Protection Afforded by Fluoroquinolones in Animal Models of Respiratory Infections with Bacillus anthracis, Yersinia pestis, and Francisella tularensis

Successful treatment of inhalation anthrax, pneumonic plague and tularemia can be achieved with fluoroquinolone antibiotics, such as ciprofloxacin and levofloxacin, and initiation of treatment is most effective when administered as soon as possible following exposure. Bacillus anthracis Ames, Yersinia pestis CO92, and Francisella tularensis SCHU S4 have equivalent susceptibility in vitro to ciprofloxacin and levofloxacin (minimal inhibitory concentration is 0.03 μg/ml); however, limited information is available regarding in vivo susceptibility of these infectious agents to the fluoroquinolone antibiotics in small animal models. Mice, guinea pig, and rabbit models have been developed to evaluate the protective efficacy of antibiotic therapy against these life-threatening infections. Our results indicated that doses of ciprofloxacin and levofloxacin required to protect mice against inhalation anthrax were approximately 18-fold higher than the doses of levofloxacin required to protect against pneumonic plague and tularemia. Further, the critical period following aerosol exposure of mice to either B. anthracis spores or Y. pestis was 24 h, while mice challenged with F. tularensis could be effectively protected when treatment was delayed for as long as 72 h postchallenge. In addition, it was apparent that prolonged antibiotic treatment was important in the effective treatment of inhalation anthrax in mice, but short-term treatment of mice with pneumonic plague or tularemia infections were usually successful. These results provide effective antibiotic dosages in mice, guinea pigs, and rabbits and lay the foundation for the development and evaluation of combinational treatment modalities

An Evaluation of Points-of-Dispensing Training: A Mixed Methods Approach

In the event of a public health emergency, the Allegheny County Health Department may have to activate points-of-dispensing (POD) sites in order to distribute life-saving medical countermeasures, such as antibiotics or vaccine. In January 2013, ACHD began a series of mandatory trainings to orient employees to working in a POD. The training focused on an overview of POD operations, POD setup, and core staffing functions. At the conclusion of the program, participants completed a written survey examining prior POD experience or training, perceived ability to work in a POD, perceived understanding, and overall satisfaction in order to determine program effectiveness. After the training, 92.1% of employees reported that they are confident in their ability to work in a POD; of those employees, 49.5% had no prior formal training or experience working at a POD. Of those surveyed, 89.6% of participants reported feeling satisfied with the training program. Interactive and hands-on activities are well received as training methods. Health Department employees feel confident in their ability to set up a POD and perform key staffing duties. Evaluation indicated that the Head of Household screening form and corresponding prophylaxis algorithm is cumbersome to use and should be revised in order to increase efficiency in the screening process. More evidence of historical POD operations should be incorporated into future training modules to address participants’ concern about the dispensing capabilities of the POD model. In evaluation of future training, a comparison of pre- and post-training skill assessments will better measure training effectiveness and allow for a more in-depth analysis of understanding of training materials. The public health significance of this evaluation is that it will aid in improving current training methods and bettering public health preparedness capabilities for an array of different infectious disease emergencies for Allegheny County

Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009

"These recommendations from the Advisory Committee on Immunization Practices (ACIP) update the previous recommendations for anthrax vaccine adsorbed (AVA) (CDC). Use of anthrax vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2000;49:1-20; CDC. Use of anthrax vaccine in response to terrorism: supplemental recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2002;51:1024-6) and reflect the status of anthrax vaccine supplies in the United States. This statement 1) provides updated information on anthrax epidemiology; 2) summarizes the evidence regarding the effectiveness and efficacy, immunogenicity, and safety of AVA; 3) provides recommendations for pre-event and preexposure use of AVA; and 4) provides recommendations for postexposure use of AVA. In certain instances, recommendations that did not change were clarified. No new licensed anthrax vaccines are presented. Substantial changes to these recommendations include the following: 1) reducing the number of doses required to complete the pre-event and preexposure primary series from 6 doses to 5 doses, 2) recommending intramuscular rather than subcutaneous AVA administration for preexposure use, 3) recommending AVA as a component of postexposure prophylaxis in pregnant women exposed to aerosolized Bacillus anthracis spores, 4) providing guidance regarding preexposure vaccination of emergency and other responder organizations under the direction of an occupational health program, and 5) recommending 60 days of antimicrobial prophylaxis in conjunction with 3 doses of AVA for optimal protection of previously unvaccinated persons after exposure to aerosolized B. anthracis spores." - p. 1prepared by Jennifer Gordon Wright, Conrad P. Quinn, Sean Shadomy, Nancy Messonnier.Includes bibliographical references (p. 23-29).Infectious DiseasePublic Health Preparedness and ResponseCurrentACIP2065164

National Preparedness: Efforts to Address the Medical Needs of Children in a Chemical, Biological, Radiological, or Nuclear Incident

A letter report issued by the Government Accountability Office with an abstract that begins "According to the Department of Health and Human Services (HHS), about 60 percent of the chemical, biological, radiological, and nuclear (CBRN) medical countermeasures in the Strategic National Stockpile (SNS) have been approved for children, but in many instances approval is limited to specific age groups. In addition, about 40 percent of the CBRN countermeasures have not been approved for any pediatric use. Furthermore, some of the countermeasures have not been approved to treat individuals for the specific indications for which they have been stockpiled. For example, ciprofloxacin is stockpiled in the SNS for the treatment of anthrax, plague, and tularemia, but is not approved for these indications. Countermeasures may be used to treat unapproved age groups or indications under an emergency use authorization (EUA) or an Investigational New Drug (IND) application submitted to the Food and Drug Administration (FDA).

Modeling Staffing Dynamics for POD Operations in an Infectious Disease Emergency

The effects of variables impacting mass prophylaxis point-of-dispensing (POD) staffing in an infectious disease emergency could potentially aid in preparedness efforts by advising recruiting, training, and emergency planning. This project aims to explore three factors that may impact staffing capabilities for POD: pathogen, absenteeism, and response rates. These factors were explored through building an agent-based model in the NetLogo modeling platform. An agent-based modeling approach was used to emphasize the impact of indirect interaction between individuals that results as roles are filled by individuals who volunteer first. This model set the environment at different absenteeism and response levels, and different POD staffing requirements based on pathogen (influenza vaccinations or anthrax antibiotics). To measure the effects of these variables, time-to-staff and staff shortages were recorded at the end of each simulation run. For influenza conditions, staffing capabilities became more constrained as absenteeism increased, and response decreased. However, for anthrax conditions, these constraints were very mild, and the differences in these trends between influenza and anthrax were significant. Overall, this model provides an example of staffing constrains that could be anticipated if such a model were to be developed for use in local health departments. Such a model could allow for planners to find staffing weaknesses before they manifest, and tailor recruiting and training efforts accordingly to create a staff pool that would be overall more able to successfully staff PODs in an emergency. The public health significance of this project is to provide a foundation for future development of this type of agent-based model to aid in public health preparedness planning

Epidemiology and prevention of vaccine-preventable diseases

Suggested citation: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. Sth ed. Washington DC; Public Health Foundation, 2006.1. Principles of Vaccination -- 2. General Recommendations on Immunization -- 3. Immunization Strategies for Healthcare Practices and Providers -- 4. Vaccine Safety -- 5. Diphtheria -- 6. Tetanus -- 7. Pertussis -- 8. Poliomyelitis -- 9. Haemophilus influenzae Type b (Hib) -- 10. Measles -- 11. Mumps -- 12. Rubella -- 13. Varicella -- 14. Hepatitis A -- 15. Hepatitis B -- 16. Influenza -- 17. Pneumococcal Disease -- 18. Meningococcal Disease -- 19. Smallpox -- 20. Anthrax -- Appendix A. Schedules and Recommendations -- Appendix B. Vaccines -- Appendix C. Vaccine Storage and Handling -- Appendix D. Vaccine Administration -- Appendix E. Vaccine Information Statements -- Appendix F. Vaccine Safety -- Appendix G. Data and Statistics -- Appendix H. Standards -- Appendix I. Immunization Resources.2006677

Bacillus anthracis Bioterrorism Research Priorities for Public Health Response

This meeting provided a forum for 132 representatives from the Department of Health and Human Services (Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and National Institutes of Health (NIH)), Environmental Protection Agency (EPA), Department of Defense (DoD), Department of Energy (DoE), US Postal Service, State Health Departments, universities and other organizations to identify, prioritize, and coordinate near-term Bacillus anthracis bioterrorism research for public health response. During the recent anthrax bioterrorism investigation CDC and its partners identified a number of areas where additional research may be useful in improving public health response.The disciplines and specific expertise required to approach many of these areas are varied and exist within multiple federal government entities and elsewhere. To address those research questions that are most critical to improving public health response to B. anthracis-related bioterrorism, CDC convened this meeting to obtain input on critical research priorities and coordinate with federal partners and other stakeholders in planning and conduct of applied research that needs to be initiated within the next 12 months.The workshop format consisted of two plenary sessions in which experts provided summaries of the existing science in key topic areas. Background talks were given on the \u201cEvaluation of B. anthracis containing powders or substances\u201d by Mathew Shaw, Battelle Memorial Institute; \u201cEpidemiologic Investigation\u201d by Philip Brachman, Emory University, School of Public Health; \u201cEnvironmental Assessment\u201d by Edwin Kilbourne, Agency for Toxic Substances and Drug Research; \u201cSurveillance\u201d by Ruth Berkelman, Emory University; \u201cIntroduction to issues in Diagnosis, Treatment, and Prevention of Anthrax\u201d by Art Friedlander, US Army Medical Research Institute for Infectious Diseases (USAMRIID), DoD; \u201cDiagnosis\u201d by Susan Alpert, C.R. Bard, Inc.; \u201cTreatment\u201d by Dennis Stevens, Veterans Affairs Medical Center, University of Washington; \u201cPost-exposure prophylaxis\u201d by Diane Murphy, Food and Drug Administration; and \u201cRemediation\u201d by Dorothy Cantor, Environmental Protection Agency.Following the first plenary session, participants were divided into eight pre-assigned working groups. The eight working groups included: 1) Evaluation of B. anthracis containing powders or substances, 2) Epidemiological investigation, 3) Environmental assessment, 4) Surveillance, 5) Diagnosis, 6) Treatment, 7) Post-exposure prophylaxis, and 8) Remediation. Each of the 8 working groups had pre-assigned co-leaders, one from outside of CDC and one from CDC. Each of the CDC co-leads were senior scientists who had been heavily involved in the anthrax bioterrorism investigation and response. Lists of specific questions were given to each of the working groups to help stimulate discussion and provide direction based on observations during the anthrax bioterrorism investigation. During the second plenary session each of the groups presented interim results of discussion for input from the larger group of meeting participants. In the second working group session, groups were asked to prepare a written report of their group\u2019s top three research priorities.Executive Summary -- Working Group Reports on Top Three Priority Priorities: Evaluation of B. anthracis Containing Powders or Substances, Epidemiological Investigation, Environmental Assessment, Surveillance, Diagnosis, Treatment, Post-exposure Prophylaxis, Remediation -- Agenda -- Meeting Guidance and Suggestions for Working Group Sessions I and II -- Questions for the Working Groups -- List of Suggested References -- List of Meeting Participants & Contact Information [deleted from online document per request] \u2013 Acknowledgements.200

Syndromic Surveillance for Bioterrorism-related Inhalation Anthrax in an Emergency Department Population

Objective: To utilize clinical data from emergency department admissions and published clinical case reports from the 2001 bioterrorism-related inhalation anthrax (IA) outbreak to develop a detection algorithm for syndromic surveillance. Methods: A comprehensive review of case reports and medical charts was undertaken to identify clinical characteristics of IA. Eleven historical cases were compared to 160 patients meeting a syndromic case definition based on acute respiratory failure and the presence of mediastinal widening or lymphadenopathy on a chest radiograph. Results: The majority of syndromic group patients admitted were due to motor vehicle accident (52%), followed by fall (10%), or other causes (4%). Positive culture for a gram positive rod was the most predictive feature for anthrax cases. Among signs and symptoms, myalgias, fatigue, sweats, nausea, headache, cough, confusion, fever, and chest pain were found to best discriminate between IA and syndromic patients. When radiological findings were examined, consolidation and pleural effusions were both significantly higher among IA patients. A four step algorithm was devised based on combinations of the most accurate clinical features and the availability of data during the course of typical patient care. The sensitivity (91%) and specificity (96%) of the algorithm were found to be high. Conclusions: Surveillance based on late stage findings of IA can be used by clinicians to identify high risk patients in the Emergency Department using a simple decision tree. Implications for public health: Monitoring pre-diagnostic indicators of IA can provide enough credible evidence to initiate an epidemiological investigation leading to earlier outbreak detection and more effective public health response

Pediatric Emergency Preparedness for Natural Disasters, Terrorism, and Public Health Emergencies: A National Consensus Conference: 2009 Update

This is the third consensus document in an ongoing process to convene experts from the multiple disciplines that are involved in the planning for children affected by disasters

Pediatric Emergency Preparedness for Natural Disasters, Terrorism, and Public Health Emergencies: A National Consensus Conference: 2009 Update

This is the third consensus document in an ongoing process to convene experts from the multiple disciplines that are involved in the planning for children affected by disasters