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PubMed2002

Anthrax of the gastrointestinal tract.

When swallowed, anthrax spores may cause lesions from the oral cavity to the cecum. Gastrointestinal anthrax is greatly underreported in rural disease-endemic areas of the world. The apparent paucity of this form of anthrax reflects the lack of facilities able to make the diagnosis in these areas. The spectrum of disease, ranging from subclinical infection to death, has not been fully recognized. In some community-based studies, cases of gastrointestinal anthrax outnumbered those of cutaneous anthrax. The oropharyngeal variant, in particular, is unfamiliar to most physicians. The clinical features of oropharyngeal anthrax include fever and toxemia, inflammatory lesion(s) in the oral cavity or oropharynx, enlargement of cervical lymph nodes associated with edema of the soft tissue of the cervical area, and a high case-fatality rate. Awareness of gastrointestinal anthrax in a differential diagnosis remains important in anthrax-endemic areas but now also in settings of possible bioterrorism.

Anthrax↗
PubMed2002

Inhalational anthrax outbreak among postal workers, Washington, D.C., 2001.

In October 2001, four cases of inhalational anthrax occurred in workers in a Washington, D.C., mail facility that processed envelopes containing Bacillus anthracis spores. We reviewed the envelopes' paths and obtained exposure histories and nasal swab cultures from postal workers. Environmental sampling was performed. A sample of employees was assessed for antibody concentrations to B. anthracis protective antigen. Case-patients worked on nonoverlapping shifts throughout the facility, suggesting multiple aerosolization events. Environmental sampling showed diffuse contamination of the facility. Potential workplace exposures were similar for the case-patients and the sample of workers. All nasal swab cultures and serum antibody tests were negative. Available tools could not identify subgroups of employees at higher risk for exposure or disease. Prophylaxis was necessary for all employees. To protect postal workers against bioterrorism, measures to reduce the risk of occupational exposure are necessary.

Adult↗
PubMed2002

Specific, sensitive, and quantitative enzyme-linked immunosorbent assay for human immunoglobulin G antibodies to anthrax toxin protective antigen.

The bioterrorism-associated human anthrax epidemic in the fall of 2001 highlighted the need for a sensitive, reproducible, and specific laboratory test for the confirmatory diagnosis of human anthrax. The Centers for Disease Control and Prevention developed, optimized, and rapidly qualified an enzyme-linked immunosorbent assay (ELISA) for immunoglobulin G (IgG) antibodies to Bacillus anthracis protective antigen (PA) in human serum. The qualified ELISA had a minimum detection limit of 0.06 micro g/mL, a reliable lower limit of detection of 0.09 micro g/mL, and a lower limit of quantification in undiluted serum specimens of 3.0 micro g/mL anti-PA IgG. The diagnostic sensitivity of the assay was 97.8%, and the diagnostic specificity was 97.6%. A competitive inhibition anti-PA IgG ELISA was also developed to enhance diagnostic specificity to 100%. The anti-PA ELISAs proved valuable for the confirmation of cases of cutaneous and inhalational anthrax and evaluation of patients in whom the diagnosis of anthrax was being considered.

Anthrax↗
PubMed2003

Preparing for a bioterrorist attack: legal and administrative strategies.

This article proposes and discusses legal and administrative preparations for a bioterrorist attack. To perform the duties expected of public health agencies during a disease outbreak caused by bioterrorism, an agency must have a sufficient number of employees and providers at work and a good communications system between staff in the central offices of the public health agency and those in outlying or neighboring agencies and hospitals. The article proposes strategies for achieving these objectives as well as for removing legal barriers that discourage agencies, institutions, and persons from working together for the overall good of the community. Issues related to disease surveillance and special considerations regarding public health restrictive orders are discussed.

Bioterrorism↗
PubMed2004

Syndromic surveillance for influenzalike illness in ambulatory care network.

Conventional disease surveillance mechanisms that rely on passive reporting may be too slow and insensitive to rapidly detect a large-scale infectious disease outbreak; the reporting time from a patient's initial symptoms to specific disease diagnosis takes days to weeks. To meet this need, new surveillance methods are being developed. Referred to as nontraditional or syndromic surveillance, these new systems typically rely on prediagnostic data to rapidly detect infectious disease outbreaks, such as those caused by bioterrorism. Using data from a large health maintenance organization, we discuss the development, implementation, and evaluation of a time-series syndromic surveillance detection algorithm for influenzalike illness in Minnesota.

Ambulatory Care↗
PubMed2005

Simulated anthrax attacks and syndromic surveillance.

We measured sensitivity and timeliness of a syndromic surveillance system to detect bioterrorism events. A hypothetical anthrax release was modeled by using zip code population data, mall customer surveys, and membership information from HealthPartners Medical Group, which covers 9% of a metropolitan area population in Minnesota. For each infection level, 1,000 releases were simulated. Timing of increases in use of medical care was based on data from the Sverdlovsk, Russia, anthrax release. Cases from the simulated outbreak were added to actual respiratory visits recorded for those dates in HealthPartners Medical Group data. Analysis was done by using the space-time scan statistic. We evaluated the proportion of attacks detected at different attack rates and timeliness to detection. Timeliness and completeness of detection of events varied by rate of infection. First detection of events ranged from days 3 to 6. Similar modeling may be possible with other surveillance systems and should be a part of their evaluation.

Anthrax↗
PubMed2005

Australian public and smallpox.

A national survey of 1,001 Australians found that most were concerned about a bioterrorist attack and were ill-informed about smallpox prevention and response. Since general practitioners were commonly identified as the initial point of care, they should become a focus of bioterrorism response planning in Australia.

Adult↗
PubMed2005

SARS and biothreat preparedness--a survey of ACT general practitioners.

In late 2003 and early 2004 the ACT Division of General Practice and ACT Health conducted two concurrent surveys designed to identify knowledge, attitudes and practices of Australian Capital Territory (ACT) general practitioners around severe acute respiratory syndrome (SARS) and biothreat preparedness. One survey asked individual general practitioners (GPs) about how they gathered information about SARS in 2003, how they preferred to receive information, current practices, and how they perceived the threat of SARS and other infectious agents. The second survey asked practice principals how they organised their practice to respond to the SARS threat in 2003, any difficulties they had with implementing this response, use of SARS infection control guidelines and current policies. The response rate for the individual GP survey was 48 per cent (184/381) and the response rate for the practice organisation survey was 54 per cent (74/136). GPS used many sources of information on SARS during the 2003 outbreak. Facsimiles from the ACT Division of General Practice were the primary source (17%) and facsimile was the preferred method of receiving information in future outbreaks. The majority of GP respondents felt adequately informed about SARS during the 2003 outbreak, but many general practices did not follow the national guidelines on telephone screening of patients, warning signs and having infection control kits available. The majority of practices reported that they had policies or procedures in place to isolate potentially infectious patients from others in the waiting room. GPs rated an influenza pandemic as a threat to themselves and their patients much more highly than SARS or bioterrorism. Suggestions and comments on how ACT GPs could be better prepared to respond to future outbreaks included the need for timeliness of information, information delivery mechanisms, communication issues, education, the availability of guidelines and protocols, planning, role delineation, the use of response teams, provision of equipment, and vaccination. Planning for future infectious disease outbreak events in the Australian Capital Territory should incorporate general practitioners so that the plans reflect what is a feasible response in the general practice setting.

Adult↗
PubMed2005

Threat assessment of mycotoxins as weapons: molecular mechanisms of acute toxicity.

Mycotoxins are impractical as tactical weapons, butthey can be used by small poor terrorist organizations to poison food and water sources or can be released in crowded, confined areas. Crude concentrated or dried extracts of readily grown fungal cultures can be used as weapons. The production of fungal weapons does not require elaborate facilities for the growth of fungi, sophisticated equipment for the purification of the toxins, or highly trained personnel. Aflatoxin B1, fumonisin B1, ochratoxin A, and the trichothecenes T-2 toxin and deoxynivalenol could be weaponized for bioterrorism. Knowledge of the symptoms of intoxication and the biochemical mechanisms of action of mycotoxins is necessary for the rapid identification of the toxins, the development of prophylactic antidotes, and the design of effective treatments of affected persons. All of these mycotoxins except deoxynivalenol are carcinogens (Stark, A. A., Annu. Rev. Microbiol. 34:235-262, 1980; Stark, A. A., p. 435-445, in P. S. Steyn and R. Vleggaar, ed., Mycotoxins and phycotoxins, 1986; Stark, A. A., p. 47-60, in C. L. Wilson and S. Droby, ed., Microbial food contamination, 2000; Stark, A. A., and N. Paster, p. 60-64, in M. L. Wahlqvist, A. S. Truswell, R. Smith, and P. L. Nestel, ed., Nutrition in a sustainable environment, 1994). Because immediate and widespread death, illness, or panic is the goal of bioterrorists, the mechanisms by which mycotoxins exert acute toxicity are the focus of this article.

Aflatoxins↗
PubMed2004

Looking beyond the national interest: reconstructing the debate on health and foreign policy.

Current international instability has promoted health to the foreign and security policy agenda; however, health is narrowly conceived in terms of promoting the national interest and defending the state, particularly from the risks of infectious disease and bioterrorism. This development involves the risk of global health being co-opted into an international agenda that focuses narrowly on security concerns rather than on broader global health issues. An alternative construction places greater emphasis on shared humanitarian values in a globalised world. This offers a more equal relationship between health and foreign policy and allows a broader range of issues (eg, trade in goods and services affecting health) to be considered in bringing together global health and foreign and security policy.

Altruism↗
PubMed2003

Accuracy of screening for inhalational anthrax after a bioterrorist attack.

BACKGROUND: Bioterrorism using anthrax claimed five lives in the United States in 2001 and remains a potential public health threat. In the aftermath of a large-scale anthrax attack, mass screening to identify early inhalational anthrax may improve both the management of individual cases and the efficiency of health resource utilization. PURPOSE: To develop the evidence base for outpatient anthrax screening protocols by quantifying differences in clinical presentation between inhalational anthrax and common viral respiratory tract infections. DESIGN: Review, compilation, and data extraction from English-language case reports of inhalational anthrax and epidemiologic studies of influenza and other viral respiratory infections. DATA SOURCES: 13 reports of 28 cases of inhalational anthrax from 1920 to 2001 and 5 studies reporting on the clinical features of 2762 cases of influenza and 1932 cases of noninfluenza viral respiratory disease. DATA SYNTHESIS: Characterization of presenting clinical symptoms in anthrax and viral disease and calculation of likelihood ratios for the presence of selected clinical features. RESULTS: Fever and cough do not reliably discriminate between inhalational anthrax and viral respiratory tract infection. Features suggestive of anthrax include the presence of nonheadache neurologic symptoms (positive likelihood ratio cannot be calculated), dyspnea (positive likelihood ratio, 5.3 [95% CI, 3.7 to 7.4]), nausea or vomiting (positive likelihood ratio, 5.1 [CI, 3.0 to 8.5]), and finding of any abnormality on lung auscultation (positive likelihood ratio, 8.1 [CI, 5.3 to 12.5]). In contrast, rhinorrhea (positive likelihood ratio, 0.2 [CI, 0.1 to 0.4]) and sore throat (positive likelihood ratio, 0.2 [CI, 0.1 to 0.5]) are more suggestive of viral respiratory tract infection. CONCLUSION: Inhalational anthrax has characteristic clinical features that are distinct from those seen in common viral respiratory tract infections. Screening protocols based on these features may improve rapid identification of patients with presumptive inhalational anthrax in the setting of a large-scale anthrax attack.

Anthrax↗
PubMedDate not supplied

Anticipating smallpox as a bioterrorist weapon.

The treat of bioterrorism means it is important to be able to diagnose smallpox. The responsibility for the initial recognition of cases lies with clinicians, and early diagnosis is the key to the successful control of an outbreak. Unless rapidly contained, a bioterrorist release of smallpox would constitute not just a national but a global threat to health. This brief review sets smallpox in its modern context as an infection potentially spread by bioterrorists and recommends sources of information from the twentieth century that will assist clinicians in diagnosing the disease.

Bioterrorism↗
PubMed2000

The role of the clinical laboratory in managing chemical or biological terrorism.

BACKGROUND: Domestic and international acts of terrorism using chemicals and pathogens as weapons have recently attracted much attention because of several hoaxes and real incidents. Clinical laboratories, especially those affiliated with major trauma centers, should be prepared to respond rapidly by providing diagnostic tests for the detection and identification of specific agents, so that specific therapy and victim management can be initiated in a timely manner. As first-line responders, clinical laboratory personnel should become familiar with the various chemical or biological agents and be active participants in their local defense programs. APPROACH: We review the selected agents previously considered or used in chemical and biological warfare, outline their poisonous and pathogenic effects, describe techniques used in their identification, address some of the logistical and technical difficulties in maintaining such tests in clinical laboratories, and comment on some of the analytical issues, such as specimen handling and personal protective equipment. CONTENT: The chemical agents discussed include nerve, blistering, and pulmonary agents and cyanides. Biological agents, including anthrax and smallpox, are also discussed as examples for organisms with potential use in bioterrorism. Available therapies for each agent are outlined to assist clinical laboratory personnel in making intelligent decisions regarding implementation of diagnostic tests as a part of a comprehensive defense program. SUMMARY: As the civilian medical community prepares for biological and chemical terrorist attacks, improvement in the capabilities of clinical laboratories is essential in supporting counterterrorism programs designed to respond to such attacks. Accurate assessment of resources in clinical laboratories is important because it will provide local authorities with an alternative resource for immediate diagnostic analysis. It is, therefore, recommended that clinical laboratories identify their current resources and the extent of support they can provide, and inform the authorities of their state of readiness.

Animals↗
PubMed2001

Are Saudi Arabian hospitals prepared for the threat of biological weapons?

The use of biological weapons has been recorded repeatedly in history. Until recently, biological terrorism had been little discussed or written about. However, events over the past 12 to 18 months have made it clear that likely perpetrators already envisage every possible scenario. Nations and dissident groups exist that have both the motivation and access to utilize biological weapons. In April 1994, a Russian biological weapons expert presented the conclusions of the Russian experts as to the agents most likely to be used: smallpox, anthrax, and plague. Health care workers in the Kingdom of Saudi Arabia (physicians, nurses, and emergency medical technicians) need to be aware of the seriousness of the threat of biological weapons, and to have an approach for the early identification, triage, and management of biological weapons victims. Clues to the occurrence of a bioterrorism attack include the abrupt onset of a large number of cases of a similar disease or syndrome, the occurrence of diseases with unusual geographic or seasonal distribution, and epidemics of non-endemic diseases. Health care workers must maintain a high index of suspicion, involve the hospital epidemiologist or infectious diseases specialist, identify a clear administrative chain-of-command to minimize confusion, and rely on existing networks such as the hospital disaster-and-safety committee to ensure a multidisciplinary response. Maximum readiness can be achieved by periodic readiness drills.

Biological Warfare↗
PubMed2001

A personal glimpse of clinical infectious diseases: 1949-1999.

We have witnessed the advent of the antibiotic era and the development of potent immunization agents in the second half of the 20th century. These remarkable scientific tools enable us to treat and control infectious diseases effectively. Yet the development of microbial resistance to antimicrobial agents and the emergence of new or previously unrecognized infectious diseases continue to challenge the medical and public health professionals. Most ominously, the ill-natured terrorists and mistrustful administrators in certain nations have capitalized on the modern microbial technology to create means for bioterrorism and biological warfare. When will humans ever learn?

Bacteria↗
PubMed2001

[The worldwide challenges of "new" or reemerging communicable diseases at the dawn of the 21st century].

In the first part of this review, AIDS, prion diseases, Hantavirus and arbovirus infections, Ebola hemorrhagic fever, legionellosis, hepatitis C, enterotoxigenic Escherichia coli infections, Lyme disease, tuberculosis have provided alarming examples of emerging or reemerging infectious diseases. In this second part, the stress is placed on the reemergence of diphtheria and of serious streptococcal infections, on bartonelloses, Chlamydia infections, fungal infections, while malaria and cholera are still prevalent in several areas. The increasing resistance of too many pathogens to antimicrobial agents is a major source of concern, directly related to the challenge of nosocomial infections. An infectious cause has been demonstrated (or strongly suspected) for various diseases and the scope of infectiology keeps widening, while the threat of bioterrorism cannot be neglected. The causes of the emergence or reemergence of infectious diseases are multiple and diverse, often in direct relation with human activities (population migrations, changes in husbandry or farming practices, worldwide exchanges of goods and foods, inadequate uses of antibiotics) but also with climatic variations in several areas. The challenge represented by this unexpected comeback of infections to the forefront of human and animal pathology can only be met with a significant improvement of hygienic practices, cessation of certain dangerous behaviors and also, of course, with the development of novel antimicrobial molecules (acting on original targets) as well as of a whole series of new specific vaccines.

Anti-Bacterial Agents↗
PubMed2001

A chemical decontamination plan for an emergency department.

How a hospital with limited resources successfully implemented an effective emergency decontamination program. While the article addresses chemical decontamination specifically, the author believes the plan would be useful in managing potential victims of bioterrorism.

Bioterrorism↗
PubMed2001

[Infectious diseases as a weapon: vigilance is needed].

The deliberate inclusion of Bacillus anthracis spores in mail has led to several cases of anthrax in the USA of which to date four have been fatal. Shortly before these incidents, the Health Council of the Netherlands had issued an advisory document which stressed the need for a well-established infrastructure and rigorous protocols so that an immediate and adequate response to cases of bioterrorism could be ensured. Physicians are expected to know the characteristics of the relevant diseases and to immediately notify the Health Inspectorate in the event of an infectious cluster which is unusual with respect to time, place or age, a cluster of a highly serious disease in healthy persons, or a cluster characterised by flaccid paralysis with bulbar signs.

Anthrax↗