IC's boomerang: everything old is new again.
From whooping cough to bioterrorism, history repeats itself.
Bioterrorism↗
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Anthrax attacks and practice patterns: a learning opportunity for health care systems.
Sudden and unexpected events directly influencing clinical practice patterns are uncommon. After the first report of bioterrorism-related anthrax, the authors studied retrospectively 13 months of anthrax-related antibiotic prescription rates for Veterans Affairs outpatients in one urban area where no cases of anthrax were reported. During the 26 days after the first anthrax report, the rate of acute respiratory illnesses treated with fluoroquinolones was 62.8 per 10,000 outpatient visits, an increase of 41 percent over the rate of 44.4 observed approximately one year earlier (p = 0.058). Acute sociopolitical events such as bioterrorist attacks present a unique opportunity to investigate changes in health care.
Acute Disease↗
Rapid diagnosis of smallpox infection and differentiation from its mimics.
The potential for a bioterrorism-induced smallpox outbreak has been much discussed of late. The literature of the late 1960s stressed that the distinction between smallpox and the other viral-induced vesicle-forming diseases, namely varicella zoster and disseminated herpes simplex, was difficult to make. Given that the cutaneous manifestations of smallpox would be among the initial symptoms, we reviewed 2 cases of smallpox diagnosed in South America in the 1970s in conjunction with 9 cases of multiple skin vesicles diagnosed as either disseminated herpes simplex or varicella-zoster. These were examined by routine hematoxylin and eosin stain (H&E) as well as by in situ hybridization. A blind review of the cases demonstrated that each showed striking intraepithelial vesicles containing multinucleated squamous cells exhibiting a ground glass appearance of the nuclear chromatin. Thus, as expected, routine H&E examination could not differentiate the 2 smallpox cases from the other 9 samples. In situ hybridization easily distinguished the 2 cases of smallpox from the other 9 samples, 5 of which contained varicella-zoster (two had been misdiagnosed as herpes) and the other 4 were disseminated herpes simplex. The in situ test, readily accomplished in any histology-based molecular laboratory in 4 hours, allows for the rapid and specific identification of smallpox infection and, importantly, its distinction from its mimics. Formalin fixation, which is optimal for in situ hybridization, guarantees the inactivation of the smallpox virus.
Bioterrorism↗
Local and state collaboration for effective preparedness planning.
State and local collaboration is critical to effective preparedness and response planning. Through various assessments, the National Association of County and City Health Officials (NACCHO) is tracking the way in which local and state public health agencies are coordinating their planning efforts to ensure adequate bioterrorism and emergency response capacities. NACCHO's analysis of planning provides a case study of effective and ineffective collaboration. NACCHO intends to share these lessons to provide local and state public health agencies with strategies for enhancing collaboration in the future.
Bioterrorism↗
Persistence of a mock bio-agent in cross-contaminated mail and mailboxes.
Among the 22 confirmed or suspected cases of anthrax during the bioterrorism incidents in 2001, all but two seemed traceable to spores from threat letters. Although no anthrax spores were found in the environments frequented by two females who died of the disease, a suspicion persists that the deaths were somehow related to the mail. This study assesses the spread and persistence of a mock biological agent from a source-letter to other mail and to a receiving mailbox. Successive placement and removal of letters were found to reduce the number of residual bio-agent particles in a mailbox. This suggests that a sweeping action is taking place that can affect the quantity of bio-agent remaining. The exercise supports the possibility that the two females were exposed to spores on mail that had been in their mailboxes although no trace of spores could later be found in their boxes.
Aged↗
Public health preparedness and response capacity inventory validity study.
The Centers for Disease Control and Prevention's Public Health Practice Program Office has issued a Public Health Preparedness and Response Capacity Inventory to help state and local public health systems assess their progress towards achievement of the critical capacities and benchmarks specified in the federal Supplemental Funds for Public Health Preparedness and Response for Bioterrorism. The criterion validity of the capacity inventory was assessed by comparing selected state and local agency responses with documentation provided by the agencies to corroborate their answers. Content validity assessment took the form of a mailed survey that also identified the most important questions from the perspective of a separate set of state and local officials. Responses generally upheld the validity of the capacity inventory, although circumstantial threats to validity were identified in the testing process. The instrument's use has been reported to the Centers for Disease Control and Prevention by approximately half the states and over 800 local public health entities. An interactive electronic version includes a scoring mechanism that allows agencies to judge progress towards the critical capacities and benchmarks over time.
Bioterrorism↗
Investigation of an electronic emergency department information system as a data source for respiratory syndrome surveillance.
Emergency department syndromic surveillance may provide early warning of disease outbreaks due to bioterrorism or natural phenomena. The purpose of this investigation was to explore how an electronic emergency department information system could be used as a data source for respiratory syndrome surveillance. The process of data collection, entry, and transmission is described, and then a subset of data elements with potential epidemiological value is selected. The quality of the data contained in the system was evaluated by conducting a retrospective analysis of emergency department visits recorded in the system during 2001 and by reviewing clinical charts of cases with respiratory diagnoses. Diagnosis codes, discharge disposition, and demographic data were relatively complete; additional clinical data were not. Diagnosis codes were rapidly and reliably recorded. Data available in the system allows a description of emergency department visits for respiratory syndrome in terms of age, gender, location, severity of illness, and distribution in time. Encrypted data were transmitted every four hours to the health department without added work for emergency department personnel. Although significant obstacles remain, electronic emergency department information systems such as this may provide rapid, reliable data for syndromic surveillance.
Adult↗
New Jersey's smallpox vaccination clinic experiences, 2003.
PURPOSE: During 2003, the New Jersey Department of Health and Senior Services, in collaboration with other agencies, began planning and implementing voluntary smallpox vaccination clinics. METHODS: Surveys were distributed to all vaccinees, hospital bioterrorism coordinators, and local health departments to assess clinic experiences. RESULTS: During January-July 2003, 23 clinics were conducted with more than 1,000 participants. Of 670 persons vaccinated, 529 (79%) completed surveys. We received 65 surveys from 68 (77%) of 84 hospitals, and 25 responses from 22 regional health agencies. CONCLUSIONS: Vaccination is one component of preparedness; future initiatives must incorporate multiagency collaboration and developing public health infrastructure.
Bioterrorism↗
Emergency preparedness academy adds public health to readiness equation.
From November 2003 to May 2004, the University of South Carolina Center for Public Health Preparedness and the South Carolina Department of Health and Environmental Control co-sponsored a 6-month-long Academy for Public Health Emergency Preparedness. Six-member teams made up of public health staff and community partner representatives (N = 78) attended from their respective health districts. The Academy consisted of three 6-day training sessions designed to prepare the teams to complete a team-based covert biological bioterrorism tabletop exercise. Program evaluation results revealed increases in (1) public health emergency preparedness core competencies; (2) capacity to plan, implement, and evaluate a tabletop exercise; and (3) successful collaboration and partnership formation between participating Public Health District teams and their local partner agencies. Lessons learned are also described.
Academic Medical Centers↗
Disaster mental health training in Florida and the response to the 2004 hurricanes.
The need for mental health interventions in disasters has long been recognized. The Florida Center for Public Health Preparedness (FCPHP) has been providing disaster mental health training to employees of the Florida Department of Health and others since 2001. One of the training programs was Bioterrorism Trauma Intervention Specialist Training (BTIST), offered between May 2003 and January 2004. The FCPHP has also developed three distance learning courses, including one that provides advice to responders who are experiencing compassion fatigue. The BTIST curriculum prepares participants to provide mental health interventions during and following disasters. The four hurricanes that struck Florida in a 7-week period in 2004 created a great demand for mental health services. The FCPHP supported the Florida Department of Health response effort by providing a roster of BTIST trainees and hundreds of copies of the compassion fatigue audio CD. The FCPHP conducted a Web-based survey of the BTIST participants after the hurricanes. A large majority of respondents reported that the training had given them greater knowledge of disaster mental health, provided many disaster mental health skills, and the skills had been valuable in their professional and personal lives. Most of those who had actively responded to the hurricanes indicated that the training had given them confidence for their response and that they had used the acquired skills in their response efforts.
Attitude of Health Personnel↗
Inhalational anthrax.
Inhalational anthrax is a lethal infection acquired from the inhalation of Bacillus anthracis, a pathogen classified as a Category A bioterrorist agent by the Centers for Disease Control and Prevention. The recent 2001 attack in which weaponized spores were delivered by mail to several US cities exposed our vulnerability to bioterrorism, and taught us important lessons in the timely diagnosis of this devastating disease. It is clear that patient mortality is significantly decreased by early recognition and immediate administration of antibiotic therapy. Unfortunately, the nonspecific clinical presentation is often misinterpreted as a flu-like illness and confirmatory microbiologic tests may take up to 24 hours. Radiologic manifestations, however, are distinctive and may prove essential in directing appropriate clinical care in the critical early hours of inhalational anthrax.
Anthrax↗
A risk analysis for airborne pathogens with low infectious doses: application to respirator selection against Coccidioides immitis spores.
Probability models incorporating a deterministic versus stochastic infectious dose are described for estimating infection risk due to airborne pathogens that infect at low doses. Such pathogens can be occupational hazards or candidate agents for bioterrorism. Inputs include parameters for the infectious dose model, distribution parameters for ambient pathogen concentrations, the breathing rate, the duration of an exposure period, the anticipated number of exposure periods, and, if a respirator device is used, distribution parameters for respirator penetration values. Application of the models is illustrated with a hypothetical scenario involving exposure to Coccidioides immitis, a fungus present in soil in areas of the southwestern United States Inhaling C. immitis spores causes a respiratory tract infection and is a recognized occupational hazard in jobs involving soil dust exposure in endemic areas An uncertainty analysis is applied to risk estimation in the context of selecting respiratory protection with a desired degree of efficacy.
Air Microbiology↗
Intravenous immunoglobulin products contain neutralizing antibodies to vaccinia.
BACKGROUND AND OBJECTIVES: Individuals with primary or secondary immune-deficiency diseases may be at risk for vaccinia infection if widespread smallpox-immunization programmes are implemented in the United States of America (USA) for bioterrorism preparedness. The objective of this study was to determine whether commercial immune globulin (intravenous, human) products contain biologically active antibodies to vaccinia that have the potential to protect people, with immune deficiencies, from complications of vaccinia. MATERIALS AND METHODS: Eight currently United States (US)-licensed and two European intravenous immunoglobulin (IVIG) products were tested in a vaccinia plaque-reduction neutralization assay. The in vivo activity of five of these lots was assessed in severely immune-deficient mice. RESULTS: All tested products contained neutralizing anti-vaccinia activity, in vitro and in vivo. CONCLUSIONS: The use of IVIG by individuals with inherited or acquired humoral immune deficiencies may provide some protection if they are inadvertently exposed to vaccinia.
Animals↗
Bacillus anthracis contamination and inhalational anthrax in a mail processing and distribution center.
AIMS: Four inhalational anthrax cases occurred in a large mail processing and distribution center in Washington, DC, after envelopes containing Bacillus anthracis spores were processed. This report describes the results of sampling for B. anthracis spores during investigations conducted in October and December 2001. METHODS AND RESULTS: Wet swabs, wet wipes, vacuum sock, and air-filter samples were collected throughout the facility to characterize the extent of building contamination. The results showed widespread contamination of B. anthracis spores, particularly associated with one delivery bar code sorter (DBCS) machine that had sorted the spore-containing envelopes and an area where the envelopes were handled by postal workers. Spore concentrations decreased as distance from the DBCS machine increased, but spores were widely dispersed into surrounding areas. CONCLUSION: The spatial distribution of culture positive samples was closely related to the work areas of the inhalational anthrax cases and supported epidemiological evidence that the workers became ill from exposure to B. anthracis spores in areas where the contaminated envelopes had travelled. SIGNIFICANCE AND IMPACT OF THE STUDY: The results of this investigation were used to guide decontamination efforts and provided baseline spore concentrations for follow-up measurements after the building had been cleaned. Implementing methods to reduce aerosolization and dispersion of dust within the facility would reduce postal workers' potential exposures to bioterrorism agents.
Air Pollution, Indoor↗
Plant models for animal pathogenesis.
Several bacteria that are pathogenic to animals also infect plants. Mechanistic studies have proven that some human/animal pathogenic bacteria employ a similar subset of virulence determinants to elicit disease in animals, invertebrates and plants. Therefore, the results of plant infection studies are relevant to animal pathogenesis. This discovery has resulted in the development of convenient, cost-effective, and reliable plant infection models to study the molecular basis of infection by animal pathogens. Plant infection models provide a number of advantages in the study of animal pathogenesis. Using a plant model, mutations in animal pathogenic bacteria can easily be screened for putative virulence factors, a process which if done using existing animal infection models would be time-consuming and tedious. High-throughput screening of plants also provides the potential for unravelling the mechanisms by which plants resist animal pathogenic bacteria, and provides a means to discover novel therapeutic agents such as antibiotics and anti-infective compounds. In this review, we describe the developing technique of using plants as a model system to study Pseudomonas aeruginosa, Enterococcus faecalis and Staphylococcus aureus pathogenesis, and discuss ways to use this new technology against disease warfare and other types of bioterrorism.
Animals↗
Differential willingness to undergo smallpox vaccination among African-American and white individuals.
OBJECTIVE: To examine potential disparities in willingness to be vaccinated against smallpox among different U.S. racial/ethnic groups. DESIGN: Cross-sectional survey using an experimental design to assess willingness to be vaccinated among African Americans compared to whites according to 2 strategies: a post-exposure "ring vaccination" method and a pre-exposure national vaccination program. SETTING: Philadelphia County district courthouse. PARTICIPANTS: Individuals awaiting jury duty. MEASUREMENTS: We included 2 scenarios representing these strategies in 2 otherwise identical questionnaires and randomly assigned them to participants. We compared responses by African Americans and whites. MAIN RESULTS: In the pre-exposure scenario, 66% of 190 participants were willing to get vaccinated against smallpox. In contrast, 84% of 200 participants were willing to get vaccinated in the post-exposure scenario (P =.0001). African Americans were less willing than whites to get vaccinated in the pre-exposure scenario (54% vs 77%; P =.004), but not in the post-exposure scenario (84% vs 88%; P =.56). In multivariate analyses, overall willingness to undergo vaccination was associated with vaccination strategy (odds ratio, 3.29; 95% confidence interval, 1.8 to 6.1). CONCLUSIONS: Racial disparity in willingness to get vaccinated varies by the characteristics of the vaccination program. Overall willingness was highest in the context of a post-exposure scenario. These results highlight the importance of considering social issues when constructing bioterror attack response plans that adequately address the needs of all of society's members.
Adult↗
Absence of detectable viremia in plasma and peripheral blood mononuclear cells from smallpox vaccinees: implications for blood safety.
BACKGROUND: Mass smallpox vaccination with live vaccinia virus has been considered as a preventive measure to counter bioterrorism involving smallpox. This has raised concerns about the possibility of vaccinia virus being transmitted from vaccinated blood donors to recipients. The results of this study could be used to define an appropriate deferral period for blood donors (vaccinated against smallpox) to ensure safety of the blood supply. STUDY DESIGN AND METHODS: A procedure was developed to culture vaccinia virus from plasma and peripheral blood mononuclear cells (PBMNCs) of vaccinees enrolled in three smallpox vaccine clinical trials. A total of 665 plasma and PBMNC samples were obtained from 95 vaccinated subjects. RESULTS: Vaccinia viremia was not detected by virus culture from plasma and PBMNC samples of healthy vaccinees 3 to 56 days after vaccination under our assay conditions. Plasma viremia assay had a sensitivity of approximately 66 plaque-forming units per mL with a Vero cell culture assay. CONCLUSION: The results of this study present evidence that in the case of mass vaccination, the risk of transmission of vaccinia virus by blood transfusion would likely be low.
Animals↗
Smallpox vaccination: a national survey of emergency health care providers.
UNLABELLED: Concerns about bioterrorism have prompted a national voluntary smallpox (SP) vaccination program in the United States. Although emergency health care providers are among the first targeted for vaccination, little is known about how these providers view the risks and benefits of SP vaccination. OBJECTIVES: To assess the willingness of emergency health care personnel to receive pre-event SP vaccination prior to the start of the national program. METHODS: The authors conducted a national cross-sectional, anonymous survey of 1,701 emergency physicians, nurses, and mid-level practitioners working full time in 13 adult and pediatric academic emergency departments in large U.S. cities in November and December 2002. The main outcome measure was willingness to be vaccinated against SP. Secondary outcomes included the prevalence of self-reported contraindications, and reasons for and against vaccination. RESULTS: 732 emergency health care providers returned questionnaires (response rate 43%). Overall, 73% (95% CI = 66% to 80%) were willing to receive pre-event SP vaccination. 18% (95% CI = 14% to 23%) reported contraindications to vaccination, and 50% (95% CI = 39% to 61%) of these providers were willing to receive pre-event SP vaccination. Self-protection (72%) was the most common reason cited for desiring vaccination against SP; concern about vaccine-related adverse events (54%) was the most common reason cited for not wanting immunization. CONCLUSIONS: Most emergency health care providers express a willingness to receive pre-event SP immunization; self-protection is a principal motivating reason. A subset of health care providers, however, may place themselves at increased risk by desiring vaccination despite contraindications.
Adult↗