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Only a small minority of hospitals have adequate systems in place. Many existing systems may be adaptable to bioterrorism preparedness. Benchmarking opportunities are available for facilities with inadequate systems.
The fear of terrorist attacks has increased since the events of 11 September 2001 in New York. In the weeks following the terrorist attack, letters containing anthrax spores were received at various locations in the USA. This shows that bioterrorism is possible and that is necessary to be prepared for the potential release of biological agents. Such agents can be distributed not only via the air and drinking water but also via household pets. The aim of terrorist attacks, namely, the disruption of society and daily life, can be achieved in three ways, ways which are of importance to practising veterinarians, namely, via pets, via contamination of pet foods of animal origin, and by the spread of infectious animal diseases that have far-reaching economic consequences. These ways are discussed in this article, together with possible ways in which veterinarians can act to diminish the consequences of such an event.
In view of current events the question is discussed to what extent the risk of bioterrorism may be an issue relevant for forensic medicine also in Germany, although at present there seems to be no concrete threat. The cases which became known so far were either false alarms or foolish pranks (copycats), which have to be, and are indeed, prosecuted by the state (section 126 German Criminal Code). Reference is also made to the measures of disinfection recommended by the Robert Koch Institute.
Because of the success of vaccination and the ring strategy in eradicating smallpox from the world, smallpox vaccine has not been recommended for the United States civilian populations for decades. Given the low but possible threat of bioterrorism, smallpox vaccination is now recommended for those teams investigating potential smallpox cases and for selected personnel of acute-care hospitals who would be needed to care for victims in the event of a terrorist attack. Treatment and post-exposure prophylaxis for anthrax are ciprofloxacin or doxycycline. Anthrax vaccine alone is not effective for post-exposure prevention of anthrax; vaccination is accompanied by 60 days of antibiotic therapy. In addition to military use, anthrax vaccine is recommended for pre-exposure use in those persons whose work involves repeated exposure to Bacillus anthracis spores.
The Bush administration is emphasizing immunization as a way to prevent the U.S. population from being harmed by bioterrorism, especially where smallpox is concerned. But immunology and public health experts are warning that a policy of mass pre-emptive immunization for smallpox would very likely cause harm to HIV-positive people, as well as other groups who are at risk for harm from the smallpox vaccine.
The etiologic agents of smallpox and viral hemorrhagic fever have emerged as potential agents of bioterrorism due to their virulence, potential for human to human dissemination and limited strategies for treatment and prevention. Cidofovir has shown significant promise in animal models, and limited case reports in humans are encouraging. Ribavirin is the treatment of choice for certain hemorrhagic fever viral infections, but has no current application to Ebola and Marburg infections. Current vaccine strategies for smallpox are effective, but carry significant risk for complications. Licensed vaccines for hemorrhagic fever viruses are limited to yellow fever, but animal studies are promising. Genomic analysis of the viral pathogen and the animal model response to infection may provide valuable information enabling the development of novel treatment and prevention strategies. Current knowledge of these strategies is reviewed.
Ms. Bruce's paper analyzes the interplay between the Model State Emergency Health Powers Act and the HIPAA Privacy Rule. The article begins by examining specific relevant provisions of the Act and Rule. Next, it traces the history of public health law through the court system and then uses this foundation to discuss how the Model State Emergency Health Powers Act and the HIPAA Privacy Rule could co-exist, protecting Americans in the case of a bioterror attack, while being appropriately sensitive to the confidentiality of private health information.
Recent bioterror attacks and other world events have focused the medical community's attention on agents that might be used in biological warfare. One of these potential biological weapons is Francisella tularensis, a gramnegative coccobacillus that is one of the most infectious bacteria known. F tularensis can cause severe, even fatal, systemic tularemia. Under normal circumstances, F tularensis is transmitted by infected ticks, insects, and other animals. As a weapon of terrorism, the bacterium would likely be disseminated as an aerosol and contracted by inhalation. Because many cases of tularemia are characterized by head and neck symptoms, otolaryngologists should be familiar with the diagnosis and management of this disease. In this article, we describe a case of zoonotic tularemia that manifested as a neck mass, and we review the pathophysiology, diagnosis, and treatment of tularemia. We also summarize what is known about its potential as a biological weapon.
The former Secretary of the Department of Health and Human Services, Donna Shalala, indicated in an address in 1999 that complacency needs to be replaced with a sense of urgency in order for us to deal successfully with the threats of bioterrorism. The attack on September 11, 2001 and the anthrax threats have made our vulnerability clear. We are now living in a new and frightening world. Our complacency is gone. The victims and the survivors shall remain forever in our minds. Dr. Jeffery Koplan, Director, Centers for Disease Control and Prevention in his broadcast, Building Infrastruture to Protect the Public Health said we must look at preparedness in a new way. We need to: build a solid public health infrastructure with grant monies; rapidly address the problem of inadequately trained staff; and address the capacity of a laboratory to produce timely and accurate results for the diagnosis of agents in the investigation of outbreaks. We must take action to prepare the healthcare system to rapidly meet any challenge, overt or covert, that may emerge.
OBJECTIVE: To describe the function and levels of analysis performed by members of the Laboratory Response Network in coping with biological agents of terrorism. DATA SOURCES: Current literature and the Internet. CONCLUSIONS: The Laboratory Response Network is designed to enable rapid, safe, and accurate diagnosis of disease in order to mobilize the nation's response to acts of bioterrorism.
During the bioterrorism-associated anthrax investigation of 2001 in the United States, 11 patients were diagnosed with inhalational anthrax and 11 more with the cutaneous forms of the disease. Over 125,000 specimens were processed at laboratories of the Laboratory Response Network including those at the Centers for Disease Control and Prevention. Although the 2001 anthrax investigation initially began as a public health investigation, the forensic aspect quickly became a preeminent component of the investigation. Whereas a public health investigation aims primarily to identify the causative agent and its source, so that appropriate and timely control and preventative measures can be implemented, a forensic investigation goes further to associate the source of the causative agent with a specific individual or group. In addition to identification and molecular characterization of the causative agents, which are the crucial components of forensic microbiology, there are many other requirements and activities that need to be in place for investigators to successfully complete a forensic investigation. These activities include establishment of quality assurance/quality control criteria and regular proficiency testing for all laboratories where evidence is analyzed; additional and/or specialized training in handling and processing samples in accordance with forensic microbiology criteria, not only for first responders but also for laboratory and other public health scientists; and establishing and maintaining repositories and databases containing isolates of diverse temporal and geographic origins to provide a comparative and diverse background for investigators to identify and track the origin and source of such agents.
In anticipation of future terrorist attacks, the nation has been focused on emergency preparedness, including threats to public health and the ability of communities to respond to them. The Center for Studying Health System Change's (HSC) recent site visits to 12 nationally representative communities found early benefits to public health due to heightened attention to bioterrorism preparedness: more visibility and credibility for public health, stronger public health infrastructure and improved communication and coordination across sectors. Modest negative effects included staff diversions and delays in some program implementation. As the site visits continued from fall 2002 into 2003, concerns grew that the federal smallpox vaccination program was diverting resources from such traditional public health activities as routine immunizations, health promotion and screening.
In this article contemporary views on terrorism with biological weapons use are presented. The bioterrorism phenomenon is described; some of the attacks known so far are reviewed as well as sources of possible agents' acquisition, terrorists' capabilities and lines of conduct.
In this article general principles of defense against bioterrorism are presented. Furthermore, the effort, already undertaken for organization of the system enabling effective countermeasures to this threat as well as liquidation of the effects of such an event, is shown.
Between October 4, 2001 and November 20, 2001, 22 cases of anthrax were identified in a bioterrorism attack on the US. This study examined the patterns of anthrax calls before and after the bioterrorist attack based on calls received by poison centers in Texas, a state that reported no anthrax cases as a result of the attack. During 1998-2002, 553 calls about anthrax were received. The majority of the anthrax calls occurred in 2001 (n = 489, 88.4%) and 2002 (n = 52, 9.4%). The number of calls increased greatly in the days after October 4, 2001, reaching a peak of 31 anthrax calls in 1 d and then declining sharply in succeeding months. However, by December 2002 the number of calls about anthrax still had not returned to pre-attack levels. This study demonstrated the value of poison centers in documenting public need for information on biological agents used in a terrorist attack, even if the attack did not occur in the area serviced by the poison center. Poison centers may expect to receive calls regarding a bioterrorist attack shortly after the public became aware of the attack and will continue to receive related calls for months afterward. Poison centers need to be prepared with appropriate information prior to such attacks to provide to the public upon request.
U.S. military and public health experts are increasingly concerned that the general public is at risk for terrorist attacks. Traditional weapons of mass destruction such as explosive and chemical devices remain the most likely forms of terrorism, however the threat of bioterrorism is also present and may be increasing. An intentional biologic event may be covert and if so, will not become apparent for days or even weeks when many ill people present with an unidentified illness. Health care providers will be the first responders during a biologic attack and will be called upon to diagnose diseases such as anthrax, tularemia or even smallpox. In the first of a two-part article, a hypothetical scenario is presented to illustrate how such an attack might first be discovered and the agent identified. As the scenario unfolds, evidence is collected that suggests the outbreak was intentional. Information about epidemiologic clues, disease syndromes and specific high-risk agents are discussed.
Smallpox was declared to be eradicated on 8 May 1980, during the Thirty-third World Health Assembly. However, concerns about the possible use of the virus as a weapon of bioterrorism have increased in recent years. Governments have responded by initiating selective vaccination programmes and other public health measures. This review uses historical data from 20th century outbreaks to assess the risks to current populations (which have declining immunity) from a deliberate release of virus. The data presented supports the conclusion of a previous reviewer (Mack) that "smallpox cannot be said to live up to its reputation. Far from being a quick-footed menace, it has appeared as a plodding nuisance with more bark than bite." Its R value (the average number of secondary cases infected by a primary case) is lower than that for measles, human parvovirus, chickenpox, mumps, rubella, and poliomyelitis; only the value for severe acute respiratory syndrome (SARS) is lower. Like SARS, close person-to-person contact is required for effective spread of the disease, and exposure to the virus in hospitals has played an important role in transmission for both viruses. In the present paper the dangers of mass vaccination are emphasized, along with the importance of case isolation, contact tracing, and quarantine of close contacts for outbreak control. The need for rapid diagnosis and the continued importance of maintaining a network of electron microscopes for this purpose are also highlighted.
In September 2001, shortly after terrorist attacks in the United States, the issue of bioterrorism--and specifically fear about reported cases of anthrax in the US--led the Canadian Minister of Health to be concerned about the available stocks of the drug ciprofloxacin to treat this disease.