Responding to a bioterrorist attack: environmental investigation of anthrax in New Jersey

Comparison and evaluation of a high volume air sampling system for the collection of Clostridioides difficile endospore aerosol in health care environments

BACKGROUND

Environmental contamination of patient rooms and adjacent areas with C. difficile spores is a recognized transmission risk. Previous studies have shown that spores are aerosolized during patient care. These spores can remain airborne for extended periods and may contaminate distant surfaces. High-volume air sampling equipment allows for the collection of a large volume of air and was evaluated in the collection of C. difficile aerosol.

METHOD

Air samplers evaluated in this research included the DFU-1000, XMX/2L-MIL, Biocapture-650, and a MB2. Aerosols of C. difficile were generated in a 5-m³ chamber and each air sampler sampled in the aerosol test chamber simultaneously with referee air samplers.

RESULTS

The DFU-1000 achieved the highest efficiency of the 4 air samplers (P = .0145) with a mean efficiency of 38.60%. The relative efficiencies of the Biocapture-650, XMX/2L-MIL, and MB2 were 28.16%, 10.51%, and 3.05%, respectively.

DISCUSSION/CONCLUSIONS

This study demonstrated high variation based on the sampling method employed. Based on the results of these studies, high-volume air samplers may be effectively applied to sample for airborne C. difficile in health care environments. The high sampling flow rate of the DFU-1000 would allow for the complete sampling of a patient room-sized volume in less than 1 hour.

Considerations for estimating microbial environmental data concentrations collected from a field setting

In the event of an indoor release of an environmentally persistent microbial pathogen such as Bacillus anthracis, the potential for human exposure will be considered when remedial decisions are made. Microbial site characterization and clearance sampling data collected in the field might be used to estimate exposure. However, there are many challenges associated with estimating environmental concentrations of B. anthracis or other spore-forming organisms after such an event before being able to estimate exposure. These challenges include: (1) collecting environmental field samples that are adequate for the intended purpose, (2) conducting laboratory analyses and selecting the reporting format needed for the laboratory data, and (3) analyzing and interpreting the data using appropriate statistical techniques. This paper summarizes some key challenges faced in collecting, analyzing, and interpreting microbial field data from a contaminated site. Although the paper was written with considerations for B. anthracis contamination, it may also be applicable to other bacterial agents. It explores the implications and limitations of using field data for determining environmental concentrations both before and after decontamination. Several findings were of interest. First, to date, the only validated surface/sampling device combinations are swabs and sponge-sticks on stainless steel surfaces, thus limiting availability of quantitative analytical results which could be used for statistical analysis. Second, agreement needs to be reached with the analytical laboratory on the definition of the countable range and on reporting of data below the limit of quantitation. Finally, the distribution of the microbial field data and statistical methods needed for a particular data set could vary depending on these data that were collected, and guidance is needed on appropriate statistical software for handling microbial data. Further, research is needed to develop better methods to estimate human exposure from pathogens using environmental data collected from a field setting.

Effect of Surface Sampling and Recovery of Viruses and Non-Spore-Forming Bacteria on a Quantitative Microbial Risk Assessment Model for Fomites

Quantitative microbial risk assessment (QMRA) is a powerful decision analytics tool, yet it faces challenges when modeling health risks for the indoor environment. One limitation is uncertainty in fomite recovery for evaluating the efficiency of decontamination. Addressing this data gap has become more important as a result of response and recovery from a potential malicious pathogen release. To develop more accurate QMRA models, recovery efficiency from non-porous fomites (aluminum, ceramic, glass, plastic, steel, and wood laminate) was investigated. Fomite material, surface area (10, 100, and 900 cm(2)), recovery tool (swabs and wipes), initial concentration on the fomites and eluent (polysorbate 80, trypticase soy broth, and beef extract) were evaluated in this research. Recovery was shown to be optimized using polysorbate 80, sampling with wipes, and sampling a surface area of 10-100 cm(2). The QMRA model demonstrated, through a relative risk comparison, the need for recovery efficiency to be used in these models to prevent underestimated risks.

False-negative rate, limit of detection and recovery efficiency performance of a validated macrofoam-swab sampling method for low surface concentrations of Bacillus anthracis Sterne and Bacillus atrophaeus spores

AIMS

We sought to evaluate the effects of Bacillus species, low surface concentrations, and surface material on recovery efficiency (RE), false-negative rate (FNR) and limit of detection for recovering Bacillus spores using a validated macrofoam-swab sampling procedure.

METHODS AND RESULTS

The performance of a macrofoam-swab sampling method was evaluated using Bacillus anthracis Sterne (BAS) and Bacillus atrophaeus Nakamura (BG) spores applied at nine low target surface concentrations (2 to 500 CFU per plate or coupon) to positive-control plates and test coupons (25·8064 cm(2) ) of four surface materials (glass, stainless steel, vinyl tile and plastic). The Bacillus species and surface material had statistically significant effects on RE, but surface concentration did not. Mean REs were the lowest for vinyl tile (50·8% with BAS and 40·2% with BG) and the highest for glass (92·8% with BAS and 71·4% with BG). FNR values (which ranged from 0 to 0·833 for BAS and from 0 to 0·806 for BG) increased as surface concentration decreased in the range tested. Surface material also had a statistically significant effect on FNR, with FNR the lowest for glass and highest for vinyl tile. Finally, FNR tended to be higher for BG than for BAS at lower surface concentrations, especially for glass.

CONCLUSIONS

Concentration and surface material had significant effects on FNR, with Bacillus species having a small effect. Species and surface material had significant effects on RE, with surface concentration having a nonsignificant effect.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results provide valuable information on the performance of the macrofoam-swab method for low surface concentrations of Bacillus spores, which can be adapted to assess the likelihood that there is no contamination when all macrofoam-swab samples fail to detect B. anthracis.

Responding to biological incidents--what are the current issues in remediation of the contaminated environment?

Since 2000 there have been a number of biological incidents resulting in environmental contamination with Bacillus anthracis, the causative agent of anthrax. These incidents include the US anthrax attacks in 2001, the US and UK drumming incidents in 2006-2008 and more recently, anthrax contamination of heroin in 2009/2010 and 2012/2013. Remediation techniques used to return environments to normal have varied between incidents, with different decontamination technologies being employed. Many factors need to be considered before a remediation strategy or recovery option can be implemented, including; cost, time (length of application), public perception of risk, and sampling strategies (and results) to name a few. These incidents have demonstrated that consolidated guidance for remediating biologically contaminated environments in the aftermath of a biological incident was required. The UK Recovery Handbook for Biological Incidents (UKRHBI) is a project led by Public Health England (PHE), formerly the Health Protection Agency (HPA) to provide guidance and advice on how to remediate the environment following a biological incident or outbreak of infection, and is expected to be published in 2015.

Evaluation of surface sampling for Bacillus spores using commercially available cleaning robots

Five commercially available domestic cleaning robots were evaluated on their effectiveness for sampling aerosol-deposited Bacillus atrophaeus spores on different indoor material surfaces. The five robots tested include three vacuum types (R1, R2, and R3), one wet wipe (R4), and one wet vacuum (R5). Tests were conducted on two different surface types (carpet and laminate) with 10(6) colony forming units of B. atrophaeus spores deposited per coupon (35.5 cm × 35.5 cm). Spores were deposited on the center surface (30.5 × 30.5 cm) of the coupon's total surface area (71.5 × 71.5 cm), and the surfaces were sampled with an individual robot in an isolation chamber. Chamber air was sampled using a biofilter sampler to determine the potential for resuspension of spores during sampling. Robot test results were compared to currently used surface sampling methods (vacuum sock for carpet and sponge wipe for laminate). The test results showed that the average sampling efficacies for R1, R2, and R3 on carpet were 26, 162, and 92% of vacuum sock sampling efficacy, respectively. On laminate, R1, R2, R3, R4, and R5 average sampling efficacies were 8, 11, 2, 62, and 32% of sponge wipe sampling efficacy, respectively. We conclude that some robotic cleaners were as efficacious as the currently used surface sampling methods for B. atrophaeus spores on these surfaces.

False-negative rate and recovery efficiency performance of a validated sponge wipe sampling method

Recovery of spores from environmental surfaces varies due to sampling and analysis methods, spore size and characteristics, surface materials, and environmental conditions. Tests were performed to evaluate a new, validated sponge wipe method using Bacillus atrophaeus spores. Testing evaluated the effects of spore concentration and surface material on recovery efficiency (RE), false-negative rate (FNR), limit of detection (LOD), and their uncertainties. Ceramic tile and stainless steel had the highest mean RE values (48.9 and 48.1%, respectively). Faux leather, vinyl tile, and painted wood had mean RE values of 30.3, 25.6, and 25.5, respectively, while plastic had the lowest mean RE (9.8%). Results show roughly linear dependences of RE and FNR on surface roughness, with smoother surfaces resulting in higher mean REs and lower FNRs. REs were not influenced by the low spore concentrations tested (3.10 × 10(-3) to 1.86 CFU/cm(2)). Stainless steel had the lowest mean FNR (0.123), and plastic had the highest mean FNR (0.479). The LOD(90) (≥1 CFU detected 90% of the time) varied with surface material, from 0.015 CFU/cm(2) on stainless steel up to 0.039 on plastic. It may be possible to improve sampling results by considering surface roughness in selecting sampling locations and interpreting spore recovery data. Further, FNR values (calculated as a function of concentration and surface material) can be used presampling to calculate the numbers of samples for statistical sampling plans with desired performance and postsampling to calculate the confidence in characterization and clearance decisions.

National validation study of a swab protocol for the recovery of Bacillus anthracis spores from surfaces

Twelve Laboratory Response Network (LRN) affiliated laboratories participated in a validation study of a macrofoam swab protocol for the recovery, detection, and quantification of viable B. anthracis (BA) Sterne spores from steel surfaces. CDC personnel inoculated steel coupons (26cm(2)) with 1-4 log(10) BA spores and recovered them by sampling with pre-moistened macrofoam swabs. Phase 1 (P1) of the study evaluated swabs containing BA only, while dust and background organisms were added to swabs in Phase 2 (P2) to mimic environmental conditions. Laboratories processed swabs and enumerated spores by culturing eluted swab suspensions and counting colonies with morphology consistent with BA. Processed swabs were placed in enrichment broth, incubated 24h, and cultured by streaking for isolation. Real-time PCR was performed on selected colonies from P2 samples to confirm the identity of BA. Mean percent recovery (%R) of spores from the surface ranged from 15.8 to 31.0% (P1) and from 27.9 to 55.0% (P2). The highest mean percent recovery was 31.0% (sd 10.9%) for P1 (4 log(10) inoculum) and 55.0% (sd 27.6%) for P2 (1 log(10) inoculum). The overall %R was higher for P2 (44.6%) than P1 (24.1%), but the overall reproducibility (between-lab variability) was lower in P2 than in P1 (25.0 vs 16.5%CV, respectively). The overall precision (within-lab variability) was close to identical for P1 and P2 (44.0 and 44.1, respectively), but varied greatly between inoculum levels. The protocol demonstrated linearity in %R over the three inoculum levels and is able to detect between 26 and 5x10(6)spores/26cm(2). Sensitivity as determined by culture was >98.3% for both phases and all inocula, suggesting that the culture method maintains sensitivity in the presence of contaminants. The enrichment broth method alone was less sensitive for sampled swabs (66.4%) during P2, suggesting that the presence of background organisms inhibited growth or isolation of BA from the broth. The addition of real-time PCR testing to the assay increased specificity from >85.4% to >95.0% in P2. Although the precision was low at the 1 log(10) inoculum level in both phases (59.0 and 50.2%), this swab processing protocol, was sensitive, specific, precise, and reproducible at 2-4 log(10)/26cm(2) spore concentrations.

Epidemics of panic during a bioterrorist attack – A mathematical model

A bioterrorist attacks usually cause epidemics of panic in a targeted population. We have presented epidemiologic aspect of this phenomenon as a three-component model – host, information on an attack and social network. We have proposed a mathematical model of panic and counter-measures as the function of time in a population exposed to a bioterrorist attack. The model comprises ordinary differential equations and graphically presented combinations of the equations parameters. Clinically, we have presented a model through a sequence of psychic conditions and disorders initiated by an act of bioterrorism. This model might be helpful for an attacked community to timely and properly apply counter-measures and to minimize human mental suffering during a bioterrorist attack.

Public health investigation after the discovery of ricin in a South Carolina postal facility

OBJECTIVES

In October 2003, a package containing ricin and a note threatening to poison water supplies was discovered in a South Carolina postal facility, becoming the first potential chemical terrorism event involving ricin in the United States. We examined the comprehensive public health investigation that followed and discuss the lessons learned from it.

METHODS

An investigation consisting primarily of environmental sampling for ricin contamination, performance of health assessments on affected personnel, and local, regional, and national surveillance for ricin-associated illness.

RESULTS

Laboratory analysis of 75 environmental sampling specimens revealed no ricin contamination. Health assessments of 36 affected employees were completed. Local surveillance initially identified 3 suspected cases, and national surveillance identified 399 outliers during the 2-week period after the incident. No confirmed cases of ricin-associated illness were identified.

CONCLUSIONS

A multifaceted and multidisciplinary approach is required for an effective public health response to a chemical threat such as ricin. The results of all of the described activities were used to determine that the facility was safe to reopen and that no public health threat existed.

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.

Evaluation of a macrofoam swab protocol for the recovery of Bacillus anthracis spores from a steel surface

A protocol to recover Bacillus anthracis spores from a steel surface using macrofoam swabs was evaluated for its accuracy, precision, reproducibility, and limit of detection. Macrofoam swabs recovered 31.7 to 49.1% of spores from 10-cm2 steel surfaces with a < or =32.7% coefficient of variation in sampling precision and reproducibility for inocula of > or =38 spores.