Application of a Risk Analysis Tool to Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Outbreak in Saudi Arabia.

The Grunow-Finke assessment tool (GFT) is an accepted scoring system for determining likelihood of an outbreak being unnatural in origin. Considering its high specificity but low sensitivity, a modified Grunow-Finke tool (mGFT) has been developed with improved sensitivity. The mGFT has been validated against some past disease outbreaks, but it has not been applied to ongoing outbreaks. This study is aimed to score the outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia using both the original GFT and mGFT. The publicly available data on human cases of MERS-CoV infections reported in Saudi Arabia (2012-2018) were sourced from the FluTrackers, World Health Organization, Saudi Ministry of Health, and published literature associated with MERS outbreaks investigations. The risk assessment of MERS-CoV in Saudi Arabia was analyzed using the original GFT and mGFT criteria, algorithms, and thresholds. The scoring points for each criterion were determined by three researchers to minimize the subjectivity. The results showed 40 points of total possible 54 points using the original GFT (likelihood: 74%), and 40 points of a total possible 60 points (likelihood: 67%) using the mGFT, both tools indicating a high likelihood that human MERS-CoV in Saudi Arabia is unnatural in origin. The findings simply flag unusual patterns in this outbreak, but do not prove unnatural etiology. Proof of bioattacks can only be obtained by law enforcement and intelligence agencies. This study demonstrated the value and flexibility of the mGFT in assessing and predicting the risk for an ongoing outbreak with simple criteria.

Anthrax Exposure, Belief in Exposure, and Postanthrax Symptoms Among Survivors of a Bioterrorist Attack on Capitol Hill.

BACKGROUND: Following chemical, biological, radiological, and nuclear disasters, medically unexplained symptoms have been observed among unexposed persons. OBJECTIVES: This study examined belief in exposure in relation to postdisaster symptoms in a volunteer sample of 137 congressional workers after the 2001 anthrax attacks on Capitol Hill. METHODS: Postdisaster symptoms, belief in exposure, and actual exposure status were obtained through structured diagnostic interviews and self-reported presence in offices officially designated as exposed through environmental sampling. Multivariate models were tested for associations of number of postdisaster symptoms with exposure and belief in exposure, controlling for sex and use of antibiotics. RESULTS: The sample was divided into 3 main subgroups: exposed, 41%; unexposed but believed they were exposed, 17%; and unexposed and did not believe that they were exposed, 42%. Nearly two-thirds (64%) of the volunteers reported experiencing symptoms after the anthrax attacks. Belief in anthrax exposure was significantly associated with the number of ear/nose/throat, musculoskeletal, and all physical symptoms. No significant associations were found between anthrax exposure and the number of postdisaster symptoms. CONCLUSIONS: Given the high incidence of these symptoms, these data suggest that even in the absence of physical injury or illness, there may be surges in health care utilization. (Disaster Med Public Health Preparedness. 2019;13:555-560).

An Evaluation of Situation Reports and Incident Notices: The DBPR/ESRB Experience.

OBJECTIVE: The main objective of this study is to review information within the situation reports (SITREPs) and incident notices (INs) prepared by the Division of Bioterrorism Preparedness and Response/Epidemiology Surveillance and Response Branch, (DBPR/ESRB), Centers for Disease Control and Prevention (CDC). The secondary objective is to evaluate accuracy and completeness of the information provided in these documents. METHODS: The authors reviewed all SITREPs/INs prepared by DBPR/ESRB from January 2007 to June 2009. Data were abstracted for variables related to the type of incidents, the type of CDC assistance requested, the geographic origin of the calls, and the organization reporting the event or requesting CDC assistance or both. In addition, variables were also created to assess the accuracy and completeness of reports for quality improvement analysis. RESULTS: The DBPR/ESRB prepared 77 SITREPs and 22 INs. Most of them were related to unknown white powders/suspicious packages or BioWatch Actionable Reports (78%). Most calls (79%), requesting CDC assistance or not, were domestic. Almost all calls requesting CDC assistance were for clinical and/or laboratory consultation and/or request for analysis of samples. Most of the calls requesting CDC assistance came from city, county, state, or federal government agencies and military organizations (82%). However, 14 of the analyzed documents (14.4%) were misclassified, that is, a SITREP was written when it should have been an IN or vice versa. The authors also noted the absence of some relevant information among some of the documents, for example, date/time of update. CONCLUSIONS: All of the issues/incidents reported in this article to which DBPR/ESRB responded were cause for legitimate concern. However, significant improvement can be made in the preparation of these reports by CDC staff to ensure efficient and effective response from CDC and its partners. Finally, local entities may wish to develop a similar documentation and reporting process to help manage significant incidents.

[Evaluation of the Number of Varicella Patients Estimated by Prescription Surveillance].

OBJECT: It is important to know the precise number of varicella patients infected for evaluation of routine immunization and anti-bioterrorism attack using smallpox. Prescription Surveillance (PS) has been providing the estimated number of varicella patients up to the present. However, the estimated number of varicella patients cannot be validated because to date there has been no other comparable precise method of estimation. Recently, all electronic medical claims nationwide (NDB) have been disclosed. In this paper, we compare the number of varicella patients estimated by PS with NDB data, and adjust the number estimated with PS, if necessary. METHOD: For both NDB and PS, we used the monthly data from April, 2010 to March, 2013. The estimation of the number of varicella patients from the PS data was adjusted by the proportion of estimated number based on PS to the one based on NDB in the entire study period. Moreover, we adjusted it month by month, if the former method may not be enough to compensate for the discrepancy between the two datasets. RESULTS: The average discrepancy between NDB and PS was 48.00% in three years. By the adjustment using NDB in the three years, the discrepancy was improved to 11.49%. However, seasonal patterns of overestimation or underestimation were found. Conversely, by the adjustment using NDB month by month, the discrepancy was greatly reduced to 4.33%. Moreover, the seasonal patterns of overestimation or underestimation disappeared. CONCLUSION: The number of patients based on NDB would appear the most precise number, however, there may be a delay of about one year before it becomes available. On the other hand, PS data are updated every day and provide us with the up-to-date situation. This paper found that combining the timeliness of the PS data and preciseness of the NDB data will provide substantial benefit for public health.

Towards a Food Safety Knowledge Base Applicable in Crisis Situations and Beyond.

In case of contamination in the food chain, fast action is required in order to reduce the numbers of affected people. In such situations, being able to predict the fate of agents in foods would help risk assessors and decision makers in assessing the potential effects of a specific contamination event and thus enable them to deduce the appropriate mitigation measures. One efficient strategy supporting this is using model based simulations. However, application in crisis situations requires ready-to-use and easy-to-adapt models to be available from the so-called food safety knowledge bases. Here, we illustrate this concept and its benefits by applying the modular open source software tools PMM-Lab and FoodProcess-Lab. As a fictitious sample scenario, an intentional ricin contamination at a beef salami production facility was modelled. Predictive models describing the inactivation of ricin were reviewed, relevant models were implemented with PMM-Lab, and simulations on residual toxin amounts in the final product were performed with FoodProcess-Lab. Due to the generic and modular modelling concept implemented in these tools, they can be applied to simulate virtually any food safety contamination scenario. Apart from the application in crisis situations, the food safety knowledge base concept will also be useful in food quality and safety investigations.

[Lessons learnt from the German smallpox outbreaks after World War II]. / Pockenausbrüche nach dem zweiten Weltkrieg in Deutschland.

BACKGROUND: Even though smallpox was declared eradicated by WHO in 1980, it cannot be ruled out that the etiological variola virus could be used as a biological weapon. Undestroyed viruses from biowarfare programmes, virus strains left undetected in a freezer or dangerous recombinant poxvirus constructs could cause dangerous outbreaks in a relatively unprotected population. OBJECTIVES: Despite an abundance of studies performed during the eradication of smallpox, epidemiological data for preparedness planning and outbreak control in modern, industrialized countries are scarce. MATERIAL AND METHODS: Full-text hand search for the period from 1945 to 1975 in the main German public health journals. RESULTS: After World War II 12 smallpox outbreaks occurred in Germany. They were studied with the focus on the period of contagiousness, the protective effect of vaccination, booster-effect of revaccination and the place of infection. A total of 95 individuals contracted smallpox, including 10 fatalities. Despite having been previously vaccinated, 81 vaccinated persons came down with smallpox, yet 91% of them developed only mild symptoms. These patients presented a high risk for spreading the infection to contact persons due to misinterpretation of symptoms and the continuing social contacts. Basically, the risk of transmission in the first 2 to 3 days after onset of symptoms was low, thus facilitating antiepidemic measures. The importance of hospital preparedness is emphasized by the fact that most infections occurred in hospitals. CONCLUSION: The data analyzed provide valuable information for today's outbreak response planning and counter bioterrorism preparedness.

Cost-effectiveness comparison of response strategies to a large-scale anthrax attack on the chicago metropolitan area: impact of timing and surge capacity.

Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.

Molecular and cell biology of the prototypic arenavirus LCMV: implications for understanding and combating hemorrhagic fever arenaviruses.

Arenaviruses merit interest as experimental model systems to study virus-host interactions and as clinically important human pathogens. Several arenaviruses, chiefly Lassa virus (LASV), cause hemorrhagic fever (HF) in humans. In addition, evidence indicates that the worldwide-distributed prototypic arenavirus lymphocytic choriomeningitis virus (LCMV) is a neglected human pathogen. Moreover, arenaviruses pose a biodefense threat. No licensed arenavirus vaccines are available, and current therapy is limited to the use of ribavirin, which is only partially effective and associated with significant side effects. The development of arenavirus reverse genetics systems has made it possible to manipulate the arenavirus genome, which is contributing to significant progress in understanding arenavirus molecular and cell biology, as well as arenavirus-host interactions underlying arenavirus-induced HF disease in humans. This, in turn, should facilitate the development of novel both vaccines and antiviral drugs to combat the dual threats of naturally occurring and intentionally introduced arenavirus infections.

Smallpox, risks of terrorist attacks, and the Nash equilibrium: an introduction to game theory and an examination of the smallpox vaccination program.

INTRODUCTION: The smallpox vaccination emergency preparedness program has been unsuccessful in enrolling sufficient numbers of healthcare workers. OBJECTIVE: The objective of this study was to use game theory to analyze a pre-event vaccination versus post-event vaccination program using the example of a terrorist considering an attack with smallpox or a hoax. METHODS: A three-person game (normal and extensive form), and an in-person game are played for pre-event and post-event vaccinations of healthcare workers facing the possibility of a smallpox attack or hoax. RESULTS: Full pre-event vaccinations of all targeted healthcare workers are not necessary to deter a terrorist attack. In addition, coordinating vaccinations among healthcare workers, individual healthcare worker risk aversion, and the degree to which terrorists make the last move based on specific information on the status of pre-event vaccination all greatly impact strategy selection for both sides. A Nash Equilibrium of pre- and post-event vaccination strategies among a large number of healthcare professionals will tend to eliminate the advantage (of the terrorists) of a smallpox attack over a hoax, but may not eliminate some probability of a smallpox attack. CONCLUSIONS: Emergency preparedness would benefit from game theory analysis of the costs and payoffs of specific terrorism/counter-terrorism strategies.

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.

Syndromic surveillance: STL for modeling, visualizing, and monitoring disease counts.

BACKGROUND: Public health surveillance is the monitoring of data to detect and quantify unusual health events. Monitoring pre-diagnostic data, such as emergency department (ED) patient chief complaints, enables rapid detection of disease outbreaks. There are many sources of variation in such data; statistical methods need to accurately model them as a basis for timely and accurate disease outbreak methods. METHODS: Our new methods for modeling daily chief complaint counts are based on a seasonal-trend decomposition procedure based on loess (STL) and were developed using data from the 76 EDs of the Indiana surveillance program from 2004 to 2008. Square root counts are decomposed into inter-annual, yearly-seasonal, day-of-the-week, and random-error components. Using this decomposition method, we develop a new synoptic-scale (days to weeks) outbreak detection method and carry out a simulation study to compare detection performance to four well-known methods for nine outbreak scenarios. RESULT: The components of the STL decomposition reveal insights into the variability of the Indiana ED data. Day-of-the-week components tend to peak Sunday or Monday, fall steadily to a minimum Thursday or Friday, and then rise to the peak. Yearly-seasonal components show seasonal influenza, some with bimodal peaks.Some inter-annual components increase slightly due to increasing patient populations. A new outbreak detection method based on the decomposition modeling performs well with 90 days or more of data. Control limits were set empirically so that all methods had a specificity of 97%. STL had the largest sensitivity in all nine outbreak scenarios. The STL method also exhibited a well-behaved false positive rate when run on the data with no outbreaks injected. CONCLUSION: The STL decomposition method for chief complaint counts leads to a rapid and accurate detection method for disease outbreaks, and requires only 90 days of historical data to be put into operation. The visualization tools that accompany the decomposition and outbreak methods provide much insight into patterns in the data, which is useful for surveillance operations.

Detection of disease outbreaks by the use of oral manifestations.

Oral manifestations of diseases caused by bioterrorist agents could be a potential data source for biosurveillance. This study had the objectives of determining the oral manifestations of diseases caused by bioterrorist agents, measuring the prevalence of these manifestations in emergency department reports, and constructing and evaluating a detection algorithm based on them. We developed a software application to detect oral manifestations in free text and identified positive reports over three years of data. The normal frequency in reports for oral manifestations related to anthrax (including buccal ulcers-sore throat) was 7.46%. The frequency for tularemia was 6.91%. For botulism and smallpox, the frequencies were 0.55% and 0.23%. We simulated outbreaks for these bioterrorism diseases and evaluated the performance of our system. The detection algorithm performed better for smallpox and botulism than for anthrax and tularemia. We found that oral manifestations can be a valuable tool for biosurveillance.

Extracting key information from historical data to quantify the transmission dynamics of smallpox.

BACKGROUND: Quantification of the transmission dynamics of smallpox is crucial for optimizing intervention strategies in the event of a bioterrorist attack. This article reviews basic methods and findings in mathematical and statistical studies of smallpox which estimate key transmission parameters from historical data. MAIN FINDINGS: First, critically important aspects in extracting key information from historical data are briefly summarized. We mention different sources of heterogeneity and potential pitfalls in utilizing historical records. Second, we discuss how smallpox spreads in the absence of interventions and how the optimal timing of quarantine and isolation measures can be determined. Case studies demonstrate the following. (1) The upper confidence limit of the 99th percentile of the incubation period is 22.2 days, suggesting that quarantine should last 23 days. (2) The highest frequency (61.8%) of secondary transmissions occurs 3-5 days after onset of fever so that infected individuals should be isolated before the appearance of rash. (3) The U-shaped age-specific case fatality implies a vulnerability of infants and elderly among non-immune individuals. Estimates of the transmission potential are subsequently reviewed, followed by an assessment of vaccination effects and of the expected effectiveness of interventions. CONCLUSION: Current debates on bio-terrorism preparedness indicate that public health decision making must account for the complex interplay and balance between vaccination strategies and other public health measures (e.g. case isolation and contact tracing) taking into account the frequency of adverse events to vaccination. In this review, we summarize what has already been clarified and point out needs to analyze previous smallpox outbreaks systematically.

Implications of chemical biological terrorist events for children and pregnant women.

During the past decade, the world has become more aware that chemical and biological weapons could be used on civilians as terrorism and that casualties could include children. It is essential that nurses who care for children and pregnant women know how to recognize the effects of this type of weapon on the population and how to alleviate or mitigate their impact. This article reviews key aspects of chemical-biological agents, the consequences of their use, the potential impact of a chemical-biological attack on children and pregnant women, and issues to consider in the event of such a catastrophe.

Birth defects among infants born to women who received anthrax vaccine in pregnancy.

In response to bioterrorism threats, anthrax vaccine has been used by the US military and considered for civilian use. Concerns exist about the potential for adverse reproductive health effects among vaccine recipients. This retrospective cohort evaluated birth defects, in relation to maternal anthrax vaccination, among all infants born to US military service women between 1998 and 2004. Department of Defense databases defined maternal vaccination and infant diagnoses; multivariable regression models described potential associations between anthrax vaccination and birth defects in liveborn infants. Among 115,169 infants born to military women during this period, 37,140 were born to women ever vaccinated against anthrax, and 3,465 were born to women vaccinated in the first trimester of pregnancy. Birth defects were slightly more common in first trimester-exposed infants (odds ratio = 1.18, 95% confidence interval: 0.997, 1.41) when compared with infants of women vaccinated outside of the first trimester, but this association was statistically significant only when alternative referent groups were used. Although the small observed association may be unlikely to represent a causal relation between vaccination in early pregnancy and birth defects, this information should be considered when making decisions about administering anthrax vaccine to pregnant women.

An ounce of prevention is worth a pound of cure: improving communication to reduce mortality during bioterrorism responses.

OBJECTIVE: To identify communication needs and evaluate the effectiveness of alternative communication strategies for bioterrorism responses. METHODS: We provide a framework for evaluating communication needs during a bioterrorism response. Then, using a simulation model of a hypothetical response to anthrax bioterrorism in a large metropolitan area, we evaluate the costs and benefits of alternative strategies for communication during a response. RESULTS: Expected mortality increases significantly with increases in the time for attack detection and announcement; decreases in the rate at which exposed individuals seek and receive prophylaxis; increases in the number of unexposed people seeking prophylaxis; and increases in workload imbalances at dispensing centers. Thus, the timeliness, accuracy, and precision of communications about the mechanisms of exposure and instructions for obtaining prophylaxis and treatment are critical. Investment in strategies that improve adherence to prophylaxis is likely to be highly cost effective, even if the improvement in adherence is modest, and even if such strategies reduce the prophylaxis dispensing rate. CONCLUSIONS: Communication during the response to a bioterror attack must involve the right information delivered at the appropriate time in an effective manner from trusted sources. Because the response system for bioterror communication is only fully operationalized once an attack has occurred, tabletop planning and simulation exercises, and other up-front investments in the design of an effective communication strategy, are critical for effective response planning.

Misrepresentation of health risks by mass media.

BACKGROUND: Mass media are a leading source of health information for general public. We wished to examine the relationship between the intensity of media coverage for selected health topics and their actual risk to public health. METHODS: Mass media reports in the United States on emerging and chronic health hazards (severe acute respiratory syndrome (SARS), bioterrorism, West Nile Fever, AIDS, smoking and physical inactivity) were counted for the year 2003, using LexisNexis database. The number of media reports for each health risk was correlated with the corresponding death rate as reported by the Centers for Disease Control and Prevention. RESULTS: The number of media reports inversely correlated with the actual number of deaths for the health risks evaluated. SARS and bioterrorism killed less than a dozen people in 2003, but together generated over 100 000 media reports, far more than those covering smoking and physical inactivity, which killed nearly a million Americans. CONCLUSIONS: Emerging health hazards are over-reported in mass media by comparison to common threats to public health. Since premature mortality in industrialized societies is most often due to well-known risks such as smoking and physical inactivity, their under-representation on public agendas may cause suboptimal prioritization of public health resources.

Mass violence and mental health--a view from forensic psychiatry.

The objectives of this paper are to develop insights into the mind of the terrorist, to conduct a review of health impacts on the health of populations, especially from the point of view of mental health impacts caused by terrorist attacks and to discern the role to be played by forensic psychiatry in emergencies caused by terrorist actions. These objectives are developed at the population level and at the individual level from the point of view of a description of the terrorist and of victim's need for forensic intervention and representation. On entrance, the paper starts with a general frame of definitions and a historical overview of terrorism as an ancient, purposeful, political tool used to change a situation objectionable to the terrorist group via intimidation of a captive population. People are used as expendable pawns and become psychologically captive to the aims of the terrorist group. As well, the paper reviews the new reality of bioterrorism and the use of improved technologies to inflict expensive damage to national infrastructures and massive loss of life.