The CODE RED Solution: biothreat response training for first responders

The terrorist events of 2001 brought to light the need for a close working relationship between the first responder communities and the public health laboratories in New York State (NYS). Since 2002, the Wadsworth Center's Biodefense Laboratory (BDL) has been providing outreach training to first responders in New York, to enable them to respond safely, correctly, and confidently to biothreat events. A pocket trifold was developed, titled "CODE RED," which describes sampling protocols, risk analysis criteria, and important contact information for use during an emergency response to a potential bioterrorism situation. In addition, the BDL has provided training to more than 1,000 first responders in the basic knowledge of biothreat agents, routes of dissemination, sampling and decontamination methods, contamination control protocols, biothreat risk assessment, and legal chain of custody procedures. The training methods have been established for use by first responders wearing personal protective equipment (PPE). All states can benefit from highly trained first responders who are capable of efficient, safe, and effective biothreat response, resulting in increased safety of the first responders and laboratorians, as well as decreased turnaround times for laboratory results. The CODE RED trifold provides a working model for training first responders at the state and county levels for emergency biothreat response.     

A psychosocial risk assessment and management framework to enhance response to CBRN terrorism threats and attacks

Evidence in the disaster mental health literature indicates that psychosocial consequences of terrorism are a critical component of chemical, biological, radiological, and nuclear (CBRN) events, both at the clinical level and the normal behavioral and emotional levels. Planning for such psychosocial aspects should be an integral part of emergency preparedness. As Canada and other countries build the capacity to prevent, mitigate, and manage CBRN threats and events, it is important to recognize the range of social, psychological, emotional, spiritual, behavioral, and cognitive factors that may affect victims and their families, communities, children, the elderly, responders, decision makers, and others at all phases of terrorism, from threat to post-impact recovery. A structured process to assist CBRN emergency planners, decision makers, and responders in identifying psychosocial risks, vulnerable populations, resources, and interventions at various phases of a CBRN event to limit negative psychosocial impacts and promote resilience and adaptive responses is the essence of our psychosocial risk assessment and management (P-RAM) framework. This article presents the evidence base and conceptual underpinnings of the framework, the principles underlying its design, its key elements, and its use in the development of decision tools for responders, planners, decision makers, and the general public to better assess and manage psychosocial aspects of CBRN threats or attacks.     

Willingness of New England dental professionals to provide assistance during a bioterrorism event

A bioterrorism attack could overwhelm medical personnel and facilities, suggesting a need for aid from nonmedical personnel. The American Dental Association suggests that dental professionals should assist in such cases, utilizing their strong scientific and technical skills. This study describes New England dental professionals' willingness, potential roles, motivators, and barriers to providing this aid. This cross-sectional study used a self-administered survey to collect data addressing the knowledge and opinions of dental professionals concerning acting as responders. The survey was distributed to 370 attendees of the 2005 Yankee Dental Conference, in Boston, Massachusetts. Most dental professionals expressed willingness to help during an attack (N = 340, 92%), reporting that dental professionals, in general, should perform a mean number of 6 roles. Three-quarters of dentists and dental students were personally willing, with proper training, to give immunizations, and 54% would perform triage. Knowledge was weak, but most dental professionals were interested in obtaining further education (83%). Since dental professionals are willing to assist during a bioterrorism attack and are motivated to obtain disaster response training, government officials and local directors and managers of disaster/emergency response agencies should consider incorporating dental professionals into their disaster management plans.     

Public Health Response Systems In-Action: Learning from Local Health Departments’ Experiences with Acute and Emergency Incidents

As part of their core mission, public health agencies attend to a wide range of disease and health threats, including those that require routine, acute, and emergency responses. While each incident is unique, the number and type of response activities are finite; therefore, through comparative analysis, we can learn about commonalities in the response patterns that could improve predictions and expectations regarding the resources and capabilities required to respond to future acute events. In this study, we interviewed representatives from more than 120 local health departments regarding their recent experiences with real-world acute public health incidents, such as infectious disease outbreaks, severe weather events, chemical spills, and bioterrorism threats. We collected highly structured data on key aspects of the incident and the public health response, particularly focusing on the public health activities initiated and community partners engaged in the response efforts. As a result, we are able to make comparisons across event types, create response profiles, and identify functional and structural response patterns that have import for future public health preparedness and response. Our study contributes to clarifying the complexity of public health response systems and our analysis reveals the ways in which these systems are adaptive to the character of the threat, resulting in differential activation of functions and partners based on the type of incident. Continued and rigorous examination of the experiences of health departments throughout the nation will refine our very understanding of what the public health response system is, will enable the identification of organizational and event inputs to performance, and will allow for the construction of rich, relevant, and practical models of response operations that can be employed to strengthen public health systems.     

School nurses as volunteers in a bioterrorism event

Most public health departments do not have enough public health nurses to adequately respond to a bioterrorist attack or other large-scale health emergency and would need to look to volunteers to help with staffing needs in an emergency. The National Association of School Nurses supports the use of school nurses, a skilled workforce, as responders in a mass casualty event, whether it is naturally occurring or as a result of bioterrorism. This article explores the use of school nurses to supplement public health staff during an emergency. A Likert-scale survey was used to assess the preparedness and willingness of school nurses to respond to a health threat. Although school nurses are willing to respond, the findings highlight the importance of continued education on risk and personal protection.     

The HIPAA privacy rule and bioterrorism planning, prevention, and response

Effective bioterrorism planning, prevention, and response require information sharing between various entities, ranging from public health authorities and health-care workers to national security and law enforcement officials. While the source of much information exchanged may be nonidentifiable, many entities legitimately need access to personally identifiable health information (or "protected health information" [PHI]) in planning for and responding to a bioterrorism event. The HIPAA Privacy Rule allows for essential exchanges of health data during a public health emergency while protecting against unnecessary disclosures of PHI. In the event of a bioterrorist attack, the Privacy Rule allows covered entities to disclose PHI without individual authorization in the following instances: (1) for treatment by health-care providers, (2) to avert a serious threat to health or safety, (3) to public health authorities for public health purposes, (4) to protect national security, (5) to law enforcement under certain conditions, and (6) for judicial or administrative proceedings. Despite these favorable disclosure provisions, some privacy challenges remain. The flow of PHI may be slowed by misunderstandings of the Privacy Rule's accounting requirement. In addition, in a bioterrorism scenario, nontraditional entities may find themselves acting as health-care providers, triggering Privacy Rule provisions. Finally, the potential for de facto disclosures of individuals' disease or exposure status increases where conspicuous treatment methods, isolation, or quarantine are implemented without additional measures to protect privacy. Understanding the Privacy Rule's impact on bioterrorism planning and response ensures that various entities can conduct their activities with needed information while still protecting individual privacy.     

Managing biosecurity threats in China

Compared to the extensive literature on bioterrorism and biosecurity in the United States, less analysis has been conducted on similar challenges in China. This article seeks to fill this void by providing an integrated and updated assessment of 3 major biosecurity threats China faces: biowarfare, bioterrorism, and biocrimes. An analysis of China's biosecurity threats and biodefense building suggest varying levels of risk associated with each threat type. First, a direct bioweapons attack on China is highly unlikely, although the threat of biowarfare cannot be simply written off. Second, potential perpetrators of bioterrorism have capabilities at their disposal for carrying out such attacks. While terrorist organizations in China do not have a strong interest in bioterrorism, the limited state capability to counter such a threat may increase the risk in the future. Third, unlike the threats of biowarfare and bioterrorism, potential perpetrators of biocrimes have both incentives and capabilities, and biocrimes can produce reactions far out of proportion to the actual number of casualties. Despite the distinct biosecurity challenges it faces, China has yet to articulate a differentiated and coherent strategy to effectively tackle the challenges. Assessing different types of biosecurity threats in terms of degrees of risk not only provides greater analytical clarity but also has important implications for the strategies required to manage the risks.     

Hazards,threats and risks: lessons from the past to a defensive attitude for the future

Since ever infectious diseases have been a major hazard for the armed forces in operations. Nowadays our nations are facing the threat of terrorism, including bioterrorism. This threat is much more related to the potential disorganization of the society than to the lethal effects of the agents. Biological weapons are considered more like terror weapons than like mass destruction weapons, hence the importance of preparing specific defence measures. The know-how acquired from the struggle against natural infectious diseases is a useful help to face the biological weapon threats and risks. Likewise, the defence attitude is based on three pillars: anticipating, managing, and restoring. This military as well as civilian defence attitude applies to six important functions: (1) alert, (2) detection, diagnosis and identification, (3) medical countermeasures (drugs, vaccines and sera), (4) medical care in hospital, (5) training and information, (6) research and development of dedicated technologies.     

Are community health centers prepared for bioterrorism?

Community health centers (CHCs) are essential in the delivery of primary care services to underserved populations. Given the critical function of CHCs, surprisingly little is known about their role in preparing for or responding to acts of terrorism. This survey-based study examines the state of CHCs in terrorism preparedness and assesses their training needs. Of the administrators who responded to the survey, 87% indicated that their centers had an emergency response or disaster plan. Of those, 78% indicated they had updated their plans within the past year. Among those who had a written plan, 41% addressed bioterrorism preparedness, 38% had contingencies for a mass influx of patients, and 3% indicated that their plans addressed increasing operational capacity. Additionally, while 48% reported having assessed the education and training needs of their professional staff in the area of disease surveillance and reporting, only 24% had assessed these needs in relation to bioterrorism. Our findings suggest that CHCs have made great strides in preparing for some emergencies but that preparedness does not yet extend to specifically include terrorism events. Policy and practice recommendations are included to more fully develop CHCs as a resource.     

Global crop improvement networks to bridge technology gaps

To ensure future food security, there is an urgent need for improved co-ordination of agricultural research. While advances in biotechnology hold considerable promise, significant technology gaps exist that may reduce their impact. Examples include an incomplete knowledge of target breeding environments, a limited understanding and/or application of optimal crop management practices, and underfunded extension services. A better co-ordinated and more globalized approach to agricultural research through the implementation of Global Crop Improvement Networks (GCIN) is proposed. Such networks could underpin agricultural research and development by providing the following types of services: (i) increased resolution and precision of environmental information, including meteorological data, soil characteristics, hydrological data, and the identification of environmental 'hotspots' for a range of biotic, abiotic, and socio-economic constraints; (ii) augmented research capacity, including network-based variety and crop management trials, faster and more comprehensive diagnosis of emerging constraints, timely sharing of new technologies, opportunities to focus research efforts better by linking groups with similar productivity constraints and complementary skills, and greater control of experimental variables in field-based phenotyping; and (iii) increased communication and impacts via more effective dissemination of new ideas and products, the integration of information globally to elicit well-timed local responses to productivity threats, an increased profile, and the publicity of threats to food security. Such outputs would help target the translation of research from the laboratory into the field while bringing the constraints of rural communities closer to the scientific community. The GCIN could provide a lens which academia, science councils, and development agencies could use to focus in on themes of common interest, and working platforms to integrate novel research approaches on crop adaptation and rural development.     

Recruiting physicians to rural practice. Suggestions for success.

Medical school graduates from 1986 to 1988 and current residents in 12 family practice residency programs in the Northwest (N = 302) were surveyed to identify important factors in the recruitment process for their first postresidency placement. The study sought to compare the recruitment practices of rural communities and urban sites. Specific questions addressed in the study concerned sources of information about practice opportunities, stage in training when job search was initiated, factors related to unsuccessful site visits, and activities scheduled in the visit. Results indicated that referrals from faculty were the most valued source of information. Most job searches were initiated in the first 6 months of the third year in training. An unreceptive physician community and a reluctant spouse or partner were substantial problems for residents making site visits to rural communities. Rural sites tended to provide a broader mix of professional and personal activities during the visit.     

Use of the internet to enhance infectious disease surveillance and outbreak investigation

Modernization of electronic communication systems to facilitate infectious disease surveillance and outbreak investigation became a priority after the 2001 anthrax attacks. However, the extent to which communicable disease investigators are using web-based information resources, e-mail notifications, or secure information exchange systems to facilitate surveillance is unknown. To address this question, we conducted a survey in 2004 of state and local communicable disease investigators responsible for infectious disease surveillance and outbreak investigation in three states. The majority (70.7%) of the 297 respondents accessed the Internet for information regarding infectious disease surveillance and outbreaks at least weekly. Most (74%) respondents who searched for information from the Centers for Disease Control and Prevention (CDC) website reported that they found what they were looking for 75-100% of the time, compared with 54% who found the information from their state health department websites 75-100% of the time. One-third of respondents read e-mail notifications regarding outbreaks under investigation in their state less frequently than monthly; 34% of those enrolled in CDC's Epidemic Information Exchange (Epi-X) read e-mail notifications of new reports less frequently than monthly. Forty-seven (18%) respondents read ProMED-mail at least monthly, while 46% indicated they had never consulted MEDLINE/PubMed. Some progress has been made in use of the Internet to facilitate communication in infectious disease surveillance and outbreak investigation. Addressing barriers to access and usability of new information systems in conjunction with training and technical support could enhance infectious disease surveillance and timely investigation of outbreaks and bioterrorism events.     

Twitter in the Cross Fire—The Use of Social Media in the Westgate Mall Terror Attack in Kenya

On September 2013 an attack on the Westgate mall in Kenya led to a four day siege, resulting in 67 fatalities and 175 wounded. During the crisis, Twitter became a crucial channel of communication between the government, emergency responders and the public, facilitating the emergency management of the event. The objectives of this paper are to present the main activities, use patterns and lessons learned from the use of the social media in the crisis. Using TwitterMate, a system developed to collect, store and analyze tweets, the main hashtags generated by the crowd and specific Twitter accounts of individuals, emergency responders and NGOs, were followed throughout the four day siege. A total of 67,849 tweets were collected and analyzed. Four main categories of hashtags were identified: geographical locations, terror attack, social support and organizations. The abundance of Twitter accounts providing official information made it difficult to synchronize and follow the flow of information. Many organizations posted simultaneously, by their manager and by the organization itself. Creating situational awareness was facilitated by information tweeted by the public. Threat assessment was updated through the information posted on social media. Security breaches led to the relay of sensitive data. At times, misinformation was only corrected after two days. Social media offer an accessible, widely available means for a bi-directional flow of information between the public and the authorities. In the crisis, all emergency responders used and leveraged social media networks for communicating both with the public and among themselves. A standard operating procedure should be developed to enable multiple responders to monitor, synchronize and integrate their social media feeds during emergencies. This will lead to better utilization and optimization of social media resources during crises, providing clear guidelines for communications and a hierarchy for dispersing information to the public and among responding organizations.     

Rapid detection and antimicrobial resistance gene profiling of Yersinia pestis using pyrosequencing technology

When a bioterrorism attack is attempted or perpetrated there is considerable risk for public health and large scale socioeconomic consequences. It is imperative that we possess established assays for the rapid identification of biothreat agents with high sensitivity and specificity to ensure emergency response measures can be deployed appropriately. Highly trustworthy information within a relevant timeframe is required to make a rapid and informed decision. Obtaining DNA sequence data from a suspected agent provides an added layer of confidence compared to a presumptive positive PCR amplicon. Sequencing based technologies, such as pyrosequencing, have sufficient discrimination potential to be used for microbial identification and can also be used to identify antimicrobial resistance (AMR) genes. We have shown in this study the power of pyrosequencing in the unambiguous detection and identification of nine Yersinia pestis strains based on virulence genes. Furthermore, we developed assays to characterize their AMR gene profiles. Sequence results ranging from 40 to 84bp were generated in about 60 min following initial PCR amplification and provide a rapid method for determining the AMR profile as compared to the conventional plate method which takes several days. The high sequence identities (95-100%) and specificity observed indicate the high level of accuracy of pyrosequencing technology. In addition, the read lengths of up to 84 bp observed in this study are unprecedented for pyrosequencing using the Pyromark Q24. We propose this method as a novel, rapid, sequence based detection and identification tool for Y. pestis with a potential application in biodefence.     

Valuing wetland conservation: A contingent valuation analysis among Iranian beneficiaries

Wetland ecosystems conservation is a critical environmental policy and practice challenge. Though policy protection mechanisms ostensibly establish a commitment to long-term protection, the level and types of wetland threats are growing. Management of sustainable wetland resources requires community commitments to protection amongst predominantly rural stakeholders that draw upon wetland ecosystem services for their livelihoods and is vital to forming a policy strategy. This empirical study uses contingent valuation methodology with rural residents around four key wetlands areas in the ecologically fragile Khuzestan province in Iran. We find that 65% of the residents are willing to pay an amount of personal income to protect wetland ecosystems. The estimated Logit model with 84% prediction accuracy showed the variables of education and job relationship with the wetland had a positive effect on the probability of price acceptance, and the variables of living costs and marital status had a negative effect on the probability of price acceptance. In total, the conservation value of wetlands is estimated at 103351.52 USD. Finally, we assess the policy-relevance of our findings towards community windfall payments, tax disbursements, community resource management schemes, public participation, and social outreach programs to improve social learning buy-in to long-term conservation practices.     

Missouri nurses' bioterrorism preparedness

Nurses are the largest group of healthcare providers and will be at the forefront during a response to a bioterrorism attack in the U.S. However, nurses' bioterrorism risk perceptions and their participation in bioterrorism preparedness activities, such as bioterrorism-related exercises or drills, have not been evaluated. We mailed a survey to all members of the Missouri Nurses Association in July 2006, consisting of 1,528 registered nurses. The instrument measured risk perception, perceived susceptibility, perceived seriousness, bioterrorism education received, participation in exercises/drills, and personal response plan thoroughness. The response rate was 31% (474/1,528). Most respondents believe that a bioterrorism attack will occur in the U.S. (82.3%; n = 390), but few (21.3%; n = 101) believe that one will occur in their community. The majority of nurses reported that they believe that a bioterrorism attack would have serious consequences (96.1%, n = 448), including having a serious impact on U.S. citizens' safety (90.7%, n = 446) and on their own safety (84.3%, n = 379). Most (60%, n = 284) reported that they had not received any bioterrorism-related education nor participated in any drills/exercises (82.7%, n = 392). Of those who had received education, most had participated in 3 or fewer programs and in only 1 drill. Few nurses (3.6%, n = 15) reported having all aspects of a personal bioterrorism response plan; approximately 20% (19.4%, n = 81) did not have any components of a plan. Most of the registered nurses in Missouri who were surveyed are not receiving bioterrorism education, participating in bioterrorism exercises, or developing thorough personal response plans. Nurses need to be aware of and encouraged to participate in the many education and training opportunities on bioterrorism and infectious disease disasters.     

Consistency and use of information about threats in the participatory process for identification of priority conservation areas in the Brazilian Amazon

Despite the increasing number of scientific papers on the subject, conservation planning has failed to actively prioritise the creation of new protected areas. Strategies proposed to increase the creation of new protected areas based on conservation plans include broad stakeholder participation in decision-making processes in order to include their concerns and facilitate social acceptance of proposed actions. However, there are controversial views about the effectiveness of stakeholder participation. The quality of the decision depends both on the information used by stakeholders and on how it is used, so it is necessary to evaluate both these aspects of a decision-making process. Threats are intrinsically related to conservation decisions because they are more easily understood by people than biodiversity values, and they can affect both decisions and outcomes of conservation actions. This article analyses how information about threats was used in the decision-making process conducted by the Brazilian Government in 2006 to indicate priority areas for the conservation of the Amazon biome. We first verified the consistency of the information on threats attributed by stakeholders to these new priority areas, and then assessed whether the existence, levels and types of threats influenced the choice of areas for conservation. The results showed that there were some successes in recognising threats, but also many inconsistencies, especially in assigning levels of intensity for some types of threats such as fishing. The decision-making process also did not fully use available information to indicate areas for conservation. The lack of understanding on the motivation behind these inconsistencies could suggest the presence of political opportunism. A more quantitative approach to assigning priorities is needed: one that is less dependent on the individual input of stakeholders and more accurately reflects the actual emergency status of proposed areas. This indicates that greater effort should be allocated to combining a participatory approach with a robust decision support system.     

What Is the Accurate Prevalence of Obesity in Sweden in the 21st Century? Methodological Experiences From the Skaraborg Project

Objective: To examine the impact of non‐response to self‐reported body weight and height in health questionnaires for the estimation of obesity prevalence. Methods and Procedures: A cross‐sectional population‐based health survey in the community of Vara with 16,009 residents (in year 2002) in South‐western Sweden. Participants randomly selected in strata by sex and age among residents being 30–74 years old were consecutively invited to the local health care center for a health examination, including two visits. Self‐reported information on body weight and height were obtained by health questionnaires at the first visit, and measured information on both variables at the second visit. For this study 1,809 subjects (904 men and 905 women) completed both visits (participation rate 81%), and a nurse measured body weight and height of all at visit two. Participants not self‐reporting body weight and/or height at the first visit were defined as non‐responders. Results: Both male and female non‐responders were significantly older than responders. Female non‐responders had significantly higher BMI (29.8 ± 5.8 kg/m²) than female responders (26.6 ± 5.3 kg/m²), (P < 0.001). No similar findings were seen in men. Non‐responders were more likely to be obese than responders both in men (odds ratio (OR) 2.06, 95% confidence interval (CI) 1.03–4.11) and in women (OR 2.24, 95% CI 1.25–4.02). Discussion: Non‐responders to self‐reported body weight and height in health questionnaires contribute to the underestimation of obesity. Measured body weight and height are to prefer when describing the accurate prevalence of obesity in populations.     

BIRS – Bioterrorism Information Retrieval System

Bioterrorism is the intended use of pathogenic strains of microbes to widen terror in a population. There is a definite need to promote research for development of vaccines, therapeutics and diagnostic methods as a part of preparedness to any bioterror attack in the future. BIRS is an open-access database of collective information on the organisms related to bioterrorism. The architecture of database utilizes the current open-source technology viz PHP ver 5.3.19, MySQL and IIS server under windows platform for database designing. Database stores information on literature, generic- information and unique pathways of about 10 microorganisms involved in bioterrorism. This may serve as a collective repository to accelerate the drug discovery and vaccines designing process against such bioterrorist agents (microbes). The available data has been validated from various online resources and literature mining in order to provide the user with a comprehensive information system.

Availability

The database is freely available at http://www.bioterrorism.biowaves.org