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Medical response to bioterrorism: are we prepared?

The 1995 bombing of the Federal Building in Oklahoma City made terrorism a shocking reality for all Oklahomans. The fact that such an event could happen here, far from foreign political and ethnic conflicts and from large coastal cities, made us realize that no one is immune from the terrorist threat. But as horrific as that event and other terrorist incidents have been, the present threat of the use of infectious agents in acts of terrorism has the potential to cause far greater human death and suffering than any previously used terrorist weapon. Although health care professionals have not historically participated in terrorist planning and response activities, the addition of infectious agents to the terrorists' arsenal makes medical and public health professionals critical players in these efforts. Indeed, physicians have the ability to first recognize and report such an event and thereby diminish the impact. To meet the bioterrorism responsibility, physicians must be knowledgeable of this type of threat. In this article we present an overview of bioterrorism and review the organisms most likely to be used in a terrorist event.

Biological Warfare↗

Bioterrorism and the importance of the public health laboratory.

Biological terrorism is a threat to the United States that public health laboratories cannot afford to ignore. With the ability to recognize unusual strains of organisms, or an increase in test requests or isolation of specific organisms, the public health laboratory can detect the beginning of an outbreak. The laboratory can also facilitate appropriate response measures with rapid diagnostic testing and by determining antibiotic resistance patterns. Public health laboratory personnel need to assess their capabilities, improve them where indicated, and know where to turn for assistance. As improvements in bioterrorism detection occur in the civilian sector, military laboratories must integrate with local, state, and federal health department systems. Laboratories are essential components in surveillance, recognition, and response for both bioterrorism and naturally occurring disease outbreaks.

Biological Warfare↗

Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States.

From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported.

Adult↗

Bichat guidelines for the clinical management of tularaemia and bioterrorism-related tularaemia.

Francisella tularensis is one of the most infectious pathogenic bacteria known, requiring inoculation or inhalation of as few as 10 organisms to initiate human infection. Inhalational tularaemia following intentional release of a virulent strain of F. tularensis would have great impact and cause high morbidity and mortality. Another route of contamination in a deliberate release could be contamination of water. Seven clinical forms, according to route of inoculation (skin, mucous membranes, gastrointestinal tract, eyes, respiratory tract), dose of the inoculum and virulence of the organism (types A or B) are identified. The pneumonic form of the disease is the most likely form of the disease should this bacterium be used as a bioterrorism agent. Streptomycin and gentamicin are currently considered the treatment of choice for tularemia. Quinolone is an effective alternative drug. No isolation measures for patients with pneumonia are necessary. Streptomycin, gentamicin, doxycycline or ciprofloxacin are recommended for post-exposure prophylaxis.

Bioterrorism↗

Death due to bioterrorism-related inhalational anthrax: report of 2 patients.

On October 9, 2001, a letter containing anthrax spores was mailed from New Jersey to Washington, DC. The letter was processed at a major postal facility in Washington, DC, and opened in the Senate's Hart Office Building on October 15. Between October 19 and October 26, there were 5 cases of inhalational anthrax among postal workers who were employed at that major facility or who handled bulk mail originating from that facility. The cases of 2 postal workers who died of inhalational anthrax are reported here. Both patients had nonspecific prodromal illnesses. One patient developed predominantly gastrointestinal symptoms, including nausea, vomiting, and abdominal pain. The other patient had a "flulike" illness associated with myalgias and malaise. Both patients ultimately developed dyspnea, retrosternal chest pressure, and respiratory failure requiring mechanical ventilation. Leukocytosis and hemoconcentration were noted in both cases prior to death. Both patients had evidence of mediastinitis and extensive pulmonary infiltrates late in their course of illness. The durations of illness were 7 days and 5 days from onset of symptoms to death; both patients died within 24 hours of hospitalization. Without a clinician's high index of suspicion, the diagnosis of inhalational anthrax is difficult during nonspecific prodromal illness. Clinicians have an urgent need for prompt communication of vital epidemiologic information that could focus their diagnostic evaluation. Rapid diagnostic assays to distinguish more common infectious processes from agents of bioterrorism also could improve management strategies.

Abdominal Pain↗

The Model State Emergency Health Powers Act: planning for and response to bioterrorism and naturally occurring infectious diseases.

The Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities drafted the Model State Emergency Health Powers Act (MSEHPA or Model Act) at the request of the Centers for Disease Control and Prevention. The Model Act provides state actors with the powers they need to detect and contain bioterrorism or a naturally occurring disease outbreak. Legislative bills based on the MSEHPA have been introduced in 34 states. Problems of obsolescence, inconsistency, and inadequacy may render current state laws ineffective or even counterproductive. State laws often date back to the early 20th century and have been built up in layers over the years. They frequently predate the vast changes in the public health sciences and constitutional law. The Model Act is structured to reflect 5 basic public health functions to be facilitated by law: (1) preparedness, comprehensive planning for a public health emergency; (2) surveillance, measures to detect and track public health emergencies; (3) management of property, ensuring adequate availability of vaccines, pharmaceuticals, and hospitals, as well as providing power to abate hazards to the public's health; (4) protection of persons, powers to compel vaccination, testing, treatment, isolation, and quarantine when clearly necessary; and (5) communication, providing clear and authoritative information to the public. The Model Act also contains a modernized, extensive set of principles and requirements to safeguard personal rights. Law can be a tool to improve public health preparedness. A constitutional democracy must balance the common good with respect for personal dignity, toleration of groups, and adherence to principles of justice.

Bioterrorism↗

Capitol hill staff workers' experiences of bioterrorism: qualitative findings from focus groups.

Little systematic information is available on mental health issues related to bioterrorism. Five focus groups were conducted with Capitol Hill office staff (n = 28 total participants) to learn about their experience of the anthrax incident on October 15, 2001. More than 2,000 verbal passages were coded into categories and themes by using qualitative analysis software. Issues emerging from the discussions included difficulties utilizing customary social supports, concerns over potential long-term dangers created by efforts to eradicate the anthrax, and nonadherence to antianthrax medication regimens. Nonadherence to antibiotic prophylaxis is of immediate concern for response to future bioterrorist events as well as infectious disease epidemics. Other topics that warrant attention are social support and mental health interventions.

Administrative Personnel↗

Pyrolysis mass spectrometry for distinguishing potential hoax materials from bioterror agents.

Pyrolysis mass spectrometry (PyMS) was investigated as a rapid tool to distinguish potential bioterror hoax materials from samples containing pathogenic bacteria. A pyrolysis time-of-flight (TOF) mass spectrometer equipped with an alternative ionization technique, metastable atom bombardment (MAB), was used to produce sample spectra. These spectra were analyzed by principal component and discriminant analysis for pattern recognition. Materials investigated were two strains of Vibrio parahaemolyticus, one of which produced the tdh toxin, two Salmonella enterica serotypes, a biological mosquito control product containing spores of Bacillus thuringiensis, and several white to off-white powders (which could be used as hoax materials), such as flour, corn starch, methyl cellulose, and xanthan gum. PyMS distinguished bacterial samples from hoax materials. Furthermore, pattern analysis differentiated Vibrios from Salmonellae, Salmonella enterica Anatum from S. enterica Heidelberg, and the two V. parahaemolyticus strains from each other. The B. thuringiensis mixture was distinguished from other bacteria and powders, suggesting that PyMS with pattern recognition may differentiate samples containing pathogens, including Bacillus spp., from nonbiological agents and that it can be a rapid method for detection of bacteria. MS data acquisition took only 7 min for each sample.

Bacillus thuringiensis↗

Hospital preparedness to bioterrorism and other infectious disease emergencies.

In the last 2 decades, successive outbreaks caused by new, newly recognised and resurgent pathogens, and the risk that high-consequence pathogens might be used as bioterrorism agents amply demonstrated the need to enhance capacity in clinical and public health management of highly infectious diseases. In this article we review these recent and current threats to public health, whether naturally occurring or caused by accidental or intentional release. Moreover, we discuss some components of hospital preparedness for, and response to, infectious disease of the emergencies in developed countries. The issues of clinical awareness and education, initial investigation and management, surge capacity, communication, and caring for staff and others affected by the emergency are discussed. We also emphasise the importance of improving the everyday practice of infection control by healthcare professionals.

Bioterrorism↗

Development of a matrix to evaluate the threat of biological agents used for bioterrorism.

Adequate public health preparedness for bioterrorism includes the elaboration of an agreed list of biological and chemical agents that might be used in an attack or as threats of deliberate release. In the absence of counterterrorism intelligence information, public health authorities can also base their preparedness on the agents for which the national health structures would be most vulnerable. This article aims to describe a logical method and the characteristics of the variables to be brought in a weighing process to reach a priority list for preparedness. The European Union, in the aftermath of the anthrax events of October 2001 in the United States, set up a task force of experts from multiple member states to elaborate and implement a health security programme. One of the first tasks of this task force was to come up with a list of priority threats. The model, presented here, allows Web-based updates for newly identified agents and for the changes occurring in preventive measures for agents already listed. The same model also allows the identification of priority protection action areas.

Bioterrorism↗

Incorporating community mental health into local bioterrorism response planning: experiences from the DeKalb County Board of Health.

Following a brief introduction to response planning for terrorism and other disasters, the authors present their experiences in developing a grassroots, interdisciplinary group charged with incorporating a mental health response component into the bioterrorism response plan for the metropolitan Atlanta area. This group was organized and supported by the Center for Public Health Preparedness at the DeKalb County Board of Health. Various viewpoints of key participating agencies are presented. Recommendations are provided for other localities and stakeholders who plan to incorporate a community mental health component into local disaster response plans.

Bioterrorism↗

An emergency department response to severe acute respiratory syndrome: a prototype response to bioterrorism.

STUDY OBJECTIVE: On March 13, 2003, Singapore physicians were alerted about an outbreak of atypical pneumonia that became known as severe acute respiratory syndrome (SARS). I describe the application of an emergency department (ED) disaster response plan to manage the SARS outbreak. METHODS: The ED implemented protection for staff, patients, and facility; infection control measures; and disaster-response workflow changes. The Ministry of Health, Singapore, centralized SARS cases in the hospital, and the ED became the national screening center. A screening questionnaire and a set of admission criteria were applied after assessment of clinical features and chest radiograph findings. RESULTS: For the duration of the outbreak that ended on May 31, 2003, the ED screened 11,461 persons for SARS, of whom 1,386 (12.9%) were admitted to rule out SARS and 235 (17%) were confirmed to have SARS. Among 10,075 persons discharged from the ED, there were 28 reattending patients who were admitted and diagnosed with SARS, giving an undertriage rate of 0.3% (95% confidence interval [CI] 0.1% to 0.4%). The sensitivity of an ED admission for SARS was 89.4% (95% CI 85.6% to 93.1%), and specificity was 89.7% (95% CI 89.2% to 90.3%). The positive predictive value was 17% (95% CI 15.7% to 18.4%), and the negative predictive value was 99.7% (95% CI 99.6% to 99.8%). No patient contracted SARS as a result of an ED visit. After full implementation of protective measures, 1 ED nurse with undiagnosed diabetes mellitus was treated for suspected SARS. CONCLUSION: Although the SARS outbreak was not a bioterrorism event, the ED disaster response was applicable in the outbreak's management. The use of a screening questionnaire and admission criteria enabled the ED to screen, treat, and safely discharge the majority of the patients.

Adult↗

Clinicopathologic aspects of animal and zoonotic diseases of bioterrorism.

We live in an era of emerging infectious diseases and the threat of bioterrorism. Most of the infectious agents of modern concern, from plague to avian influenza H5N1, are zoonotic diseases: infectious agents that reside in quiet animal reservoir cycles that are transmitted occasionally to humans. The public health, health care, and veterinary communities have an enormous challenge in the early recognition, reporting, treatment, and prevention of zoonotic diseases. An intimate understanding of the natural ecology, geographic distribution, clinical signs, lesions, and diagnosis of these diseases is essential for the early recognition and control of these diseases.

Animals↗

Lessons learned: the "pale horse" bioterrorism response exercise.

The city of San Antonio, Texas, and the Fort Sam Houston Army Post conducted a bioterrorism response exercise to test the command infrastructure in a large tabletop exercise. A number of local, state, and federal agencies participated in the exercise. The scenario, program format, and multiple lessons learned from this experience are described. Needs for additional services, planning, and legal issues are identified.

Bioterrorism↗

Physician preparedness for bioterrorism recognition and response: a Utah-based needs assessment.

The medical community accepts that they have a need to be prepared to recognize and respond to bioterrorism events. A needs assessment conducted among physicians throughout the state of Utah provided insights into their perceived training needs and preferred methods of learning. Physicians have many competing demands on their time and tailored educational offering can increase the intended audience's acceptance and learning.

Bioterrorism↗

The treatment of children exposed to pathogens linked to bioterrorism.

Health care providers must understand the following regarding pathogens linked to bioterrorism: (1) the classification and qualities of possible biologic agents; (2) the natural history and management of biologic, chemical and radiologic injuries and exposures; (3) chemical agents that may be used and their properties; (4) different types of radiologic terrorism; (5) decontamination procedures; and (6) availability of antidotes and other therapeutics.

Antitoxins↗

Emergency departments (EDs) in the United Kingdom (UK) are not prepared for emerging biological threats and bioterrorism.

OBJECTIVE: To assess the preparedness of emergency departments (EDs) in the United Kingdom (UK) for the management of potential biological incidents. METHODS: We telephoned all hospitals in the UK listed as having a major ED. We surveyed their ED facilities and procedures for managing patients with infectious diseases. We determined how many of the EDs had an isolation room available and, if present, whether this had an independent ventilation system and separate access from outside the ED. In addition, we determined how many of the EDs would isolate patients with suspected cases of chickenpox, tuberculosis (TB), severe acute respiratory syndrome (SARS) and other suspicious infections. RESULTS: We obtained complete data from 203 (79%) of the 257 hospitals approached. Only 49 (24%) of these hospitals had isolation facilities available in the ED. Of these 49 EDs, 30 (61%) reported an independent ventilation system and 18 (37%) reported a separate access from outside the ED. The majority of EDs would isolate patients with potential infectious diseases, however, 47 (23%) would not isolate patients with suspected chickenpox, 37 (18%) EDS would not isolate patients with suspected TB, 12 (6%) EDS would not isolate patients with suspected SARS and 55 (27%) EDS would not isolate patients with other suspicious infections. CONCLUSION: EDs in the UK are not prepared for emerging biological threats and bioterrorism. With current facilities and procedures it is highly likely that an infectious agent will spread to staff and other patients in any future biological incident.

Bioterrorism↗