Anthrax bioterrorism: lessons learned and future directions

Strengthening the United Nations Secretary-General's Mechanism to an alleged use of bioweapons through a quality-assured laboratory response

The cascade of innovations in biotechnology opens new pathways for biological warfare. The international laboratory network being developed under the UN Secretary-General’s Mechanism could provide vital evidence in case of an alleged biological attack.

Impact of COVID-19 Pandemic on Laboratory Utilization

Background

Coronavirus Disease 2019 (COVID-19) was formally characterized as a pandemic on March 11, 2020. Since that time, the COVID-19 pandemic has led to unprecedented demand for healthcare resources. The purpose of this study was to identify changes in laboratory test utilization in the setting of increasing local incidence of COVID-19.

Methods

We performed a retrospective assessment of laboratory test order and specimen container utilization at a single, urban tertiary care medical center. Data were extracted from the laboratory information system database over a 10-week period, spanning the primordial inflection of COVID-19 incidence in our region. Total testing volumes were calculated during the first and last two-weeks of the observation period and used as reference points to examine the absolute and relative differences in test order volume between the pre-pandemic and COVID-19 surge periods.

Results

Between February 2, 2020 and April 11, 2020, there were 873,397 tests ordered and final verified. The in-house SARS-CoV-2 PCR positivity rate for admitted patients in the last week of the observation period was 30.8%. Significant increases in workload were observed in the send-out laboratory section and for COVID-19 diagnosis (PCR) and management-related testing. Otherwise, there was a net decrease in overall demand across nearly all laboratory sections. Increases in testing were noted for tests related to COVID-19 management. Viral transport media and citrated blue top containers demonstrated increases in utilization.

Conclusion

Increasing local incidence of COVID-19 had a profound impact on laboratory operations. While volume increases were seen for laboratory tests related to COVID-19 diagnostics and management, including some with limited evidence to support their use, overall testing volumes decreased substantially. During events such as COVID-19, monitoring of such patterns can help inform laboratory management, staffing, and test stewardship recommendations for managing resource and supply availability.

Global Characteristics of Chemical, Biological, and Radiological Poison Use in Terrorist Attacks

BACKGROUND

Chemical, biological, and radiological (CBR) terrorism continues to be a global threat. Studies examining global and historical toxicological characteristics of CBR terrorism are lacking.

METHODS

Global Terrorism Database (GTD) and RAND Database of Worldwide Terrorism Incidents (RDWTI) were searched for CBR terrorist attacks from 1970 through 2017. Events fulfilling terrorism and poisoning definitions were included. Variables of event date and location, event realization, poisonous agent type, poisoning agent, exposure route, targets, connected events, additional means of harm, disguise methods, poisonings, and casualties were analyzed along with time trends and data gaps.

RESULTS

A total of 446 events of CBR terrorism were included from all world regions. A trend for increased number of events over time was observed (R2 = 0.727; coefficient = 0.511). In these attacks, 4,093 people lost their lives and 31,903 were injured. Chemicals were the most commonly used type of poison (63.5%). The most commonly used poisonous agents were acids (12.3%), chlorine or chlorine compounds (11.2%), riot control agents (10.8%), cyanides (5.8%), and Bacillus anthracis (4.9%). Occurrence of poisoning was confirmed in 208 events (46.6%). Most common exposure routes were skin, mucosa, or eye (57.2%) and inhalation (47.5%). Poison was delivered with additional means of harm in 151 events (33.9%) and in a disguised way in 214 events (48.0%), respectively.

CONCLUSIONS

This study showed that CBR terrorism is an on-going and increasingly recorded global threat involving diverse groups of poisons with additional harmful mechanisms and disguise. Industrial chemicals were used in chemical attacks. Vigilance and preparedness are needed for future CBR threats.

Zoonotic Infections and Biowarfare Agents in Critical Care: Anthrax, Plague, and Tularemia

Bacterial zoonotic infections are rare in developed countries in the twenty-first century but may cause major morbidity and mortality in developing regions of the world. In addition, their potential use as biological weapons makes early recognition and effective empiric therapy important for the critical care practitioner. Anthrax, plague, and tularemia share overlapping presenting syndromes, including fulminant respiratory infections and less severe but still highly morbid lymphocutaneous infections. Although all three may be transmitted as infectious aerosols, only plague has a risk of direct human-to-human transmission. Diagnostic testing will require special precautions for laboratory staff and most often involvement of regional and national reference laboratories. Empiric therapy with aminoglycosides may be life-saving for plague and tularemia, while the treatment of anthrax is complex and varies depending on the site of infection. In outbreaks or for post-exposure prophylaxis, treatment with doxycycline or a fluoroquinolone is recommended for all three diseases.

Historical Data Analysis of Hospital Discharges Related to the Amerithrax Attack in Florida

Interrupted time-series analysis (ITSA) can be used to identify, quantify, and evaluate the magnitude and direction of an event on the basis of time-series data. This study evaluates the impact of the bioterrorist anthrax attacks ("Amerithrax") on hospital inpatient discharges in the metropolitan statistical area of Palm Beach, Broward, and Miami-Dade counties in the fourth quarter of 2001. Three statistical methods-standardized incidence ratio (SIR), segmented regression, and an autoregressive integrated moving average (ARIMA)-were used to determine whether Amerithrax influenced inpatient utilization. The SIR found a non-statistically significant 2 percent decrease in hospital discharges. Although the segmented regression test found a slight increase in the discharge rate during the fourth quarter, it was also not statistically significant; therefore, it could not be attributed to Amerithrax. Segmented regression diagnostics preparing for ARIMA indicated that the quarterly data time frame was not serially correlated and violated one of the assumptions for the use of the ARIMA method and therefore could not properly evaluate the impact on the time-series data. Lack of data granularity of the time frames hindered the successful evaluation of the impact by the three analytic methods. This study demonstrates that the granularity of the data points is as important as the number of data points in a time series. ITSA is important for the ability to evaluate the impact that any hazard may have on inpatient utilization. Knowledge of hospital utilization patterns during disasters offer healthcare and civic professionals valuable information to plan, respond, mitigate, and evaluate any outcomes stemming from biothreats.

Historical evolution of human anthrax from occupational disease to potentially global threat as bioweapon

PURPOSE

Anthrax is caused by Bacillus anthracis, which can naturally infect livestock, wildlife and occupationally exposed humans. However, for its resistance due to spore formation, ease of dissemination, persistence in the environment and high virulence, B. anthracis has been considered the most serious bioterrorism agent for a long time. During the last century anthrax evolved from limited natural disease to potentially global threat if used as bioweapon. Several factors may mitigate the consequences of an anthrax attack, including 1. the capability to promptly recognize and manage the illness and its public health consequences; 2. the limitation of secondary contamination risk through an appropriate decontamination; and 3. the evolution of genotyping methods (for microbes characterization at high resolution level) that can influence the course and/or focus of investigations, impacting the response of the government to an attack.

METHODS

A PubMed search has been done using the key words “bioterrorism anthrax”.

RESULTS

Over one thousand papers have been screened and the most significant examined to present a comprehensive literature review in order to discuss the current knowledge and strategies in preparedness for a possible deliberate release of B. anthracis spores and to indicate the most current and complete documents in which to deepen.

CONCLUSIONS

The comprehensive analysis of the two most relevant unnatural anthrax release events, Sverdlovsk in the former Soviet Union (1979) and the contaminated letters in the USA (2001), shows that inhalational anthrax may easily and cheaply be spread resulting in serious consequences. The damage caused by an anthrax attack can be limited if public health organization, first responders, researchers and investigators will be able to promptly manage anthrax cases and use new technologies for decontamination methods and in forensic microbiology.

Anthrax toxin lethal factor domain 3 is highly mobile and responsive to ligand binding

The secreted anthrax toxin consists of three components: the protective antigen (PA), edema factor (EF) and lethal factor (LF). LF, a zinc metalloproteinase, compromises the host immune system primarily by targeting mitogen-activated protein kinase kinases in macrophages. Peptide substrates and small-molecule inhibitors bind LF in the space between domains 3 and 4 of the hydrolase. Domain 3 is attached on a hinge to domain 2 via residues Ile300 and Pro385, and can move through an angular arc of greater than 35° in response to the binding of different ligands. Here, multiple LF structures including five new complexes with co-crystallized inhibitors are compared and three frequently populated LF conformational states termed `bioactive', `open' and `tight' are identified. The bioactive position is observed with large substrate peptides and leaves all peptide-recognition subsites open and accessible. The tight state is seen in unliganded and small-molecule complex structures. In this state, domain 3 is clamped over certain substrate subsites, blocking access. The open position appears to be an intermediate state between these extremes and is observed owing to steric constraints imposed by specific bound ligands. The tight conformation may be the lowest-energy conformation among the reported structures, as it is the position observed with no bound ligand, while the open and bioactive conformations are likely to be ligand-induced.

Origin of the dengue fever mosquito, Aedes aegypti, in California

Dengue fever is among the most widespread vector-borne infectious diseases. The primary vector of dengue is the Aedes aegypti mosquito. Ae. aegypti is prevalent in the tropics and sub-tropics and is closely associated with human habitats outside its native range of Africa. While long established in the southeastern United States of America where dengue is re-emerging, breeding populations have never been reported from California until the summer of 2013. Using 12 highly variable microsatellite loci and a database of reference populations, we have determined that the likely source of the California introduction is the southeastern United States, ruling out introductions from abroad, from the geographically closer Arizona or northern Mexico populations, or an accidental release from a research laboratory. The power to identify the origin of new introductions of invasive vectors of human disease relies heavily on the availability of a panel of reference populations. Our work demonstrates the importance of generating extensive reference databases of genetically fingerprinted human-disease vector populations to aid public health efforts to prevent the introduction and spread of vector-borne diseases.

Dengue fever is a vector-borne disease that has dramatically increased in frequency and severity in recent decades, affecting over half of the world's population. The primary vector of dengue is Aedes aegypti. Breeding populations of this mosquito were reported for the first time in California in summer 2013, and the origin of these populations was unknown. We genotyped Ae. aegypti from California and compared their genetic composition and diversity against reference populations from Asia and the Americas, and with laboratory strains, to identify the source of this introduction. We identified the southeastern United States of America as the likeliest origin of California Ae. aegypti. This information will aid the design of containment, control, and elimination strategies to prevent the establishment of a permanent breeding vector population in the state. Note that the resolution achieved in tracking the origin of new disease-vector introductions is proportional to the completeness of the reference dataset. Our analysis was delayed to gather further data on regions close to California and would otherwise have been completed within a week. This work highlights the importance of having an extended dataset of human disease-vector genotypes in place prior to the occurrence of invasions that compromise public health.

Public health emergencies and responses: what are they, how long do they last, and how many staff does your agency need?

Responding to outbreaks is one of the most routine yet most important functions of a public health agency. However, some outbreaks are bigger, more visible, or more complex than others, prompting discussion about when an "outbreak" becomes a "public health emergency." When a public health emergency is identified, resources (eg, funding, staff, space) may need to be redirected from core public health programs to contribute to the public health emergency response. The need to sustain critical public health functions while preparing for public health emergency responses raises a series of operational and resource management questions, including when a public health emergency begins and ends, why additional resources are needed, how long an organization should expect staff to be redirected, and how many staff (or what proportion of the agency's staff ) an organization should anticipate will be needed to conduct a public health emergency response. This article addresses these questions from a national perspective by reviewing events for which the Centers for Disease Control and Prevention redirected staff from core public health functions to respond to a series of public health emergencies. We defined "public health emergency" in both operational and public health terms and found that on average each emergency response lasted approximately 4 months and used approximately 9.5% of our workforce. We also provide reasons why public health agencies should consider the impact of redirecting resources when preparing for public health emergencies.

Detection of non-PCR amplified S. enteritidis genomic DNA from food matrices using a gold-nanoparticle DNA biosensor: a proof-of-concept study

Bacterial pathogens pose an increasing food safety and bioterrorism concern. Current DNA detection methods utilizing sensitive nanotechnology and biosensors have shown excellent detection, but require expensive and time-consuming polymerase chain reaction (PCR) to amplify DNA targets; thus, a faster, more economical method is still essential. In this proof-of-concept study, we investigated the ability of a gold nanoparticle-DNA (AuNP-DNA) biosensor to detect non-PCR amplified genomic Salmonella enterica serovar Enteritidis (S. enteritidis) DNA, from pure or mixed bacterial culture and spiked liquid matrices. Non-PCR amplified DNA was hybridized into sandwich-like structures (magnetic nanoparticles/DNA/AuNPs) and analyzed through detection of gold voltammetric peaks using differential pulse voltammetry. Our preliminary data indicate that non-PCR amplified genomic DNA can be detected at a concentration as low as 100 ng/mL from bacterial cultures and spiked liquid matrices, similar to reported PCR amplified detection levels. These findings also suggest that AuNP-DNA biosensors are a first step towards a viable detection method of bacterial pathogens, in particular, for resource-limited settings, such as field-based or economically limited conditions. Future efforts will focus on further optimization of the DNA extraction method and AuNP-biosensors, to increase sensitivity at lower DNA target concentrations from food matrices comparable to PCR amplified DNA detection strategies.

Public health surveillance and infectious disease detection

Emerging infectious diseases, such as HIV/AIDS, SARS, and pandemic influenza, and the anthrax attacks of 2001, have demonstrated that we remain vulnerable to health threats caused by infectious diseases. The importance of strengthening global public health surveillance to provide early warning has been the primary recommendation of expert groups for at least the past 2 decades. However, despite improvements in the past decade, public health surveillance capabilities remain limited and fragmented, with uneven global coverage. Recent initiatives provide hope of addressing this issue, and new technological and conceptual advances could, for the first time, place capability for global surveillance within reach. Such advances include the revised International Health Regulations (IHR 2005) and the use of new data sources and methods to improve global coverage, sensitivity, and timeliness, which show promise for providing capabilities to extend and complement the existing infrastructure. One example is syndromic surveillance, using nontraditional and often automated data sources. Over the past 20 years, other initiatives, including ProMED-mail, GPHIN, and HealthMap, have demonstrated new mechanisms for acquiring surveillance data. In 2009 the U.S. Agency for International Development (USAID) began the Emerging Pandemic Threats (EPT) program, which includes the PREDICT project, to build global capacity for surveillance of novel infections that have pandemic potential (originating in wildlife and at the animal-human interface) and to develop a framework for risk assessment. Improved understanding of factors driving infectious disease emergence and new technological capabilities in modeling, diagnostics and pathogen identification, and communications, such as using the increasing global coverage of cellphones for public health surveillance, can further enhance global surveillance.

Characterizing bioaerosol risk from environmental sampling

In the aftermath of a release of microbiological agents, environmental sampling must be conducted to characterize the release sufficiently so that mathematical models can then be used to predict the subsequent dispersion and human health risks. Because both the dose-response and environmental transport of aerosolized microbiological agents are functions of the effective aerodynamic diameter of the particles, environmental assessments should consider not only the total amount of agents but also the size distributions of the aerosolized particles. However, typical surface sampling cannot readily distinguish among different size particles. This study evaluates different approaches to estimating risk from measurements of microorganisms deposited on surfaces after an aerosol release. For various combinations of sampling surfaces, size fractions, HVAC operating conditions, size distributions of release spores, uncertainties in surface measurements, and the accuracy of model predictions are tested in order to assess how much detail can realistically be identified from surface sampling results. The recommended modeling and sampling scheme is one choosing 3, 5, and 10 μm diameter particles as identification targets and taking samples from untracked floor, wall, and the HVAC filter. This scheme provides reasonably accurate, but somewhat conservative, estimates of risk across a range of different scenarios. Performance of the recommended sampling scheme is tested by using data from a large-scale field test as a case study. Sample sizes of 10-25 in each homogeneously mixed environmental compartment are sufficient to develop order of magnitude estimates of risk. Larger sample sizes have little benefit unless uncertainties in sample recoveries can be reduced.

Investigations of selected historically important syndromic outbreaks: impact and lessons learned for public health preparedness and response

Public health readiness has increased at all jurisdictional levels because of increased sensitivity to threats. Since 2001, with billions of dollars invested to bolster the public health system's capacity, the public expects that public health will identify the etiology of and respond to events more rapidly. However, when etiologies are unknown at the onset of the investigation but interventions must be implemented, public health practitioners must benefit from past investigations' lessons to strengthen preparedness for emerging threats. We have identified such potentially actionable lessons learned from historically important public health events that occurred primarily as syndromes for which the etiological agent initially was unknown. Ongoing analysis of investigations can advance our capability to recognize and investigate syndromes and other problems and implement the most appropriate interventions.

Novel broad-spectrum bis-(imidazolinylindole) derivatives with potent antibacterial activities against antibiotic-resistant strains

Given the limited number of structural classes of clinically available antimicrobial drugs, the discovery of antibacterials with novel chemical scaffolds is an important strategy in the development of effective therapeutics for both naturally occurring and engineered resistant strains of pathogenic bacteria. In this study, several diarylamidine derivatives were evaluated for their ability to protect macrophages from cell death following infection with Bacillus anthracis, a gram-positive spore-forming bacterium. Four bis-(imidazolinylindole) compounds were identified with potent antibacterial activity as measured by the protection of macrophages and by the inhibition of bacterial growth in vitro. These compounds were effective against a broad range of gram-positive and gram-negative bacterial species, including several antibiotic-resistant strains. Minor structural variations among the four compounds correlated with differences in their effects on bacterial macromolecular synthesis and mechanisms of resistance. In vivo studies revealed protection by two of the compounds of mice lethally infected with B. anthracis, Staphylococcus aureus, or Yersinia pestis. Taken together, these results indicate that the bis-(imidazolinylindole) compounds represent a new chemotype for the development of therapeutics for both gram-positive and gram-negative bacterial species as well as against antibiotic-resistant infections.

Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases

Patients with highly infectious diseases require safe, secure, high-quality medical care with high-level infection control, which may be most effectively delivered by specially trained staff in the setting of a high-level isolation unit (HLIU). The European Network of Infectious Diseases is a European Commission co-funded network of experts in the management of highly infectious diseases from national (or regional) centres designated for the care of this patient population. Participants took a consensus-based approach to develop a framework for the design and operation of HLIUs in Europe, covering clinical care provision, diagnostic services, transport, health and safety, and essential design and construction features, to support planning by health authorities for the safe and effective management of highly infectious diseases and preparedness for infectious disease emergencies in Europe.

Promoting Community Preparedness: Lessons Learned From the Implementation of a Chemical Disaster Tabletop Exercise

Health educators are frequently called on to facilitate community preparedness planning. One planning tool is community-wide tabletop exercises. Tabletop exercises can improve the preparedness of public health system agencies to address disaster by bringing together individuals representing organizations with different roles and perspectives in specific disasters. Thus, they have the opportunity to identify each other’s roles, capabilities, and limitations and to problem-solve about how to address the gaps and overlaps in a low-threat collaborative setting. In 2005, the North Carolina Office of Public Health Preparedness and Response developed a series of exercises to test the preparedness for chemical disasters in a metropolitan region in the southeastern United States. A tabletop exercise allowed agency heads to meet in an environment promoting inter- and intraagency public—private coordination and cooperation. The evaluation results reported here suggest ways in which any tabletop exercise can be enhanced through recruitment, planning, and implementation.

Facilitation of risk communication during the anthrax attacks of 2001: the organizational backstory

The anthrax attacks of 2001 created risk communication problems that cannot be fully understood without appreciating the dynamics among organizations. Case studies of communication in New Jersey, consisting of interviews with a range of participants, found that existing organizational and professional networks facilitated trust among decisionmakers. This interpersonal trust improved communication among agencies and thereby risk communication with the public. For example, "white powder scares" were a problem even in places without contamination. Professionals' trust in each other was vital for responding productively. Conversely, organizational challenges, including conflict among agencies, hindered communication with key audiences. Although centralization and increased control are often seen as the remedy for communicative confusion, they also can quash the improvisational responses needed during crises.

The Bacillus cereus group: novel aspects of population structure and genome dynamics

AIMS

To provide new insights into the population and genomic structure of the Bacillus cereus group of bacteria.

METHODS AND RESULTS

The genetic relatedness among B. cereus group strains was assessed by multilocus sequence typing (MLST) using an optimized scheme based on seven chromosomal housekeeping genes. A set of 48 strains from different clinical sources was included, and six clonal complexes containing several genetically similar isolates from unrelated patients were identified. Interestingly, several clonal groups contained strains that were isolated from similar human sources. Furthermore, comparative whole genome sequence analysis of 16 strains led to the discovery of novel ubiquitous genome features of the B. cereus group, such as atypical group II introns, IStrons, and hitherto uncharacterized repeated elements.

CONCLUSIONS

The B. cereus group constitutes a coherent population unified by the presence of ubiquitous and specific genetic elements which do not show any pattern, either in their sequences or genomic locations, which allows to differentiate between the member species of the group. Nevertheless, the population is very dynamic, as particular lineages of clinical origin can evolve to form clonal complexes. At the genome level, the dynamic behaviour is indicated by the presence of numerous mobile and repeated elements.

SIGNIFICANCE AND IMPACT OF THE STUDY

The B. cereus group of bacteria comprises species that are of medical and economic importance. The MLST data, along with the primers and protocols used, will be available in a public, web-accessible database (http://mlstoslo.uio.no).

Automated Screening for Biological Weapons in Homeland Defense

Biological threat detection programs that collect air samples and monitor for large-scale release of biowarfare agents generate large numbers of samples that must be quickly and accurately screened for the presence of biological agents. An impediment to the rapid analysis of large numbers of environmental biological samples is that manual laboratory processes are time-consuming and require resources to maintain infrastructure, trained personnel, and adequate supplies of testing reagents. An ideal screening system would be capable of processing multiple samples rapidly, cost-effectively, and with minimal personnel. In the present study, we evaluated the Automated Biological Agent Testing System (ABATS) to explore the capability of automation to increase sample throughput, maximize system accuracy, and reduce the analysis costs associated with biological threat agent screening in environmental samples. This study demonstrates the utility of this concept and the potential of an automated system to address the growing environmental monitoring needs of the United States.

The bcr1 DNA repeat element is specific to the Bacillus cereus group and exhibits mobile element characteristics

Bacillus cereus strains ATCC 10987 and ATCC 14579 harbor an approximately 155-bp repeated element, bcr1, which is conserved in B. cereus, B. anthracis, B. thuringiensis, and B. mycoides but not in B. subtilis and B. licheniformis. In this study, we show by Southern blot hybridizations that bcr1 is present in all 54 B. cereus group strains tested but absent in 11 Bacillus strains outside the group, suggesting that bcr1 may be specific and ubiquitous to the B. cereus group. By comparative analysis of the complete genome sequences of B. cereus ATCC 10987, B. cereus ATCC 14579, and B. anthracis Ames, we show that bcr1 is exclusively present in the chromosome but absent from large plasmids carried by these strains and that the numbers of full-length bcr1 repeats for these strains are 79, 54, and 12, respectively. Numerous copies of partial bcr1 elements are also present in the three genomes (91, 128, and 53, respectively). Furthermore, the genomic localization of bcr1 is not conserved between strains with respect to chromosomal position or organization of gene neighbors, as only six full-length bcr1 loci are common to at least two of the three strains. However, the intergenic sequence surrounding a specific bcr1 repeat in one of the three strains is generally strongly conserved in the other two, even in loci where bcr1 is found exclusively in one strain. This finding indicates that bcr1 either has evolved by differential deletion from a very high number of repeats in a common ancestor to the B. cereus group or is moving around the chromosome. The identification of bcr1 repeats interrupting genes in B. cereus ATCC 10987 and ATCC 14579 and the presence of a flanking TTTAT motif in each end show that bcr1 exhibits features characteristic of a mobile element.

Biological agents with potential for misuse: a historical perspective and defensive measures

Biological and chemical agents capable of producing serious illness or mortality have been used in biowarfare from ancient times. Use of these agents has progressed from crude forms in early and middle ages, when snakes and infected cadavers were used as weapons in battles, to sophisticated preparations for use during and after the second World War. Cults and terrorist organizations have attempted the use of biological agents with an aim to immobilize populations or cause serious harm. The reasons for interest in these agents by individuals and organizations include relative ease of acquisition, potential for causing mass casualty or panic, modest financing requirement, availability of technology, and relative ease of delivery. The Centers for Disease Control and Prevention has classified Critical Biological Agents into three major categories. This classification was based on several criteria, which include severity of impact on human health, potential for delivery in a weapon, capacity to cause panic and special needs for development, and stockpiling of medication. Agents that could cause the greatest harm following deliberate use were placed in category A. Category B included agents capable of producing serious harm and significant mortality but of lower magnitude than category A agents. Category C included emerging pathogens that could be developed for mass dispersion in future and their potential as a major health threat. A brief description of the category A bioagents is included and the pathophysiology of two particularly prominent agents, namely anthrax and smallpox, is discussed in detail. The potential danger from biological agents and their ever increasing threat to human populations have created a need for developing technologies for their early detection, for developing treatment strategies, and for refinement of procedures to ensure survival of affected individuals so as to attain the ultimate goal of eliminating the threat from intentional use of these agents. International treaties limiting development and proliferation of weapons and continuing development of defense strategies and safe guards against agents of concern are important elements of plans for eliminating this threat.

Physician preparedness for bioterrorism recognition and response: a Utah-based needs assessment

The medical community accepts that they have a need to be prepared to recognize and respond to bioterrorism events. A needs assessment conducted among physicians throughout the state of Utah provided insights into their perceived training needs and preferred methods of learning. Physicians have many competing demands on their time and tailored educational offering can increase the intended audience's acceptance and learning.

Evaluating detection and diagnostic decision support systems for bioterrorism response

We evaluated the usefulness of detection systems and diagnostic decision support systems for bioterrorism response. We performed a systematic review by searching relevant databases (e.g., MEDLINE) and Web sites for reports of detection systems and diagnostic decision support systems that could be used during bioterrorism responses. We reviewed over 24,000 citations and identified 55 detection systems and 23 diagnostic decision support systems. Only 35 systems have been evaluated: 4 reported both sensitivity and specificity, 13 were compared to a reference standard, and 31 were evaluated for their timeliness. Most evaluations of detection systems and some evaluations of diagnostic systems for bioterrorism responses are critically deficient. Because false-positive and false-negative rates are unknown for most systems, decision making on the basis of these systems is seriously compromised. We describe a framework for the design of future evaluations of such systems.

Respiratory medical societies and the threat of bioterrorism

Respiratory medical societies throughout the world have an important role in helping governments to develop public policy to counter the threat of bioterrorism.

Surge capacity for response to bioterrorism in hospital clinical microbiology laboratories

Surge capacity is the ability to rapidly mobilize to meet an increased demand. While large amounts of federal funding have been allocated to public health laboratories, little federal funding has been allocated to hospital microbiology laboratories. There are concerns that hospital laboratories may have inadequate surge capacities to deal with a significant bioterrorism incident. A workflow analysis of a clinical microbiology laboratory that serves an urban medical center was performed to identify barriers to surge capacity in the setting of a bioterrorism event and to identify solutions to these problems. Barriers include a national shortage of trained medical technologists, the inability of clinical laboratories to deal with a dramatic increase in the number of blood cultures, a delay while manufacturers increase production of critical products and then transport and deliver these products to clinical laboratories, and a shortage of class II biological safety cabinets. Federal funding could remedy staffing shortages by making the salaries of medical technologists comparable to those of similarly educated health care professionals and by providing financial incentives for students to enroll in clinical laboratory science programs. Blood culture bottles, and possibly continuous-monitoring blood culture instruments, should be added to the national antibiotic stockpile. Federal support must ensure that companies that manufacture essential laboratory supplies are capable of rapidly scaling up production. Hospitals must provide increased numbers of biological safety cabinets and amounts of space dedicated to clinical microbiology laboratories. Laboratories should undertake limited cross-training of technologists, ensure that adequate packaging supplies are available, and be able to move to a 4-day blood culture protocol.