Tularemia as a biological weapon: medical and public health management.

OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if tularemia is used as a biological weapon against a civilian population. PARTICIPANTS: The working group included 25 representatives from academic medical centers, civilian and military governmental agencies, and other public health and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to October 2000, using the Medical Subject Headings Francisella tularensis, Pasteurella tularensis, biological weapon, biological terrorism, bioterrorism, biological warfare, and biowarfare. Review of these references led to identification of relevant materials published prior to 1966. In addition, participants identified other references and sources. CONSENSUS PROCESS: Three formal drafts of the statement that synthesized information obtained in the formal evidence-gathering process were reviewed by members of the working group. Consensus was achieved on the final draft. CONCLUSIONS: A weapon using airborne tularemia would likely result 3 to 5 days later in an outbreak of acute, undifferentiated febrile illness with incipient pneumonia, pleuritis, and hilar lymphadenopathy. Specific epidemiological, clinical, and microbiological findings should lead to early suspicion of intentional tularemia in an alert health system; laboratory confirmation of agent could be delayed. Without treatment, the clinical course could progress to respiratory failure, shock, and death. Prompt treatment with streptomycin, gentamicin, doxycycline, or ciprofloxacin is recommended. Prophylactic use of doxycycline or ciprofloxacin may be useful in the early postexposure period.

Bioterrorism preparedness: planning for the future.

The release of nerve gas in a Tokyo subway and attempted releases of biological agents by the Aum Shinrikyo cult have demonstrated the willingness and ability of modern-day terrorists to use unconventional weapons. Unlike explosive weapons, the use of biologic weapons may only become apparent once people become ill. The detection and response to these man-made outbreaks will occur initially at the medical and public health levels. Therefore, the Centers for Disease Control and Prevention and its partners are strengthening their response, disease detection, diagnostic, and communication capabilities to better protect the nation's citizens against biological or chemical terrorism.

Emergency department impact of the Oklahoma City terrorist bombing.

STUDY OBJECTIVE: To collect descriptive epidemiologic injury data on patients who suffered acute injuries after the April 19, 1995, Oklahoma City bombing and to describe the effect on metropolitan emergency departments. METHODS: A retrospective review of the medical records of victims seen for injury or illness related to the bombing at 1 of the 13 study hospitals from 9:02 AM to midnight April 19, 1995. Rescue workers and nontransported fatalities were excluded. RESULTS: Three hundred eighty-eight patients met inclusion criteria; 72 (18.6%) were admitted, 312 (80.4%) were treated and released, 3 (.7%) were dead on arrival, and 1 had undocumented disposition. Patients requiring admission took longer to arrive to EDs than patients treated and released (P =.0065). The EDs geographically closest to the blast site (1.5 radial miles) received significantly more victims than more distant EDs (P <.0001). Among the 90 patients with documented prehospital care, the most common interventions were spinal immobilization (964/90, 71.1%), field dressings (40/90, 44.4%), and intravenous fluids (32/90, 35.5%). No patients requiring prehospital CPR survived. Patients transported by EMS had higher admission rates than those arriving by any other mode (P <.0001). The most common procedures performed were wound care and intravenous infusion lines. The most common diagnoses were lacerations/contusion, fractures, strains, head injury, abrasions, and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and analgesics were the most common pharmaceutical agents used. Plain radiology, computed tomographic radiology, and the hospital laboratory were the most significantly utilized ancillary services. CONCLUSION: EMS providers tended to transport the more seriously injured patients, who tended to arrive in a second wave at EDs. The closest hospitals received the greatest number of victims by all transport methods. The effects on pharmaceutical use and ancillary service were consistent with the care of penetrating and blunt trauma. The diagnoses in the ED support previous reports of the complex but often nonlethal nature of bombing injuries.

Chemical warfare agents: emergency medical and emergency public health issues.

The threat of exposure to chemical warfare agents has traditionally been considered a military issue. Several recent events have demonstrated that civilians may also be exposed to these agents. The intentional or unintentional release of a chemical warfare agent in a civilian community has the potential to create thousands of casualties, thereby overwhelming local health and medical resources. The resources of US communities to respond to chemical incidents have been designed primarily for industrial agents, but must be expanded and developed regarding incident management, agent detection, protection of emergency personnel, and clinical care. We present an overview of the risk that chemical warfare agents presently pose to civilian populations and a discussion of the emergency medical and emergency public health issues related to preparedness and response.

Medical and public health services at the 1996 Atlanta Olympic Games: an overview.

Planning for the 2000 Sydney Olympic Games may benefit from the experience of the 1996 Atlanta Olympics. Excellent health promotion and prevention activities before and during the Games resulted in fewer medical and public health problems than anticipated. Despite this, there was room for improvement in the level of communication and cooperation between the many service providers to ensure the most appropriate and efficient responses.

Strategic disaster preparedness and response: implications for military medicine under joint command.

With the end of the Cold War, renewed emphasis has been placed on humanitarian assistance such as disaster relief, refugee management, and humanitarian intervention during conflicts by the military forces of all nations. The role of the military in humanitarian assistance has been the subject of much recent debate, as the ability of the United States to mount an effective emergency response is linked to our nation's strategic policy and planning. This article describes and broadens the understanding of the evolving concepts of strategic disaster management and the role of Joint Military Commands in providing disaster relief. Examples of strategic humanitarian relief operations are discussed.

The rapid implementation of a statewide emergency health information system during the 1993 Iowa flood.

In the face of disastrous flooding, the Iowa Department of Public Health established the statewide Emergency Computer Communications Network to establish rapid electronic reporting of disaster-related health data, provide e-mail communications among all county health departments, monitor the long-range public health effects of the disaster, and institute a general purpose public health information system in Iowa. Based on software (CDC WONDER/PC) provided by the Centers for Disease Control and Prevention and using standard personal computers and modems, this system has resulted in a 10- to 20-fold increase in surveillance efficiency at the health department, not including time saved by county network participants. It provides a critical disaster assessment capability to the health department but also facilitates the general practice of public health.

Complex, humanitarian emergencies: III. Measures of effectiveness.

Complex humanitarian emergencies lack a mechanism to coordinate, communicate, assess, and evaluate response and outcome for the major participants (United Nations, International Committee of the Red Cross, non-governmental organizations and military forces). Success in these emergencies will depend on the ability to accomplish agreed upon measures of effectiveness (MOEs). A recent civil-military humanitarian exercise demonstrated the ability of participants to develop consensus-driven MOEs. These MOEs combined security measures utilized by the military with humanitarian indicators recognized by relief organizations. Measures of effectiveness have the potential to be a unifying disaster management tool and a partial solution to the communication and coordination problems inherent in these complex emergencies.

Drug susceptibility of Mycobacterium tuberculosis isolates from recent Haitian migrants: correlation with clinical response.

Between November 1991 and June 1993, approximately 11,000 Haitian migrants were screened for active tuberculosis and human immunodeficiency virus type 1 (HIV-1) infection at the U.S. Naval Base in Guantánamo Bay, Cuba. Cultures of specimens from 37 of these patients yielded Mycobacterium tuberculosis; eight (22%) of these isolates were resistant to standard medications, including isoniazid (22%), rifampin (0), ethambutol (3%), and streptomycin (3%). Two isolates (5.4%) were resistant to two drugs simultaneously. All but one of 340 patients who were treated for presumptive active tuberculosis and who were followed up for about 1 month had a favorable initial clinical response to a standard four-drug regimen. Among 259 HIV-1-infected patients who had normal findings on screening chest radiographs and who received prophylaxis with isoniazid, there were 1.8 incident cases of active tuberculosis per 100 person-years; this rate was 76% lower than that (reported by others) among HIV-1-infected Haitian patients who were not treated with isoniazid. No serious toxic effects due to standard four-drug regimens or to prophylaxis with isoniazid were observed. These data suggest that standard empirical therapeutic interventions for tuberculosis are adequate and well tolerated in Haitian migrants.

Disaster medical assistance teams: providing health care to a community struck by Hurricane Iniki.

STUDY OBJECTIVE: To describe the type of medical care that disaster medical assistance teams (DMATs) provided to a community struck by a major hurricane. STUDY DESIGN: A prospective study describing the use of DMAT field clinics by a population affected by a major hurricane. Data regarding the type of medical care provided to disaster victims and the acuity of each patient's medical condition were abstracted from medical charts at each field clinic. SETTING: Three DMAT field clinics that provided medical care to residents of Kauai, Hawaii, after Hurricane Iniki struck the island on September 11, 1992. RESULTS: From September 16 to 19, 1992, three DMATs provided medical care to 614 people. The patients' average age was 34 years, and 60% were male. The largest treatment categories were injury (40.4%), illness (38.6%), and preventive services (9.0%). Most illnesses and injuries were minor, and 99% of the patients were ambulatory. Only 33 patients (5.4%) were referred to another medical provider. Referrals were generally for procedures not available in DMAT field clinics rather than for life-threatening conditions. CONCLUSION: DMATs sent to assist with the medical needs of a US community struck by a major hurricane should be prepared to deliver basic medical services and primary health care. The need for these medical services will continue beyond the impact phase of a hurricane disaster.

Haitian mass migration: Uniformed Service medical support, May 1992.

Beginning in November 1991, the United States Department of Defense established a Joint Task Force (JTF) to deal with the mass migration of Haitians. During the next 9 months, pending a determination of their immigration status, 34,000 Haitians were managed by uniformed service personnel at a temporary camp facility at the U.S. Naval Base in Guantanamo Bay, Cuba. To meet the urgent clinical and public health needs of this population, the JTF developed a camp medical system. This article describes the system of uniformed service medical support for the Haitians at the Guantanamo Bay facility during May 1992, the busiest month of the operation, when 11,400 Haitians (34% of the total) arrived.

Disaster assessment: the emergency health evaluation of a population affected by a disaster.

In the past decade, interest in the operational and epidemiologic aspects of disaster medicine has grown dramatically. State, local, and federal organizations have created vast emergency response networks capable of responding to disasters, while hospitals have developed extensive disaster plans to address mass casualty situations. Increasingly, the US armed forces have used both their ability to mobilize quickly and their medical expertise to provide humanitarian assistance rapidly during natural and man-made disasters. However, the critical component of any disaster response is the early conduct of a proper assessment to identify urgent needs and to determine relief priorities for an affected population. Unfortunately, because this component of disaster management has not kept pace with other developments in emergency response and technology, relief efforts often are inappropriate, delayed, or ineffective, thus contributing to increased morbidity and mortality. Therefore, improvements in disaster assessment remain the most pressing need in the field of disaster medicine.