Evaluating the Environmental Persistence and Inactivation of MS2 Bacteriophage and the Presumed Ebola Virus Surrogate Phi6 Using Low Concentration Hydrogen Peroxide Vapor.

Ebola virus (EBOV) disease outbreaks, as well as the ability of EBOV to persist in the environment under certain conditions, highlight the need to develop effective decontamination techniques against the virus. We evaluated the efficacy of hydrogen peroxide vapor (HPV) to inactivate MS2 and Phi6 bacteriophages, the latter a recommended surrogate for EBOV. The phages were inoculated onto six material types with and without the presence of whole human blood. The inoculated materials were then exposed to either a high or low concentration of HPV for various elapsed times. The phages were also recovered from positive controls at these same elapsed times, to assess environmental persistence and decontamination efficacy. Low concentration hydrogen peroxide vapor (LCHP; 25 ppm) was effective against both phages on all materials without the presence of blood at 2 h. LCHP was ineffective against the phages in the presence of blood, on all materials, even with a 3-day contact time. Higher concentrations of HPV (>400 ppm) with contact times of 24-32 h achieved approximately 2-6 log reduction of the phages in the presence of blood.

Review of Decontamination Techniques for the Inactivation of Bacillus anthracis and Other Spore-Forming Bacteria Associated with Building or Outdoor Materials.

Since the intentional release of Bacillus anthracis spores through the U.S. Postal Service in the fall of 2001, research and development related to decontamination for this biological agent have increased substantially. This review synthesizes the advances made relative to B. anthracis spore decontamination science and technology since approximately 2002, referencing the open scientific literature and publicly available, well-documented scientific reports. In the process of conducting this review, scientific knowledge gaps have also been identified. This review focuses primarily on techniques that are commercially available and that could potentially be used in the large-scale decontamination of buildings and other structures, as well as outdoor environments. Since 2002, the body of scientific data related to decontamination and microbial sterilization has grown substantially, especially in terms of quantifying decontamination efficacy as a function of several factors. Specifically, progress has been made in understanding how decontaminant chemistry, the materials the microorganisms are associated with, environmental factors, and microbiological methods quantitatively impact spore inactivation. While advancement has been made in the past 15 years to further the state of the science in the inactivation of bacterial spores in a decontamination scenario, further research is warranted to close the scientific gaps that remain.

Inactivation of Bacillus anthracis spores to decontaminate subway railcar and related materials via the fogging of peracetic acid and hydrogen peroxide sporicidal liquids.

The inactivation of Bacillus anthracis spores on subway and used subway railcar materials was evaluated using fogged peracetic acid/hydrogen peroxide (PAA) and hydrogen peroxide (H2O2). A total of 21 separate decontamination tests were conducted using bacterial spores of both B. anthracis Ames (B.a.) and Bacillus atrophaeus (B.g.) inoculated onto several types of materials. Tests were conducted using commercial off-the-shelf fogging equipment filled with either PAA or H2O2 to fumigate a ∼15 cubic meter chamber under uncontrolled ambient relative humidity and controlled temperature (10 or 20 °C) from 8 to 168 h. For the present study, no conditions were found that resulted in complete inactivation of either B.a. Ames or B.g. on all test materials. Approximately 41% and 38% of the decontamination efficacies for B.a. and B.g., respectively, exhibited ≥6 log10 reduction (LR); efficacy depended greatly on the material. When testing at 10 °C, the mean LR was consistently lower for both B.a. and B.g. as compared to 20 °C. Based on the statistical comparison of the LR results, B.g. exhibited equivalent or greater resistance than B.a. for approximately 92% of the time across all 21 tests. The efficacy data suggest that B.g. may be a suitable surrogate for B.a. Ames when assessing the decontamination efficacy of fogged PAA or H2O2. Moreover, the results of this testing indicate that in the event of B.a. spore release into a subway system, the fogging of PAA or H2O2 represents a decontamination option for consideration.

Evaluation of the Efficacy of Methyl Bromide in the Decontamination of Building and Interior Materials Contaminated with Bacillus anthracis Spores.

The primary goal of this study was to determine the conditions required for the effective inactivation of Bacillus anthracis spores on materials by using methyl bromide (MeBr) gas. Another objective was to obtain comparative decontamination efficacy data with three avirulent microorganisms to assess their potential for use as surrogates for B. anthracis Ames. Decontamination tests were conducted with spores of B. anthracis Ames and Geobacillus stearothermophilus, B. anthracis NNR1Δ1, and B. anthracis Sterne inoculated onto six different materials. Experimental variables included temperature, relative humidity (RH), MeBr concentration, and contact time. MeBr was found to be an effective decontaminant under a number of conditions. This study highlights the important role that RH has when fumigation is performed with MeBr. There were no tests in which a ≥6-log10 reduction (LR) of B. anthracis Ames was achieved on all materials when fumigation was done at 45% RH. At 75% RH, an increase in the temperature, the MeBr concentration, or contact time generally improved the efficacy of fumigation with MeBr. This study provides new information for the effective use of MeBr at temperatures and RH levels lower than those that have been recommended previously. The study also provides data to assist with the selection of an avirulent surrogate for B. anthracis Ames spores when additional tests with MeBr are conducted.

Capture of methyl bromide emissions with activated carbon following the fumigation of a small building contaminated with a Bacillus anthracis spore simulant.

A wide-area Bacillus anthracis spore contamination incident will present immense challenges related to decontamination capacity. For this reason, fumigation with methyl bromide (MeBr) has been proposed as a potential remediation option. Although a few bench-scale laboratory studies have been conducted to evaluate activated carbon for the capture of MeBr, these studies were conducted at conditions replicating commodity fumigation using relatively low MeBr concentrations, temperatures, and/or relative humidity (RH) levels. The more rigorous MeBr fumigation requirements to fully inactivate B. anthracis spores are much more of a challenge for an activated carbon system (ACS) to capture MeBr, and warrant their own investigation. Further, while the aforementioned studies have shown activated carbon to be a possible option for the capture of MeBr in gas streams, these tests were conducted at laboratory bench scale, and thus lack operational perspective and data. Thus, we present for the first time the results of a full-scale study to evaluate an ACS employed for the capture of MeBr at conditions that would be used for decontaminating a building structure contaminated with B. anthracis spores. Airflow rate, temperature, RH, and MeBr levels were measured within the ACS during its operation. Despite the relatively high humidity, temperature, and MeBr levels, the MeBr capture efficiency of the ACS was demonstrated to be more than 99%. The concentration of MeBr exhausted from the structure was reduced from 41,000 to 136 ppmv in 3.5 hr, corresponding to an overall atmospheric emission rate of less than 2 kg. The practical adsorption rate of the ACS was determined to be 4.83 kg MeBr/100 kg carbon. The information and data presented here will facilitate future use of this technology when fumigating with MeBr.

Emergency department rapid medical assessment: overall effect and mechanistic considerations.

BACKGROUND: Although the use of a physician and nurse team at triage has been shown to improve emergency department (ED) throughput, the mechanism(s) by which these improvements occur is less clear. OBJECTIVES: 1) To describe the effect of a Rapid Medical Assessment (RMA) team on ED length of stay (LOS) and rate of left without being seen (LWBS); 2) To estimate the effect of RMA on different groups of patients. METHODS: For Objective 1, we compared LOS and LWBS on dates when we utilized RMA to comparable dates when we did not. For Objective 2, we utilized patient logs to divide patients into groups and estimated the effects of the RMA on each. RESULTS: Objective 1. LOS fell from 297.8 min pre-RMA to 261.7 min during RMA, an improvement of 36.1 (95% confidence interval 21.8-50.4) min; LWBS did not change significantly. Objective 2. Patients seen and dispositioned by the RMA had an estimated decrease in LOS of 117.8 min (estimated decrease in LOS of 45%), but patients seen by the RMA whose care was transitioned to the main ED had an estimated increase in LOS of 25.0 min (estimated increase in LOS of 8%). CONCLUSIONS: On a system level, the addition of an RMA shift at a single facility was associated with an improvement in LOS, but not LWBS. On a mechanistic level, it seems that improvements occurred as a result of the rapid disposition component of the RMA rather than placing advanced orders at triage.

Effect of inoculation method on the determination of decontamination efficacy against Bacillus spores.

Decontamination studies investigating the effectiveness of products and processes for the inactivation of Bacillus species spores have traditionally utilized metering viable spores in a liquid suspension onto test materials (coupons). The current study addresses the representativeness of studies using this type of inoculation method compared to when coupons are dosed with a metered amount of aerosolized spores. The understanding of this comparability is important in order to assess the representativeness of such laboratory-based testing when deciding upon decontamination options for use against Bacillus anthracis spores. Temporal inactivation of B. anthracis surrogate (B. subtilis) spores on representative materials using fumigation with chlorine dioxide, spraying of a pH-adjusted bleach solution, or immersion in the solution was investigated as a function of inoculation method (liquid suspension or aerosol dosing). Results indicated that effectiveness, measured as log reduction, was statistically significantly lower when liquid inoculation was used for some material and decontaminant combinations. Differences were mostly noted for the materials observed to be more difficult to decontaminate (i.e., wood and carpet). Significant differences in measured effectiveness were also noted to be a function of the pH-adjusted bleach application method used in the testing (spray or immersion). Based upon this work and the cited literature, it is clear that inoculation method, decontaminant application method, and handling of non-detects (i.e., or detection limits) can have an impact on the sporicidal efficacy measurements.

Review of techniques for the in-situ sterilization of soil contaminated with Bacillus anthracis spores or other pathogens.

This review summarizes the literature on efficacy of techniques to sterilize soil. Soil may need to be sterilized if contaminated with pathogens such as Bacillus anthracis. Sterilizing soil in-situ minimizes spread of the bio-contaminant. Soil is difficult to sterilize, with efficacy generally diminishing with depth. Methyl bromide, formaldehyde, and glutaraldehyde are the only soil treatment options that have been demonstrated at full-scale to effectively inactivate Bacillus spores. Soil sterilization modalities with high efficacy at bench-scale include wet and dry heat, metam sodium, chlorine dioxide gas, and activated sodium persulfate. Simple oxidants such as chlorine bleach are ineffective in sterilizing soil.

Neutralization of ricin toxin on building interior surfaces using liquid decontaminants.

Ricin is a highly toxic protein, capable of inhibiting protein synthesis within cells, and is produced from the beans of the Ricinus communis (castor bean) plant. Numerous recent incidents involving ricin have occurred, many in the form of mailed letters resulting in both building and mail sorting facility contamination. The goal of this study was to assess the decontamination efficacy of several commercial off-the-shelf (COTS) cleaners and decontaminants (solutions of sodium hypochlorite [bleach], quaternary ammonium, sodium percarbonate, peracetic acid, and hydrogen peroxide) against a crude preparation of ricin toxin. The ricin was inoculated onto four common building materials (pine wood, drywall joint tape, countertop laminate, and industrial carpet), and the decontaminants were applied to the test coupons using a handheld sprayer. Decontamination efficacy was quantified using an in-vitro cytotoxicity assay to measure the quantity of bioactive ricin toxin extracted from test coupons as compared to the corresponding positive controls (not sprayed with decontaminant). Results showed that decontamination efficacy varied by decontaminant and substrate material, and that efficacy generally improved as the number of spray applications or contact time increased. The solutions of 0.45% peracetic acid and the 20,000-parts per million (ppm) sodium hypochlorite provided the overall best decontamination efficacy. The 0.45% peracetic acid solution achieved 97.8 to 99.8% reduction with a 30-min contact time.

Fate and transport of viable Bacillus anthracis simulant spores in ambient air during a large outdoor decontamination field exercise.

The Wide Area Demonstration (WAD) was a field exercise conducted under the U.S. EPA's Analysis of Coastal Operational Resiliency program, in conjunction with the U.S. Department of Homeland Security and the U.S. Coast Guard. The purpose of the WAD was to operationalize at field scale aspects of remediation activities that would occur following an outdoor release of Bacillus anthracis spores, including sampling and analysis, decontamination, data management, and waste management. The WAD was conducted in May 2022 at Fort Walker (formerly known as Fort A.P. Hill) and utilized Bacillus atrophaeus as a benign simulant for B. anthracis. B. atrophaeus spores were inoculated onto the study area at the beginning of the study, and air samples were collected daily during each of the different phases of the WAD using Dry Filter Units (DFUs). Ten DFU air samplers were placed at the perimeter of the study area to collect bioaerosols onto two parallel 47-mm diameter polyester felt filters, which were then subsequently analyzed in a microbiological laboratory for the quantification of B. atrophaeus. The study demonstrated the use of DFUs as a rugged and robust bioaerosol collection device. The results indicated that the highest B. atrophaeus spore air concentrations (up to ~ 5 colony forming units/m3) occurred at the beginning of the demonstration (e.g. during inoculation and characterization sampling phases) and generally downwind from the test site, suggesting transport of the spores was occurring from the study area. Very few B. atrophaeus spores were detected in the air after several weeks and following decontamination of exterior surfaces, thus providing an indication of the site decontamination procedures' effectiveness. No B. atrophaeus spores were detected in any of the blank or background samples.Implications: Following an incident involving a release of Bacillus anthracis spores or other biological threat agent into the outdoor environment, understanding the factors that may affect the bioagent's fate and transport can help predict viable contaminant spread via the ambient air. This paper provides scientific data for the first time on ambient air concentrations of bacterial spores over time and location during different phases of a field test in which Bacillus atrophaeus (surrogate for B. anthracis) spores were released outdoors as part of a full-scale study on sampling and decontamination in an urban environment. This study advances the knowledge related to the fate and transport of bacterial spores (such as those causing anthrax disease) as an aerosol in the outdoor environment over the course of three weeks in a mock urban environment and has exposure and health risk implications. The highest spore air concentrations occurred at the beginning of the study (e.g. during inoculation of surfaces and characterization sampling), and in the downwind direction, but diminished over time; few B. atrophaeus spores were detected in the air after several weeks and following decontamination. Therefore, in an actual incident, potential reaerosolization of the microorganism and subsequent transport in the air during surface sampling and remediation efforts should be considered for determining exclusion zone locations and estimating potential risk to neighboring communities. The data also provide evidence suggesting that the large-scale decontamination of outdoor surfaces may reduce air concentrations of the bioagent, which is important since exposure of B. anthracis via inhalation is a primary concern.

Effectiveness of formaldehyde in various soil types as a wide area decontamination approach for Bacillus anthracis spores.

The purpose of this study was to evaluate and compare the decontamination efficacy of liquid formaldehyde solutions for three soil types (sand, loam, and clay) against spores of Bacillus anthracis (B.a.) and Bacillus atrophaeus. Approximately 1 x 108 colony forming units were inoculated into each sample. Through a series of six bench-scale experiments, two concentrations and two volumes of liquid formaldehyde solution were then added to the soil samples and allowed to remain in contact for either 24 or 48 hours. Decontamination efficacy was assessed at either 22° or 10°C with or without lids atop the sample jars. Complete inactivation (no spores recovered from the soil samples, typically providing > 7 log reduction) of B.a. occurred in all soil types in five of the six tests, while complete inactivation of B. atrophaeus was achieved in all soil types for three of the six tests. The results demonstrated a higher probability of complete inactivation of spores for samples that were covered, samples that received the higher volume of formaldehyde, and those contaminated with B.a. Overall, the use of liquid formaldehyde solution (2.5-5%) was highly effective in inactivating entire spore populations (typically > 107 CFU) for both B.a. and B. atrophaeus in the soil matrices studied. Covering the soil after application would allow for less formaldehyde solution to be used without impacting the overall efficacy of the process. The data from this study may aid in the selection of appropriate decontamination parameters when using liquid formaldehyde for soil remediation. The data may also aid in the decision to use B. atrophaeus as a surrogate for B.a. when performing further decontamination studies using liquid formalin solutions.

Evaluation of electrostatic sprayers and foggers for the application of disinfectants in the era of SARS-CoV-2.

Although research has shown that the COVID-19 disease is most likely caused by airborne transmission of the SARS-CoV-2 virus, disinfection of potentially contaminated surfaces is also recommended to limit the spread of the disease. Use of electrostatic sprayers (ESS) and foggers to rapidly apply disinfectants over large areas or to complex surfaces has emerged with the COVID-19 pandemic. ESSs are designed to impart an electrostatic charge to the spray droplets with the goal of increasing deposition of the droplets onto surfaces, thereby promoting more efficient use of the disinfectant. The purpose of this research was to evaluate several spray parameters for different types of sprayers and foggers, as they relate to the application of disinfectants. Some of the parameters evaluated included the spray droplet size distribution, the electrostatic charge, the ability of the spray to wrap around objects, and the loss of disinfectant chemical active ingredient due to the spray process. The results show that most of the devices evaluated for droplet size distribution had an average volume median diameter ≥ 40 microns, and that four out of the six ESS tested for charge/mass produced sprays of at least 0.1 mC/kg. A minimal wrap-around effect of the spray deposition onto a cylindrical object was observed. The loss of disinfectant active ingredient to the air due to spraying was minimal for the two disinfectants tested, and concurrently, the active ingredient concentrations of the liquid disinfectants sprayed and collected 3 feet (1 meter) away from the spray nozzle do not decrease.

Environmental persistence of a highly pathogenic avian influenza (H5N1) virus.

Human cases of disease caused by highly pathogenic avian influenza (HPAI) viruses of the H5N1 subtype are rare, yet characterized with a mortality rate of approximately 60%. Tests were conducted to determine the environmental persistence of an HPAI (H5N1) virus on four materials (glass, wood, galvanized metal, and topsoil) that could act as fomites or harbor the virus. Test coupons were inoculated with the virus and exposed to one of five environmental conditions that included changes in temperature, relative humidity, and simulated sunlight. At time periods up to 13 days, the virus was extracted from each coupon, and quantified via cytopathic effects on Madin-Darby canine kidney cells. The virus was most persistent under the low temperature condition, with less than 1 log reduction on glass and steel after 13 days at low relative humidity. Thus, at these conditions, the virus would be expected to persist appreciably beyond 13 days.

Adsorption of chlorine dioxide gas on activated carbons.

Research and field experience with chlorine dioxide (ClO2) gas to decontaminate structures contaminated with Bacillus anthracis spores and other microorganisms have demonstrated the effectiveness of this sterilant technology. However, because of its hazardous properties, the unreacted ClO2, gas must be contained and captured during fumigation events. Although activated carbon has been used during some decontamination events to capture the ClO2 gas, no data are available to quantify the performance of the activated carbon in terms of adsorption capacity and other sorbent property operational features. Laboratory experiments were conducted to determine and compare the ClO2 adsorption capacities of five different types of activated carbon as a function of the challenge ClO2 concentration. Tests were also conducted to investigate other sorbent properties, including screening tests to determine gaseous species desorbed from the saturated sorbent upon warming (to provide an indication of how immobile the ClO2 gas and related compounds are once captured on the sorbent). In the adsorption tests, ClO2 gas was measured continuously using a photometric-based instrument, and these measurements were verified with a noncontinuous method utilizing wet chemistry analysis. The results show that the simple activated carbons (not impregnated or containing other activated sorbent materials) were the most effective, with maximum adsorption capacities of approximately 110 mg/g. In the desorption tests, there was minimal release of ClO(2) from all sorbents tested, but desorption levels of chlorine (Cl2) gas (detected as chloride) varied, with a maximum release of nearly 15% of the mass of ClO2 adsorbed.

The future of emergency medicine.

BACKGROUND: The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care. SUMMARY: In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to-and will continue to contribute to-a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EM's future; 7) It is important that all providers of emergency care receive continuing postgraduate education.

The future of emergency medicine.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem. In July 2009, representatives of the leading emergency medicine organizations met in Dallas, TX, for the Future of Emergency Medicine Summit. This consensus document, agreed to and cowritten by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty.

The use of ozone gas for the inactivation of Bacillus anthracis and Bacillus subtilis spores on building materials.

A study was conducted to assess the efficacy of ozone gas in inactivating spores of both Bacillus anthracis and Bacillus subtilis inoculated onto six building materials (glass, wood, carpet, laminate, galvanized metal, and wallboard paper). Testing conditions consisted of ozone gas concentrations ranging from 7,000-12,000 parts per million (ppm), contact times from 4 to 12 h, and two relative humidity (RH) levels of 75 and 85%. Results showed that increasing the ozone concentration, contact time, and RH generally increased decontamination efficacy. The materials in which the highest decontamination efficacy was achieved for B. anthracis spores were wallboard paper, carpet, and wood with ≥ 6 log10 reduction (LR) occurring with 9,800 ppm ozone, 85% RH, for 6 h. The laminate and galvanized metal materials were generally more difficult to decontaminate, requiring 12,000 ppm ozone, 85% RH, and 9-12 h contact time to achieve ≥6 LR of B. anthracis. Lastly, overall, there were no significant differences in decontamination efficacy between the two species.

Correlation of sonographic measurements of the internal jugular vein with central venous pressure.

Determination of volume status is crucial in treating acutely ill patients. This study examined bedside ultrasonography of the internal jugular vein (IJV) to predict central venous pressure (CVP). Ultrasonography was performed on 34 nonventilated patients with monitored CVPs. The IJV was measured during the respiratory cycle and with the patient in different positions. Mean IJV diameter in patients with CVP less than 10 cm H2O was 7.0 mm (95% confidence interval [CI], 5.7-8.3) vs 12.5 mm (95% CI, 11.2-13.8) in patients with CVP of 10 cm H2O and greater. Measurement of end expiratory diameter with the patient supine had the highest correlation coefficient: 0.82 (95% CI). There was strong agreement among ultrasonographers: correlation coefficient, 0.92 (95% CI). This pilot study shows promise that ultrasonography of the IJV can be a noninvasive tool to predict CVP. Measurement of end expiratory diameter in supine patients exhibited a high correlation to CVP.

Influence of environmental conditions on the attenuation of ricin toxin on surfaces.

Ricin is a highly-toxic compound derived from castor plant beans. Several incidents involving contamination of residences and buildings due to ricin production or dissemination have occurred in recent years. The goal of this study was to determine whether ricin bioactivity could be attenuated in reasonable time via simple modifications of the indoor environment. Attenuation was assessed on six different materials as a function of temperature, relative humidity (RH), and contact time, using both a pure and crude preparation of the toxin. Ricin bioactivity was quantified via a cytotoxicity assay, and attenuation determined as the difference in ricin recovered from test and positive controls. The results showed that pure ricin could be attenuated successfully, while the crude ricin was generally more persistent and results more variable. We found no significant attenuation in crude ricin after two weeks at typical indoor environmental conditions, except on steel. Attenuation mostly improved with increasing temperature, but the effect of RH varied. For pure ricin, heat treatments at 40°C for 5 days or 50°C for 2-3 days achieved greater than 96% attenuation on steel. In contrast, appreciable recovery of the crude ricin preparation still occurred at 40°C after two weeks.