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PubMedDate not supplied

Missed sentinel case of naturally occurring pneumonic tularemia outbreak: lessons for detection of bioterrorism.

BACKGROUND: Family physicians are likely to care for patients that have been exposed to diseases associated with bioterrorism. Persons with seemingly nondescript initial disease symptoms could be harbingers of a larger outbreak, whether naturally occurring or purposefully created. METHODS: We report a missed sentinel case of pneumonic tularemia associated with a naturally occurring outbreak. The patient's initial clinical symptoms and signs were nondescript, and the diagnosis was recognized by subsequent blood tests. The medical literature was searched using the key words "tularemia," "bioterrorism," "index of suspicion," and "sentinel case." RESULTS AND CONCLUSIONS: Being alert to possible unexpected causes of a pneumonic summer illness in a patient with associated weight loss might have led to an earlier diagnosis of this sentinel case tularemia and its association with the subsequent outbreak. Individual patients are likely to visit a physician's office after a purposeful bioterrorism event. Greater efforts must be made to increase awareness in all primary care physicians who might see patients exposed to a bioterrorism illness.

Bioterrorism↗
PubMed2006

Animals as sentinels of bioterrorism agents.

We conducted a systematic review of the scientific literature from 1966 to 2005 to determine whether animals could provide early warning of a bioterrorism attack, serve as markers for ongoing exposure risk, and amplify or propagate a bioterrorism outbreak. We found evidence that, for certain bioterrorism agents, pets, wildlife, or livestock could provide early warning and that for other agents, humans would likely manifest symptoms before illness could be detected in animals. After an acute attack, active surveillance of wild or domestic animal populations could help identify many ongoing exposure risks. If certain bioterrorism agents found their way into animal populations, they could spread widely through animal-to-animal transmission and prove difficult to control. The public health infrastructure must look beyond passive surveillance of acute animal disease events to build capacity for active surveillance and intervention efforts to detect and control ongoing outbreaks of disease in domestic and wild animal populations.

Animals↗
PubMed2001

Preparing for expected bioterrorism attacks.

The threat of bioterrorism in the United States is increasing. Health professionals, especially "front-line" practitioners, must be able to recognize the potential for major impacts from a bioterrorism event. Although an effective attack could produce numbers of casualties equivalent to those resulting from a nuclear weapon, an unannounced attack would be unlikely to be recognized immediately. Health workers may be the first to recognize an attack. However, only limited assistance is available to aid local community medical organizations in planning for bioterrorism. Military medical personnel have had more experience in planning for terrorist activities than many of their civilian colleagues. Their experience may be invaluable to local civilian treatment facilities in developing practical plans to meet the unique aspects of bioterrorism. In addition to considering agent-specific medical problems and requirements, it is particularly important for plans to address command and control, communication, and coordination if the resultant response is to be effective.

Biological Warfare↗
PubMed2001

Update: Investigation of bioterrorism-related anthrax, 2001.

This report updates the investigation of bioterrorism-related anthrax and the provision of antimicrobial prophylaxis to exposed persons and highlights CDC assistance to other countries investigating cases of bioterrorism-related anthrax. Since November 7, 2001, CDC and state and local public health agencies have identified no new cases of bioterrorism-related anthrax. As of November 14, a total of 22 cases of anthrax has met the CDC case definition; 10 were confirmed inhalational anthrax, and 12 (seven confirmed and five suspected) were cutaneous anthrax. Investigation of a case of inhalational anthrax in a hospital stock room worker aged 61 years in New York City (NYC) found no evidence of anthrax contamination at the work site or home; the source of exposure is unknown. Environmental clean-up of contaminated facilities continues, and surveillance for newcases of bioterrorism-related anthrax is ongoing in Delaware (DE), District of Columbia (DC), Florida (FL), Maryland (MD), New Jersey (NJ), NYC, Pennsylvania (PA), Virginia (VA), and other states.

Anthrax↗
PubMed2001

Bioterrorism. Implications for the occupational and environmental health nurse.

1. Bioterrorism is the intentional release of a biological agent--bacterial, viral, or genetically altered--to instill fear or create chaos, massive casualities, illness, and death in humans, animals, or plants. 2. The threat of bioterrorism is real. Although every community is vulnerable, terrorists seek densely populated, highly visible targets. 3. Occupational and environmental health nurses must to be able to recognize and report signs and symptoms of an early bioweapons outbreak in their workplaces and communities. Only thorough preparedness and planning will result in effective mitigation and treatment. 4. The Bioterrorism Readiness Plan (at http://www.apic.org and http://www.CDC.gov/ncidod/hip) is a template for health care professionals to help plan a realistic response to bioterrorism. It serves as a tool for successful collaboration and communication among all disciplines and public health agencies for the best possible outcomes.

Anthrax↗
PubMed2001

Bioterrorism, physician education, and the Internet.

To meet the challenges of bioterrorism, the practicing physician must have information that is authoritative, specific, and timely with respect to any outbreaks or suspected outbreaks of bioterrorism. Educational activities for physicians and other health care workers are important. In the United States, bioterrorism was not an issue until October 2001, and bioterrorism disease organisms are not ones commonly dealt with in civilian health care. Web sites that satisfy these information and educational requirements are discussed.

Bioterrorism↗
PubMed2006

Salmonella-based plague vaccines for bioterrorism.

Yersinia pestis, the causative agent of plague, is an emerging threat as a means of bioterrorism. Accordingly, the Working Group on Civilian Biodefense, as well as the Centers for Disease Control and Prevention, has specified Y. pestis as a prime candidate for use in bioterrorism. As the threat of bioterrorism increases, so does the need for an effective vaccine against this potential agent. Experts agree that a stable, non-invasive vaccine would be necessary for the rapid large-scale immunization of a population following a bioterrorism attack. Thus far, live Salmonella-based oral vaccines show the most potential for this purpose. When delivered via a mucosal route, Salmonella-based plague vaccines show the ability to protect against the deadly pneumonic form of plague. Also, mass production, distribution, and administration are easier and less costly for attenuated Salmonella-based plague vaccines than for plague vaccines consisting of purified proteins. Most attenuated Salmonella-based plague vaccines have utilized a plasmid-based expression system to deliver plague antigen(s) to the mucosa. However, these systems are frequently associated with plasmid instability, an increased metabolic burden upon the vaccine strain, and highly undesirable antibiotic resistance genes. The future of Salmonella-based plague vaccines seems to lie in the use of chromosomally encoded plague antigens and the use of in vivo inducible promoters to drive their expression. This method of vaccine development has been proven to greatly increase the retention of foreign genes, and also eliminates the need for antibiotic resistance genes within Salmonella-based vaccines.

Antigens, Bacterial↗
PubMed2006

Are we preparing health services administration students to respond to bioterrorism and mass casualty management?

Bioterrorism/natural disaster events add significant specialized demands and disrupt normal operation of the health system, often for an indefinite period of time. Health administration leaders should be educationally prepared for and informed about these potential events, but few receive this knowledge via their academic preparation in health administration. This study examined the existence of coverage of bioterrorism topics in health administration curricula and characteristics of bioterrorism coverage in current health administration programs through a self-completed survey among AUPHA graduate and undergraduate program members. Of the total survey respondents, only 32% of programs have current coverage of bioterrorism. The main reasons for nothavingbioterrorism coverage were not having enough resources; not having enough time to develop course/materials; and not thinking it is necessary to add these courses/materials. To prepare better and to inform future health administrators regarding major disruptive circumstances, advocacy and documentation are important to develop and implement bioterrorism awareness. Possibly, suggested minimum curricular requirements, content, and mechanisms for inclusion can be developed in the near future. Health administration educators should address the new reality and demonstrate that their graduates can function and lead in crises and situations disruptive to normal commerce.

Administrative Personnel↗
PubMed2000

Bioterrorism: challenges and opportunities for local health departments.

The emerging threat of bioterrorism will significantly impact local health departments. If a bioterrorism attack occurs, local medical and public health personnel will have the primary role of recognition and response. Federal assistance and training to deal with bioterrorism have been directed to 120 of our largest cities. Despite progress, much needs to be done. The public health approach to bioterrorism must begin with the development of local and state plans developed by public health, emergency response, and law enforcement communities, which must work together closely if an epidemic is to be detected in a timely manner.

Biological Warfare↗
PubMed2003

Increased detection of rickettsialpox in a New York City hospital following the anthrax outbreak of 2001: use of immunohistochemistry for the rapid confirmation of cases in an era of bioterrorism.

BACKGROUND: Rickettsialpox is a self-limited febrile illness with skin lesions that may be mistaken for signs of potentially more serious diseases, such as cutaneous anthrax or chickenpox. The cluster of cutaneous anthrax cases from bioterrorism in October 2001 likely heightened awareness of and concern for cutaneous eschars. OBJECTIVES: To apply an immunohistochemical technique on paraffin-embedded skin biopsy specimens for diagnosing rickettsialpox, and to compare the reported incidence of rickettsialpox before, during, and after the cluster of cutaneous anthrax cases. DESIGN: Case series. SETTING: Dermatology department in a large tertiary care hospital in New York City. PATIENTS: Eighteen consecutive patients with the clinical diagnosis of rickettsialpox from February 23, 2001, through October 31, 2002. MAIN OUTCOME MEASURES: Results of immunohistochemical testing of skin biopsy specimens and of serological testing. RESULTS: Immunohistochemical testing revealed spotted fever group rickettsiae in all 16 eschars and in 5 of the 9 papulovesicles tested. A 4-fold or greater increase in IgG antibody titers reactive with Rickettsia akari was observed in all 9 patients for whom acute and convalescent phase samples were available; 6 patients had single titers indicative of rickettsialpox infection (> or =1:64). Of the 18 patients, 9 (50%) presented in the 5 months following the bioterrorism attacks. CONCLUSIONS: Rickettsialpox remains endemic in New York City, and the bioterrorism attacks of October 2001 may have led to increased awareness and detection of this disease. Because rickettsialpox may be confused with more serious diseases, such as cutaneous anthrax or chickenpox, clinicians should be familiar with its clinical presentation and diagnostic features. Immunohistochemical staining of skin biopsy specimens, particularly from eschars, is a sensitive technique for confirming the clinical diagnosis.

Adolescent↗
PubMed2005

Ability of physicians to diagnose and manage illness due to category A bioterrorism agents.

BACKGROUND: Early recognition of a terrorist attack with biologic agents will rely on physician diagnosis. Physicians' ability to diagnose and care for patients presenting after a bioterror event is unknown. The role of online case-based didactics to measure and improve knowledge in the diagnosis and treatment of these patients is unknown. METHODS: A multicenter online educational intervention was completed by 631 physicians at 30 internal medicine residency programs in 16 states and Washington, DC, between July 1, 2003, and June 10, 2004. Participants completed a pretest, assessing ability to diagnose and manage potential cases of smallpox, anthrax, botulism, and plague. A didactic module reviewing diagnosis and management of these diseases was then completed, followed by a posttest. Pretest performance measured baseline knowledge. Posttest performance compared with pretest performance measured effectiveness of the educational intervention. Results were compared based on year of training and geographic location of the residency program. RESULTS: Correct diagnoses of diseases due to bioterrorism agents were as follows: smallpox, 50.7%; anthrax, 70.5%; botulism, 49.6%; and plague, 16.3% (average, 46.8%). Correct diagnosis averaged 79.0% after completing the didactic module (P<.001). Correct management of smallpox was 14.6%; anthrax, 17.0%; botulism, 60.2%; and plague, 9.7% (average, 25.4%). Correct management averaged 79.1% after completing the didactic module (P<.001). Performance did not differ based on year of training (P = .54) or geographic location (P = .64). Attending physicians performed better than residents (P<.001). CONCLUSIONS: Physician diagnosis and management of diseases caused by bioterrorism agents is poor. An online didactic module may improve diagnosis and management of diseases caused by these agents.

Anthrax↗
PubMed2002

Responding to the threat of bioterrorism: a microbial ecology perspective--the case of anthrax.

Anthrax is a disease of herbivores caused by the gram-positive bacterium Bacillus anthracis. It can affect cattle, sheep, swine, horses and various species of wildlife. The routes for the spread among wildlife are reviewed. There are three kinds of human anthrax--inhalation, cutaneous, and intestinal anthrax--which differ in their routes of infection and outcomes. In the United States, confirmation of cases is made by the isolation of B. anthracis and by biochemical tests. Vaccination is not recommended for the general public; civilians who should be vaccinated include those who, in their work places, come in contact with products potentially contaminated with B. anthracis spores, and people engaged in research or diagnostic activities. After September 11, 2001, there were bioterrorism anthrax attacks in the United States: anthrax-laced letters sent to multiple locations were the source of infectious B. anthracis. The US Postal Service issued recommendations to prevent the danger of hazardous exposure to the bacterium. B. anthracis spores can spread easily and persist for very long times, which makes decontamination of buildings very difficult. Early detection, rapid diagnosis, and well-coordinated public health response are the key to minimizing casualties. The US Government is seeking new ways to deter bioterrorism, including a tighter control of research on infectious agents, even though pathogens such as B. anthracis are widely spread in nature and easy to grow. It is necessary to define the boundary between defensive and offensive biological weapons research. Deterring bioterrorism should not restrict critical scientific research.

Anthrax↗
PubMed2004

Bioterrorism and children: unique concerns with infection control and vaccination.

Treatment of child victims of a bioterrorism attack is complicated because they may be more vulnerable to the agents used and may suffer more complications from the treatment strategies. Isolation and other infection control measures can be psychologically harmful to young children and may require that they undergo sedation. Most of the recommended antibiotics and antiviral treatments for bioterror agents have not been approved for use in children, and children undergoing smallpox vaccination have a higher incidence of complications than adults. Pediatric anesthesiologists should expect to be part of the pediatric care team and must be careful to observe infection control procedures to limit the spread of disease caused by bioterror attack.

Bioterrorism↗
PubMed2003

Medical management of biological warfare and bioterrorism: place of the immunoprevention and the immunotherapy.

Biological weapons are considered as mass destruction and terror weapons. Terrorism including bioterrorism is the major threat in the future conflicts for our nations. The aim of bioterrorism is more related to the potential disorganisation of the society than to the lethal effects of the agents used. The dramatic consequences cannot be discarded, especially if contagious agents such viral are used. The preparation of specific defence measures is a major challenge for our countries. The knowledge acquired from the struggle against natural infectious diseases and recent events are essential to improve behaviours to face the biological weapon threats. The defence attitude is based on the anticipation of the threat, the management of the victims, and the restoration of the operational capabilities. This global defence attitude implies six important functions: (i) alert, (ii) detection and diagnosis, (iii) availability of pharmaceutical countermeasures such as vaccine, sera and anti-infectious medicine and products, (iv) medical management of victims, (v) training and information, (vi) research and development. Passive and active immunoprevention and immuntherapy belong to the approaches discussed in the context of bioterrorism countermeasures. Further researches might be focused on these topics.

Animals↗
PubMed2002

Future challenges in preparing for and responding to bioterrorism events.

The future success of our preparations for bioterrorism depends on many issues as presented in this article. If these issues are properly addressed, the resulting improvements in bioterrorism preparations will allow us to better deter and mitigate a bioterrorism incident and will also provide us with the added benefit of improvements in early detection, diagnosis, and treatment of natural disease outbreaks. Emergency physicians must take an active leading role in working with the various disciplines to produce a better-prepared community.

Bioterrorism↗
PubMed2002

Bioterrorism preparedness. III: State and federal programs and response.

Management of a bioterrorism event will begin with early detection and intervention at the local level. Any large-scale event will require rapid state and federal assistance. Federal initiatives targeting bioterrorism have increasingly become a complex web of executive and legislative actions, frequently initiated in reaction to specific events, and often unrelated to this threat. Multiple executive and legislative branch actions have resulted in a proliferation of federal programs, and coordination of these efforts remains a significant challenge. Still, great strides have been taken to improve our defensive posture against this emerging threat, and, at all levels, governmental authorities and agencies are much better prepared to respond to such events than they were a decade ago. The events of September 11, 2001 and subsequent events are clear indicators that the timeline for preparedness has been significantly compressed. Federal emergency operations, historically designed more for recovery than response, seemed up to the task in the wake of the World Trade Center and Pentagon attacks, although there was criticism of federal responsiveness to the subsequent anthrax incidents [71,72], and the timeliness of federal resources in the event of a large-scale outbreak resulting from a bioterrorism attack has yet to be truly tested. The recent establishment of the Office of Homeland Security and the Homeland Security Council holds promise that some of these inefficiencies may be rectified and overall coordination of programs will improve. Continued improvements in the effectiveness of the federal government in meeting the challenges of this and other emerging threats to homeland security will require: Establishment of consensus standards, metrics, and measures of effectiveness for all aspects of disaster, epidemic, and terrorism management at the local, regional, state, and federal levels Delineation of expected, quantifiable state and local capabilities to mitigate, prepare, respond, and recover from all disasters, including those caused by terrorist actions Development of predefined or clear and rapidly discernible criteria for deployment of state and federal emergency resources Full accountability of program costs and expenditures Continued consolidation or coordination of the many overlapping and at times redundant federal programs.

Bioterrorism↗
PubMed2005

A multiplex polymerase chain reaction microarray assay to detect bioterror pathogens in blood.

Heightened concern about the dangers of bioterrorism requires that measures be developed to ensure the safety of the blood supply. Multiplex detection of such agents using a blood-screening DNA microarray is a sensitive and specific method to screen simultaneously for a number of suspected agents. We have developed and optimized a multiplex polymerase chain reaction microarray assay to screen blood for three potential bioterror bacterial pathogens and a human ribosomal RNA gene internal control. The analytical sensitivity of the assay was demonstrated to be 50 colony-forming units/ml for Bacillus anthracis, Francisella tularensis, and Yersinia pseudotuberculosis (surrogate for Yersinia pestis). The absence of any false-positives demonstrated high analytical specificity. Screening B. anthracis-infected mouse blood samples and uninfected controls demonstrated effectiveness and specificity in a preclinical application. This study represents proof of the concept of microarray technology to screen simultaneously for multiple bioterror pathogens in blood samples.

Animals↗
PubMedDate not supplied

Vaccine administration by paramedics: a model for bioterrorism and disaster response preparation.

The events of 11 September 2001 have had a profound effect on disaster planning efforts in the United States. This is true especially in the area of bioterrorism. One of the major tenets of bioterrorism response is the vaccination of at-risk populations. This paper investigates the efficacy of training emergency medical services paramedics to administer vaccines in public health settings as preparation for and response to bioterrorism events and other disaster events. The concept of vaccination administration by specially trained paramedics is not new. Various programs to provide immunizations for emergency services personnel and at-risk civilian populations have been reported. Vaccination programs by paramedics should follow the guidelines of the National Vaccine Advisory Committee of the Centers for Disease Control and Prevention (CDC). This paper compares the seven standards of the CDC guidelines to routine paramedic practice and education. It is concluded that paramedics are adequately trained to administer vaccines. However, specific training and protocols are needed in the areas of administrative paperwork and patient education. A proposed outline for a paramedic-training program is presented.

Bioterrorism↗