Chemical-Biological Terrorism and Its Impact on Children.

Chemical and biological events (including infectious disease outbreaks) may affect children disproportionately, and the threat of a chemical or biological attack remains in the United States and worldwide. Although federal programs and funding support a broad range of federal initiatives for public health preparedness and response, funding at the state and local levels has been flat or is decreasing, potentially leaving communities vulnerable. Consequently, pediatricians need to prepare and be ready to care for children in their communities before, during, and after a chemical or biological event, including during long-term recovery. Some medical countermeasures for particular chemical and biological agents have not been adequately studied or approved for children. The American Academy of Pediatrics provides resources and education on disaster preparedness and response, including information on the pediatrician's role in disasters, pediatric medical countermeasures, and mental health after an event as well as individual and family preparedness. This policy statement addresses the steps that clinicians and policy makers can take to protect children and mitigate the effects of a chemical or biological attack.

A Systematic Review of Risk Analysis Tools for Differentiating Unnatural From Natural Epidemics.

INTRODUCTION: In the era of genetic engineering of pathogens, distinguishing unnatural epidemics from natural ones is a challenge. Successful identification of unnatural infectious disease events can assist in rapid response, which relies on a sensitive risk assessment tool used for the early detection of deliberate attacks (i.e., bioterrorism). METHODS: A systematic review was conducted according to the outline of Preferred Reporting Items for Systematic Reviews. Published papers related to the detection of unnatural diseases were searched in MEDLINE (January 1927-April 2016), EMBASE (January 1937-March 2016), and Web of Science (January 1978-March 2016). Full texts were reviewed for the selection of studies on scoring systems specially designed to discern between unnatural and natural outbreaks. RESULTS: A total of 1,753 papers were reviewed, of which we identified the following five scoring systems specifically designed for detecting unnatural outbreaks: (1) the Grunow-Finke epidemiological assessment tool, (2) potential epidemiological clues to a deliberate epidemic, (3) bioterrorism risk assessment scoring, (4) and (5) two modified scoring systems based on (3). Various criteria ranging from the information on perpetrators, type of agents, spatial distribution, and intelligence of deliberate release were involved. Of these systems, the Grunow-Finke assessment tool remains the most widely used, but has low sensitivity for correctly identifying unnatural epidemics when tested against actual historical outbreaks. Others were applied into a few scenarios but provided different perspectives for bioterrorism detection and bio-preparedness. CONCLUSION: There are few risk assessment tools for differentiating unnatural from natural epidemics. These tools are increasingly necessary and valuable, but improved scoring systems with higher sensitivity, specificity, timeliness, and wider application to biological attacks must be developed.

[Characteristic and classification of biological agents]. / Charakterystyka i klasyfikacja czynników biologicznych.

Respiratory tract infections are caused by biological pathogens, which are found in the environment around us. They cause inflammation of varying severity, threatening the health and lives. For this reason they can be used as a biological weapon. Dealing with victims requires special diagnostic and therapeutic procedures. In some cases, it is necessary to quarantine patients and apply an intensive treatment in specialized centers.

The national framework and consequence management guidance following a biological attack.

Consequence management following a release of aerosolized Bacillus anthracis spores requires a high level of technical understanding and direction. National policies and regulations address the topics of preparedness goals and organizational structure, but they do not tell responders how to perform remediation. Essential considerations include determining what must be cleaned, evaluating health risks, ascertaining the priority of cleanup, and selecting appropriate decontamination technologies to meet consensus and risk-derived clearance goals. This article highlights key features of a national-level framework that has been developed to guide a risk-based decision process and inform technical personnel of the best practices to follow during each activity leading to the restoration of functions at affected facilities or areas. The framework and associated guidance follows the scheme of 6 phases for response and recovery arrived at through interagency consensus and approval. Each phase is elaborated in a series of detailed decision flowcharts identifying key questions that must be addressed and answered from the time that first indications of a credible biological attack are received to final reoccupancy of affected areas and a return to normal daily functions.

A review of sentinel laboratory performance: identification and notification of bioterrorism agents.

CONTEXT: The anthrax incident of 2001 in the United States prompted the College of American Pathologists (CAP), the Association of Public Health Laboratories, and the Centers for Disease Control and Prevention to develop exercises for Laboratory Response Network (LRN) sentinel laboratories. OBJECTIVE: To provide an overview of the results of the CAP bioterrorism Laboratory Preparedness Survey (LPS, 2007) and Laboratory Preparedness Exercise (LPX, 2008) and assist LRN sentinel laboratories and public health agencies in planning for bioterrorism events. DESIGN: Bioterrorism agents and nonbiothreat mimic organisms were provided in 2 mailings per year (2007 and 2008, 20 total challenges). Within each mailing, 2 to 3 agents were category A or category B bioterrorism agents (total of 10 categoric challenges). Some category A/B isolates were modified/vaccine strains. The total number of laboratories participating in these exercises ranged from 1316 to 1381. Isolate characteristics used to identify the organisms were compiled along with the participants' reporting actions. Educational commentary was provided with each exercise. RESULTS: Acceptable identification responses were as follows: Bacillus anthracis, 90% (2007) and 99.9% (2008); Yersinia pestis, 83.8% (2007) and 87.6% (2008); and Francisella tularensis subsp Holarctica, 86.6% (2007) and 91.6% (2008). The time interval between specimen receipt and notification of results to an LRN reference laboratory decreased from more than 10 days in 2007 to 3 or 4 days in 2008 for some challenges. CONCLUSIONS: The bioterrorism challenge program (LPS, LPX) provides important comparative data from more than 1300 sentinel laboratories that can be used by individual laboratories to evaluate their identification and LRN reporting performance.

Bioterrorism and invasive species.

The risk of dispersing invasive species, especially human pathogens, through acts of bioterrorism, cannot be neglected. However, that risk appears quite low in comparison with the risk of dispersing animal pathogens that could dramatically burden the agricultural economy of food animal producing countries, such as Australia and countries in Europe and North and South America. Although it is not directly related to bioterrorism, the intentional release of non-native species, particularly undesired companion animals or wildlife, may also have a major economic impact on the environment and, possibly, on animal and human health, in the case of accidental release of zoonotic agents.

Reclassifying bioterrorism risk: are we preparing for the proper pathogens?

Existing classifications of potential biological weapons, acknowledge only limited important parameters of biological weapon potential. Certain pathogen factors would further influence the outcome of a potential attack in context with social and political aspects of the time and space of the attack. The importance of these factors was investigated through various attack scenarios that have been developed by the authors, and an individual score for each of these factors was calculated, based on the overall effect their variation had in the scenario outcome. A new classification score for potential biological weapons was subsequently developed, one, which drastically alters the perception of risk for certain pathogens, such as filoviruses and anthrax. This frame further allows for more accurate evaluation of the bioweapon potential of agents such as avian flu. Recognition of intervening factors and proper assessment of the actual risk might augment in proper distribution of interest and funds on relevant medical research.

Biological terrorism.

A biological terrorism event could have a large impact on the general population and health care system. The impact of an infectious disaster will most likely be great to emergency departments, and the collaboration between emergency and infectious disease specialists will be critical in developing an effective response. A bioterrorism event is a disaster that requires specific preparations beyond the usual medical disaster planning. An effective response would include attention to infection control issues and plans for large-scale vaccination or antimicrobial prophylaxis. This article addresses some general issues related to preparing an effective response to a biological terrorism event. It will also review organisms and toxins that could be used in biological terrorism, including clinical features, management, diagnostic testing, and infection control.

The effectiveness of ICD-10-CM in capturing public health diseases.

This research study examined the usefulness of the ICD-10-CM system in capturing public health diseases (reportable diseases or the nationally notifiable infectious diseases, leading causes of death, and morbidity/mortality related to terrorism), when compared to ICD-9-CM.1-3 It also examined agreement levels of coders when coding public health diseases in both ICD-10-CM and ICD-9-CM. Overall results demonstrate that ICD-10-CM is more specific and fully captures more of the public health diseases examined than ICD-9-CM. In the analysis of all the public health diseases, such as reportable diseases (p<0.001), top 10 causes of death (p<0.001), and those related to terrorism (p<0.001), it was found that the overall rankings for disease capture for ICD-10-CM were significantly higher than the rankings for ICD-9-CM. When examining whether diseases were captured more straightforwardly and clearly (regarding agreement levels) between coding systems, statistically significant differences were found for external causes of injury (p<0.001), diabetes (average rank only, p<0.05), lower respiratory disease (p<0.001), heart disease (p<0.001), and malignant neoplasms (p<0.05). Although this result may be due to the coder's higher level of experience with ICD-9-CM, it also points to the potential need for more specific coding education and practice with the ICD-10-CM system.

Development of a risk-priority score for category A bioterrorism agents as an aid for public health policy.

In developing public health policy and planning for a bioterrorist attack or vaccination of military personnel, the most common method for assigning priority is using the probability of attack with a particular agent as the single criterion. Using this approach, smallpox is often dismissed as an unlikely threat. We aimed to develop an evidence-based, systematic, multifactorial method for prioritizing the level of risk of each category A bioterrorism agent. Using 10 criterion, anthrax scored the highest, followed by smallpox. Tularemia was the lowest scoring agent. We suggest that such a system would be useful for developing public policy, stockpiling of vaccines and therapeutics, vaccination of military personnel, and planning for public health responses to a bioterrorist attack.

Generating a reliable reference standard set for syndromic case classification.

OBJECTIVE: To generate and measure the reliability for a reference standard set with representative cases from seven broad syndromic case definitions and several narrower syndromic definitions used for biosurveillance. DESIGN: From 527,228 eligible patients between 1990 and 2003, we generated a set of patients potentially positive for seven syndromes by classifying all eligible patients according to their ICD-9 primary discharge diagnoses. We selected a representative subset of the cases for chart review by physicians, who read emergency department reports and assigned values to 14 variables related to the seven syndromes. MEASUREMENTS: (1) Positive predictive value of the ICD-9 diagnoses; (2) prevalence of the syndromic definitions and related variables; (3) agreement between physician raters demonstrated by kappa, kappa corrected for bias and prevalence, and Finn's r; and (4) reliability of the reference standard classifications demonstrated by generalizability coefficients. RESULTS: Positive predictive value for ICD-9 classification ranged from 0.33 for botulinic to 0.86 for gastrointestinal. We generated between 80 and 566 positive cases for six of the seven syndromic definitions. Rash syndrome exhibited low prevalence (34 cases). Agreement between physician raters was high, with kappa > 0.70 for most variables. Ratings showed no bias. Finn's r was >0.70 for all variables. Generalizability coefficients were >0.70 for all variables but three. CONCLUSION: Of the 27 syndromes generated by the 14 variables, 21 showed high enough prevalence, agreement, and reliability to be used as reference standard definitions against which an automated syndromic classifier could be compared. Syndromic definitions that showed poor agreement or low prevalence include febrile botulinic syndrome, febrile and nonfebrile rash syndrome, respiratory syndrome explained by a nonrespiratory or noninfectious diagnosis, and febrile and nonfebrile gastrointestinal syndrome explained by a nongastrointestinal or noninfectious diagnosis.

Forensic dentistry in a terrorist world.

While body identification by dental means has not changed substantially since 9/11, or even since the bombing of the Murrah Federal Building in Oklahoma City in 1995, the conditions and potential risks of a bioterrorism action to the dental personnel is new. The purpose of this article is to review general forensic dentistry disaster responses and to address the impact a bioterrorism action might have on primary, secondary and tertiary dental responders. It will also examine the triage role that dental offices might play in the event of such a disaster.

Potential use of microarray technology for rapid identification of central nervous system pathogens.

Outbreaks of central nervous system (CNS) diseases result in significant productivity and financial losses, threatening peace and wartime readiness capabilities. To meet this threat, rapid clinical diagnostic tools for detecting and identifying CNS pathogens are needed. Current tools and techniques cannot efficiently deal with CNS pathogen diversity; they cannot provide real-time identification of pathogen serogroups and strains, and they require days, sometimes weeks, for examination of tissue culture. Rapid and precise CNS pathogen diagnostics are needed to provide the opportunity for tailored therapeutic regimens and focused preventive efforts to decrease morbidity and mortality. Such diagnostics are available through genetic and genomic technologies, which have the potential for reducing the time required in serogroup or strain identification from 500+ hours for some viral cultures to less than 3 hours for all pathogens. In the near future, microarray diagnostics and future derivations of these technologies will change the paradigm used for outbreak investigations and will improve health care for all.