Meeting the challenge of bioterrorism: lessons learned from West Nile virus and anthrax

Who Should We Fear More: Biohackers, Disgruntled Postdocs, or Bad Governments? A Simple Risk Chain Model of Biorisk

The biological risk landscape continues to evolve as developments in synthetic biology and biotechnology offer increasingly powerful tools to a widening pool of actors, including those who may consider carrying out a deliberate biological attack. However, it remains unclear whether it is the relatively large numbers of low-resourced actors or the small handful of high-powered actors who pose a greater biosecurity risk. To answer this question, this paper introduces a simple risk chain model of biorisk, from actor intent to a biological event, where the actor can successfully pass through each of N steps. Assuming that actor success probability at each independent step is sigmoidally distributed and actor power follows a power-law distribution, if a biorisk event were to occur, this model shows that the expected perpetrator would likely be highly powered, despite lower-powered actors being far more numerous. However, as the number of necessary steps leading to a biological release scenario decreases, lower-powered actors can quickly overtake more powerful actors as the likely source of a given event. If steps in the risk chain are of unequal difficulty, this model shows that actors are primarily limited by the most difficult step. These results have implications for biosecurity risk assessment and health security strengthening initiatives and highlight the need to consider actor power and ensure that the steps leading to a biorisk event are sufficiently difficult and not easily bypassed.

Vulnerable Populations in Hospital and Health Care Emergency Preparedness Planning: A Comprehensive Framework for Inclusion

INTRODUCTION

As attention to emergency preparedness becomes a critical element of health care facility operations planning, efforts to recognize and integrate the needs of vulnerable populations in a comprehensive manner have lagged. This not only results in decreased levels of equitable service, but also affects the functioning of the health care system in disasters. While this report emphasizes the United States context, the concepts and approaches apply beyond this setting.

OBJECTIVE

This report: (1) describes a conceptual framework that provides a model for the inclusion of vulnerable populations into integrated health care and public health preparedness; and (2) applies this model to a pilot study.

METHODS

The framework is derived from literature, hospital regulatory policy, and health care standards, laying out the communication and relational interfaces that must occur at the systems, organizational, and community levels for a successful multi-level health care systems response that is inclusive of diverse populations explicitly. The pilot study illustrates the application of key elements of the framework, using a four-pronged approach that incorporates both quantitative and qualitative methods for deriving information that can inform hospital and health facility preparedness planning.

CONCLUSIONS

The conceptual framework and model, applied to a pilot project, guide expanded work that ultimately can result in methodologically robust approaches to comprehensively incorporating vulnerable populations into the fabric of hospital disaster preparedness at levels from local to national, thus supporting best practices for a community resilience approach to disaster preparedness.

A Randomized Controlled Trial of the Effectiveness of Traditional and Mobile Public Health Communications With Health Care Providers

Objectives

Health care providers play an essential role in public health emergency preparedness and response. We conducted a 4-year randomized controlled trial to systematically compare the effectiveness of traditional and mobile communication strategies for sending time-sensitive public health messages to providers.

Methods

Subjects (N=848) included providers who might be leveraged to assist with emergency preparedness and response activities, such as physicians, pharmacists, nurse practitioners, physician’s assistants, and veterinarians. Providers were randomly assigned to a group that received time-sensitive quarterly messages via e-mail, fax, or cell phone text messaging (SMS) or to a no-message control group. Follow-up phone interviews elicited information about message receipt, topic recall, and perceived credibility and trustworthiness of message and source.

Results

Our main outcome measures were awareness and recall of message content, which was compared across delivery methods. Per-protocol analysis revealed that e-mail messages were recalled at a higher rate than were messaged delivered by fax or SMS, whereas the as-treated analysis found that e-mail and fax groups had similar recall rates and both had higher recall rates than the SMS group.

Conclusions

This is the first study to systematically evaluate the relative effectiveness of public health message delivery systems. Our findings provide guidance to improve public health agency communications with providers before, during, and after a public health emergency. (Disaster Med Public Health Preparedness. 2016;10:98–107)

Health-care provider preferences for time-sensitive communications from public health agencies

OBJECTIVE

The Rapid Emergency Alert Communication in Health (REACH) Trial was a randomized control trial to systematically compare and evaluate the effectiveness of traditional and mobile communication modalities for public health agencies to disseminate time-sensitive information to health-care providers (HCPs). We conducted a sub-study to identify the communication channels by which HCPs preferred receiving public health alerts and advisories.

METHODS

Enrolled HCPs were blindly randomized into four message delivery groups to receive time-sensitive public health messages by e-mail, fax, or short message service (SMS) or to a no-message control group. Follow-up interviews were conducted 5-10 days after the message. In the final interview, additional questions were asked regarding HCP preferences for receiving public health alerts and advisories. We examined the relationship between key covariates and preferred method of receiving public health alert and advisory messages.

RESULTS

Gender, age, provider type, and study site showed statistically significant associations with delivery method preference. Older providers were more likely than younger providers to prefer e-mail or fax, while younger providers were more likely than older providers to prefer receiving messages via SMS.

CONCLUSIONS

There is currently no evidence-based research to guide or improve communication between public health agencies and HCPs. Understanding the preferences of providers for receiving alerts and advisories may improve the effectiveness of vital public health communications systems and, in turn, may enhance disease surveillance, aid in early detection, and improve case finding and situational awareness for public health emergencies.

Linking emergency preparedness and health care worker vaccination against influenza: a novel approach

Background

Health care workers (HCWs) can acquire and transmit influenza to their patients and coworkers, even while asymptomatic. The U.S. Healthy People 2010 initiative set a national goal of 60% coverage for HCW influenza vaccination by 2010. Yet vaccination rates remain low. In the 2008–2009 influenza season, Flushing Hospital Medical Center (FHMC; New York) adopted a “push/pull” point-of-dispensing (POD) vaccination model that was derived from emergency preparedness planning for mass vaccination and/or prophylaxis to respond to an infectious disease outbreak, whether occurring naturally or due to bioterrorism.

Launch of the HCW Vaccination Program

In mid-September 2008, a two-week HCW vaccination program was launched using a sequential POD approach. In Push POD, teams assigned to specific patient units educated all HCWs about influenza vaccination and offered on-site vaccination; vaccinated HCWs received a 2009 identification (ID) validation sticker. In Pull POD, HCWs could enter the hospital only through one entrance; all other employee entrances were “locked down.” A 2009 ID validation sticker was required for entry and to punch in for duty. Employees without the new validation sticker were directed to a nearby vaccination team. After the Push/Pull POD was completed, the employee vaccination drive at FHMC was continued for the remainder of the influenza season by the Employee Health Service.

Results

Using this model, in two days 72% of the employees were reached, with 54% of those reached accepting vaccination.

Conclusions

This model provides a novel approach for institutions to improve their HCW influenza vaccination rates within a limited period through exercising emergency preparedness plans for infectious disease outbreaks.

Disaster Training for Prehospital Providers

OBJECTIVE

To survey prehospital providers to determine 1) the quantity and format of training recalled over the past year in chemical, biological, radiological/nuclear (CBRN), and other mass casualty events (MCEs); 2) preferred educational formats; 3) self-assessed preparedness for various CBRN/MCEs; and 4) perceived likelihood of occurrence for CBRN/MCEs.

METHODS

A survey, consisting of 11 questions, was distributed to 1,010 prehospital providers in a system where no formal CBRN/mass casualty training was given.

RESULTS

Surveys were completed by 640 (63%) prehospital providers. Twenty-two percent (22%) of prehospital providers recalled no training within the past year for CBRN or other MCEs, 19% reported 1-5 hours, 15% reported 6-10 hours, 24% reported 11-39 hours, and 7% reported receiving greater than 40 hours. Lectures and drills were the most common formats for prior education. On a five-point scale (1: "Never Helpful" through 5: "Always Helpful") regarding the helpfulness of training methods, median scores were the following: drills-5, lectures-4, self-study packets-3, Web-based learning-3, and other-4. On another five-point scale (1: "Totally Unprepared" through 5: "Strongly Prepared"), prehospital providers felt most prepared for MCEs-4, followed by chemical-4, biological-3, and radiation/nuclear-3. Over half (61%) felt MCEs were "Somewhat Likely" or "Very Likely" to occur, whereas chemical (42%), biological (38%), or radiation/nuclear (33%) rated lower.

CONCLUSION

The amount of training in the past year reported for CBRN events varied greatly, with almost a quarter recalling no education. Drills and lectures were the most used and preferred formats for disaster training. Prehospital providers felt least prepared for a radiological;/nuclear event. Future studies should focus on the consistency and quality of education provided.

An analysis of hospital preparedness capacity for public health emergency in four regions of China: Beijing, Shandong, Guangxi, and Hainan

BACKGROUND

Hospital preparedness is critical for the early detection and management of public health emergency (PHE). Understanding the current status of PHE preparedness is the first step in planning to enhance hospitals' capacities for emergency response. The objective of this study is to understand the current status of hospital PHE preparedness in China.

METHODS

Four hundred hospitals in four city and provinces of China were surveyed using a standardized questionnaire. Data related to hospital demographic data; PHE preparation; response to PHE in community; stockpiles of drugs and materials; detection and identification of PHE; procedures for medical treatment; laboratory diagnosis and management; staff training; and risk communication were collected and analyzed.

RESULTS

Valid responses were received from 318 (79.5%) of the 400 hospitals surveyed. Of the valid responses, 264 (85.2%) hospitals had emergency plans; 93.3% had command centres and personnel for PHE; 22.9% included community organisations during the training for PHE; 97.4% could transport needed medical staff to a PHE; 53.1% had evaluated stockpiles of drugs; 61.5% had evaluated their supply systems; 55.5% had developed surveillance systems; and 74.6% could monitor the abnormity(See in appendix). Physicians in 80.2% of the analyzed hospitals reported up-to-date knowledge of their institution's PHE protocol. Of the 318 respondents, 97.4% followed strict laboratory regulations, however, only about 33.5% had protocols for suspected samples. Furthermore, only 59.0% could isolate and identify salmonella and staphylococcus and less than 5% could isolate and identify human H5N1 avian flu and SARS. Staff training or drill programs were reported in 94.5% of the institutions; 50.3% periodically assessed the efficacy of staff training; 45% had experts to provide psychological counselling; 12.1% had provided training for their medical staff to assess PHE-related stress. All of the above capacities related to the demographic characteristics of hospitals and will be discussed in-depth in this paper.

CONCLUSION

Our survey suggested that, at the time of the survey, hospital preparedness for PHE in China was at an early stage of development. Comprehensive measures should be taken to enhance hospital capacity in the prevention and management of PHE.

Will emergency health care providers respond to mass casualty incidents?

INTRODUCTION

Emergency response plans often call on health care providers to respond to the workplace outside of their normal working pattern.

HYPOTHESIS

Providers will report to work during a mass casualty emergency regardless of family duties, type of incident, or availability of treatment.

METHODS

Survey of emergency personnel needed to respond to a mass casualty incident. Two scenarios were presented: one involving the release of a nontransmissible biological agent with proven treatment and the other the release of a transmissible biological agent with no treatment. At critical time points, participants were asked whether they would report to work. Additional questions considered the effect of commonly used treatment dissemination methods.

RESULTS

A total of 186 surveys were issued and returned. (45 physicians, 29 nurses, 86 EMS personnel, and 20 support staff); 6 were incomplete and excluded. Initial commitment rates were 78%. The highest commitment rate identified was 84% and the lowest was 18%. Any treatment dissemination method excluding providers' family members led to decreases in commitment rate, as did agents identified to be transmissible.

CONCLUSIONS

As an event develops, fewer health care providers will report to work and at no time will all providers report when asked. This conclusion may be generalizable to several types of incidents ranging from pandemic influenza to bioterrorism. Identification of the causative agent is a major decision point for providers to return to or stay away from work. Offering on-site treatment of providers' family increases commitment to work. These factors should be considered in emergency planning.

Surge capacity for health care systems: early detection, methodologies, and process

Excessive demand on hospital services from large-scale emergencies is something that every emergency department health care provider and hospital administrator knows could happen at any time. Nowhere in this country have we recently faced a disaster of the magnitude of concern we now face involving agents of mass destruction or social disruption, especially those in the area of infectious diseases and radiological materials. The war on terrorism is not a conventional war, and terrorists may use any means of convenience to carry out their objectives in an unpredictable time line. Have we adequately prepared for the potentially excessive surge in demand for medical services that a large-scale event could bring to our medical care system? Are our emergency departments ready for such events? Surveillance systems, such as BioWatch, BioSense, the National Biosurveillance Integration System, and the countermeasure program BioShield, offer hope that we will be able to meet these new challenges.

Measuring Access to Continuing Professional Education among the Health Workers in Ghana: Constructing an Index

To measure the levels of access to continuing professional education (CPE) among the health workers, an index (continuing professional education access index: CEAI) was constructed. The CEAI is composed of six indicators: (i) availability of CPE; (ii) distribution of CPE; (iii) informational access; (iv) geographical access; (v) economic access; and (vi) preparedness to release staff. When developing the equation of the CEAI, these six component indicators were weighted in accordance with the order of importance reported by the earlier studies. To test its validity, the CEAI was applied to the CPE status in three regions of Ghana. The results of this application revealed that there was greater discrepancies in the CEAI values according to the type of health facilities. The type of health facilities with the greatest CEAI (= 0.609) implying the best access to CPE was clinics while training/research institutes resulted in the lowest CEAI (= 0.447). Regional variation among the three regions was not significant. A simple linear regression between CEAI and adjusted number of CPE opportunities per health worker produced an extremely high conformity in the model (R 2 = 0.960). This may indicate the validity of the proposed CEAI model to the large extent.

Using problem-based learning as a strategy for cross-discipline emergency preparedness training

The rapid and effective response to a bioterrorist event requires the coordinated efforts of trained personnel from different agencies. This article describes the design and implementation of a 1-week cross-disciplinary course employing problem-based learning (PBL) for professionals with backgrounds in public health, fire/emergency medical services (EMS), law enforcement, emergency management, and hospital administration. The curriculum provided opportunities for professionals from different disciplines to meet and learn the priorities and resources of partner agencies. In course evaluations, participants rated the training highly and found it applicable to their work and a good use of time and training resources. PBL techniques were successful in fostering cross-agency communication, thereby showing promise as an effective training method for meeting local and national emergency preparedness objectives.

Evaluation of an online bioterrorism continuing medical education course

INTRODUCTION

Much of the international community has an increased awareness of potential biologic, chemical, and nuclear threats and the need for physicians to rapidly acquire new knowledge and skills in order to protect the public's health. The present study evaluated the educational effectiveness of an online bioterrorism continuing medical education (CME) activity designed to address clinical issues involving suspected bioterrorism and reporting procedures in the United States.

METHODS

This was a retrospective survey of physicians who had completed an online CME activity on bioterrorism compared with a nonparticipant group who had completed at least 1 unrelated online CME course from the same medical school Web site and were matched on similar characteristics. An online survey instrument was developed to assess clinical and systems knowledge and confidence in recognition of illnesses associated with a potential bioterrorism attack. A power calculation indicated that a sample size of 100 (50 in each group) would achieve 90% power to detect a 10% to 15% difference in test scores between the two groups.

RESULTS

Compared with nonparticipant physicians, participants correctly diagnosed anthrax (p = .01) and viral exanthem (p = .01), but not smallpox, more frequently than nonparticipants. Participants knew more frequently than nonparticipants who to contact regarding a potential bioterrorism event (p = .03) Participants were more confident than nonparticipants about finding information to guide diagnoses of patients with biologic exposure (p = .01), chemical exposure (p = .02), and radiation exposure (p = .04).

DISCUSSION

An online bioterrorism course shows promise as an educational intervention in preparing physicians to better diagnose emerging rare infections, including those that may be associated with a bioterrorist event, in increasing confidence in diagnosing these infections, and in reporting of such infections for practicing physicians.

Hospital Response to Acute-Onset Disasters: The State of the Science in 2005

The level of emergency preparedness in US hospitals is a concern in light of the steady threat of natural disasters, transportation and industrial accidents, and the possibility of terror attack resulting in mass casualties. The science of hospital emergency preparedness is in an early stage of development. For research to logically expand knowledge, an accurate assessment--or examination of the state of the science--is conducted to determine the current state of knowledge, gaps in knowledge, and opportunities for future research. Milsten reviewed the literature on hospital response to acute-onset disasters from 1977 to 1999. His review of 107 articles contains research studies, case studies,and lessons learned pieces largely published in the medical literature.Milsten's analysis provides a substantial starting point. This article examines Milsten's review, identifies articles that have been published that add to this knowledge base, and identifies additional phenomena of interest.

The challenges of deliberate chemical/biological attack

Major incident plans in many countries have recently been updated to address the issues surrounding the deliberate release of chemical and biological agents. Despite this, many 'front line' doctors who would be responsible for treating victims of such incidents are poorly integrated into the plans. This article examines some of the challenges that face clinicians in the pre-hospital and hospital phases of a deliberate release incident.