Heartland Virus Disease-An Underreported Emerging Infection.

First recognized 15 years ago, Heartland virus disease (Heartland) is a tickborne infection contracted from the transmission of Heartland virus (HRTV) through tick bites from the lone star tick (Amblyomma americanum) and potentially other tick species. Heartland symptoms include a fever <100.4 °F, lethargy, fatigue, headaches, myalgia, a loss of appetite, nausea, diarrhea, weight loss, arthralgia, leukopenia and thrombocytopenia. We reviewed the existing peer-reviewed literature for HRTV and Heartland to more completely characterize this rarely reported, recently discovered illness. The absence of ongoing serosurveys and targeted clinical and tickborne virus investigations specific to HRTV presence and Heartland likely contributes to infection underestimation. While HRTV transmission occurs in southern and midwestern states, the true range of this infection is likely larger than now understood. The disease's proliferation benefits from an expanded tick range due to rising climate temperatures favoring habitat expansion. We recommend HRTV disease be considered in the differential diagnosis for patients with a reported exposure to ticks in areas where HRTV has been previously identified. HRTV testing should be considered early for those matching the Heartland disease profile and nonresponsive to initial broad-spectrum antimicrobial treatment. Despite aggressive supportive therapy, patients deteriorating to sepsis early in the course of the disease have a very grim prognosis.

Psittacosis: An Underappreciated and Often Undiagnosed Disease.

The bacterial agent Chlamydia psittaci, and the resulting disease of psittacosis, is a little-known and underappreciated infectious disease by healthcare practitioners and in public health in general. C. psittaci infections can cause significant psittacosis outbreaks, with person-to-person transmission documented in the last decade. In this publication, we review the pathogen and its disease, as well as examine the potential for genetic manipulation in this organism to create a more deadly pathogen. Recent disease surveys indicate that currently, the highest incidences of human disease exist in Australia, Germany and the UK. We recommend the universal public health reporting of C. psittaci and psittacosis disease and increasing the promotion of public health awareness.

A Universal Travel Risk Assessment Questionnaire: Travel Assessment During COVID-19 Pandemic and Endemicity.

INTRODUCTION: Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, military commanders have been challenged with providing appropriate travel guidance for their military and civilian personnel and dependents. This guidance, where promulgated, lacks uniformity. Travel aids and computer applications similarly differ and are not updated as often as jurisdictional travel health guidance is changed. Given the ever-evolving Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variants with differing degrees of infectivity, COVID-19 travel guidance will remain relevant for military travelers during the transition from pandemic to endemic phases and for the foreseeable future. MATERIALS AND METHODS: We reviewed all germane travel guidance promulgated by the U.S, Department of Defense; the U.S. Centers for Disease Control and Prevention; and other federal, state, and international agencies. From these materials, we identified and delineated applicable universal components for COVID-19 travel risk and created a universal Travel Risk Assessment Questionnaire (TRAQ). RESULTS: We present a universal TRAQ that identifies and allows for a graded most-appropriate response to known travel risk assessment factors including travel restrictions, travel mode, travel time, travel party size, trip duration, COVID-19 incidence rate at travel destination, lodging, planned activities, personal interaction level, vaccination coverage at destination, travel location, traveler's vaccination status, previous COVID-19 infection, mask wear compliance, mask type, and work environment, along with additional considerations and post-travel COVID-19 questions. We provide examples of the use of this questionnaire that describe low, medium, and high risk to the traveler for contracting COVID-19. CONCLUSION: Our TRAQ provides an easy-to-use format that can enable military, business, or personal travelers to more completely assess their likelihood of COVID-19 exposure and help them to reduce their potential for contracting COVID-19 during travel and subsequently transmitting it to others upon return. It should help commanders and traveling personnel to better assess COVID-19 travel risks through application of known travel risk factors.

Training initiatives within the AFHSC-Global Emerging Infections Surveillance and Response System: support for IHR (2005).

Training is a key component of building capacity for public health surveillance and response, but has often been difficult to quantify. During fiscal 2009, the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supported 18 partner organizations in conducting 123 training initiatives in 40 countries for 3,130 U.S. military, civilian and host-country personnel. The training assisted with supporting compliance with International Health Regulations, IHR (2005). Training activities in pandemic preparedness, outbreak investigation and response, emerging infectious disease (EID) surveillance and pathogen diagnostic techniques were expanded significantly. By engaging local health and other government officials and civilian institutions, the U.S. military's role as a key stakeholder in global public health has been strengthened and has contributed to EID-related surveillance, research and capacity-building initiatives specified elsewhere in this issue. Public health and emerging infections surveillance training accomplished by AFHSC-GEIS and its Department of Defense (DoD) partners during fiscal 2009 will be tabulated and described.

Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic.

The Armed Forces Health Surveillance Center's Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supports and oversees surveillance for emerging infectious diseases, including respiratory diseases, of importance to the U.S. Department of Defense (DoD). AFHSC-GEIS accomplishes this mission by providing funding and oversight to a global network of partners for respiratory disease surveillance. This report details the system's surveillance activities during 2009, with a focus on efforts in responding to the novel H1N1 Influenza A (A/H1N1) pandemic and contributions to global public health. Active surveillance networks established by AFHSC-GEIS partners resulted in the initial detection of novel A/H1N1 influenza in the U.S. and several other countries, and viruses isolated from these activities were used as seed strains for the 2009 pandemic influenza vaccine. Partners also provided diagnostic laboratory training and capacity building to host nations to assist with the novel A/H1N1 pandemic global response, adapted a Food and Drug Administration-approved assay for use on a ruggedized polymerase chain reaction platform for diagnosing novel A/H1N1 in remote settings, and provided estimates of seasonal vaccine effectiveness against novel A/H1N1 illness. Regular reporting of the system's worldwide surveillance findings to the global public health community enabled leaders to make informed decisions on disease mitigation measures and controls for the 2009 A/H1N1 influenza pandemic. AFHSC-GEIS's support of a global network contributes to DoD's force health protection, while supporting global public health.

Coronavirus Disease 2019 on the Heels of Ebola Virus Disease in West Africa.

This study utilized modeling and simulation to examine the effectiveness of current and potential future COVID-19 response interventions in the West African countries of Guinea, Liberia, and Sierra Leone. A comparison between simulations can highlight which interventions could have an effect on the pandemic in these countries. An extended compartmental model was used to run simulations incorporating multiple vaccination strategies and non-pharmaceutical interventions (NPIs). In addition to the customary categories of susceptible, exposed, infected, and recovered (SEIR) compartments, this COVID-19 model incorporated early and late disease states, isolation, treatment, and death. Lessons learned from the 2014-2016 Ebola virus disease outbreak-especially the optimization of each country's resource allocation-were incorporated in the presented models. For each country, models were calibrated to an estimated number of infections based on actual reported cases and deaths. Simulations were run to test the potential future effects of vaccination and NPIs. Multiple levels of vaccination were considered, based on announced vaccine allocation plans and notional scenarios. Increased vaccination combined with NPI mitigation strategies resulted in thousands of fewer COVID-19 infections in each country. This study demonstrates the importance of increased vaccinations. The levels of vaccination in this study would require substantial increases in vaccination supplies obtained through national purchases or international aid. While this study does not aim to develop a model that predicts the future, it can provide useful information for decision-makers in low- and middle-income nations. Such information can be used to prioritize and optimize limited available resources for targeted interventions that will have the greatest impact on COVID-19 pandemic response.

Operational Perspective of Lessons Learned From the Ebola Crisis.

Given its potential to quickly spread internationally and initially uncontrollable nature, the 2014 to 2015 Ebola outbreak has implications for global biosecurity. The Defense Threat Reduction Agency's Technical Reachback provided near real-time analysis and recommendations as outbreak-relevant events unfolded. Our review of often-conflicting or incomplete information was required to answer policy decision makers about the expanding Ebola epidemic, and enable the formulation of best-possible U.S. Department of Defense and Government response. Challenging questions often did not have obvious information available from which to provide a definitive answer. Nevertheless, through use of best-practice science and medicine, we provided timely and scientifically accurate weekly review for decision makers. Our comprehensive analyses included the nature of the outbreak, its global and national impact, contributing factors to this and future Ebola outbreaks, the U.S. Government and international response, and continuing interventions. We also provided guidance for Ebola transmission outside of West Africa, medical countermeasures, challenges with the international response, lessons learned, major constraints, and considerations for future preparedness. We believe an assessment of these events may help an improved response for future infectious disease outbreaks with global and national security implications.

Strategic National Stockpile program: implications for military medicine.

The Strategic National Stockpile (SNS) program, managed by the Centers for Disease Control and Prevention, Department of Health and Human Services, is designed to deliver critical medical resources to the site of a national emergency. A recent interagency agreement between the Department of Defense and the Department of Health and Human Services indicates that military medical treatment facility commanders should be actively engaged in cooperative planning with local and state public health officials, so that reception, storage, distribution, and dispensing of SNS materials as a consequence of an actual event could occur without disruption or delay. This article describes the SNS program and discusses issues of relevance to medical treatment facility commanders and Department of Defense medical planners and logisticians.

Bioterrorism preparedness. I: The emergency department and hospital.

Fundamental precepts in hospital-based planning for bioterrorist events include having a comprehensive well-rehearsed disaster plan that is based on a threat and vulnerability analysis. JCAHO Environment of Care Standards and an "all-hazards" approach to disaster planning and management form the basis for a solid bioterrorism response plan. During preparation, education and training are imperative. Clinicians must maintain a high index of suspicion for use of bioterrorism agents, be able to make a rapid diagnosis, and promptly initiate empiric treatment. Other personnel from administration, security, public relations, laboratory, pharmacy, and facilities management should be familiar with the plan, know when and how to activate it, and understand their roles in the response. A recognized incident command system should be used. Hospital leadership must be aware of the facility's capabilities and capacities, and should have plans for expansion of services to meet the surge in demand. The command center should coordinate emergency personnel teams, decontamination, security, acquisition of supplies, and notification of public health and other authorities and the media. If the plan is ever implemented, stress management with psychologic support will play an important role in recovery.

Bioterrorism preparedness. III: State and federal programs and response.

Management of a bioterrorism event will begin with early detection and intervention at the local level. Any large-scale event will require rapid state and federal assistance. Federal initiatives targeting bioterrorism have increasingly become a complex web of executive and legislative actions, frequently initiated in reaction to specific events, and often unrelated to this threat. Multiple executive and legislative branch actions have resulted in a proliferation of federal programs, and coordination of these efforts remains a significant challenge. Still, great strides have been taken to improve our defensive posture against this emerging threat, and, at all levels, governmental authorities and agencies are much better prepared to respond to such events than they were a decade ago. The events of September 11, 2001 and subsequent events are clear indicators that the timeline for preparedness has been significantly compressed. Federal emergency operations, historically designed more for recovery than response, seemed up to the task in the wake of the World Trade Center and Pentagon attacks, although there was criticism of federal responsiveness to the subsequent anthrax incidents [71,72], and the timeliness of federal resources in the event of a large-scale outbreak resulting from a bioterrorism attack has yet to be truly tested. The recent establishment of the Office of Homeland Security and the Homeland Security Council holds promise that some of these inefficiencies may be rectified and overall coordination of programs will improve. Continued improvements in the effectiveness of the federal government in meeting the challenges of this and other emerging threats to homeland security will require: Establishment of consensus standards, metrics, and measures of effectiveness for all aspects of disaster, epidemic, and terrorism management at the local, regional, state, and federal levels Delineation of expected, quantifiable state and local capabilities to mitigate, prepare, respond, and recover from all disasters, including those caused by terrorist actions Development of predefined or clear and rapidly discernible criteria for deployment of state and federal emergency resources Full accountability of program costs and expenditures Continued consolidation or coordination of the many overlapping and at times redundant federal programs.

Bioterrorism preparedness. II: The community and emergency medical services systems.

Disaster planning is an arduous task. Perhaps no form of disaster is more difficult to prepare for than one resulting from the intentional, covert release of a biological pathogen or toxin. The complexities of response operations and the perils of inadequate preparation cannot be overemphasized. Even with detailed planning, deviations from anticipated emergency operations plans are likely to occur. Several federal programs have been initiated to assist communities in enhancing their preparedness for events involving biological and other agents of mass destruction. Many of these, such as the Metropolitan Medical Response Systems (MMRS) Program [37,38], will be discussed elsewhere. Community preparedness will be enhanced by: 1. Implementing a real-time public health disease surveillance program linking local healthcare, emergency care, EMS, the CDC, local law enforcement, and the FBI 2. Improved real-time regional patient and healthcare capacity status management 3. Development of affordable, accurate biological agent detection systems 4. Incorporation of standardized education and training curricula (appropriate for audience) on terrorism and biological agents into healthcare training programs 5. Expansion of federal and state programs to assist communities in system development 6. Increased public awareness and education programs.