On Halloween 1998 a facility in Louisville that was mistaken for an abortion clinic received a disturbing envelope. It contained a mysterious powder and a note that read: "This letter contains anthrax."
Working with local hospitals, the Jefferson County Health Department and the FBI, U of L microbiologist Ron Atlas and pathologist Jim Snyder, both experts on bioterrorism, quickly
determined the letter was a hoax.The federal government took notice.
Dr. Richard Clover is co-director of the CDBB.
"Our ability to efficiently show that the letter did not contain anthrax indicated that our community could effectively respond to an attack," says Richard Clover, dean of the U of L School of Public Health and Health Information Sciences. "Five other cities also received similar letters that day, including Los Angeles and Atlanta. Their ability to resolve the scenario took much, much longer."
When U of L formed the Center for the Deterrence of Biowarfare and Bioterrorism in late 2001, most assumed that it was a timely reaction to the anthrax attacks that occurred in the wake of Sept. 11. But the seeds for such a center╤one dedicated to coordinating research, education and services to quickly recognize and respond to biological terrorism acts╤had been planted several years earlier.
"We were fortunate enough to have multiple experts who just happened to be here," admits Clover, co-director of the center and a long-time health adviser to the federal government. "We had already done a lot of work trying to prepare us not only for potential terror activities but any biohazard event that might occur."
Since the 1998 anthrax hoax, the university has participated in what's known as "table top" exercises in which the Centers for Disease Control and Prevention (CDC) deposits a canister in a community and studies the response. One such exercise occurred just a month before the 9-11 terrorist attacks.
"They don't tell you where [the mock canister] is," Clover says. "They want to observe how quickly you can find the agent, identify it and come up with a game plan for protecting the community."
When the anthrax episodes occurred in Florida and Washington, D.C., U of L quickly combined its efforts and expertise in the area of bioterrorism deterrence and wrote a strategy to form the Center for the Deterrence of Biowarfare and Bioterrorism (CDBB).
Sen. Mitch McConnell secured the center's original $1.5 million funding through the CDC last year. He recently obtained another $1.2 million for the center through, also through the CDC.
Less than a year after its formation, the CDC named U of L's bioterrorism deterrence center one of just seven specialty centers for public health preparedness in the country.
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"The designation means that the school's talented researchers will be on the front lines in protecting our communities," McConnell says.
Jerry Hauer, assistant secretary for public health emergency preparedness at the U.S. Department of Health and Human Services, says U of L is unique in its resources and capabilities to research and prepare for a terror-related biological disaster.
"The center's faculty expertise ranges from identifying and developing vaccines against potential bioterrorism organisms to training emergency personnel to properly respond to an attack," Hauer says.
Besides providing courses on bioterrorism response, the CDBB is developing information systems to aid in disease surveillance and epidemiology. It also is conducting research to enhance medical and public health response capabilities. And, of course, the center is working on new training programs to help health-care workers and students rapidly identify any health problems resulting from "biothreat" agents.
Innovative Training
A key goal of the CDBB is to develop and conduct innovative educational programs for health-care workers and others who would be pressed into service in the event of a bioterrorism attack.
Since the CDBB began in late 2001, more than 1,000 physicians, nurses, emergency response personnel, medical students and private citizens statewide have received training.
"An important part of our mission to make sure the community and care providers have the absolute latest information to ensure our preparedness in case of a disaster," says Dr. Sharon Whitmer, U of L's director of continuing health sciences education. "Good information is our strongest defense."
The education programs are under the overall direction of one of the CDBB's key bioterrorism experts, Dr. W. Paul McKinney, associate director for education and curriculum development.
For some of its most innovative and intense training, the CDBB uses two U of L School of Medicine programs--the Dr. John M. and Dorothy Paris Simulation Center and the Standardized Patient Program. These programs help the CDBB stage a variety of bioterror attack scenarios so students and health-care providers can improve their diagnostic skills.
The Paris Simulation Center has more patient simulators than any other academic training site in the world. These computerized mannequins can recreate human physical responses to everything from botulism to asthma to a drug overdose. The Standardized Patient Program (SPP) trains actors to simulate the symptoms of various diseases and reactions associated with bioterrorism.
"The programs provide students an opportunity to interact with patients in a very realistic setting with no risk to anyone," says Gina Wesley, SPP's director. "Among other things, this means that students have access to patients much earlier than before."
While some of the standardized patients are professional actors from the likes of Louisville's Actors Theater or Stage One, most are lay people, Wesley says. "They all have a tremendous desire to improve medical education and hearts big enough to go the distance to help make those improvements."
Using specialized makeup called "moulage," Wesley and her staff develop realistic lesions on the standardized patient's skin. Michelle Thompson, a moulage expert who joined the SPP at its inception in 2000, has a vast background in theatrical makeup.
"She can simulate bubonic plague, smallpox and cutaneous anthrax lesions, local reactions to the smallpox vaccine, chicken pox and a wide variety of traumas such as gun shot wounds, burns and lacerations," Wesley says. "Each one requires a lot of work to make it look and feel like the real thing.
"Most of the physicians we work with won't even touch the simulated lesions because they look so real. We like to say that if we've made a clinician feel sick, we've done our job."
What skin ailment is the most difficult to recreate?
Dr. Martin Eason treats standardized patient John Pendleton during a simulation.
"Bubonic plague because it requires a lot of material to build a terrifically swollen lymph node," Wesley responds. "There is also a lot of color involved because the idea is to make the area look really swollen, hot and sore. Combine those criteria with location╤usually on the neck or under the arm╤and it's a tough job."
Standardized patients are talented and dedicated, but there are some physical reactions to biological agents that they just can't recreate (and wouldn't want to).
That's where the Paris Simulation Center and its high-tech, computer-regulated mannequins come in.
"The mannequins mimic human responses in an amazingly realistic manner," says Dr. Gary Loyd, the lab's clinical director.
Patient simulation specialist Mike Goodrow, who formerly worked for Boeing in Saint Louis, says the program offers the same teaching technology that enables pilots to learn emergency procedures in a controlled environment.
"We have the ability to simulate any physiological reaction and emergency scenario," Goodrow says. "If you can describe it, we can simulate it."
The center boasts four training suites, comprised of a classroom, videotaping equipment and a lab featuring the state-of-the-art mannequins.
The mannequins can change heartbeat, constrict their airways, alter the rise and fall of their chests, and produce various vital signs or breathing sounds. They can even respond to anesthesia and drugs.
"This is a wonderful new innovation," Loyd says. "It raises education from just information to actual application at the highest level."
'Bio-surveillance'
The CDBB is not only moving forward with its innovative educational programs, it also is providing the expertise to develop and implement a good bio-surveillance system in Kentucky, Clover says.
The system should quickly detect disease outbreak or bioterror attack and get that information to the right people through tracking patterns.
For example, when flu starts making its way around a community, school absenteeism increases. As the kids bring it home to their parents, work absences rise, too, along with doctor visits.
"We want to develop good systems where we can track unusual patterns, such as several people presenting pneumonia in the summertime, when it is much less common," Clover says.
The center is developing good bio-surveillance systems, or "informatics," to detect these abnormal patterns, communicate them immediately to the right people and then notify the community.
Expediting communication and cooperation is all part of the CDBB's regional focus. Its goal is to be an important resource for all of Kentucky along with parts of Indiana and Ohio and any other neighboring area that requires help.
"We're trying to be responsive to the needs of the state," Clover says. "We're a specialty center with a regional focus and a regional mandate that we take very seriously."
