOQ, it can continue to grow on us and we can be in multiple stages, which we shouldn't forget of an outbreak response at the same time. We think of West Africa and the evil outbreak, not only were we continuously in early response, we were in the middle of response and consequence management and recovery. You think about it, all at the same time. And this is what makes the incidence so complex. So rapid response certainly is key, and I would say that it also has an impact on the preparedness, if we respond early and we keep exposure down and we limit the epi curve we may not have two deplete our strategic national stockpile so that will impact the availability of those resources. If we look at knowing early on that it is a contamination event, more so than a natural infectious outbreak, taking early measures can limit exposure. Can also limit the impact of contamination across critical infrastructure and prevent [indiscernible] use of that critical infrastructure. Some of the things that homeland security and the sector has been struggling with for a number of years in working with a multitude of sectors. So, for this goal there are a number of objectives underneath it. I want to just read through to remind you what all this goal encompasses as we get ready to invite the panelists up here to give their perspective for about five minutes to address the questions. So one of the objectives is to compile and share bio threat, bio incident information to enable appropriate decision-making, response operations across all levels of government and with nongovernmental private-sector and international entities is appropriate. Second objective. Conduct federal response operations activities in coordination with the relevant nonfederal actors to contain, control and rapidly mitigate impacts of bio threats or bio incidents. Objective number three, conduct operations investigations and use all available tools to hold perpetrators accountable. And the last objective in this goal is to execute a risk informed accurate timely and actionable public health messaging. So a wide variety of objectives and if you look in the Annex you will see, or in the appendix that there's a number of sub elements here that expand on this. So it's quite a complex area. So with that, we are going to invite the panelists to come up here and join us and provide their five-minute perspective on the goal and try to answer some of these questions. Our first panelist of that I'm going to invite, welcome up to the stage is John Benitez. He's the Medical Director Emergency Preparedness of Tennessee Department of Health. And he's also a Lieut. Col. in the Army, in the reserves and preventative medicine. So he has a broad perspective on this topic area. So John, please.
>> JOHN BENITEZ: Well, good afternoon. I don't have any bright slides to show you. But I do have some comments basically coming from the Tennessee Department of Health perspective and trying to implement things from a federal down to the local perspective. I'd like to thank you all for having me here. Dr. Kadlec, ASPR, the National Academy of Medicine. And just to give you a brief background of me on the different perspective on where I come from as a clinician originally but I basically started out in private practice, went to academic practice and then moved into government and military service. I'm doing things sort of backward to what most people do. But sometimes different perspectives help things out. At the state Department of Health, probably our biggest thing has been you know, a funding issue. We start off with a high peak of funding, then it came down to and I think again, long-term sustainability. It's relatively stable for right now, but there's that overall slight trend downward which tells you a little bit of sustainability down the line. We have in the state government there's different models across the country for how state health departments work. We have one where there is a strong central office that oversees regional offices who oversee the local offices. That is not true in every single state. Some of them are very independent local offices. Independent, if you will, of the state government. So that makes a difference in terms of how we operate. So how we are funded, how we spend the money is going to be different than how other agencies do that, and we need to take that into consideration, so that we can structure things appropriately at every state. We also have a labor force that is changing. It's becoming older, and that's probably true in many industries. But how do we replace ourselves in the long term for sustainability and understanding all these issues that we are talking about. Coordination with partners in healthcare facilities and we don't directly oversee healthcare facilities, but we try to entice them, bribe them, coerce them? Not really. But we try to really work with them to come to common solutions. And that becomes a challenge in and of itself. I've got some lists of examples and then I will sort of shut up and let the next speaker talk and we will answer additional questions as needed. But basically, just for example, coordination at the federal level, we get most of our funding primarily through CDC and ASPR. There are some other sources that come in there. But we have different systems were how to report all of our doables, our deliverables, report on our budgets and the funding sources, and even the instruments that we use for reporting and uploading all these documents is difficult because they are separate systems. Situational awareness. I think in general we are fairly good at that, and I'm saying that with kind of a question mark in my face a little bit because I think we are pretty good at getting situational awareness of what's going on at least from the health and human services side, CDC as to what's going on in the world, what's going on around the country. And then on a regional level. We get reporting. We get reporting down to locals pretty quickly, so we make them aware of this. Some examples that I also specifically have along those lines is measles, for example, and I think a couple people have talked about the recent measles outbreaks, we have all sort of had them here and there in different stages, but one of the big problems we've noticed for example is just recognizing it clinically. Somebody mentioned a few minutes ago about some better diagnostic tools that we can use closer to the point of testing that we can do. But clinicians when they see a rash in a sense they can't always come up with measles as a diagnosis. It's not just measles. But I'm using that as an example. And it's not just that because again we have a patient who comes to a clinician in whatever setting, we are examining, touching them etc., and of course that patient has sat where in a waiting room at some point with others and potentially contaminating surfaces and other people over time. But also that messaging that we need to get to the public. Don't go to your doctor when you are sick. That sort of sounds counter to what we usually tell people. Because under certain situations, stay home and ask questions is really the first thing. And don't go to the doctor unless we tell you that we are ready to see you under isolation type procedure. Emergency funds. Probably one big gap that we have is that there's no really emergency funds that we can suddenly, quickly activate to get to public health or healthcare facilities. It is one of the few agencies where if you go back to Congress and ask for more money for the emergency. And you know how long that takes to get that question answered. So, working on those kind of solutions. As an example, then I will basically quit, is that Zika for example that hit our country not that long ago, there was no emergency Zika fund. There was no Zika monies specifically for us to address at the state level and the way it got addressed, which is ingenious, but at the same time caused a lot of problems and gave us some learning to do, is we basically at the state level had to give money back to the feds to create a pool of money that would get redistributed to address Zika. So that meant administratively we had to take money away from programs we had targeted, send it back, re-create our budgets for what we are going to do with a little money and then the feds say, okay, now we have this pool of money. We are going to redistribute it, so now apply for it and tell us how you are going to use it. So that created another administrative burden and then tracking that as we spend it. So I will stop with that and let the next panelist come up.
>> LANCE BROOKS: Next I'd like to welcome to the stage Dr. Chris Kratochvil. He is associate Vice Chancellor for Clinical Research at the University of Nebraska Medical Center. He's the Vice President for research of the Nebraska Medicine and chief medical officer at UNeHealth.
>> CHRISTOPHER KRATOCHVIL: Well, good afternoon. Thank you. I really do appreciate the opportunity to be here today. It's an honor and a privilege to share some information with you. And you will notice on my slides that they are going to be fairly picture heavy. And part of the reason for that is that I really want to point out that there are activities going on in this sphere. They need to be expanded. They need to be sustainable, but they are going on. The other thing is if a picture is worth 1000 words, those of you who know me, I'm a native of Nebraska and I talk pretty slow. That buys me about 10 more minutes of content I can develop. So, happy to have that. All right, so what's my perspective from the Prairie? So, a couple things. I want to go through some of the activities going on in Nebraska right now, for really two different reasons. One of them is, so, you have a perspective when I present my challenges and opportunities in the next couple slides. But I also want to highlight a bit about what can be done when you have good public private partnerships. These are a variety of initiatives that we have going on successfully because we are able to pull together an entire academic medical center. We are able to pull together folks from industry, folks from philanthropy. Local government, state government, federal government. And in doing so, we really have been able to have a variety of very unique initiatives. So, one which some of you may know of is our biocontainment unit. A 10-bed unit developed after 9/11 really as a resource as a partnership with CDC, the hospital and our university. And that was sustained for about a decade before it was used for the Ebola outbreak in 2014 in large part because our public and our academic folks thought it was important to keep that going as a federal resource. That was then leveraged into quarantine units, which were activated during the 2014-15 outbreak. And now a fixed facility being opened this July. You heard Dr. Evans mentioned NETEC, the National Ebola Training Education Center, which is a great partnership with Emory, Bellevue Hospital in New York and Nebraska funded by CDC and ASPR. We have the regional disaster health response system, a really nice way of looking at how can we pull together and integrate the resources of an entire state, and that is an initiative funded by ASPR in Nebraska as well as Massachusetts. If you look at some of our DOD initiatives, we have the national strategic research Institute at UARS which partners us with strat com. We have C Stars which is a partner with the Air Force where we have active duty ID teams permanently stationed with us developing training to be delivered to the Air Force. And by pulling all these things together through these public-private partnerships we are able to leverage and do things at a pretty moderate sized academic Health Center that there's no way we could have done otherwise. So as we look forward, what are some of the gaps? What are the challenges that we are identified that I think we need to be contemplating moving forward? And these were half a dozen things that I very quickly pulled together when I was first asked to give this talk, and really they ring true. Now certainly, this could be a much more exhaustive list, but if you think of some of the top priorities, one of the things that makes us very nervous is the surge capacity. If you look at our academic Health Center, I'm sure it's very similar at many of yours, we run at 80 to 90% at any time. If we have influenza season we can be pushing that and we very frequently already have people waiting in the hallways of the ER. Certainly there's the facilities, there's the expertise, the personnel, the supply chain, the medical countermeasures, all those things are already tapped really to a far degree. Investigational medical countermeasures. When we had our patients for Ebola, we were very quickly pulling together emergency INDs, trying to get information on what drug we could use and very little research data could be pulled together because of that rapid response. How can we launch clinical trials in real-time, collected and have data available for use? How can we have better communication across the board? We've seen some of the large national exercises, the challenges that we have that we need to address in communication throughout the spectrum. International outreach, clearly there's much more that could be done. How can we train folks, so if you look at Ebola, if you look at special pathogens, how can we get the training out to these hospitals to get them up to adequate training and be able to maintain that. How can we exercise to test the system? So there are several initiatives going on. So, one of which is a regional approach I mentioned. So what we have in the model in Nebraska and Massachusetts, it's really pulling together the private folks, the federal agencies, the VA, the National Guard units. Pulling those altogether to activate resources and to communicate. The NETEC model, where we have three regional centers of expertise and then one center in each of the 10 regions that has active biocontainment beds. We do site visits annually. We do exercises with them. It's a small scale, but something that certainly can be scalable with the ASPRs vision and how we can have the regional approach. The special pathogens regions network this is funded by ASPR using those same sites at the regional treatment centers. We have a centralized IRB at Nebraska. We can do a rapid response review in 24 hours. We have reliance agreements with each of those 10 regional treatment centers. We are developing a centralized bio repository as well as a data repository. Trying to get a model in place that we can actively get out there and get experimental medical countermeasures into the community. Expanded training. The picture down below that you can see a bit is NDMS did a large training of several thousand of their medical providers this summer in donning and doffing of high-level PPE for radiation, bio and chemical exposure. International, clearly there's some limited work going on the needs to be expanded and we think it really can have a high yield. And then exercises. This last year, HHS ASPR the tranquil terminus, the largest exercise ever done, moving patients around from assessment hospitals, they were identified, they were moved to regional treatment centers, a great way to exercise not only the patient care, the transport in air, but also we activated the research medical countermeasures. We pulled together research infrastructure. We actually shipped mock drug all in this few day exercise that went across the nation. There are more plans. They are critically important helping us to identify what works and where the gaps are. So, that's just a quick overview of some of the things we are doing. But again, I think it's really a model that can be extrapolated out. And also I think by taking this and doing a regional approach nationally we can develop much greater resiliency across the US. Thank you.