Ability of Physicians to Diagnose and Manage Illness Due to Category A Bioterrorism Agents

Deliberate release: Plague - A review

Yersinia pestis is the causative agent of plague and is considered one of the most likely pathogens to be used as a bioweapon. In humans, plague is a severe clinical infection that can rapidly progress with a high mortality despite antibiotic therapy. Therefore, early treatment of Y. pestis infection is crucial. This review provides an overview of its clinical manifestations, diagnosis, treatment, prophylaxis, and protection requirements for the use of clinicians.

We discuss the likelihood of a deliberate release of plague and the feasibility of obtaining, isolating, culturing, transporting and dispersing plague in the context of an attack aimed at a westernized country. The current threat status and the medical and public health responses are reviewed. We also provide a brief review of the potential prehospital treatment strategy and vaccination against Y. pestis. Further, we discuss the plausibility of antibiotic resistant plague bacterium, F1-negative Y. pestis, and also the possibility of a plague mimic along with potential strategies of defense against these. An extensive literature search on the MEDLINE, EMBASE, and Web of Science databases was conducted to collate papers relevant to plague and its deliberate release. Our review concluded that the deliberate release of plague is feasible but unlikely to occur, and that a robust public health response and early treatment would rapidly halt the transmission of plague in the population. Front-line clinicians should be aware of the potential of a deliberate release of plague and prepared to instigate early isolation of patients. Moreover, front-line clinicians should be weary of the possibility of suicide attackers and mindful of the early escalation to public health organizations.

Dangers of Noncritical Use of Historical Plague Data

Researchers have published several articles using historical data sets on plague epidemics using impressive digital databases that contain thousands of recorded outbreaks across Europe over the past several centuries. Through the digitization of preexisting data sets, scholars have unprecedented access to the historical record of plague occurrences. However, although these databases offer new research opportunities, noncritical use and reproduction of preexisting data sets can also limit our understanding of how infectious diseases evolved. Many scholars have performed investigations using Jean-Noël Biraben’s data, which contains information on mentions of plague from various kinds of sources, many of which were not cited. When scholars fail to apply source criticism or do not reflect on the content of the data they use, the reliability of their results becomes highly questionable. Researchers using these databases going forward need to verify and restrict content spatially and temporally, and historians should be encouraged to compile the work.

Neurological aspects of chemical and biological terrorism: guidelines for neurologists

This statement paper deals with the key role an neurologist plays in the management of victims of chemical warfare/terrorist attacks. Because terrorist factions have expanded the war zone creating a worldwide risk of terrorist attacks, not only limited to some conflict zones in the Middle East, neurologists in all countries/regions have to be prepared for disaster response. The scope of this paper is to provide guidelines for the neurological management of victims of chemical and biological terrorist attacks.

A Multiplex PCR/LDR Assay for the Simultaneous Identification of Category A Infectious Pathogens: Agents of Viral Hemorrhagic Fever and Variola Virus

CDC designated category A infectious agents pose a major risk to national security and require special action for public health preparedness. They include viruses that cause viral hemorrhagic fever (VHF) syndrome as well as variola virus, the agent of smallpox. VHF is characterized by hemorrhage and fever with multi-organ failure leading to high morbidity and mortality. Smallpox, a prior scourge, has been eradicated for decades, making it a particularly serious threat if released nefariously in the essentially non-immune world population. Early detection of the causative agents, and the ability to distinguish them from other pathogens, is essential to contain outbreaks, implement proper control measures, and prevent morbidity and mortality. We have developed a multiplex detection assay that uses several species-specific PCR primers to generate amplicons from multiple pathogens; these are then targeted in a ligase detection reaction (LDR). The resultant fluorescently-labeled ligation products are detected on a universal array enabling simultaneous identification of the pathogens. The assay was evaluated on 32 different isolates associated with VHF (ebolavirus, marburgvirus, Crimean Congo hemorrhagic fever virus, Lassa fever virus, Rift Valley fever virus, Dengue virus, and Yellow fever virus) as well as variola virus and vaccinia virus (the agent of smallpox and its vaccine strain, respectively). The assay was able to detect all viruses tested, including 8 sequences representative of different variola virus strains from the CDC repository. It does not cross react with other emerging zoonoses such as monkeypox virus or cowpox virus, or six flaviviruses tested (St. Louis encephalitis virus, Murray Valley encephalitis virus, Powassan virus, Tick-borne encephalitis virus, West Nile virus and Japanese encephalitis virus).

Increased reports of measles in a low endemic region during a rubella outbreak in adult populations

In 2013, a rubella outbreak was observed in Japan, Romania, and Poland. The outbreak in Japan was accompanied by an increase of measles reports, especially from a region where measles is highly controlled. This was attributed to the adult populations affected by this rubella outbreak, similarity of clinical signs between rubella and measles, sufficiently small impact of measles outbreaks from neighboring nations, and elimination levels of measles endemicity. Current and future concerns for measles control are discussed.

Unexplained Deaths in Connecticut, 2002–2003:Failure to Consider Category A Bioterrorism Agents in Differential Diagnoses

Background: Recognition of bioterrorism-related infections by hospital and emergency department clinicians may be the first line of defense in a bioterrorist attack.

Methods: We identified unexplained infectious deaths consistent with the clinical presentation of anthrax, tularemia, smallpox, and botulism using Connecticut death certificates and hospital chart information. Minimum work-up criteria were established to assess the completeness of diagnostic testing.

Results: Of 4558 unexplained infectious deaths, 133 were consistent with anthrax (2.9%) and 6 (0.13%) with tularemia. None were consistent with smallpox or botulism. No deaths had anthrax or tularemia listed in the differential diagnosis or had disease-specific serology performed. Minimum work-up criteria were met for only 53% of cases.

Conclusions: Except for anthrax, few unexplained deaths in Connecticut could possibly be the result of the bioterrorism agents studied. In 47% of deaths from illnesses that could be anthrax, the diagnosis would likely have been missed. As of 2004, Connecticut physicians were not well prepared to intentionally or incidentally diagnose initial cases of anthrax or tularemia. More effective clinician education and surveillance strategies are needed to minimize the potential to miss initial cases in a bioterrorism attack. (Disaster Med Public Health Preparedness. 2008;2:87–94)

Medical aspects of bio-terrorism

INTRODUCTION

Bioterrorism is a terrorist action involving the intentional release or dissemination of a biological warfare agent (BWA), which includes some bacteria, viruses, rickettsiae, fungi or biological toxins. BWA is a naturally occurring or human-modified form that may kill or incapacitate humans, animals or plants as an act of war or terrorism. BWA is a weapon of choice for mass destruction and terrorism, because of the incubation period, less effective amount than chemical warfare agents, easily distribution, odorless, colorless, difficult to detect, no need of specialized equipment for production and naturally distribution which can easily be obtained. BWA may be disseminating as an aerosol, spray, explosive device, and by food or water.

CLASSIFICATION

Based on the risk for human health, BWAs have been prioritized into three categories of A, B and C. Category A includes microorganisms or toxins that easily spread, leading to intoxication with high death rates such as Anthrax, Botulism, Plague, Smallpox, Tularemia and Viral hemorrhagic fevers. Category B has lower toxicity with wider range, including Staphylococcal Entrotoxin type B (SEB), Epsilon toxin of Clostridium perfringens, Ricin, Saxotoxins, Abrin and Trichothecene mycotoxins. The C category includes emerging pathogens that could also be engineered for mass spread such as Hanta viruses, multidrug-resistant tuberculosis, Nipah virus, the tick-borne encephalitis viruses, hemorrhagic fever viruses and yellow fever. CLINICAL MANIFESTATIONS OF BIOTOXINS IN HUMAN: Clinical features and severity of intoxication depend on the agent and exposed dose, route of entry, individual variation and environmental factors. Onset of symptoms varies from 2-24 h in Ricin to 24-96 h in Botulism. Clinical manifestations also vary from irritation of the eyes, skin and mucus membranes in T2 toxin to an acute flaccid paralysis of bilateral cranial nerve impairment of descending manner in botulism. Most of the pyrogenic toxins such as SEB produce the same signs and symptoms as toxic shock syndrome including a rapid drop in blood pressure, elevated temperature, and multiple organ failure.

MANAGEMENT

There is no specific antidote or effective treatment for most of the biotoxins. The clinical management is thus more supportive and symptomatic. Fortunately vaccines are now available for most of BWA. Therefore, immunization of personnel at risk of exposure is recommended.

CONCLUSION

Biotoxins are very wide and bioterrorism is a heath and security threat that may induce national and international problems. Therefore, the security authorities, health professional and even public should be aware of bioterrorism.

Computerized bioterrorism education and training for nurses on bioterrorism attack agents

BACKGROUND

Biological agents have the ability to cause large-scale mass casualties. For this reason, their likely use in future terrorist attacks is a concern for national security. Recent studies show that nurses are ill prepared to deal with agents used in biological warfare. Achieving a goal for bioterrorism preparedness is directly linked to comprehensive education and training that enables first-line responders such as nurses to diagnose infectious agents rapidly.

METHODS

The study evaluated participants' responses to biological agents using a computerized bioterrorism education and training program versus a standard bioterrorism education and training program.

RESULTS

Both programs improved participants' ability to complete and solve case studies involving the identification of specific biological agents.

CONCLUSION

Participants in the computerized bioterrorism education and training program were more likely to solve the cases critically without reliance on expert consultants. However, participants in the standard bioterrorism education and training program reduced the use of unnecessary diagnostic tests.

Discordant Brucella melitensis antigens yield cognate CD8+ T cells in vivo

Brucella spp. are intracellular bacteria that cause the most frequent zoonosis in the world. Although recent work has advanced the field of Brucella vaccine development, there remains no safe human vaccine. In order to produce a safe and effective human vaccine, the immune response to Brucella spp. requires greater understanding. Induction of Brucella-specific CD8+ T cells is considered an important aspect of the host response; however, the CD8+ T-cell response is not clearly defined. Discovering the epitope containing antigens recognized by Brucella-specific CD8+ T cells and correlating them with microarray data will aid in determining proteins critical for vaccine development that cover a kinetic continuum during infection. Developing tools to take advantage of the BALB/c mouse model of Brucella melitensis infection will help to clarify the correlates of immunity and improve the efficacy of this model. Two H-2(d) CD8+ T-cell epitopes have been characterized, and a group of immunogenic proteins have provoked gamma interferon production by CD8+ T cells. RYCINSASL and NGSSSMATV induced cognate CD8+ T cells after peptide immunization that showed specific killing in vivo. Importantly, we found by microarray analysis that the genes encoding these epitopes are differentially expressed following macrophage infection, further emphasizing that these discordant genes may play an important role in the pathogenesis of B. melitensis infection.

Responding to suspected smallpox cases in the Los Angeles County from 2002 to 2006: identifying areas for education

INTRODUCTION

Although smallpox has been eradicated, health care providers in emergency departments (EDs) need to remain vigilant to its recognition. Smallpox can be confused with chickenpox. We describe suspected smallpox cases reported in Los Angeles County from 2002 to 2006 and highlight areas for education.

METHODS

We retrospectively reviewed suspected smallpox reports from 2002 to 2006. Laboratory testing was performed. Photographs of rashes were taken.

RESULTS

Five suspected smallpox cases were reported. Two presented first to an ED. Smallpox was suspected based on rash features. Previous history of chickenpox or varicella vaccination may have caused increased suspicion for smallpox. All 5 were determined to have a final diagnosis of chickenpox. Health care providers notified public health appropriately and responses were immediate.

CONCLUSIONS

Public health investigated 5 suspected smallpox cases in the past 5 years. Two presented initially to EDs. Education differentiating smallpox from chickenpox and collaboration between public health, EDs, and health care providers remains important. The ability to respond rapidly to a potential bioterrorism emergency was tested.

A simulation-based biodefense and disaster preparedness curriculum for internal medicine residents

AIMS

Disaster and bioterrorism preparedness is poorly integrated into the curricula of internal medicine residency programs. Given that victims may present to a variety of healthcare venues, including primary care practices, inpatient hospital wards, and intensive care units, we developed a curriculum to address this need.

METHODS

The curriculum consisted of four didactic sessions with supplemental readings covering biologic, chemical, and radiologic agents, as well as public health infrastructure. All 30 internal medicine resident participants also underwent a four hour training seminar at a high fidelity human simulation center. Instruction included the use of personal protective equipment (PPE)and participation in simulated scenarios utilizing technologically sophisticated mannequins with monitoring and interactive capability. Sessions were videotaped, reviewed with participants, and followed by self-evaluation and constructive feedback.

RESULTS

Compared to a control group of residents who did not undergo training, the participants' level of knowledge was significantly better, with mean objective test scores of 66.8%+/-11.8% SD vs. 50%+/-13.1% SD, p < 0.0001. Although there was a trend toward increasing knowledge with increasing level of training in the control group, this difference was not significant. Subjective preparedness was also significantly better in the intervention group (p < 0.0001). Objective improvements were not maintained after one year.

CONCLUSIONS

In this pilot study, a disaster-preparedness curriculum including simulation-based training had a positive effect on residents' knowledge base and ability to respond to disaster. However, this effect had diminished after one year, indicating the need for reinforcement at regular intervals.

Bioterrorism

Bioterrorism is defined as the deliberate and malicious deployment of microbial agents or their toxins as weapons in a non-combat setting, represents perhaps the most overt example of human behavior impacting epidemic infectious diseases. There is historical precedent for the use of biological agents against both military and civilian populations. The use of biological (and chemical) agents as weapons of war has been well documented. The German biological warfare program during World War I included covert infections of Allied livestock with anthrax and glanders. The Japanese army began conducting experiments on the effects of bacterial agents of biowarfare on Chinese prisoners in occupied Manchuria in 1932 at their infamous Unit 731. The United States began its own offensive biological weapons program in 1942 and, during its 28-year official existence, weaponized and stockpiled lethal biological agents, such as anthrax, as well as incapacitating agents, such as the etiologic agent of Q fever. There are some recent examples of bioterrorism, though not necessarily resulting in attacks causing morbidity or mortality, may serve as harbingers of future events. Saddam Hussein's regime in Iraq developed and deployed anthrax and botulinum-laden warheads in the years leading up to the Gulf War. The reasons that these weapons were never used in an actual attack probably had more to do with the implicit threat of overwhelming US retaliation and Iraqi technological deficiencies rather than the regime's reluctance to violate any moral principles. Biological agents have also been used to forward political ideologies: in 1984 a religious cult, intent on influencing voter turnout during a local election, contaminated restaurant salad bars in The Dalles, Oregon.

Establishing a high level of knowledge regarding bioterrorist threats in emergency department physicians: methodology and the results of a national bio-preparedness project

INTRODUCTION

Medical systems worldwide are facing the new threat of morbidity associated with the deliberate dispersal of microbiological agents by terrorists. Rapid diagnosis and containment of this type of unannounced attack is based on the knowledge and capabilities of medical staff. In 2004, the knowledge of emergency department physicians of anthrax was tested. The average test score was 58%. Consequently, a national project on bioterrorism preparedness was developed. The aim of this article is to present the project in which medical knowledge was enhanced regarding a variety of bioterrorist threats, including cutaneous and pulmonary anthrax, botulinum, and smallpox.

METHODS

In 2005, military physicians and experts on bioterrorism conducted special seminars and lectures for the staff of the hospital emergency department and internal medicine wards. Later, emergency department senior physicians were drilled using one of the scenarios.

RESULTS

Twenty-nine lectures and 29 drills were performed in 2005. The average drill score was 81.7%. The average score of physicians who attended the lecture was 86%, while those who did not attend the lectures averaged 78.3% (NS).

CONCLUSIONS

Emergency department physicians were found to be highly knowledgeable in nearly all medical and logistical aspects of the response to different bioterrorist threats. Intensive and versatile preparedness modalities, such as lectures, drills, and posters, given to a carefully selected group of clinicians, can increase their knowledge, and hopefully improve their response to a bioterrorist attack.

Challenges in Brucella bacteraemia

Brucella possesses unique historical, epidemiological, phylogenetic and pathogenetic characteristics that constantly reinforce the pathogen's place at the epicentre of scientific interest. One such unique characteristic is the significance of bacteraemia in the course of the disease. Bacteraemia in brucellosis may be periodically present, of limited practical diagnostic importance, and of doubtful significance as an index of bacteriological cure. On the other hand, recognition of bacteraemia augments prognosis, typing and biotyping (and thus further research). Recent advances in molecular diagnosis with the help of real time polymerase chain reaction (rtPCR) have shown that bacteraemia in brucellosis may persist, at culture non-detectable levels, for protracted periods even after apparent clinical cure. This raises important issues for future research, implying that the pathogen may actually be non-eradicable.

Q fever in Logroño: an attack scenario

Bioterrorism has emerged as an important infectious disease and public health challenge in the 21st century, and issues of preparedness and response are now prominent. The development of attack scenarios for assessing this problem contributes to the organization of response systems and identifies aspects that may need to be improved. The authors present an attack scenario involving Q fever in a specific area, the city of Logroño, Spain. The evolution of the outbreak is described and the attempts at diagnosis and implementation of public health measures are outlined. Knowledge of the pathogen in the specific scenario and the ability to directly diagnose the disease it causes may be of help to facilitate a fast response that will contain public unrest and the eventual outcome in terms of morbidity and mortality.

Free internal medicine case-based education through the World Wide Web: how, where, and with what?

OBJECTIVE

To identify and evaluate electronic internal medicine educational sources and develop a list of major Web sites for interested practitioners.

MATERIAL AND METHODS

From July 1 to August 20, 2006, we searched Web sites derived from academic and nonacademic institutions, medical journal Web sites, and medical Web sites based on selection criteria, including extent of information, update periods, and validity of the source.

RESULTS

We present a list of related Web sites that have been selected as practical, valid, and freely accessed. Brief descriptions and particular characteristics of these sites are also provided.

CONCLUSION

Physicians willing to augment their education on decision making and advances in the field of internal medicine can consult abundant Internet resources, many derived from leading academic and nonacademic sources. The future may see entire educational courses being conducted on the World Wide Web, unifying the medical community, provided some forms of free access are implemented.

The science of surge: detection and situational awareness

As part of the broader "science of surge" consensus initiative sponsored by Academic Emergency Medicine, this report addresses the issues of detection and situational awareness as they relate to surge in the practice of emergency medicine. The purpose of this report, and the breakout group that contributed to its content, was to provide emergency physicians and other stakeholders in the emergency medicine community a sense of direction as they plan, prepare for, and respond to surge in their practice.

Hawaii veterinarians' bioterrorism preparedness needs assessment survey

The purpose of this study was to assess the objective bioterrorism-related knowledge base and the perceived response readiness of veterinarians in Hawaii to a bioterrorism event, and also to identify variables associated with knowledge-based test performance. An anonymous survey instrument was mailed to all licensed veterinarians residing in Hawaii (N = 229) up to three times during June and July 2004, using numeric identifiers to track non-respondents. The response rate for deliverable surveys was 59% (125 of 212). Only 12% (15 of 123) of respondents reported having had prior training on bioterrorism. Forty-four percent (55 of 125) reported being able to identify a bioterrorism event in animal populations; however, only 17% (21 of 125) felt able to recognize a bioterrorism event in human populations. Only 16% (20 of 123) felt they were able to respond effectively to a bioterrorist attack. Over 90% (106 of 116) expressed their willingness to provide assistance to the state in its response to a bioterrorist event. Veterinarians scored a mean of 70% correct (5.6 out of 8 questions) on the objective knowledge-based questions. Additional bioterrorism preparedness training should be made available, both in the form of continuing educational offerings for practicing veterinarians and as a component of the curriculum in veterinary schools.