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PubMedDate not supplied

Precautions against biological and chemical terrorism directed at food and water supplies.

Deliberate food and water contamination remains the easiest way to distribute biological or chemical agents for the purpose of terrorism, despite the national focus on dissemination of these agents as small-particle aerosols or volatile liquids. Moreover, biological terrorism as a result of sabotage of our food supply has already occurred in the United States. A review of naturally occurring food- and waterborne outbreaks exposes this vulnerability and reaffirms that, depending on the site of contamination, a significant number of people could be infected or injured over a wide geographic area. Major knowledge gaps exist with regard to the feasibility of current disinfection and inspection methods to protect our food and water against contamination by a number of biological and chemical agents. However, a global increase in food and water safety initiatives combined with enhanced disease surveillance and response activities are our best hope to prevent and respond quickly to food- and waterborne bioterrorism.

Biological Warfare↗

PubMed2004

Herpes simplex encephalitis: an audit of the use of laboratory diagnostic tests.

BACKGROUND: The combination of both PCR and intrathecal antibody studies is recommended to confirm or refute the diagnosis of herpes simplex encephalitis (HSE). AIM: To investigate the pattern of use of laboratory tests in the diagnosis of suspected cases of HSE, and to determine the final diagnosis in cases proven not to be HSE. DESIGN: Structured audit. METHODS: We reviewed the case-notes of all patients who, over a five-year time period, presented with suspected encephalitis; and/or were prescribed aciclovir. Clinical and laboratory criteria were used to categorize the likelihood of HSE. RESULTS: We identified 222 patients: 10 (5%) had definite HSE, 24 (10%) possible HSE, and 144 (65%) a definite alternative diagnosis. In 44 (20%), no final diagnosis was made, but the diagnosis of HSE was excluded. PCR was performed in 68 (31%), intrathecal antibody studies in 24 (11%), and brain biopsy in 17 (8%). A wide range of diseases mimicked HSE, but most common were inflammatory diseases and other infections of the central nervous system. DISCUSSION: Laboratory tests, particularly intrathecal antibody assays, are under-used in the diagnosis of HSE. Although early empirical treatment of suspected HSE is essential, confirmation or exclusion of the diagnosis is equally important to avoid overlooking alternative diagnoses. Identification of the aetiology of encephalitis is of particular importance, given the current concerns of emerging infections and bioterrorism.

Acyclovir↗

PubMed2003

Should smallpox vaccine be tested in children?

Following the terrorist attacks on 11 September 2001 there has been increased concern about bioterrorism, much of it focused on smallpox. Routine smallpox vaccination in the USA was discontinued in 1972 and most US citizens are susceptible to smallpox. The last natural case of smallpox occurred in 1978 but the virus has been stocked in freezers. If a terrorist had access to stored smallpox virus a release could produce a chaotic situation. In response the USA has developed a program for vaccinating adults but children have been left out. The only available vaccine has recently been tested in adults but a proposal for testing children was not approved. We need to know if available vaccines are safe for children so children can be safely and effectively vaccinated in an emergency situation.

Adolescent↗

PubMed2004

Q fever pneumonia.

PURPOSE OF REVIEW: In this era of emerging infectious diseases and bioterrorism it is important to be up to date with the diagnosis and management of Q fever pneumonia. RECENT FINDINGS: A considerable amount of new information has emerged regarding the pathogenesis of Coxiella burnetii infection. The complete genome of this microorganism has now been sequenced and there are several unique features. The spectrum of manifestations of infection due to C. burnetii continues to expand. Some of the more recently described findings are acalculous cholecystitis, rhabdomyolysis, long-term persistence of Coxiella, post Q fever fatigue syndrome, and hemolytic uremic syndrome. Pneumonia as a manifestation of acute Q fever shows tremendous geographic variation, being common in one area of a country such as Spain but not in another area. SUMMARY: Pneumonia continues to be an important manifestation of infection with C. burnetii. It responds to treatment with doxycycline, quinolones or macrolides.

Anti-Bacterial Agents↗

PubMed2003

Immunizations, neonatal jaundice, and animal-induced injuries.

This article reviews recent advances and recommendation changes in the areas of immunization, neonatal hyperbilirubinemia, and animal-induced injury. Physician education of families and care of patients in these three topic areas are important public health measures. First, pediatricians are always actively promoting public health through immunization, so the 2003 vaccination recommendations are critiqued along with perceived barriers to proper immunization. New information about smallpox vaccine is included in this year's review because of increased concerns about the use of smallpox as a weapon of bioterrorism since the world events in recent years. Next, the continued study of the management of hyperbilirubinemia in preventing kernicterus is examined. Finally, the management and prevention of animal-induced injuries is reviewed. In each of these areas, the pediatrician plays a prominent role in promoting the health and well being of children.

Animals↗

PubMed2005

Descending polyneuropathy in an intravenous drug user.

A 27-year-old male intravenous drug user presented to the Emergency Department of St James's Hospital with a 1-week history of progressive dysphasia, dysphagia and difficulty 'holding his head up' and 'keeping his eyes open'. He also complained of increasing weakness in his upper limbs, as a result of which he kept dropping things. He was on a methadone program but was using both intravenous heroin and cocaine at the time of presentation. Examination of his motor function revealed generalized hypotonia, hyporeflexia and reduced power in both upper limbs. No sensory loss was observed. Co-ordination was intact. The clinical picture of a proximal symmetrical descending weakness and an absence of sensory loss was suggestive of botulism. Clostridium botulinum is a spore-forming, obligate anaerobe. The three forms of human botulism are food-borne, wound and intestinal. A fourth man-made form is produced from aerosolized botulinum toxin and results in inhalational botulism. A little as 1 g of aerosolized botulinum toxin has the potential to kill 1.5 million people. Toxin is detected in serum or stool specimens in only approximately 46% of clinically diagnosed cases. Treatment involves supportive care and early passive immunization with equine antitoxin. Patients should be regularly assessed for loss of gag and cough reflex, control of oropharyngeal secretions, oxygen saturation, vital capacity and inspiratory force. When respiratory function begins to deteriorate, anticipatory intubation is indicated. Early symptom recognition and early treatment with antitoxin are essential in order to prevent mortality, and to prevent additional cases, it is important to ascertain the presence of similar symptoms in contacts of the patient and local public health officials must be notified as one case may herald an outbreak. Given the continued threat of bioterrorism, the Centre for Disease Control Surveillance System in the United States must also be notified of any cases of botulism.

Adult↗

PubMed2000

A history of biological and chemical warfare and terrorism.

This article provides a brief history of biological warfare and terrorism. It contends that examining disease in history provides public health specialists with the knowledge necessary to improve our surveillance system for potential acts of bioterrorism.

Biological Warfare↗

PubMedDate not supplied

Roadmap for public health workforce preparedness.

Major initiatives to improve the public health workforce since 1997 have been driven by a hundred-fold increase in federal financial support, technologies providing greater access to public health workers, and an emerging national priority to prepare for and respond to bioterrorism and other urgent threats. This report examines the status of the national public health workforce development agenda, including its major strategies and emphases, and offers a roadmap for assessing, enhancing, and recognizing competent performance through comprehensive public health workforce preparedness management systems.

Competency-Based Education↗

PubMedDate not supplied

Combining the benefits of decision science and financial analysis in public health management: a county-specific budgeting and planning model.

State public health agencies are charged with providing and overseeing the management of basic public health services on a population-wide basis. These activities have a re-emphasized focus as a result of the events of September 11, 2001, the subsequent anthrax events, and the continuing importance placed on bioterrorism preparedness, West Nile virus, and emerging infectious diseases (eg, monkeypox, SARS). This has added to the tension that exists in budgeting and planning, given the diverse constituencies that are served in each state. State health agencies must be prepared to allocate finite resources in a more formal manner to be able to provide basic public health services on a routine basis, as well as during outbreaks. This article describes the use of an analytical approach to assist financial analysis that is used for budgeting and planning in a state health agency. The combined benefits of decision science and financial analysis are needed to adequately and appropriately plan and budget to meet the diverse needs of the populations within a state. Health and financial indicators are incorporated into a decision model, based on multicriteria decision theory, that has been employed to acquire information about counties and public health programs areas within a county, that reflect the impact of planning and budgeting efforts. This information can be used to allocate resources, to distribute funds for health care services, and to guide public health finance policy formulation and implementation.

Budgets↗

PubMedDate not supplied

Local health department applies incident management system for successful mass influenza clinics.

Faced with a national influenza vaccine shortage in fall 2004, the Anne Arundel County (Maryland) Department of Health was forced to alter plans for influenza vaccine distribution to reach County residents most at risk. While approximately 37,000 doses of vaccine had been ordered and were to be administered through 17 large flu clinics, only 8,000 doses of flu vaccine were now available for distribution. This year's vaccine shortage provided an opportunity to test the Department's capacity to mobilize mass clinics in the event of a natural emergency or bioterrorism. Implementation of Incident Management System and utilization of partnerships with County and State agencies and media proved that the community's readiness relies on the quality and training of the local public health infrastructure.

Disaster Planning↗

PubMedDate not supplied

Developing national performance standards for local public health systems.

Since the beginning of the 1990s, public health has struggled to measure its performance and capacity to carry out the core functions of public health practice, while facing increasing challenges within the ever-changing landscape of healthcare delivery, bioterrorism response, emerging infections, and other threats to the public's health. The article describes the development of a set of national performance standards for measuring how effectively public health systems deliver the 10 Essential Public Health Services. The standards were developed through a practice-driven approach that incorporated comprehensive field testing and iterative revisions. The standards represent a national consensus framework for measuring important aspects of public health practice.

Efficiency, Organizational↗

PubMedDate not supplied

The Management Academy for Public Health: the South Carolina experience.

In the late 1990s, the South Carolina Department of Health and Environmental Control (SCDHEC) was faced with the challenges of a workforce that was not prepared in public health; the impending loss of significant agency expertise, leadership, and institutional knowledge through retirement; the lack of available and accessible training; and continuing state budget cuts. Preparedness for bioterrorism and other public health emergencies was also of concern, a need made more urgent after 2001. To respond to current and emerging public health challenges, the SCDHEC had to have a workforce with the knowledge and skills necessary for the delivery of essential public health services. To address these challenges, the department partnered with the University of North Carolina in the pilot of the Management Academy for Public Health. The Management Academy is now integrated into the South Carolina workforce development strategy, and 199 staff members and 22 community partners have graduated from the program. Along with increased knowledge, skills, and abilities of individual staff and increased organizational and community capacity, a significant result of South Carolina's experience with the Management Academy for Public Health is the development of a training program for emergency preparedness modeled on the Management Academy. This highly successful program illustrates the replicability of the Management Academy model.

Humans↗

PubMed2004

Smallpox, vaccination and adverse reactions to smallpox vaccine.

PURPOSE OF REVIEW: Public fear of the reintroduction of smallpox as a biological weapon or agent of bioterrorism has led to a renaissance of interest in smallpox, and a military and public health vaccination programme in the USA. Clinical experience from the last century together with novel immunobiological findings is the basis for current knowledge on smallpox as a disease. Pre-existing knowledge on smallpox vaccination, plus recent vaccination campaign-derived data, is the basis of current risk-benefit assessments. This article summarizes, from a dermatologist's point of view, current aspects of smallpox, smallpox vaccination and adverse reactions to vaccinia, the live virus smallpox vaccine. RECENT FINDINGS: The smallpox vaccination campaign in the USA has involved over 600,000 vaccinees, and has largely confirmed incidence data on complications. An increased rate of myopericarditis is the new finding in the current vaccination campaign. Immunodeficiencies, manifest atopic dermatitis lesions and a history of atopic dermatitis remain contraindications to vaccination. Plasmacytoid dendritic cells are a key regulator of the human antiviral immune response and are recruited to inflamed skin in many skin diseases, but are depleted in atopic dermatitis lesions. The lack of plasmacytoid dendritic cell recruitment, together with the missing upregulation of antiviral peptides such as cathelicidin LL37 in atopic dermatitis lesions, is considered relevant for an atopic dermatitis patient's susceptibility to eczema vaccinatum. SUMMARY: Recent experience from the US smallpox vaccination campaign has largely confirmed what was known in the 1960s. Current immunobiological research will enhance our understanding of the interaction between poxviruses and the skin's immune system.

Diagnosis, Differential↗

PubMed2006

Still protected against smallpox? Estimation of the duration of vaccine-induced immunity against smallpox.

BACKGROUND: Although the potential for bioterrorism has led to discussions on the durability of vaccine-induced immunity, the actual duration of protection against smallpox is still unknown. It has previously been suggested that at least partial protection against severe and fatal smallpox may persist throughout life. METHODS: In this article, we analyzed 6 major smallpox outbreaks that occurred before and after 1900 in the United Kingdom. These analyses are based on the age-dependent incidence of smallpox and the fraction of severe manifestations among individuals with or without prior vaccination. We used a likelihood-based approach to estimate the duration of immunity from the age-specific frequencies. RESULTS: The expected median duration of protection from disease ranged from 11.7 to 28.4 years after primary vaccination, and the qualitative pattern of duration could be described using Gompertz's Law. Vaccinated individuals appear to have been protected from severe disease with more than 50% probability even 50 years after successful primary vaccination. CONCLUSIONS: These findings suggest that successful primary vaccination offered full protection for a few decades, with partial protection from severe smallpox possibly lasting a lifetime, for a substantial fraction of the population.

Age Factors↗

PubMed2003

Pathology of inhalation anthrax in cynomolgus monkeys (Macaca fascicularis).

Anthrax is considered a serious biowarfare and bioterrorism threat because of its high lethality, especially by the inhalation route. Rhesus macaques (Macaca mulatta) are the most commonly used nonhuman primate model of human inhalation anthrax exposure. The nonavailability of rhesus macaques necessitated development of an alternate model for vaccine testing and immunologic studies. This report describes the median lethal dose (LD(50)) and pathology of inhalation anthrax in cynomolgus macaques (Macaca fascicularis). Gross and microscopic tissue changes were reviewed in 14 cynomolgus monkeys that died or were killed after aerosol exposure of spores of Bacillus anthracis (Ames strain). The LD(50) and 95% confidence intervals were 61800 (34000 to 110000) colony-forming units. The most common gross lesions were mild splenomegaly, lymph node enlargement, and hemorrhages in various organs, particularly involving the meninges and the lungs. Mediastinitis, manifested as hemorrhage or edema, affected 29% of the monkeys. Microscopically, lymphocytolysis occurred in the intrathoracic lymph nodes and spleens of all animals, and was particularly severe in the spleen and in germinal centers of lymph nodes. Hemorrhages were common in lungs, bronchial lymph nodes, meninges, gastrointestinal tract, and mediastinum. These results demonstrate that the Ames strain of B. anthracis is lethal by the inhalation route in the cynomolgus macaque. The LD(50) of the Ames strain of B. anthracis was within the expected experimental range of previously reported values in the rhesus monkey in an aerosol challenge. The gross and microscopic pathology of inhalation anthrax in the cynomolgus monkey is remarkably similar to that reported in rhesus monkeys and humans. The results of this study are important for the establishment of an alternative nonhuman primate model for evaluation of medical countermeasures against inhalational anthrax.

Aerosols↗

PubMed2005

Risk perception and impact of Severe Acute Respiratory Syndrome (SARS) on work and personal lives of healthcare workers in Singapore: what can we learn?

INTRODUCTION: Healthcare workers (HCWs) were at the frontline during the battle against Severe Acute Respiratory Syndrome (SARS). Understanding their fears and anxieties may hold lessons for handling future outbreaks, including acts of bioterrorism. METHOD: We measured risk perception and impact on personal and work life of 15,025 HCWs from 9 major healthcare institutions during the SARS epidemic in Singapore using a self-administered questionnaire and Impact of Events Scale and analyzed the results with bivariate and multivariate statistics. RESULTS: From 10,511 valid questionnaires (70% response), we found that although the majority (76%) perceived a great personal risk of falling ill with SARS, they (69.5%) also accepted the risk as part of their job. Clinical staff (doctors and nurses), staff in daily contact with SARS patients, and staff from SARS-affected institutions expressed significantly higher levels of anxiety. More than half reported increased work stress (56%) and work load (53%). Many experienced social stigmatization (49%) and ostracism by family members (31%), but most (77%) felt appreciated by society. Most felt that the personal protective measures implemented were effective (96%) and that the institutional policies and protocols were clear (93%) and timely (90%). CONCLUSION: During epidemics, healthcare institutions have a duty to protect HCWs and help them cope with their personal fears and the very stressful work situation. Singapore's experience shows that simple protective measures based on sound epidemiological principles, when implemented in a timely manner, go a long way to reassure HCWs.

Adaptation, Psychological↗

PubMed2002

Administration to mice of a monoclonal antibody that neutralizes the intracellular mature virus form of vaccinia virus limits virus replication efficiently under prophylactic and therapeutic conditions.

The WHO smallpox eradication program was concluded 21 years ago and the non-vaccinated population is now at risk of poxvirus infections, either by contact with monkeypox or through bioterrorism. Since drugs specific against poxvirus infections are limited, neutralizing monoclonal antibodies (mAbs) that are effective in vivo may be an important tool in controlling poxvirus infections. To this end, we studied the efficacy of the mAb C3, reactive against the trimeric 14-kDa protein of vaccinia virus (VV) localized in the membrane of the intracellular form of mature virus, for its ability to neutralize VV infection in mice. The results show that prophylactic as well as therapeutic administration of mAb C3 can be an effective means of control of VV replication within the host. The interval of antibody efficacy following a single administration, before and after VV inoculation, has been defined. This study reinforces the notion that neutralizing mAbs should be developed to control health-related human infections by poxviruses.

Animals↗

PubMed2007

Phenotypic and molecular characterizations of Yersinia pestis isolates from Kazakhstan and adjacent regions.

Recent interest in characterizing infectious agents associated with bioterrorism has resulted in the development of effective pathogen genotyping systems, but this information is rarely combined with phenotypic data. Yersinia pestis, the aetiological agent of plague, has been well defined genotypically on local and worldwide scales using multi-locus variable number tandem repeat analysis (MLVA), with emphasis on evolutionary patterns using old isolate collections from countries where Y. pestis has existed the longest. Worldwide MLVA studies are largely based on isolates that have been in long-term laboratory culture and storage, or on field material from parts of the world where Y. pestis has potentially circulated in nature for thousands of years. Diversity in these isolates suggests that they may no longer represent the wild-type organism phenotypically, including the possibility of altered pathogenicity. This study focused on the phenotypic and genotypic properties of 48 Y. pestis isolates collected from 10 plague foci in and bordering Kazakhstan. Phenotypic characterization was based on diagnostic tests typically performed in reference laboratories working with Y. pestis. MLVA was used to define the genotypic relationships between the central-Asian isolates and a group of North American isolates, and to examine Kazakh Y. pestis diversity according to predefined plague foci and on an intermediate geographical scale. Phenotypic properties revealed that a large portion of this collection lacks one or more plasmids necessary to complete the blocked flea/mammal transmission cycle, has lost Congo red binding capabilities (Pgm-), or both. MLVA analysis classified isolates into previously identified biovars, and in some cases groups of isolates collected within the same plague focus formed a clade. Overall, MLVA did not distinguish unique phylogeographical groups of Y. pestis isolates as defined by plague foci and indicated higher genetic diversity among older biovars.

Animals↗