North Carolina's Response to Biological Threats:
The First Year

Although Centers for Disease Control and Prevention (CDC) funds totaling nearly $23.8 million for bolstering public health's ability to respond to bioterrorism were not made available until June 2002, North Carolina's Division of Public Health (DPH) was taking steps to improve preparedness long before that time.

Even before the events of September 11 and the anthrax crisis in October of 2001, state public health officials had mounted several improvement projects designed with an eye toward bioterrorism prevention, detection and response. But the ball really started rolling in November 2001 when more than $3 million from the state's "Rainy Day Fund" was made available to the public health officials to launch a full-scale revitalization of its disease prevention and detection infrastructure. Thanks to the fact that the federal grant money could be used to cover many of the expenditures accumulated during the seven months between November and June, only $483,899 from the rainy day fund was actually spent. Having access to the state funds, however, gave North Carolina a jump-start over most of the nation's other states and gave our preparedness efforts momentum that carries on today.

As of September 2002, the newly-created state Office of Public Health Preparedness and Response (OPHPR) and the seven Public Health Regional Surveillance Teams (RSTs) have filled about 95 percent of their established staff positions. (Host counties for the seven regional teams are Buncombe, Mecklenburg, Guilford, Durham, Cumberland, Pitt, and New Hanover). Of particular note is the addition of retired Army Col. James W. Kirkpatrick who became the first full-time coordinator of OPHPR on September 3. Before retiring in August, Kirkpatrick, a medical doctor served as chief academic officer, dean/commandant of the U.S. Army Academy of Health Sciences.

A vital link in the state's ability to detect and respond to a disease threat is laboratory capacity. In that regard, the N.C. State Laboratory of Public Health is expanding its capacity and is working with the local health departments in Buncombe, Mecklenburg, and Pitt counties to develop regional bioterrorism laboratory testing capabilities. The facilities in Mecklenburg and Buncombe counties are undergoing renovations to create the proper laboratory configuration. Pitt is purchasing a modular Biosafety Level-2 laboratory to meet the needs of that region. The State Lab is reviewing the plans for its new modular BSL-3 laboratory and has a projected completion date of January 2003.

Another key component to the effort is communications. DPH has established a trial version of its statewide component of the national Health Alert Network (HAN). North Carolina's HAN is a communications system that will provide for a 24/7 flow of critical health information among hospital emergency departments, state and local health officials, and law enforcement officials. The system incorporates the simultaneous use of phones, faxes, email, and pagers to communicate urgent health information. The state system is being field-testing in three counties and statewide training begins in October 2002.

DPH has also increased and updated its technological capacity to facilitate electronic disease reporting. Coordinated by the CDC through a program titled National Electronic Disease Surveillance System (NEDSS), this effort fosters the ready exchange of health data between local and state health departments, among states, and between states and CDC. Until recently, CDC had only included two states (Nebraska and Tennessee) to be part of the systems initial testing. North Carolina was selected to become the third state for inclusion in the system after a CDC review in August determined that our state's technology exceeded CDC guidelines for NEDSS and HAN.

Tying all of these components together is a newly-created website used both as a conduit for exchanging health information and as a resource for accessing an almost limitless collection of information on disease control and bioterrorism issue. The location of that website is http://www.nchan.org/.

Some additional public health achievements accomplished thus far include the following.

Surveillance and Epidemiology Capacity

In coordination with CDC, conducted an extensive epidemiologic investigation of the first anthrax patient who developed symptoms while visiting in North Carolina.

Received and provided information to thousands of calls from private citizens, various agencies – both private and state, and healthcare providers across the state.

Developed and presented anthrax presentations to healthcare providers, various organizations and civic groups.

Provided consultation to healthcare providers on: diagnosis and treatment of anthrax; determination of potential level of exposure and available treatment options; and on the status of the anthrax outbreak.

Provided consultation to head of the Epidemiology Section, the State Health Director, as well as heads of other key public and private agencies.

Collaborating with North Carolina Department of Agriculture to strengthen bonds between animal and human health surveillance and disease investigation.

Strengthened collaboration with UNC through joint training and surveillance activities working with the Center for Public Health Preparedness.

Provided training in outbreak investigation (including BT agents) to regional teams

Regional teams beginning training to all local health departments in outbreak investigation.

Collaborating with Emergency Management and SBI to coordinate response activities and plans.

Working through hospitals to provide additional epidemiologic capacity to the entire state (for hospital-related and community-acquired infections).

Laboratory Capacity – Biologic Agents

Working with DHHS Property and Facility Staff to design modular BSL-3 Laboratory to enhance capacity for testing – bids for modular unit are pending.

Hired Lab Medical Specialist for Regional BT lab in Buncombe Co.

Interviewed candidates for Lab Medical Specialists for Regional BT labs (Mecklenburg and Pitt counties). Offer to hire made to candidate for Mecklenburg facility; position reposted for Pitt facility.

Molecular instrumentation ordered for the NCSLPH.

Reviewed renovation progress of the Mecklenburg regional lab – construction underway and expected to be completed by mid-October

Contractors have begun working on the bioterrorism and special bacteriology databases to facilitate surveillance and reporting. These databases will feed to NEDSS when it becomes operational.

Interviews for Research Scientist are completed and the hiring process is underway.

The SLPH BT Laboratory Medical Specialist lectured to the Regional BT Industrial Hygienists about proper specimen collection and submission protocols as a component of their HAZWOPR training.

Planning and National Pharmaceutical Stockpile (NPS)

Creation of a Bioterrorism Preparedness Planning Committee representing four state departments, 11 divisions, the Special Operations Response Team, FBI, SBI, and the Local Boards of Health.

Writing the North Carolina Public Health Bioterrorism Addendum to the North Carolina Emergency Management Emergency Operations Plan.

Writing the North Carolina Public Health Bioterrorism Preparedness and Response Plan.

Review and Editing of the North Carolina Mass Casualty Disaster Mortuary Plan State Meeting of the Combined Regional Response System – three day meeting.

Since 9/11: Provided 7 Half-Day Single and Multi-County Bioterrorism Planning Briefings and Meetings provided to 15 counties.

Participated in National Pharmaceutical Stockpile Demonstration in Seattle Washington.

Participated in event, event planning, and after-event evaluations of multi-county, joint civilian and military exercises with 19 counties.

Assisted in planning, drafting and review of 56 county bioterrorism Plans.

Establishment of State/Local NPS Management Infrastructure--Key DHHS positions responsible for evaluating the need for the NPS following an outbreak and advising the Governor are in place. Top state level management positions for NPS-related planning, preparedness and response activities (part-time public health physician and full time pharmacist positions) have been established. NPS Committee that reports to the BT Coordinator and BT Steering Committee has been established.

NPS Logistics--State NPS Plan has been developed and revised twice. Major necessary and required components of the state plan are in place with more additions and revisions underway.

Draft plans and procedures for debulking and repackaging and/or direct delivery to hospitals, dispensing sites, etc have been developed in the state plan. Additional planning with hospitals, health departments and MMRS is scheduled.

Development of enhanced statewide surveillance and coordination of rapid reporting of morbidity and mortality at treatment centers to identify BT-related or naturally occurring illness and assess the need for the NPS is well underway.

Development of a functional and secure statewide communications system for all BT-related activities, including those related to the NPS.

Risk Communication and Health Information

Established three Crisis Communication training focus areas; Crisis Communication Fundamentals, Media Fundamentals, and Hands On workshop.

Conducted three media Crisis Communication workshops with state and regional BioT staff.

Established State Bioterrorism Communication and Notification Policies.

Conducted communication needs assessment with State and Local Health Departments.

Coordinating Bioterrorism web page and HAN linkages with BioT IT coordinator and governor's office.

Overseeing and coordinating the Public Health Regional Surveillance Team's use of media awareness discretionary money.

Established Bioterrorism Public Information and Information Referral specialists (hotline) positions.

Creation of Crisis Communication training series for local health department health educators through Healthy Carolinians Office is underway.

Attended CDC Office of Communications "Crisis Emergency Risk Communication" trial demonstration and contributed to critique of the training.

Reviewed and commented on white paper by ASTHO's Information and Communications workgroup addressing New York communication strategies used in the wake of September 11^th.

Education and Training

Creation of an Ad Hoc Committee for the Review and Approval of Bioterrorism Related Training Identification of the Proposed List of Members of the Bioterrorism Education and Training Standards of Practice Board

State Tabletop Exercise of the State's Bioterrorism Response Plan.

Epidemiological Outbreak Training and Epi 2000 training of the RSTs and their Veterinary Medical Officer partners.

Provided 21 full day, multi-county bioterrorism tabletop exercises to 68 counties.

Conducted trainings of the RSTs in working with local communities in development of and exercising of bioterrorism response plans.

Legal

Established work group to study model state emergency health powers act by 11/20/01.

Developed draft rules for a biological agent registry by 11/28/01.

Biological agent registry rules are adopted and effective statewide by 1/10/02.

Legal Work Group has reviewed the adequacy of NC Public Health law against the model act and identified deficiencies by 1/31/02.

First draft of Public Health Bioterrorism Preparedness legislation developed by 4/1/02.

Garnered support for the Public Health Bioterrorism Preparedness legislation from N.C. Medical Society, N.C. Hospital Association and Division of Emergency Management by 4/20/02.

Public Health Bioterrorism Preparedness legislation approved for introduction by the Public Health Study Commission by 4/25/02.

Public Health Bioterrorism Preparedness legislation introduced in the N.C. General Assembly by 6/03/02. The legislation passed the House on 7/30/02 and passed the Senate on 8/28/02.

North Carolina's Response to Biological Threats: The First Year