New York City Department of Health Response to Terrorist Attack, September 11, 2001 FREE

MMWR. 2001;50:821-2

In response to two jet aircraft crashing into and causing the collapse of the 110-storied World Trade Center (WTC) towers and the subsequent destruction of nearby portions of lower Manhattan, the New York City Department of Health (NYCDOH) immediately activated its emergency response protocol, including the mobilization of an Emergency Operations Center. Surveillance, clinical, environmental, sheltering, laboratory, management information systems, and operations were among the preestablished emergency committees. Because of its proximity to the WTC site, an emergency clinic was established at NYCDOH for triage and treatment of injured persons. NYCDOH focused its initial efforts on assessing the public health and medical impact of the attack and the resources needed to respond to it such as the care and management of large numbers of persons injured or killed by the crash; subsequent fire and building collapse; the health and safety of rescue workers; the environmental health risks (e.g., asbestos, smoke, dust, or chemical inhalation); other illnesses related to the disruption of the physical infrastructure (e.g., waterborne and foodborne diseases); and mental health concerns. Despite the evacuation and relocation of NYCDOH's headquarters, the department continued essential public health services, including death registration.

A rapid assessment conducted by NYCDOH during the first 24 hours after the incident indicated that most emergency department (ED) visits were for minor injuries; approximately 10%-15% of ED patients were admitted and few deaths occurred. Hospital bed and staff capacity was adequate.

Following the incident, NYCDOH prioritized four surveillance activities: (1) in collaboration with the Greater New York Hospital Association, an ongoing assessment of hospital staffing and equipment needs, and cumulative numbers of incident-related ED visits and hospital admissions; (2) an epidemiologic assessment of the types of injuries seen during the first 48 hours after the attack at one tertiary referral hospital and the four EDs closest to the crash site where the largest number of incident-related cases presented; (3) prospective surveillance of illnesses and injuries among rescue workers evaluated at the four hospitals and Disaster Medical Assistance Team triage units located at the crash site; and (4) active surveillance in EDs for specified clinical syndromes to identify unusual disease manifestations or clusters associated with these incidents, including those syndromes that could result from the release of a biologic agent. To assist NYCDOH with syndromic surveillance, CDC Epidemic Intelligence Service officers have been stationed at EDs in 15 sentinel hospitals distributed throughout the five New York City boroughs. Other NYCDOH activities included an already existing syndromic surveillance system to monitor 911 emergency calls. No unusual patterns of illness have been identified. NYCDOH also conducted laboratory testing of environmental samples and did not find evidence of a biologic agent release.

Air quality, safety of the municipal water supply, restaurant safety and rodent control, and other environmental conditions in the area continue to be monitored by NYCDOH, in collaboration with local, state, and federal agencies, to ensure the health and safety of workers at the site and residents in the immediate vicinity. Frequent alerts are sent by broadcast facsimile and electronic mail to advise metropolitan New York health-care providers of ongoing public health concerns related to the aftermath of the attack. Advisories have been developed to address the public's concerns about such issues as asbestos exposure in collapsed buildings, decomposing bodies, and managing emotional trauma. Working with the American Red Cross, NYCDOH school health program has provided nursing services and physician consultations to Red Cross shelters. The shelters serve families and persons displaced by the incident and provide respite to rescue workers. NYCDOH nurses provide nursing assessments, first-aid services, and medical referrals when needed.

In response to events in lower Manhattan and the related attack on the Pentagon in Washington, DC, the Federal Response Plan was activated. The U.S. Department of Health and Human Services (DHHS) deployed federal resources under Emergency Support Function #8 (Health and Medical) to augment the state and local medical response. A shipment of intravenous supplies, airway supplies, emergency medication, bandages and dressings, and other materials arrived in New York City the night of September 11; this was the first emergency mobilization of the National Pharmaceutical Stockpile. NYCDOH and the health department in Washington, DC, also obtained adequate supplies of tetanus vaccine from vaccine manufacturers. CDC has sent epidemiologists, occupational health specialists, industrial hygienists, and other public health professionals to supplement local efforts. Information about federal support of the local public health response is available from DHHS at http://www.hhs.gov.

MMWR. 2001;50:777-780

1 table omitted

Echoviruses constitute one of the major groups of the genus Enterovirus and are associated with illnesses including aseptic meningitis, nonspecific rashes, encephalitis, and myositis.¹ Echovirus 13 is an enterovirus that rarely has been detected in the United States, accounting for only 65 of approximately 45,000 enterovirus isolates reported to CDC during 1970-2000. No associated outbreaks have been reported in this country. As of June 2001, eight state public health laboratories and one private laboratory had reported an increased number of echovirus 13 isolates to CDC, most associated with aseptic meningitis. This report summarizes echovirus 13 activity in the United States and highlights the investigation of aseptic meningitis outbreaks in Louisiana, Mississippi, Montana, and Tennessee. Echovirus 13 should be considered in the differential diagnosis of persons with aseptic meningitis.

CDC's National Enterovirus Surveillance System (NESS) relies on voluntary reporting of enterovirus isolates by serotype from state public health laboratories.² Aseptic meningitis was removed as a nationally notifiable disease in 1995, and no uniform nationally recognized case definition exists for this condition.³ Cases of aseptic meningitis described in this report represent physician diagnoses based on clinical presentation and laboratory findings.

As of August 14, 2001, echovirus 13 has been isolated in specimens from 76 patients in 13 states (Tennessee [26], Mississippi [10], Louisiana [nine], Florida [eight], Texas [six], California [six], Kentucky [three], Ohio [two], Montana [two], and Georgia, Illinois, Indiana, and North Carolina [one each]). Of 76 isolates tested, 51 (67%) were from cerebrospinal fluid (CSF) and 12 (16%) from stool or rectal swabs. The source specimens for these isolates were collected during March-June 2001.

Of the 76 patients, 47 (62%) were male. The patients ranged in age from 2 weeks to 29 years (median age: 7 months). Most (73 [96%]) were aged <15 years, 41 (54%) were infants aged <1 year, and 29 (38%) were aged <3 months.

Clinical diagnoses were reported for 52 (68%) of the 76 patients and included aseptic meningitis (50 patients), febrile illness (one), and diarrhea (one). Of 50 isolates from patients with a diagnosis of aseptic meningitis, 45 were associated with outbreaks of aseptic meningitis in four states (26 from Tennessee, nine from Mississippi, eight from Louisiana, and two from Montana) during April-July 2001.

In June, 27 cases of aseptic meningitis among patients admitted to one hospital during May 22–June 20 were reported to the Louisiana Office of Public Health, representing a nine-fold increase in the number of aseptic meningitis hospitalizations over the same period during 2000. All of the patients resided in three parishes (i.e., counties) in the southeastern part of the state. Of the 27 cases, 20 (74%) occurred in the same parish (hospitalization rate: 20 per 100,000 population). Reported clinical symptoms included fever (94%), headache (77%), vomiting (77%), stiff neck (50%), and photophobia (23%).

During May 5–July 31, 56 cases of aseptic meningitis were reported to the Mississippi State Department of Health from one regional medical center. Of the 56 patients, 41 (73%) resided in a county adjacent to the Louisiana parish that accounted for most of the cases in Louisiana. The hospitalization rate for this Mississippi county was 111 per 100,000 population. Reported clinical symptoms included fever (75%), headache (70%), vomiting (55%), nausea (52%), and stiff neck (20%).

During June 8–July 11, 23 cases of aseptic meningitis were reported to the Montana Department of Public Health and Human Services (MDPHHS) from a single county in the southeastern part of the state (hospitalization rate: 181 per 100,000 population). Eighteen additional cases of aseptic meningitis reported from a neighboring county since early July are being investigated by MDPHHS.

An outbreak of aseptic meningitis involving approximately 250 persons admitted to a hospital in Tennessee since April 2001 is being investigated by the Tennessee State Health Department. Echovirus 13 has been confirmed as the etiologic agent for 33 of 75 cases.

N Krishna, MS, M Little, MPH, R Ratard, MD, Louisiana Office of Public Health. M Currier, MD, S Hand, Mississippi State Dept of Health. J Murphy, Montana Dept of Public Health and Human Svcs; S Zanto, Montana Public Health Laboratory; C Taft, P Schwaiger, Big Horn County Health Dept, Hardin, Montana. T Jones, MD, Tennessee State Health Dept; J Hindman, Tennessee State Public Health Laboratory; S Buckingham, MD, G Grandberry, LeBonheur Hospital, Memphis, Tennessee. MA Patterson, W Sessions, Texas Dept of Health Laboratory. P Colarusso, MSH, R Melear, MHA, Bur of Laboratories, Florida Dept of Health. D Schnurr, PhD, California Dept of Health Svcs; J Giesick, San Diego Public Health Dept. P Brantley, North Carolina Public Health Laboratory. J Dunn, PhD, ARUP Laboratories, Salt Lake City, Utah. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and EIS officers, CDC.

This is the first report of widespread circulation of echovirus 13 and of outbreaks associated with this enterovirus in the United States. Increased echovirus 13 activity also was reported in Europe during 2000 when echovirus 13 was associated for the first time with outbreaks of aseptic meningitis in England, Wales, and Germany.^4- 5

Clinical manifestations of enterovirus infections are protean, ranging from asymptomatic carriage to life-threatening illness.⁶ Because echovirus 13 rarely has been isolated, the spectrum of disease associated with this virus has not been well established. Conditions previously associated with echovirus 13 are typical of enterovirus infections⁶ and include asymptomatic carriage,⁶ mild febrile illness,⁷ aseptic meningitis,^4- 5,8- 9 respiratory diseases (e.g., coryza, pharyngitis, bronchitis, and bronchiolitis [^7,9]), poliomyelitis-like illness,⁸ diarrhea with fever,^7,9 rash,^7,9 encephalitis,⁹ and enteroviral sepsis.⁹ Aseptic meningitis is the predominant illness that has been associated with the current echovirus 13 activity in the United States and with echovirus activity reported in Europe in 2000. However, patients with meningitis are more likely be tested for enteroviruses than are patients with milder illnesses.

In temperate climates, enteroviruses demonstrate a marked seasonality, with widespread circulation during summer and fall. A typical enterovirus season in the United States lasts from June through October.⁹ In 2001, the first isolations of echovirus 13 in the United States were reported in March. The reported outbreaks of aseptic meningitis associated with this serotype started early in the enterovirus season.

The age distribution of patients with echovirus 13 isolates and of the other cases involved in the three aseptic meningitis outbreaks indicates that young children are at highest risk for infection. A similar age distribution was observed during the aseptic meningitis outbreak associated with echovirus 13 in Germany in 2000,⁵ but the outbreaks in England and Wales predominantly affected older children.⁴

In addition to echovirus 13, other enterovirus serotypes have been identified in these outbreaks of aseptic meningitis. The isolation of several enteroviruses in community outbreaks is not unusual because numerous serotypes commonly co-circulate. Predominant enterovirus serotypes tend to change over time.¹⁰ In the United States, the serotypes most commonly reported to NESS were echoviruses 30, 6, and 7 in 1997, echoviruses 30, 9, and 11 in 1998, and echoviruses 11, 16, and 9 in 1999.² Although the clinical spectrum of diseases associated with various enterovirus serotypes overlap, some manifestations of enterovirus infection are associated commonly with certain serotypes (i.e., aseptic meningitis and echovirus 30, hand-foot-and-mouth disease and coxsackievirus A16, and acute hemorrhagic conjunctivitis and enterovirus 70 and coxsackievirus A24).⁶

Enterovirus surveillance is important for understanding circulation patterns of these viruses in the United States. In addition, this information may be helpful for evaluating potential antienterovirus drugs and in understanding the links of enteroviruses with disease. More information is needed to clarify the epidemiologic characteristics and to define better the clinical spectrum of associated diseases.

No specific prevention or control measures are available for nonpolio enteroviruses, including echovirus 13. Adherence to good hygienic practices, such as frequent and thorough hand washing (especially after diaper changes), disinfection of contaminated surfaces by household cleaners (e.g., diluted bleach solution), and avoidance of sharing utensils and drinking containers may be effective in reducing the spread of infection.

MMWR. 2001;50:784

CDC has published Health, United States, 2001 With Urban and Rural Health Chartbook, the 25th edition of the annual report on the nation's health. This report includes 148 trend tables organized around four broad subject areas: health status and determinants, health-care use, health-care resources, and health-care expenditures. Disparities in health by race/ethnicity and socioeconomic status are presented in several tables.

This year's report also includes the Urban and Rural Health Chartbook. Communities at different urbanization levels differ in their demographic, environmental, economic, and social characteristics, and these characteristics influence the magnitude and types of health problems that communities face. The chartbook presents population characteristics, health risk factors, health status indicators, and health-care access measures for residents of counties grouped by five urbanization levels (from the most urban to the most rural). Of U.S. residents examined, those who have the best health measures are residents of fringe counties of large metropolitan areas. In comparison, the urbanization level associated with adverse health measures is less consistent. Residents of the most rural counties fare worst on some measures (e.g., motor vehicle traffic-related injury mortality) and residents of the most urban counties fare worst on other measures (e.g., homicide).

Additional information about the report is available at http://www.cdc.gov/nchs (click on "Top 10 Links" to locate "Health, United States"). Print copies may be purchased from the Government Printing Office, telephone: (202) 512-1800; website: http://bookstore.gpo.gov/index.html.