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PubMed2002

Fatal inhalational anthrax in a 94-year-old Connecticut woman.

We describe the 11th case of bioterrorism-related inhalational anthrax reported in the United States. The presenting clinical features of this 94-year-old woman were subtle and nondistinctive. The diagnosis was recognized because blood cultures were obtained prior to administration of antibiotics, emphasizing the importance of this diagnostic test in evaluating ill patients who have been exposed to Bacillus anthracis. The patient's clinical course was characterized by progression of respiratory insufficiency, pleural effusions and pulmonary edema, and, ultimately, death. Although her B anthracis bacteremia was rapidly sterilized after initiation of antibiotic therapy, viable B anthracis was present in postmortem mediastinal lymph node specimens. The source of exposure to B anthracis in this patient is not known. Exposure to mail that was cross-contaminated as it passed through postal facilities contaminated with B anthracis spores is one hypothesis under investigation.

Aged↗
PubMed2004

Antibiotics for anthrax: patient requests and physician prescribing practices during the 2001 New York City attacks.

BACKGROUND: Little is known about patient encounters with primary care physicians and prescribing practices during the 2001 US anthrax attacks. METHODS: We retrospectively reviewed the electronic medical record of outpatient telephone and clinic visits at a large primary care practice in New York City from September 11 to December 31, 2001, to identify physician- and patient-related factors that were associated with prescribing antibiotics for anthrax prophylaxis. RESULTS: Average daily patient volume from October to December was higher in 2001 (221.2 patients per day) compared with 2000 (199.1; P<.01) and 2002 (215.8; P = .14). Patient-initiated discussion about anthrax or smallpox were involved in 244 patient contacts with 63 physicians, including 92 (0.6%) of 14917 telephone contacts and 152 (1.0%) of 15 539 office visits. Fifty patients (21%) requested antibiotics or vaccines and 52 (22%) received antibiotics: 39 received ciprofloxacin; 12, doxycycline; and 1, both drugs. Independent predictors of receiving anthrax prophylaxis included requesting medication (odds ratio [OR], 8.1; 95% confidence interval [CI], 3.5-18.6), reporting powder or workplace exposure (OR, 4.5; 95% CI, 2.1-10.0), having an abnormal physical examination finding (OR, 3.9; 95% CI, 1.4-11.0), and being asymptomatic (reporting any illness symptoms was associated with an OR of 0.3 [95% CI, 0.1-0.6]). CONCLUSIONS: Primary care physicians played an important and heretofore underdocumented role in responding to the 2001 anthrax attacks. Prescription of prophylactic antibiotics for anthrax was uncommon and appears to have been selective among concerned patients. These results highlight the importance of including primary care physicians in community-wide bioterrorism response planning.

Adult↗
PubMed2001

Tularemia as a biological weapon: medical and public health management.

OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if tularemia is used as a biological weapon against a civilian population. PARTICIPANTS: The working group included 25 representatives from academic medical centers, civilian and military governmental agencies, and other public health and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to October 2000, using the Medical Subject Headings Francisella tularensis, Pasteurella tularensis, biological weapon, biological terrorism, bioterrorism, biological warfare, and biowarfare. Review of these references led to identification of relevant materials published prior to 1966. In addition, participants identified other references and sources. CONSENSUS PROCESS: Three formal drafts of the statement that synthesized information obtained in the formal evidence-gathering process were reviewed by members of the working group. Consensus was achieved on the final draft. CONCLUSIONS: A weapon using airborne tularemia would likely result 3 to 5 days later in an outbreak of acute, undifferentiated febrile illness with incipient pneumonia, pleuritis, and hilar lymphadenopathy. Specific epidemiological, clinical, and microbiological findings should lead to early suspicion of intentional tularemia in an alert health system; laboratory confirmation of agent could be delayed. Without treatment, the clinical course could progress to respiratory failure, shock, and death. Prompt treatment with streptomycin, gentamicin, doxycycline, or ciprofloxacin is recommended. Prophylactic use of doxycycline or ciprofloxacin may be useful in the early postexposure period.

Anti-Bacterial Agents↗
PubMed2001

Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences.

Concern for potential bioterrorist attacks causing mass casualties has increased recently. Particular attention has been paid to scenarios in which a biological agent capable of person-to-person transmission, such as smallpox, is intentionally released among civilians. Multiple public health interventions are possible to effect disease containment in this context. One disease control measure that has been regularly proposed in various settings is the imposition of large-scale or geographic quarantine on the potentially exposed population. Although large-scale quarantine has not been implemented in recent US history, it has been used on a small scale in biological hoaxes, and it has been invoked in federally sponsored bioterrorism exercises. This article reviews the scientific principles that are relevant to the likely effectiveness of quarantine, the logistic barriers to its implementation, legal issues that a large-scale quarantine raises, and possible adverse consequences that might result from quarantine action. Imposition of large-scale quarantine-compulsory sequestration of groups of possibly exposed persons or human confinement within certain geographic areas to prevent spread of contagious disease-should not be considered a primary public health strategy in most imaginable circumstances. In the majority of contexts, other less extreme public health actions are likely to be more effective and create fewer unintended adverse consequences than quarantine. Actions and areas for future research, policy development, and response planning efforts are provided.

Bioterrorism↗
PubMedDate not supplied

The new cell culture smallpox vaccine should not be offered to the general population.

Cell based smallpox vaccines are to be welcomed, but any decision to vaccinate whole populations must await firstly better intelligence about the gravity of the threat from bioterrorists, including their ability to release smallpox in such a way that wide dissemination could take place; secondly evidence that vaccines grown in cell culture are protective and safe; and thirdly that the vaccines would be generally acceptable and their introduction would not compromise the rest of national immunisation programmes. Smallpox vaccination should not be offered to the general population until these uncertainties have been resolved, by which time bioterrorism might possibly have been overcome or the development of antiviral treatment might have made renewed smallpox vaccination unnecessary. Meanwhile, preparations for rapid deployment of the historically well-tried containment measures at the epicentres of any smallpox release should proceed, their effectiveness should be tested, and their adequacy kept under review.

Bioterrorism↗
PubMed2003

Use of ambulance dispatch data as an early warning system for communitywide influenzalike illness, New York City.

In 1998, the New York City Department of Health and the Mayor's Office of Emergency Management began monitoring the volume of ambulance dispatch calls as a surveillance tool for biologic terrorism. We adapted statistical techniques designed to measure excess influenza mortality and applied them to outbreak detection using ambulance dispatch data. Since 1999, we have been performing serial daily regressions to determine the alarm threshold for the current day. In this article, we evaluate this approach by simulating a series of 2,200 daily regressions. In the influenza detection implementation of this model, there were 71 (3.2%) alarms at the 99% level. Of these alarms, 64 (90%) occurred shortly before or during a period of peak influenza in each of six influenza seasons. In the bioterrorism detection implementation of this methodology, after accounting for current influenza activity, there were 24 (1.1%) alarms at the 99% level. Two occurred during a large snowstorm, 1 is unexplained, and 21 occurred shortly before or during a period of peak influenza activity in each of six influenza seasons. Our findings suggest that this surveillance system is sensitive to communitywide respiratory outbreaks with relatively few false alarms. More work needs to be done to evaluate the sensitivity of this approach for detecting nonrespiratory illness and more localized outbreaks.

Ambulances↗
PubMed2003

Clinical evaluation of the Emergency Medical Services (EMS) ambulance dispatch-based syndromic surveillance system, New York City.

Since 1998, the New York City Department of Health has used New York City Emergency Medical Services (EMS) ambulance dispatch data to monitor for a communitywide rise in influenzalike illness (ILI) as an early detection system for bioterrorism. A clinical validation study was conducted during peak influenza season at six New York City emergency departments (EDs) to compare patients with ILI brought in by ambulance with other patients to examine potential biases associated with ambulance dispatch-based surveillance. We also examined the utility of 4 EMS call types (selected from 52) for case detection of ILI. Clinical ILI was defined as fever (temperature higher than 100 degrees F) on history or exam, along with either cough or sore throat. Of the 2,294 ED visits reviewed, 522 patients (23%) met the case definition for ILI, 64 (12%) of whom arrived by ambulance. Patients with ILI brought in by ambulance were older, complained of more severe symptoms, and were more likely to undergo diagnostic testing, be diagnosed with pneumonia, and be admitted to the hospital than patients who arrived by other means. The median duration of symptoms prior to presenting to the ED, however, was the same for both groups (48 hours). The selected call types had a sensitivity of 58% for clinical ILI, and a predictive value positive of 22%. Individuals with symptoms consistent with the prodrome of inhalational anthrax were likely to utilize the EMS system and usually did so early in the course of illness. While EMS-based surveillance is more sensitive for severe illness and for illness affecting older individuals, there is not necessarily a loss of timeliness associated with EMS-based (versus ED-based) surveillance.

Adolescent↗
PubMed2003

Enhanced drop-in syndromic surveillance in New York City following September 11, 2001.

After the 2001 World Trade Center disaster, the New York City Department of Health was under heightened alert for bioterrorist attacks in the city. An emergency department (ED) syndromic surveillance system was implemented with the assistance of the Centers for Disease Control and Prevention to ensure early recognition of an increase or clustering of disease syndromes that might represent a disease outbreak, whether natural or intentional. The surveillance system was based on data collected 7 days a week at area EDs. Data collected were translated into syndromes, entered into an electronic database, and analyzed for aberrations in space and time within 24 hours. From September 14-27, personnel were stationed at 15 EDs on a 24-hour basis (first staffing period); from September 29-October 12, due to resource limitations, personnel were stationed at 12 EDs on an 18-hour basis (second staffing period). A standardized form was used to obtain demographic information and classify each patient visit into 12 syndrome categories. Seven of these represented early manifestations of bioterrorist agents. Data transfer and analysis for time and space clustering (alarms) by syndrome and age occurred daily. Retrospective analyses examined syndrome trends, differences in reporting between staffing periods, and the staff's experience during the project. A total of 67,536 reports were received. The system captured 83.9% of patient visits during the first staffing period, and 60.8% during the second staffing period (P < 0.01). Five syndromes each accounted for more than 1% of visits: trauma, asthma, gastrointestinal illness, upper/lower respiratory infection with fever, and anxiety. Citywide temporal alarms occurred eight times for three of the major bioterrorism-related syndromes. Spatial clustering alarms occurred 16 times by hospital location and 9 times by ZIP code for the same three syndromes. No outbreaks were detected. On-site staffing to facilitate data collection and entry, supported by daily analysis of ED visits, is a feasible short-term approach to syndromic surveillance during high-profile events. The resources required to operate such a system, however, cannot be sustained for the long term. This system was changed to an electronic-based ED syndromic system using triage log data that remains in operation.

Bioterrorism↗
PubMed2006

Brucella as a biological weapon.

Brucella has traditionally been considered a biological weapon. It was the subject of extensive offensive research in the past, and still belongs to category B pathogens on most lists. Its propensity for airborne transmission and induction of chronic debilitating disease requiring combined antibiotic regimens for treatment, its abundance around the world and its vague clinical characteristics defying rapid clinical diagnosis are some of the characteristics that apply to the pathogen's weapons potential. Yet minimal mortality, availability of treatment options, protracted inoculation period and the emergence of new, more virulent potential weapons means that its inclusion among agents of bioterrorism is nowadays mainly of historical significance. Nevertheless, in the interest of literacy and of avoiding panic, physicians and the public both should be aware of the most common zoonosis worldwide.

Animals↗
PubMed2002

Emerging and re-emerging infectious diseases.

In human history, numerous infectious diseases have emerged and re-emerged. Aside from many others, the so-called 'exotic' agents in particular are a threat to our public health systems due to limited experience in case management and lack of appropriate resources. Many of these agents are zoonotic in origin and transmitted from animals to man either directly or via vectors. The reservoirs are often infected subclinically or asymptomatically and the distribution of the diseases basically reflects the range and the population dynamics of their reservoir hosts. As examples, emergence/re-emergence is discussed here for diseases caused by filoviruses, hantaviruses, paramyxoviruses, flaviviruses and Yersinia pestis. In addition, bioterrorism is addressed as one factor which has now to be considered in infectious disease emergence/re-emergence. Preparedness for known and unknown infectious diseases will be a top priority for our public health systems in the beginning of the millennium.

Animals↗
PubMed2005

The effect of social mixing controls on the spread of smallpox--a two-level model.

Responding to a possible bioterror attack of Smallpox has become a major concern to governments, local public officials and health authorities. This concern has been reflected in numerous studies that model and evaluate possible response strategies. Many of these studies consider only vaccination policies and assume homogeneous mixing, where all instances of contacts in the population are equally likely. Such a mixing pattern is rather unlikely to represent population interaction in a modern urban setting, which typically is separated into households on the one hand, and into daily meeting sites such as schools and offices, on the other hand. In this paper we develop a two-level social interaction model where an individual moves back and forth between home and a daily meeting site, possibly passing through a general meeting site such as mass transit system or other crowded areas. Based on the model, we evaluate the effect of social mixing controls, situational awareness of the public health system and mass vaccination on the spread of smallpox. It is shown that mixing controls and alertness of the response system may have a significant impact on the spread of the epidemic. Some policy recommendations are discussed.

Bioterrorism↗
PubMed2004

Assessing hospital preparedness using an instrument based on the Mass Casualty Disaster Plan Checklist: results of a statewide survey.

BACKGROUND: Hospitals would play a critical role in a weapon of mass destruction (WMD) event. The purpose of this study is to assess preparedness for mass casualty events in short-term and long-term hospitals in Kentucky. METHODS: All short-term and long-term hospitals in Kentucky were surveyed using an instrument based on the Mass Casualty Disaster Plan Checklist and a brief supplemental bioterrorism preparedness questionnaire based on a checklist developed for the Agency for Healthcare Research and Quality. RESULTS: Responses were received from 116 of the 118 (98%) hospitals surveyed. Hospitals reported surge capacity equal to 27% of licensed beds, and virtually all respondents were engaged in planning for weapons of mass destruction events. However, advanced planning and preparation were less common. Large regional differences were observed, especially in the area of pharmaceutical planning. Preparedness planning in general and pharmaceutical management planning in particular were more advanced in counties participating in the Metropolitan Medical Response System Program (MMRS). CONCLUSIONS: Hospital mass casualty preparedness efforts were in an early stage of development at the time of this survey, and some critical capabilities, such as isolation, decontamination, and syndromic surveillance were clearly underdeveloped. Preparedness planning was more advanced among hospitals located in MMRS counties.

Accreditation↗
PubMed2004

Structural proteomics of the poxvirus family.

Recent concerns over the potential use of variola virus-commonly known as smallpox-and other orthopox viruses as weapons of bioterrorism have increased research efforts towards creating new antiviral drugs and safer more effective vaccines. Here we introduce a new resource for structural information of poxvirus proteins: the poxvirus proteomics database (PPDB). In the PPDB, we leverage recently developed bioinformatics structure prediction tools on a genomic scale and provide results in a publicly accessible format. The current version of the system contains both experimentally determined and predicted information about protein structural features, such as secondary structure and relative solvent accessibility, as well as tertiary structure and homology information. The system is automated to read the primary sequences from the database, produce the new information for each sequence, and update the database monthly and as new tools are incorporated. The PPDB contains detailed information on the open reading frames (ORFs) in the Copenhagen strain of the vaccinia virus genome. The contents of the PPDB can be accessed through a simple web interface. Inclusion of additional poxvirus genomes in the PPDB is in progress. The PPDB has an upward scalable informatics infrastructure that can readily be applied to viral, bacterial, as well as eukaryotic genomes.

Antiviral Agents↗
PubMed2004

A therapeutic strategy against the shared virulence mechanism utilized by both Yersinia pestis and Pseudomonas aeruginosa.

Yersinia pestis, which causes pneumonic plague in healthy individuals, has the potential to be used for biologic warfare. Pseudomonas aeruginosis is an opportunistic pathogen that causes severe pneumonia in immunocompromised patients. There is evidence that these two pathogens use a highly homologous virulence mechanism, the type III secretion system. The type III secretion systems of both Yersinia and P. aeruginosa possess a protein named V-antigen which can be used as a target for immunotherapy against bioterrorism and opportunistic infections. This article summarizes the recent progress of V-antigen studies in Yersinia and P. aeruginosa.

Amino Acid Sequence↗
PubMed2005

APDS: the autonomous pathogen detection system.

We have developed and tested a fully autonomous pathogen detection system (APDS) capable of continuously monitoring the environment for airborne biological threat agents. The system was developed to provide early warning to civilians in the event of a bioterrorism incident and can be used at high profile events for short-term, intensive monitoring or in major public buildings or transportation nodes for long-term monitoring. The APDS is completely automated, offering continuous aerosol sampling, in-line sample preparation fluidics, multiplexed detection and identification immunoassays, and nucleic acid-based polymerase chain reaction (PCR) amplification and detection. Highly multiplexed antibody-based and duplex nucleic acid-based assays are combined to reduce false positives to a very low level, lower reagent costs, and significantly expand the detection capabilities of this biosensor. This article provides an overview of the current design and operation of the APDS. Certain sub-components of the ADPS are described in detail, including the aerosol collector, the automated sample preparation module that performs multiplexed immunoassays with confirmatory PCR, and the data monitoring and communications system. Data obtained from an APDS that operated continuously for 7 days in a major U.S. transportation hub is reported.

Aerosols↗
PubMed2005

Hemorrhagic fever viruses.

This article reviews the epidemiology, pathophysiology, and clinical management of patients with suspected or confirmed viral hemorrhagic fever infection. The focus is on clinical management based on case series from naturally occuring outbreaks of viral hemorrhagic fever infection as well as imported cases of viral hemorrhagic fever encountered in industrialized nations. The potential risk of bioterrorism involving these agents is discussed as well as emergency department and critical care management of isolated cases or larger outbreaks. Important aspects of management, including recognition of infected patients, isolation and decontamination procedures, as well as available vaccines and therapies are emphasized.

Arenaviridae Infections↗
PubMed2005

Pulmonary disease from biological agents: anthrax, plague, Q fever, and tularemia.

Anthrax, plague, Q fever, and tularemia are all potential inhalational bioterrorism agents. The pulmonary manifestations of these agents can be readily confused with each other as well as other more common diseases such as influenza and atypical pneumonia. This article reviews the threat potential, microbiology, pathogenesis, clinical features, diagnosis, and treatment of each of these agents and highlights the similarities and differences between their pulmonary presentations.

Anthrax↗
PubMed2006

Clinical laboratories, the select agent program, and biological surety (biosurety).

The threat of bioterrorism has led to increased concerns over the availability of biological select agents and toxins (BSAT). Congress has implemented several public laws that have led to the development of federal regulations by the Centers for Disease Control and Prevention (CDC) and the US Department of Agriculture. The CDC regulation 42 CFR 73 has a direct impact on all clinical laboratories that may at some time identify BSAT in a clinical specimen. The Department of Defense has imposed a more stringent layer of regulation called biological surety (biosurety) on top of the requirements of 42 CFR 73 for military laboratories that possess BSAT. However,42 CFR 73 falls into the framework of biosurety. Both sets of regulations have four pillars (safety, physical security, agent account-ability, and personnel reliability) that are built on a foundation of training and covered by a roof of management (operations and plans).

Bioterrorism↗