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Detailed field: Medical: Health Care | Source text - English
Bioterrorism-Related Anthrax
Public Health in the Time of Bioterrorism
Bradley A. Perkins,* Tanja Popovic,* Kevin Yeskey*
*Centers for Disease Control and Prevention, Atlanta, Georgia, USA
On Thursday, October 4, 2001, just 24 days after the tragic events of September 11, the Florida Department of Health and the Centers for Disease Control and Prevention (CDC) confirmed the first case of inhalational anthrax in the United States in more than 25 years. Recognition of this unexpected case is attributed to the alertness of local infectious disease physician Larry Bush, who promptly notified Jean Malecki, director, Palm Beach County Health Department (1,2). By Saturday, October 6, a team of federal, state, and local public health and local law enforcement investigators identified intentional Bacillus anthracis spore contamination at the patient’s workplace. These events marked the beginning of the first U.S. outbreak of bioterrorism-related anthrax and (for many of us in clinical medicine, public health, and law enforcement) ushered in the transition from tabletop bioterrorism exercises to real-world investigation and response.
Contingency plans to mitigate bioterrorism-related anthrax outbreaks go back to August 1998, when CDC hosted the “Workshop on Improving Public Health Response to Possible Acts of Bioterrorism.” This workshop brought together state and local health departments, public health professional organizations, the U.S. Department of Defense, and the U.S. Department of Justice to examine ways of improving public health preparedness for bioterrorism (CDC, unpub. data). Two investments made as a result of this workshop were the Laboratory Response Network for Bioterrorism and the National Pharmaceutical Stockpile. These early investments were key components of the public health response to the 2001 bioterrorism-related anthrax outbreak.
The Laboratory Response Network was created at the recommendation of the 1998 Workshop’s “Diagnosis Working Group,” the then Association of State and Territorial Public Health Laboratories (now Association for Public Health Laboratories), and CDC. The Laboratory Response Network is a tiered system of laboratories with capacities defined in an A (lowest tier) through D (highest) pyramid structure (3,4). In support of this structure, procedures for identification of B. anthracis, and other Category A biologic agents, were validated, and in some instances developed (or redeveloped) de novo on the basis of older methods. Protocols were written into standard laboratory procedure manuals. Reagents for testing were standardized, produced, and distributed by CDC to participating laboratories. State health department laboratory scientists were trained to use these methods for identifying B. anthracis, Yersinia pestis (causative agent of plague), and Francisella tularensis (causative agent of tularemia) in the fall and winter of 2000. Capacity for specialized or more developmental diagnostic and other tests for B. anthracis (e.g., real time polymerase chain reaction [PCR] [5], direct fluorescent-antibody assay [6], immunohistochemical testing, molecular subtyping [7], and antimicrobial susceptibility testing [8]) were established at CDC and (in some instances) at a small number of other advanced U.S. laboratories (e.g., U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland; Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona). For serologic testing, which was found to be invaluable in identifying anthrax cases during the investigation, existing tests developed for vaccine evaluation were adapted for diagnostic purposes (9). All these laboratory measures were in place before the 2001 anthrax outbreak.
During the acute phase of the outbreak, Laboratory Response Network laboratories processed >121,700 specimens for B. anthracis (the bulk from environmental specimens from areas of suspected or confirmed contamination). Public Health Laboratories (other than CDC) tested 84,000 (69%) specimens; the Department of Defense tested 30,200 (25%) specimens; and CDC tested 7,500 (6%) (CDC, unpub. data). Handling the unusual surge of demand without the support of the Laboratory Response Network is difficult to imagine and would have likely compromised the investigation.
The National Pharmaceutical Stockpile was another investment made as a result of the 1998 Workshop and put in place before the 2001 outbreak. During the outbreak, the pharmaceutical stockpile team transported not only antibiotics, anthrax vaccine, clinical and environmental samples, and B. anthracis isolates but also epidemiologists, laboratory scientists, pathologists, and specialized teams of researchers. Under extreme pressure, the team made 143 sorties to 9 states and delivered 3.75 million antibiotic tablets from October 8, 2001 to January 11, 2002 (CDC, NPS Program Logistics Log, Oct 2001–Jan 2002).
Other earlier public health investments that paid off during the anthrax outbreak investigation were CDC’s more than 50-year-old applied epidemiology training program, Epidemic Intelligence Service, and other academic, state and local health department, and CDC efforts to develop the seasoned cadre of field epidemiologists (10,11) that make up the core of public health investigation and response. These epidemiologists, who work in established networks and make up and often lead complex partnerships, comprise the public health front lines of the bioterrorism response team.
The complexity of the 2001 anthrax investigation and response challenged even experienced field epidemiologists. At the state and federal levels, “incident command”-style management structures were used to address the constant emergence of new information, pursue many public health activities simultaneously across multiple investigations, and communicate effectively. These management structures, which have been adopted by the disaster management and law enforcement communities, are less familiar to public health workers. With some variation from site to site, a typical field investigation structure included local, state, and federal public health partners working on the following teams: Epidemiologic Investigation (what happened?), Intervention (post-exposure prophylaxis and follow-up), Surveillance (identify additional cases), Clinical Evaluation (rapidly evaluate suspect cases), Environmental Assessment (environmental sampling and processing), Remediation (working with the Environmental Protection Agency), and Communication (with the public, partners, and press). These teams were sometimes complemented with Federal Bureau of Investigation (FBI) liaisons; in some cases, public health officials were assigned to FBI investigation teams (12). A senior epidemiologist was also posted to FBI Headquarters in Washington, D.C.
After the October 12 recognition of cutaneous anthrax in New York (13), an emergency operations center was established at CDC, Atlanta, Georgia, to coordinate the outbreak investigation and response. The center tasked more than 2,000 employees (in the field or at headquarters in Atlanta) (CDC unpub. data) to specific functions, including 24-hour response capacity with telephone information and call-triage services and other specialized teams (14). CDC/Atlanta-based teams led by senior epidemiologists supported each field investigation team in involved jurisdictions (Florida, New York, Washington D.C., New Jersey, and Connecticut). These teams were in direct and frequent communication with their respective field team about laboratory results, other investigations, and policy decisions. Other teams included the following: Clinical Medicine (evaluation of suspected cases, post-exposure prophylaxis and treatment recommendations) (15–21); Environmental Assessment (evaluation of suspected or confirmed areas of environmental contamination); International Support (22,23); Laboratory Support (coordination across CDC laboratories and the Laboratory Response Network); National Pharmaceutical Stockpile (antibiotics, vaccine, specimens, and people transport); Postal Service Liaison (partnership with the U.S. Postal Service—CDC also assigned a senior epidemiologist to the Postal Service); and State Liaison (to coordinate requests from states without confirmed anthrax cases) (24). Beginning on October 12, CDC’s Morbidity and Mortality Weekly Report published a series of reports, notices, and guidelines as events unfolded (25).
Many unknowns confronted the public-health response team during the anthrax investigation (26). The basics about exposure to B. anthracis–contaminated envelopes specifically sent to media outlets and government leaders were understood quickly, given the events in Florida, New York, and then Washington, D.C. (13). Difficulties arose in characterizing anthrax risk to individuals and groups with suspected or confirmed exposure to B. anthracis–contaminated envelopes or environments (27). Challenges also arose in the evaluation of B. anthracis-containing powders, epidemiologic investigation (28), environmental assessment (29,30) and remediation, surveillance (31,32), diagnosis, treatment, and post-exposure prophylaxis (33–35).
Work with B. anthracis–contaminated goat hair in textile mills more than 40 years ago provided some data about the risk of B. anthracis spore-containing particles in naturally contaminated occupational environments. These data suggested that relatively high levels of B. anthracis spores were “not necessarily or consistently dangerous” in this setting (36). Biologic warfare experts considered it unlikely that terrorists could produce a B. anthracis spore powder for use in an envelope that would be capable of generating substantial primary (or secondary) aerosol threats for human infection or widespread contamination of environments. Yet, in Senator Daschle’s office, in the Hart Senate Office building, in the room where the letter was opened (as well as outside the room) exposed persons’ nasal mucosa were almost immediately contaminated (37). Re-aerosolization (secondary aerosol) at a level consistent with potential transmission was demonstrated off the implicated high-speed sorter in the Brentwood Processing and Distribution Facility (38). Recent research using simulates of B. anthracis spores from the Canadian Defense Establishment Suffield suggests that contaminated envelopes can cause heavy aerosol contamination (39). New understanding is accumulating, and this should improve public health response in the future.
The decision-making involved in closing the U.S. Postal Service’s Brentwood Processing and Distribution Facility, Washington, D.C., has been criticized. The risk to Brentwood facility employees by contaminated envelopes in transit was not recognized in time to prevent illness in four employees, two of whom died (40). Decisions concerning the Brentwood facility were based on epidemiologic observations in Florida and New York, where no disease occurred among postal workers. A possible explanation for the differential risk is that the B. anthracis spore preparation in the October 9 envelopes had a higher potential for aerosolization than the preparation in the September 18 envelopes or that the two mailings were made under or exposed to different environmental conditions (e.g., amount of moisture) that created a different potential for aerosolization. A different aerosolization potential is supported by the epidemic curve in the manuscript by Jernigan et al. (13), which shows a higher proportion of inhalational (versus cutaneous) anthrax cases associated with the October 9 mailing. In naturally occurring disease, once risk is understood, it generally remains constant; however, in intentional contamination, risk may be altered by the perpetrator(s).
During the anthrax investigation, the public health response team was better prepared in some areas than in others. Five deaths were not prevented, but widespread illness and death was averted through early recognition of threats and prompt intervention. We applied what we knew and learned what we did not know. We gained new appreciation for communication and partnerships. For the first time, on November 8, 2001, a sitting President of the United States of America, George W. Bush, visited CDC to support the efforts of public health professionals and others who participated in the anthrax investigation and response. Leaders and individual heroes rose in the ranks of public health, clinical medicine, and law enforcement (41). The substantial role of public health in the 2001 anthrax investigation and response suggests that strong public health infrastructure supported by applied public health and basic-science research are key elements to the control and prevention of future bioterrorism threats.
Acknowledgments
The guest editors of this special issue of Emerging Infectious Diseases thank all colleagues who participated in the 2001 bioterrorism investigation and response and all who contributed to articles in this issue.
References
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2. Maillard J-M, Cline S, Turner L, Fischer M. First case of bioterrorism-related inhalational anthrax, Florida, 2001: North Carolina investigation. Emerg Infect Dis 2002;8. (this issue)
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15. Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis 2001;7:933–44.
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17. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR Morb Mortal Wkly Rep 2001;50:941–8.
18. Centers for Disease Control and Prevention. Updated recommendations for antimicrobial prophylaxis among asymptomatic pregnant women after exposure to Bacillus anthracis. MMWR Morb Mortal Wkly Rep 2001;50:960.
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20. Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the prophylaxis, diagnosis, and treatment of anthrax. Emerg Infect Dis 2002 8:222–5.
21. Barakat LA, Quentzel HL, Jernigan JA, Kirschke DL, Griffith K, Spear SM, et al. Fatal inhalational anthrax in a 94-year-old Connecticut woman. JAMA 2002;287:863–8.
22. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax, 2001. MMWR Morb Mortal Wkly Rep 2001;50:1008–10.
23. Polyak CS, Macy JT, Irizarry-De La Cruz M, Lai JE, McAuliffe J, Popovic T, et al. Bioterrorism-related anthrax: international response by the Centers for Disease Control and Prevention activities. Emerg Infect Dis 2002;8. (this issue)
24. Tengelsen L, Hahn C, Hudson R, Barnes S. Coordinated response to possible anthrax contamination, Idaho, 2001. Emerg Infect Dis 2002;8. (this issue)
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26. Perkins BA, Ashford D. Bioterrorism-related Bacillus anthracis public health research priorities (meeting summary). Emerg Infect Dis 2002;8. (this issue)
27. Centers for Disease Control and Prevention. Interim guidelines for investigation and response to Bacillus anthracis exposures. MMWR Morb Mortal Wkly Rep 2001;50:987–90.
28. Greene C, Reefhuis J, Tan C, Fiore AE, Goldstein S, Beach M, et al. Epidemiologic investigations of bioterrorism-related anthrax, New Jersey, 2001. Emerg Infect Dis 2002;8. (this issue)
29. Sanderson WT, Hein M, Taylor L, Curwin B, Kinnes G, Seitz T, et al. Surface sampling methods for Bacillus anthracis spore contamination. Emerg Infect Dis 2002;8. (this issue)
30. Teshale EH, Painter J, Burr GA, Wright SV, Cseh LF, Zabrocki R, et al. Environmental sampling for spores of Bacillus anthracis. Emerg Infect Dis 2002;8. (this issue)
31. Tan CG, Sandhu H, Crawford D, Redd S, Beach M, Buehler J, et al. Surveillance for anthrax cases associated with contaminated letters—New Jersey, Delaware, and Pennsylvania, 2001. Emerg Infect Dis 2002;8. (this issue)
32. Williams A, Parashar U, Stoica A, Ridzon R, Kirschke D, Meyer R, et al. Bioterrorism-related anthrax surveillance in Connecticut, September–December, 2001. Emerg Infect Dis 2002;8. (this issue)
33. Shepard CW, Soriano-Gabarro M, Zell ER, Hayslett J, Lukacs S, Goldstein S, et al. Antimicrobial postexposure prophylaxis for anthrax: adverse events and adherence. Emerg Infect Dis 2002;8. (this issue)
34. Jefferds MD, Laserson K, Fry AM, Roy S, Hayslett J, Grummer-Strawn L, et al. Adherence to antimicrobial inhalational anthrax prophylaxis among postal workers, Washington, D.C., 2001. Emerg Infect Dis 2002;8. (this issue)
35. Williams JL, Noviello SS, Griffith KS, Wurtzel H, Hamborsky J, Perz JF, et al. Anthrax postexposure prophylaxis in postal workers, Connecticut, 2001. Emerg Infect Dis 2002;8. (this issue)
36. Brachman PS, Plotkin SA, Bumford FH, Atchison MM. An epidemic of inhalation anthrax: the first in the twentieth century. Am J Hyg 1960:72:6-23
37. Hsu VP, Lukacs SL, Handzel T, Hayslett J, Harper S, Hales T, et al. Opening a Bacillus anthracis-containing envelope, Capitol Hill, Washington, D.C.: the public health response. Emerg Infect Dis 2002;8. (this issue)
38. Dull P, Wilson K, Kournikakis B, Boulet C, Ho J, Ogston J, et al. Bacillus anthracis aerosolization associated with a contaminated mail sorting machine. Emerg Infect Dis 2002;8. (this issue)
39. Kournakakis B., Armour SJ, Boulet CA, Spence M, Barsons B. Risk assessment of anthrax threat letters. DRES Technical Report TR 2001-048. September, 2001.
40. Dewan PK, Fry AM, Laserson K, Tierney BC, Quinn CP, Hayslett JA, et al. Inhalational anthrax outbreak among postal workers, Washington, D.C., 2001. Emerg Infect Dis 2002;8. (this issue)
41. Gerberding JL, Hughes JM, Koplan JP. Bioterrorism preparedness and response: clinicians and public health agencies as essential partners. JAMA 2002;287:898–900.
Bradley A. Perkins, Guest Editor
Dr. Perkins is chief, Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention (CDC), which has technical responsibility for the epidemiologic and laboratory aspects of Bacillus anthracis, and selected other bacterial agents of public health importance. Dr. Perkins led the CDC field team in the investigation of the index case of inhalational anthrax in Florida and participated broadly in the 2001 anthrax investigation and response. His research interests include vaccine evaluation, bacterial meningitis, bioterrorism, and emerging infectious diseases. He has worked extensively on the control and prevention of meningococcal disease in the United States, Africa, and around the globe.
Tanja Popovic, Guest Editor
Dr. Popovic is chief, Epidemiologic Investigations Laboratory, Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention. As the subject matter expert on laboratory aspects of B. anthracis and anthrax at CDC, she and her staff trained laboratory scientists in all 50 states to isolate and identify B. anthracis using standard methodologies in the fall of 2000, and have performed thousands of tests for isolation of B. anthracis, its confirmatory identification and molecular subtyping during the 2001 anthrax investigation. In addition to bioterrorism preparedness and response, her research focuses on laboratory diagnosis and molecular epidemiology of bacterial meningitis and diphtheria.
Kevin Yeskey, Guest Editor
Dr. Yeskey is director, Bioterrorism Preparedness and Response Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). He has served as deputy director of Emergency Public Health in the Division of Emergency and Environmental Health Services, National Center for Environmental Health, CDC. His previous assignments include associate professor and vice chair, Department of Military and Emergency Medicine, Uniformed Services University School of Medicine, and chief medical officer, United States Public Health Service Office of Emergency Preparedness. Dr. Yeskey’s experience with disaster response includes work on hurricanes, earthquakes, floods, mass migrations, and terrorist bombings.
| Translation - Spanish
Antrax y Terrorismo Biológico
La Salud Pública en la era del terrorismo biológico
Bradley A. Perkins,* Tanja Popovic,* Kevin Yeskey*
*Centros de Control y Prevención de Enfermedades, Atlanta, Georgia, USA
El día jueves 4 de Octubre de 2001, tan sólo 24 días después de los trágicos eventos del 11 de Septiembre, el Departamento de Salud de Florida y Los Centros de Control y Prevención de Enfermedades (CCE) confirmaron el primer caso de inhalación de ántrax en los Estados Unidos en mas de 25 años. El diagnóstico de este inesperado caso se atribuye al estado de alerta del infectólogo Larry Bush, quien rápidamente alertó a Jean Malecki, director, del Departamento de Salud del Condado de Palm Beach (1,2). Para el día 6 de Octubre, un equipo federal, estatal y de salud pública local junto investigadores federales de cumplimiento de la ley determinaron una contaminación intencional por esporas de Bacillus anthracis en el lugar de trabajo de la víctima. Estos eventos marcaron la primera irrupción de ántrax en acciones de terrorismo biológico (y para muchos de nosotros en la medicina clínica, salud pública, y oficiales de la ley) empujados en la transición desde los ejercicios de escritorio relacionados con terrorismo biológico a la investigación y respuesta del mundo real.
Los planes de contingencia para mitigar la irrupción de terrorismo biológico con ántrax retrocedieron hasta Agosto de 1998, cuando el CDC fue sede del "Taller de Mejora de la Respuesta del Sistema de Salud Pública a posibles ataques de Terrorismo Biológico." Este taller reunió a los departamentos federales y locales de salud, organizaciones de profesionales de la salud pública, el Departamento de Defensa de los EE.UU. y el Departamento de Justicia para examinar formas de mejorar la preparación ante terrorismo biológico (CDC, información no publicada). Como resultado de este taller se hicieron dos inversiones La Red de Laboratorios de Respuesta ante terrorismo biológico y La Reserva Farmacéutica Nacional. Estas inversiones tempranas fueron componentes claves de la respuesta de salud pública contra la irrupción de ántrax como elemento de terrorismo biológico.
La Red de Laboratorios de Respuesta fue creada en respuesta a la recomendación del grupo de trabajo de diagnóstico del taller de 1998, la entonces Asociación de Laboratorios Estatales y Territoriales de Salud Pública (ahora asociación para Laboratorios de Salud Pública), y CDC. La Red de Laboratorios de Respuesta es un sistema de laboratorios alineados con competencias definidas en una A (línea baja) hasta D (la mas alta) estructura piramidal (3,4). Sustentando esta estructura, se validaron procedimientos para identificar B. anthracis, y otros agentes biológicos de categoría A, y en ciertas instancias desarrollado o (redesarrollados) de novo en base a métodos más antiguos. Los protocolos fueron escritos dentro de los manuales de procedimiento standard de laboratorio. Los reactivos para pruebas fueron estandarizados, producidos, y distribuidos por CDC a los laboratorios participantes. Los científicos del laboratorio del departamento de salud fueron capacitados para usar los métodos para identificar B. anthracis, Yersinia pestis (agente causativo de plaga), y Francisella tularensis (agente causativo de tularemia) en otoño e invierno del 2000. Capacidad para diagnóstico más especializado o experimental y otros test para B. anthracis (e.j, reacción en cadena en tiempo real de polimerasa [PCR] [5], ensayo directo de anticuerpos fluorescentes [6], pruebas inmuno histo química, subtipo molecular [7], y pruebas de susceptibilidad antimicrobial [8]) fueron establecidas en CDC y (en ciertas circunstancias) en un reducido número de pequeños laboratorios Estadounidenses (e.j., el Instituto de Investigación Médica de Enfermedades Infecciosas del ejército de EE.UU, Fort Detrick, Frederick, Maryland; Departamento de Ciencias Biológicas, Northern Arizona University, Flagstaff, Arizona). Para pruebas serológicas, el cual fue de invaluable valor para identificar casos de ántrax durante la investigación, los test existentes desarrollados para la evaluación de vacunas fueron adaptados para propósitos de diagnóstico (9). Todas estas medidas de laboratorio se encontraban en funcionamiento antes de la irrupción del ántrax en 2001.
Durante la fase aguda de la epidemia, la Red de Laboratorios de Respuesta procesaron >121.700 especímenes de B. anthracis (la mayor parte de especímenes medio ambientales de áreas de infección confirmada o bajo sospecha). Laboratorios de Salud Pública (distintos al CDC) testaron 84.000 (69%) especímenes; el Departamento de Defensa testó 30.200 (25%) especímenes; y el CDC testó 7.500 (6%) (CDC, información no publicada). Es difícil de imaginar el manejo de la inusual ola de demandas sin el apoyo de la Red de Laboratorios de Respuesta que con seguridad la investigación se hubiese visto comprometida.
La Reserva Farmacéutica Nacional fue otra inversión hecha como resultado del taller de 1998 y puesto en práctica antes de la epidemia del 2001. Durante la epidemia, el equipo de la reserva farmacéutica no sólo transportó antibióticos, vacunas de ántrax, muestras clínicas y ambientales, y B. anthracis aislados sino que también epidemiólogos, laboratoristas, patólogos y equipos especializados de investigación. Bajo gran presión, el equipo realizó 143 salidas a 9 estados y distribuyó 3.75 millones de tabletas antibiótica entre el 8 de octubre de 2001 y 11 de enero de 2002 (CDC, NPS Program Logistics Log, Oct 2001–Jan 2002).
Otras inversiones anteriores en salud pública que valió la pena durante la epidemia de ántrax fueron los más de 50 años del programa de entrenamiento epidemiológico del CDC, Servicio de Inteligencia Epidemiológica, y otros departamento de salud académicos, estatales y locales y los esfuerzos del CDC para desarrollar el experimentado cuadro de epidemiólogos de campo (10,11) que conformaron el corazón de la investigación de salud pública y respuesta. Estos epidemiólogos, quienes trabajaron en redes establecidas y que formaron y a menudo lideraron complejas asociaciones, conformaron la primera línea del equipo de respuesta contra el terrorismo biológico de la salud pública.
La complejidad de la investigación y respuesta ántrax 2001 retó incluso a los epidemiólogos más experimentados. A nivel federal y estatal, se usaron estructuras de administración al estilo “incident command” para tratar la constante aparición de nueva información, sigue muchas actividades en salud pública de manera simultánea a lo largo de diversas investigaciones y se comunica de manera efectiva. Estas estructuras administrativas, que han sido adoptadas por la administración de desastres y organismos de aplicación de la ley, están menos familiarizadas con los trabajadores de la salud pública. Con variaciones de un lugar a otro, una estructura típica de investigación incluye pares locales, estatales, y federales de la salud pública trabajando en conjunto en los equipos siguientes: Investigación Epidemiológica (¿Qué pasó?), Intervención (profilaxis post-exposición y seguimiento), Vigilancia (identificar casos adicionales), Evaluación Clínica (evaluación rápida de casos sospechosos), Evaluación Ambiental (muestra ambiental y procesamiento), Curación (trabajando con la Agencia de Protección Ambiental), y Comunicación (con el público, pares y prensa). Estos equipos complementados ocasionalmente por el Federal Bureau of Investigation (FBI) coordinados; en ciertos casos, funcionarios de la salud pública fueron asignados a los equipos de investigación del FBI (12). Un epidemiólogo senior también fue apostado en las oficinas centrales del FBI en Washington, D.C.
Luego del reconocimiento de ántrax cutáneo el 12 de octubre en Nueva York (13), un centro de operaciones de emergencia se estableció en el CDC, Atlanta, Georgia, para coordinar la investigación de epidemia y respuesta. El centro ocupó más de 2.000 empleados (en terreno o en las oficinas centrales en Atlanta) (CDC información no publicada) a funciones específicas, incluyendo una capacidad de respuesta las 24 horas del día y otros equipos especializados (14). Los equipos CDC/con asiento en Atlanta dirigidos por un epidemiólogo senior respaldó cada campo de investigación de las jurisdicciones involucradas (Florida, New York, Washington D.C., New Jersey, y Connecticut). Estos equipos se encontraban en directa y constante comunicación con sus respectivos equipos de campo acerca de los resultados de laboratorio, otras investigaciones y decisiones políticas. Otros equipos incluyeron los siguientes: Medicina Clínica (evaluación de casos sospechosos, profilaxis post-exposición y recomendaciones de tratamiento) (15–21); Evaluación Ambiental (evaluación de áreas sospechosas o confirmadas por contaminación ambiental); Apoyo Internacional (22,23); Apoyo de laboratorio (coordinación a través de los laboratorios CDC y Red de Laboratorios de Respuesta); Reserva Farmacéutica Nacional (antibióticos, vacunas, especímenes, y transporte de personas); coordinación con el Servicio Postal (asociación con el Servicio Postal de EE.UU —CDC asignó también un epidemiólogo senior al Servicio Postal); y coordinación estatal (para coordinar solicitudes de los estados sin casos confirmados de ántrax) (24). Iniciado el 12 de octubre, el informe semanal de morbilidad y mortalidad publicó una serie de informes, avisos, y pautas a medida que los eventos se desarrollaban (25).
Diversos imprevistos confrontó el equipo de respuesta de salud pública durante la investigación ántrax (26). Los fundamentos de la exposición a sobres contaminados conB. anthracis enviados específicamente a los medios de comunicación y líderes de gobierno fueron comprendidos con rapidez, de acuerdo a los eventos de Florida, New York, y posteriormente en Washington, D.C. (13). Los problemas aparecieron al caracterizar los riesgos del ántrax para personas y grupos sospechosos o confirmados de exposición a sobres o ambientes contaminados por B. anthracis (27). También se presentaron desafíos en la evaluación de polvos que contienen B. anthracis, investigación epidemiológica (28), evaluación ambiental (29,30) y curación, vigilancia (31,32), diagnostico, tratamiento y profilaxis post-exposición (33–35).
El trabajo de más de 40 años atrás con pelos de cabra contaminados por B. anthracis en hilanderías proporcionó cierta información acerca del riesgo de las esporas deB. anthracis que contenían partículas en ambientes laborales contaminados naturalmente. Esta información sugirió que niveles relativamente altos de esporas de B. anthracis "no eran necesariamente o consistentemente peligrosas" en este marco (36). Los expertos en guerra bacteriológica consideraron poco probable que los terroristas pudiesen producir un polvo de esporas deB. anthracis para ser usado en un sobre que fuese capaz de generar un aerosol con una amenaza substancial primaria (o secundaria) para la infección de los seres humanos o dispersar la infección de medio ambiente. A pesar de todo, en la oficina del senador Daschle, en la oficina del senado del edificio Hart, en la sala en donde la carta fue abierta (así como fuera de la sala) la mucosa nasal de las personas expuestas quedaron contaminadas casi de inmediato (37). Re-aerosolización (aerosol secundario) a un nivel consistente con una transmisión potencial se demostró que se encontraba fuera de la clasificación de rápida propagación en las instalaciones Brentwood Processing y Distribution Facility (38). Estudios recientes usando esporas simuladas de B. anthracis del Canadian Defense Establishment Suffield sugieren que los sobres contaminados pueden causar una grave contaminación aerosol (39). Se están adquiriendo nuevos conocimientos, y esto debiera mejorar la respuesta de salud pública en el futuro.
La toma de decisión que involucró el cierre del Servicio Postal de la instalación de Procesamiento y Distribución de Brentwood, Washington, D.C., ha sido criticada. No se logró comprobar a tiempo el riesgo para los empleados de la instalación de Brentwood por sobres contaminados en transito y prevenir el contagio de cuatro empleados, dos de ellos fallecieron (40). Las decisiones concernientes a la instalación de Brentwood se basaron en observaciones epidemiológicas en Florida y New York, en donde no hubo muertos entre los trabajadores postales. Una posible explicación para las diferencias del riesgo es que la preparación de esporas deB. anthracis de los sobres del 9 de octubre tenían un mayor poder de aerolización que las preparaciones del 18 de septiembre o que los dos envíos fueron hechos bajo o expuestos a condiciones medio ambientales distintas (e.j., porcentaje de humedad) que creo un potencial de aerolizacion distinto. Un potencial de aerolización diferente es sustentado por la curva epidémica en el manuscrito de Jernigan et al. (13), el cual muestra una mayor proporción de inhalación (versus cutánea) los casos de ántrax asociados con el envío de octubre 9. En enfermedades de ocurrencia natural, una vez que el riesgo es comprendido, por lo general permanece alto; sin embargo, en la contaminación intencional, los riesgos pueden ser alterados por los perpetradores.
En el transcurso de la investigación ántrax, la respuesta del equipo de salud pública estaba mejor preparada en ciertas áreas que en otras. Cinco muertes no se pudieron evitar, pero la diseminación de la enfermedad y muerte fue evitada por medio de un reconocimiento temprano de las amenazas y una intervención oportuna. Aplicamos lo que conocíamos y aprendimos lo que no. Obtuvimos un nuevo aprecio hacia las comunicaciones y el trabajo conjunto. Por primera vez, el 8 de noviembre de 2001, un presidente de los Estados Unidos en ejercicio, George W. Bush, visitó el CDC para apoyar los esfuerzos de los profesionales de la salud pública y otros que participaron en la investigación ántrax y respuesta. Líderes y héroes individuales escalaron en los cargos de salud pública, medicina clínica y aplicación de la ley (41). El role sustancial de la salud pública en la investigación ántrax y respuesta 2001sugiere que una infraestructura fuerte de la salud pública soportada por la salud pública aplicada e investigaciones de ciencia básicos son los elementos claves para el control y prevención de futuras amenazas de terrorismo biológico.
Reconocimientos
Los editores anfitriones de esta edición especial de Emerging Infectious Diseases agradecen a todos los colegas quienes participaron en la investigación terrorismo biológico 2001 y respuesta y, a todos quienes contribuyeron con los artículos de esta edición.
Referencias
1. Traeger MS, Wiersma S, Rosenstein NE, Malecki JM, Shepard CW, Raghunathan P, et al. First case of bioterrorism-related inhalational anthrax in the United States—Palm Beach County, Florida 2001. Emerg Infect Dis 2002;8. (this issue)
2. Maillard J-M, Cline S, Turner L, Fischer M. First case of bioterrorism-related inhalational anthrax, Florida, 2001: North Carolina investigation. Emerg Infect Dis 2002;8. (this issue)
3. Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. MMWR Morb Mortal Wkly Rep 2000;49:1–26.
4. Khan AS, Morse S, Lillibridge S. Public-health preparedness for biologic terrorism in the USA. Lancet 2000;356:1179–82
5. Hoffmaster AR, Meyer RF, Bowen M, Marston CK, Weyant RS, Barnett GA, et al. Evaluation and validation of a real-time polymerase chain reaction assay for rapid identification of Bacillus anthracis. Emerg Infect Dis 2002;8. (this issue)
6. De BK, Bragg SL, Sanden GN, Wilson KE, Diem LA, Marston CK, et al. A two-component direct fluorescent-antibody assay for rapid identification of Bacillus anthraci. Emerg Infect Dis 2002;8. (this issue)
7. Hoffmaster AR, Fitzgerald CC, Ribot E, Mayer LW, Popovic T. Molecular subtyping of Bacillus anthracis and the 2001 bioterrorism-related anthrax outbreak, United States. Emerg Infect Dis 2002;8. (this issue)
8. Mohammed MJ, Marston CK, Popovic T, Weyant RS, Tenover FC. Antimicrobial susceptibility testing of Bacillus anthracis: comparison of results obtained by using the National Committee for Clinical Laboratory Standards broth microdilution reference and Etest agar gradient diffusion methods. J Clin Microbiol 2002;40:1902–7.
9. Quinn CP, Semenova VA, Elie CM, Romero-Steiner S, Greene C, Li H, et al. Specific, sensitive, and quantitative enzyme-linked immunosorbent assay for human immunoglobulin G antibodies to anthrax toxin protective antigen. Emerg Infect Dis 2002;8. (this issue)
10. Thacker SB, Dannenberg AL, Hamilton DH. Epidemic intelligence service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology. Am J Epidemiol 2001;154:985–92.
11. Bales ME, Dannenberg AL, Brachman PS, Kaufmann AF, Klatsky PC, Ashford DA. Epidemiologic response to anthrax outbreaks: field investigations, 1950–2001. Emerg Infect Dis 2002;8. (this issue)
12. Butler J, Cohen M. Collaboration between public health and law enforcement: new paradigms and partnerships for bioterrorism planning and response. Emerg Infect Dis 2002;8. (this issue)
13. Jernigan D, Raghunathan P, Ashford D, Bell B, Brechner R, Bresnitz E, et al. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis 2002;8. (this issue)
14. Mott JA, Treadwell T, Hennessy T, Rosenberg P, Wolfe M, Brown C, et al. Call-tracking data and the public health response to bioterrorism-related anthrax. Emerg Infect Dis 2002;8. (this issue)
15. Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis 2001;7:933–44.
16. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep 2001;50:909–19.
17. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR Morb Mortal Wkly Rep 2001;50:941–8.
18. Centers for Disease Control and Prevention. Updated recommendations for antimicrobial prophylaxis among asymptomatic pregnant women after exposure to Bacillus anthracis. MMWR Morb Mortal Wkly Rep 2001;50:960.
19. Centers for Disease Control and Prevention. Update: interim recommendations for antimicrobial prophylaxis for children and breastfeeding mothers and treatment of children with anthrax. MMWR Morb Mortal Wkly Rep 2001;50:1014-1016.
20. Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the prophylaxis, diagnosis, and treatment of anthrax. Emerg Infect Dis 2002 8:222–5.
21. Barakat LA, Quentzel HL, Jernigan JA, Kirschke DL, Griffith K, Spear SM, et al. Fatal inhalational anthrax in a 94-year-old Connecticut woman. JAMA 2002;287:863–8.
22. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax, 2001. MMWR Morb Mortal Wkly Rep 2001;50:1008–10.
23. Polyak CS, Macy JT, Irizarry-De La Cruz M, Lai JE, McAuliffe J, Popovic T, et al. Bioterrorism-related anthrax: international response by the Centers for Disease Control and Prevention activities. Emerg Infect Dis 2002;8. (this issue)
24. Tengelsen L, Hahn C, Hudson R, Barnes S. Coordinated response to possible anthrax contamination, Idaho, 2001. Emerg Infect Dis 2002;8. (this issue)
25. Centers for Disease Control and Prevention. Selected articles. Special issue. MMWR Morb Mortal Wkly Rep 2001; 50:877;889–897;909–919;941–948;960;961;962;973–976;984–986;987–990;991;1008–1010;1014–1016;1049–1051;1051–1054.
26. Perkins BA, Ashford D. Bioterrorism-related Bacillus anthracis public health research priorities (meeting summary). Emerg Infect Dis 2002;8. (this issue)
27. Centers for Disease Control and Prevention. Interim guidelines for investigation and response to Bacillus anthracis exposures. MMWR Morb Mortal Wkly Rep 2001;50:987–90.
28. Greene C, Reefhuis J, Tan C, Fiore AE, Goldstein S, Beach M, et al. Epidemiologic investigations of bioterrorism-related anthrax, New Jersey, 2001. Emerg Infect Dis 2002;8. (this issue)
29. Sanderson WT, Hein M, Taylor L, Curwin B, Kinnes G, Seitz T, et al. Surface sampling methods for Bacillus anthracis spore contamination. Emerg Infect Dis 2002;8. (this issue)
30. Teshale EH, Painter J, Burr GA, Wright SV, Cseh LF, Zabrocki R, et al. Environmental sampling for spores of Bacillus anthracis. Emerg Infect Dis 2002;8. (this issue)
31. Tan CG, Sandhu H, Crawford D, Redd S, Beach M, Buehler J, et al. Surveillance for anthrax cases associated with contaminated letters—New Jersey, Delaware, and Pennsylvania, 2001. Emerg Infect Dis 2002;8. (this issue)
32. Williams A, Parashar U, Stoica A, Ridzon R, Kirschke D, Meyer R, et al. Bioterrorism-related anthrax surveillance in Connecticut, September–December, 2001. Emerg Infect Dis 2002;8. (this issue)
33. Shepard CW, Soriano-Gabarro M, Zell ER, Hayslett J, Lukacs S, Goldstein S, et al. Antimicrobial postexposure prophylaxis for anthrax: adverse events and adherence. Emerg Infect Dis 2002;8. (this issue)
34. Jefferds MD, Laserson K, Fry AM, Roy S, Hayslett J, Grummer-Strawn L, et al. Adherence to antimicrobial inhalational anthrax prophylaxis among postal workers, Washington, D.C., 2001. Emerg Infect Dis 2002;8. (this issue)
35. Williams JL, Noviello SS, Griffith KS, Wurtzel H, Hamborsky J, Perz JF, et al. Anthrax postexposure prophylaxis in postal workers, Connecticut, 2001. Emerg Infect Dis 2002;8. (this issue)
36. Brachman PS, Plotkin SA, Bumford FH, Atchison MM. An epidemic of inhalation anthrax: the first in the twentieth century. Am J Hyg 1960:72:6-23
37. Hsu VP, Lukacs SL, Handzel T, Hayslett J, Harper S, Hales T, et al. Opening a Bacillus anthracis-containing envelope, Capitol Hill, Washington, D.C.: the public health response. Emerg Infect Dis 2002;8. (this issue)
38. Dull P, Wilson K, Kournikakis B, Boulet C, Ho J, Ogston J, et al. Bacillus anthracis aerosolization associated with a contaminated mail sorting machine. Emerg Infect Dis 2002;8. (this issue)
39. Kournakakis B., Armour SJ, Boulet CA, Spence M, Barsons B. Risk assessment of anthrax threat letters. DRES Technical Report TR 2001-048. September, 2001.
40. Dewan PK, Fry AM, Laserson K, Tierney BC, Quinn CP, Hayslett JA, et al. Inhalational anthrax outbreak among postal workers, Washington, D.C., 2001. Emerg Infect Dis 2002;8. (this issue)
41. Gerberding JL, Hughes JM, Koplan JP. Bioterrorism preparedness and response: clinicians and public health agencies as essential partners. JAMA 2002;287:898–900.
Bradley A. Perkins, Editor Invitado
Dr. Perkins es jefe, de la Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention (CDC), el cual tiene responsabilidad técnica en los aspectos epidemiológicos y de laboratorio del Bacillus anthracis, y otros agentes selectos de importancia en la salud pública. El Dr. Perkins dirigió el equipo de campo del CDC en la investigación del caso indexado de ántrax inhalable en Florida y participó ampliamente en la investigación y respuesta ántrax 2001. Su investigación incluye la evaluación de vacunas, meningitis bacteriana, terrorismo biológico, y enfermedades infecciosas emergentes. Ha trabajado extensamente en el control y prevención de enfermedades meningocócicas en los Estados Unidos, Africa, y el mundo entero.
Tanja Popovic, Editor Invitado
Dr. Popovic es jefe, del Epidemiologic Investigations Laboratory, Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention. Puesto que el asunto consideraba a expertos en aspectos de laboratorio B. anthracis y ántrax en CDC, ella y su equipo capacitó a científicos laboratoristas en los 50 estados para aislar e identificar B. anthracis usando metodología estándar en otoño del 2000, y ha llevado a cabo miles de pruebas para aislamiento de B. anthracis, su identificación confirmatoria y subtipo molecular durante la investigación ántrax 2001. Además de la preparación para terrorismo biológico y respuesta, su investigación se centró en el diagnóstico de laboratorio y epidemiología molecular de meningitis bacteriana y difteria.
Kevin Yeskey, Editor Invitado
Dr. Yeskey es director, del Bioterrorism Preparedness and Response Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). Ha prestado servicios como director suplente del Emergency Public Health en la Division of Emergency and Environmental Health Services, National Center for Environmental Health, CDC. Sus trabajos anteriores incluyen profesor asociado y vice presidente, Department of Military and Emergency Medicine, Uniformed Services University School of Medicine, y funcionario médico jefe, United States Public Health Service Office of Emergency Preparedness. La experiencia del Dr. Yeskey en respuesta a desastres incluyen trabajos en huracanes, terremotos, inundaciones, migraciones masivas y ataques terroristas con bombas.
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More Less | | Botany, Environment, Finance, Food processing, Insurance, Medicine, Miscellaneous, Phytopathology, ships, Technical | | Other - EATRI | | Years of translation experience: 13. Registered at ProZ.com: Feb 2000. | | N/A | English to Spanish (Instituto Profesional Eatri)
English to Spanish (TOEIC (Corfo Chile))
English to Spanish (CORFO CHILE)
| | | Adobe Acrobat, Microsoft Excel, Microsoft Word, CoffeeCup Html Editor, Freehand 8.0, Pagemaker 6.0, Photoshop 5.0, SDLX 4.0, Powerpoint, SDLX | | http://www.flaviotraducciones.com | | Spanish (DOC) | | Flavio Figueroa endorses ProZ.com's Professional Guidelines (v1.0). | | About me English to Spanish translator since 1995, during this years I have been working for many different clients and on many different fields. Active member of several translator sites where I have had the opportunity to show my translations skills to many other clients.
I am also co-owner of an advertising agency called Curigr@fica Publicidad, this agency offers advertising services in several areas (mail marketing, graphic design, bilingual advertising among others) it also has its own magazine which is delivered in a freely monthly basis at local level and it is financed by the selling of advertising spaces on it, it has a total amount of 3 thousand issues and also owns a web site http://www.revistamasdatos.cl , I am the webmaster and also the editor.
My knowledge of a second language has perfectly matched my restless spirit allowing me to self-taught in different areas of my interest like computer technologies, environmental issues specially those related with clean energies (solar) and organic fertilizers (humus).
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