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PubMed2003

The smallpox threat: the school nurse's role.

Today, with the threat of bioterrorism and war, there is a new dimension to the traditional role of the school nurse. The smallpox threat to public health will invoke the school nurse's role as an educator, liaison, and consultant in the community. This article discusses smallpox, the vaccination process, adverse effects, and postvaccination care. In addition to the role of educator, the school nurse has the role of a liaison between the school and the local health department. The school nurse also plays a vital role in school health policy development and implementation. Being prepared and educated makes our nation less vulnerable to these threats and will assist in keeping our children and communities safe.

Bioterrorism↗
PubMed2003

Smallpox: an update for nurses.

The global eradication of smallpox in the late 1970s was a major achievement of the 20th century and brought out the best in science and public health. Prior to eradication, smallpox was a devastating disease with an overall mortality rate of approximately 5% to 30% for the most common form of the disease depending on vaccination status and the clinical presentation. The more severe forms of smallpox (i.e., flat and hemorrhagic type) had case fatality rates of approximately 96% to 100%. Currently, there is heightened international concern regarding the potential use of the smallpox virus as an agent for bioterrorism. Therefore, it is imperative that health care workers become familiar with clinical aspects of this disease as part of the national efforts to ensure homeland security. This article reviews the history, disease progression, and adverse events of smallpox; immunization practices; and nursing considerations.

Bioterrorism↗
PubMed2006

Distributed data processing for public health surveillance.

BACKGROUND: Many systems for routine public health surveillance rely on centralized collection of potentially identifiable, individual, identifiable personal health information (PHI) records. Although individual, identifiable patient records are essential for conditions for which there is mandated reporting, such as tuberculosis or sexually transmitted diseases, they are not routinely required for effective syndromic surveillance. Public concern about the routine collection of large quantities of PHI to support non-traditional public health functions may make alternative surveillance methods that do not rely on centralized identifiable PHI databases increasingly desirable. METHODS: The National Bioterrorism Syndromic Surveillance Demonstration Program (NDP) is an example of one alternative model. All PHI in this system is initially processed within the secured infrastructure of the health care provider that collects and holds the data, using uniform software distributed and supported by the NDP. Only highly aggregated count data is transferred to the datacenter for statistical processing and display. RESULTS: Detailed, patient level information is readily available to the health care provider to elucidate signals observed in the aggregated data, or for ad hoc queries. We briefly describe the benefits and disadvantages associated with this distributed processing model for routine automated syndromic surveillance. CONCLUSION: For well-defined surveillance requirements, the model can be successfully deployed with very low risk of inadvertent disclosure of PHI--a feature that may make participation in surveillance systems more feasible for organizations and more appealing to the individuals whose PHI they hold. It is possible to design and implement distributed systems to support non-routine public health needs if required.

Bioterrorism↗
PubMed2005

A software tool for creating simulated outbreaks to benchmark surveillance systems.

BACKGROUND: Evaluating surveillance systems for the early detection of bioterrorism is particularly challenging when systems are designed to detect events for which there are few or no historical examples. One approach to benchmarking outbreak detection performance is to create semi-synthetic datasets containing authentic baseline patient data (noise) and injected artificial patient clusters, as signal. METHODS: We describe a software tool, the AEGIS Cluster Creation Tool (AEGIS-CCT), that enables users to create simulated clusters with controlled feature sets, varying the desired cluster radius, density, distance, relative location from a reference point, and temporal epidemiological growth pattern. AEGIS-CCT does not require the use of an external geographical information system program for cluster creation. The cluster creation tool is an open source program, implemented in Java and is freely available under the Lesser GNU Public License at its Sourceforge website. Cluster data are written to files or can be appended to existing files so that the resulting file will include both existing baseline and artificially added cases. Multiple cluster file creation is an automated process in which multiple cluster files are created by varying a single parameter within a user-specified range. To evaluate the output of this software tool, sets of test clusters were created and graphically rendered. RESULTS: Based on user-specified parameters describing the location, properties, and temporal pattern of simulated clusters, AEGIS-CCT created clusters accurately and uniformly. CONCLUSION: AEGIS-CCT enables the ready creation of datasets for benchmarking outbreak detection systems. It may be useful for automating the testing and validation of spatial and temporal cluster detection algorithms.

Algorithms↗
PubMed2002

An Asilomar moment.

As governments in the US and Europe contemplate legislation that would divert funding of some genomics-driven research to Offices of Homeland Security and the like, and that would restrict the freedom of biologists to publish and share some of their data, we of the scientific community are facing a crisis, brought on by fears of bioterrorism, that eerily mirrors the early days of recombinant DNA research.

Access to Information↗
PubMed2002

The guards themselves.

If we agree that, in the present climate of fear of bioterrorism, some restrictions on the conduct and/or publication of certain types of biological research are likely, it is to our advantage to preempt government action by devising for ourselves restrictions that we can live with, then the inevitable question becomes: how should these restrictions be administered?

Bioterrorism↗
PubMed2004

The validity of chief complaint and discharge diagnosis in emergency department-based syndromic surveillance.

OBJECTIVE: Emergency department (ED)-based syndromic surveillance systems are being used by public health departments to monitor for outbreaks of infectious diseases, including bioterrorism; however, few systems have been validated. The authors evaluated a "drop-in" syndromic surveillance system by comparing syndrome categorization in the ED with chief complaints and ED discharge diagnoses from medical record review. METHODS: A surveillance form was completed for each ED visit at 15 participating Arizona hospitals between October 27 and November 18, 2001. Each patient visit was assigned one of ten clinical syndromes or "none." For six of 15 EDs, kappa statistics were used to compare syndrome agreement between surveillance forms and syndrome categorization with chief complaint and ED discharge diagnosis from medical record review. RESULTS: Overall, agreement between surveillance forms and ED discharge diagnoses (kappa = 0.55; 95% confidence interval [CI] = 0.52 to 0.59) was significantly higher than between surveillance forms and chief complaints (kappa = 0.48; 95% CI = 0.44 to 0.52). Agreement between chief complaints and ED discharge diagnoses was poor for respiratory tract infection with fever (kappa = 0.33; 95% CI = 0.27 to 0.39). Furthermore, pediatric chief complaints showed lower agreement for respiratory tract infection with fever when compared with adults (kappa = 0.34 [95% CI = 0.20 to 0.47] vs. kappa = 0.44 [95% CI = 0.28 to 0.59], respectively). CONCLUSIONS: In general, this syndromic surveillance system classified patients into appropriate syndrome categories with fair to good agreement compared with chief complaints and discharge diagnoses. The present findings suggest that use of ED discharge diagnoses, in addition to or instead of chief complaints, may increase surveillance validity for both automated and drop-in syndromic surveillance systems.

Adult↗
PubMed2006

Concept of operations for triage of mechanical ventilation in an epidemic.

The recent outbreak of severe acute respiratory syndrome and the growing potential of an influenza pandemic force us to consider the fact that despite great advances in critical care medicine, we lack the capacity to provide intensive care to the large number of patients that may be generated in an epidemic or multisite bioterrorism event. Because many epidemic and bioterrorist agent illnesses involve respiratory failure, mechanical ventilation is a frequently required intervention but one that is in limited supply. In advance of such an event, we must develop triage criteria that depend on clinical indicators of survivability and resource utilization to allocate scarce health care resources to those who are most likely to benefit. These criteria must be tiered, flexible, and implemented regionally, rather than institutionally, with the backing of public health agencies and relief of liability. This report provides a sample concept of operations for triage of mechanical ventilation in epidemic situations and discusses some of the ethical principles and pitfalls of such systems.

Bioterrorism↗
PubMed2006

Understanding surge capacity: essential elements.

As economic forces have reduced immediately available resources, the need to surge to meet patient care needs that exceed expectations has become an increasing challenge to the health care community. The potential patient care needs projected by pandemic influenza and bioterrorism catapulted medical surge to a critical capability in the list of national priorities, making it front-page news. Proposals to improve surge capacity are abundant; however, surge capacity is poorly defined and there is little evidence-based comprehensive planning. There are no validated measures of effectiveness to assess the efficacy of interventions. Before implementing programs and processes to manage surge capacity, it is imperative to validate assumptions and define the underlying components of surge. The functional components of health care and what is needed to rapidly increase capacity must be identified by all involved. Appropriate resources must be put into place to support planning factors. Using well-grounded scientific principles, the health care community can develop comprehensive programs to prioritize activities and link the necessary resources. Building seamless surge capacity will minimize loss and optimize outcomes regardless of the degree to which patient care needs exceed capability.

Bioterrorism↗
PubMed2006

Current status of surge research.

The dramatic escalation of bioterrorism and public health emergencies in the United States in recent years unfortunately has coincided with an equally dramatic decline in the institutions and services we rely on for emergency preparedness. Hospitals in nearly every metropolitan area in the country have closed; those that remain open have reduced the number of available beds. "Just in time" supplies and health professional shortages have further compromised the nation's overall surge capacity. Emergency departments routinely operate at capacity. These circumstances make evidence-based research on emergency preparedness and surge capacity both more urgently needed and more complex. The Agency for Healthcare Research and Quality and other government and private agencies have been rapidly widening the field of knowledge in this area in recent months and years. This report focuses primarily on the work of the Agency for Healthcare Research and Quality.

Allied Health Personnel↗
PubMed2006

Individual-based computational modeling of smallpox epidemic control strategies.

In response to concerns about possible bioterrorism, the authors developed an individual-based (or "agent-based") computational model of smallpox epidemic transmission and control. The model explicitly represents an "artificial society" of individual human beings, each implemented as a distinct object, or data structure in a computer program. These agents interact locally with one another in code-represented social units such as homes, workplaces, schools, and hospitals. Over many iterations, these microinteractions generate large-scale macroscopic phenomena of fundamental interest such as the course of an epidemic in space and time. Model variables (incubation periods, clinical disease expression, contagiousness, and physical mobility) were assigned following realistic values agreed on by an advisory group of experts on smallpox. Eight response scenarios were evaluated at two epidemic scales, one being an introduction of ten smallpox cases into a 6,000-person town and the other an introduction of 500 smallpox cases into a 50,000-person town. The modeling exercise showed that contact tracing and vaccination of household, workplace, and school contacts, along with prompt reactive vaccination of hospital workers and isolation of diagnosed cases, could contain smallpox at both epidemic scales examined.

Adult↗
PubMedDate not supplied

The informatics response in disaster, terrorism, and war.

The United States currently faces several new, concurrent large-scale health crises as a result of terrorist activity. In particular, three major health issues have risen sharply in urgency and public consciousness--bioterrorism, the threat of widespread delivery of agents of illness; mass disasters, local events that produce large numbers of casualties and overwhelm the usual capacity of health care delivery systems; and the delivery of optimal health care to remote military field sites. Each of these health issues carries large demands for the collection, analysis, coordination, and distribution of health information. The authors present overviews of these areas and discuss ongoing work efforts of experts in each.

Bioterrorism↗
PubMed2003

Automated syndromic surveillance for the 2002 Winter Olympics.

The 2002 Olympic Winter Games were held in Utah from February 8 to March 16, 2002. Following the terrorist attacks on September 11, 2001, and the anthrax release in October 2001, the need for bioterrorism surveillance during the Games was paramount. A team of informaticists and public health specialists from Utah and Pittsburgh implemented the Real-time Outbreak and Disease Surveillance (RODS) system in Utah for the Games in just seven weeks. The strategies and challenges of implementing such a system in such a short time are discussed. The motivation and cooperation inspired by the 2002 Olympic Winter Games were a powerful driver in overcoming the organizational issues. Over 114,000 acute care encounters were monitored between February 8 and March 31, 2002. No outbreaks of public health significance were detected. The system was implemented successfully and operational for the 2002 Olympic Winter Games and remains operational today.

Algorithms↗
PubMed2006

Finding leading indicators for disease outbreaks: filtering, cross-correlation, and caveats.

Bioterrorism and emerging infectious diseases such as influenza have spurred research into rapid outbreak detection. One primary thrust of this research has been to identify data sources that provide early indication of a disease outbreak by being leading indicators relative to other established data sources. Researchers tend to rely on the sample cross-correlation function (CCF) to quantify the association between two data sources. There has been, however, little consideration by medical informatics researchers of the influence of methodological choices on the ability of the CCF to identify a lead-lag relationship between time series. We draw on experience from the econometric and environmental health communities, and we use simulation to demonstrate that the sample CCF is highly prone to bias. Specifically, long-scale phenomena tend to overwhelm the CCF, obscuring phenomena at shorter wave lengths. Researchers seeking lead-lag relationships in surveillance data must therefore stipulate the scale length of the features of interest (e.g., short-scale spikes versus long-scale seasonal fluctuations) and then filter the data appropriately--to diminish the influence of other features, which may mask the features of interest. Otherwise, conclusions drawn from the sample CCF of bi-variate time-series data will inevitably be ambiguous and often altogether misleading.

Bioterrorism↗
PubMed2003

Yersinia pestis and the plague.

Yersinia pestis is the cause of plague, an illness that may manifest in bubonic, pneumonic, or septicemic form. Plague has killed an estimated 200 million humans throughout history, and plague is endemic in many areas of the world. Approximately 2,000 cases of plague are reported each year to the World Health Organization, and concern has been raised about the possible use of Y pestis as an agent of bioterrorism. The genome of Y pestis has been sequenced, including the 3 virulence plasmids, pPst, pLcr, and pFra, and advances have been made in understanding the bacterial pathogenesis of Y pestis infection. Advances also have been made in rapid diagnosis, the understanding of immune responses during plague, and vaccine development.

Bioterrorism↗
PubMedDate not supplied

Rapid assessment of agents of biological terrorism: defining the differential diagnosis of inhalational anthrax using electronic communication in a practice-based research network.

PURPOSE: Early detection of bioterrorism requires assessment of diagnoses assigned to cases of rare diseases with which clinicians have little experience. In this study, we evaluated the process of defining the differential diagnosis for inhalational anthrax using electronic communication within a practice-based research network (PBRN) and compared the results with those obtained from a nationwide random sample of family physicians with a mailed instrument. METHODS: We distributed survey instruments by e-mail to 55 physician members of the Wisconsin Research Network (WReN), a regional PBRN. The instruments consisted of 3 case vignettes randomly drawn from a set describing 11 patients with inhalational anthrax, 2 with influenza A, and 1 with Legionella pneumonia. Physicians provided their most likely nonanthrax diagnosis, along with their responses to 4 yes-or-no management questions for each case. Physicians who had not responded at 1 week received a second e-mail with the survey instrument. The comparison group consisted of the nationwide sample of physicians who completed mailed survey instruments. Primary outcome measures were response rate, median response time, and frequencies of diagnostic categories assigned to cases of inhalational anthrax. RESULTS: The PBRN response rate compared favorably with that of the national sample (47.3% vs 37.0%; P = not significant). The median response time for the PBRN was significantly shorter than that for the national sample (2 vs 28 days; P < .001). No significant differences were found between the PBRN and the Midwest subset of the national sample in the frequencies of major diagnostic categories or in case management. CONCLUSIONS: Electronic means of creating differential diagnoses for rare infectious diseases of national significance is feasible within PBRNs. Information is much more rapidly acquired and is consistent with that obtained by conventional methods.

Anthrax↗
PubMedDate not supplied

Public health and national security: the critical role of increased federal support.

Protecting the public's health historically has been a state and local responsibility. However, the growing threat of bioterrorism has highlighted the importance of a strong public health infrastructure to the nation's homeland security and has focused increased attention on the preparedness of the public health system. As a result, federal public health funding has increased exponentially since the anthrax attacks of late 2001, and Congress has passed sweeping new federal legislation intended to strengthen the nation's public health system. This heightened level of federal interest and support should yield important public health benefits. Most recognize that after years of neglect the public health infrastructure cannot be rebuilt overnight. As we implement a comprehensive strategy to increase the capabilities and capacity of our nation's public health system, it is essential to address a series of important policy questions, including the appropriate level of ongoing public health investments from local, state, and federal sources.

Bioterrorism↗
PubMedDate not supplied

A prescription for change: the need for qualified physician leadership in public health.

A key element missing in the federal bioterrorism preparedness plan is qualified physician leadership at the local level. Physicians now lead fewer than one-fourth of local health departments. When appointed leaders are not physicians, leadership falls on elected officials or non-medical administrators who become managers of outbreaks. As illustrated in recent case examples, these leaders may find themselves in medical emergencies that they are not qualified to handle. In serious disease outbreaks, unprepared leadership could contribute to unnecessary illness and death. Here I propose strategies to increase qualified physician leadership in state and local public health infrastructures.

Bioterrorism↗