Epidemiologic investigations of bioterrorism-related anthrax,New Jersey, 2001

At least four Bacillus anthracis-containing envelopes destined for New York City and Washington, D.C. were processed at the Trenton Processing and Distribution Center (PDC) on September 18 and October 9, 2001. When cutaneous anthrax was confirmed in a Trenton postal worker, the PDC was closed. Four cutaneous and two inhalational anthrax cases were identified. Five patients were hospitalized; none died. Four were PDC employees; the others handled or received mail processed there. Onset dates occurred in two clusters following envelope processing at the PDC. The attack rate among the 170 employees present when the B. anthracis-containing letters were sorted on October 9 was 1.2%. Of 137 PDC environmental samples, 57 (42%) were positive. Five (10%) of 50 local post offices each yielded one positive sample. Cutaneous or inhalational anthrax developed in four postal employees at a facility where B. anthracis-containing letters were processed. Cross-contaminated mail or equipment was the likely source of infection in two other case-patients with cutaneous anthrax.     

Isolated case of bioterrorism-related inhalational anthrax,New York City, 2001

On October 31, 2001, in New York City, a 61-year-old female hospital employee who had acquired inhalational anthrax died after a 6-day illness. To determine sources of exposure and identify additional persons at risk, the New York City Department of Health, Centers for Disease Control and Prevention, and law enforcement authorities conducted an extensive investigation, which included interviewing contacts, examining personal effects, summarizing patient's use of mass transit, conducting active case finding and surveillance near her residence and at her workplace, and collecting samples from co-workers and the environment. We cultured all specimens for Bacillus anthracis. We found no additional cases of cutaneous or inhalational anthrax. The route of exposure remains unknown. All environmental samples were negative for B. anthracis. This first case of inhalational anthrax during the 2001 outbreak with no apparent direct link to contaminated mail emphasizes the need for close coordination between public health and law enforcement agencies during bioterrorism-related investigations.     

Investigation of bioterrorism-related anthrax,United States, 2001: epidemiologic findings

In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.     

医院急诊处方抗菌药物使用合理性的分析

目的 了解医院抗菌药物使用的近况.方法 抽取2011年2月28日急诊处方216张,针对抗菌药物的处方进行统计分析.结果 含有抗菌药物的急诊处方139张,使用率为64.8％,抗菌药物处方含有1～3种抗菌药物分别为114、23、3张,分别占抗菌药物处方的81.4％、16.4％、2.1％,静脉用药占67.1％,口服给药占30.0％,结果表明,抗菌药物使用率高,静脉给药比例高,经验性抗菌药物的使用指征不明确,联合应用抗菌谱相重叠.结论 抗菌药物的针对性应用是提高处方合格率最有效的方法之一.     

First case of bioterrorism-related inhalational anthrax,Florida, 2001: North Carolina investigation

The index case of inhalational anthrax in October 2001 was in a man who lived and worked in Florida. However, during the 3 days before illness onset, the patient had traveled through North Carolina, raising the possibility that exposure to Bacillus anthracis spores could have occurred there. The rapid response in North Carolina included surveillance among hospital intensive-care units, microbiology laboratories, medical examiners, and veterinarians, and site investigations at locations visited by the index patient to identify the naturally occurring or bioterrorism-related source of his exposure.     

Experiences with anthrax emergency measures during 2001 and 2002 in the city of Essen

After the terrorist attacks of 11 September 2001 suspected cases of anthrax also occurred in Germany. No case could be confirmed. From October 2001 to November 2002 the fire brigade of the city of Essen was called in 110 cases of suspected anthrax contamination. In 78 cases specimens were transported to diagnostic laboratories, in 22 cases persons were transported. Only in the first few days patients with suspected contamination had to stay in hospital and underwent chemoprophylaxis. Cooperation between the fire brigade, the local health authorities and the hygienists of the involved hospitals was very intense. It seems necessary to evaluate all the German experiences with suspected anthrax cases to develop risk estimations for different exposure situations and to develop specific recommendations for decontamination, disinfection and initial therapy.     

Parental attitude towards mass antimicrobial prophylaxis during a school-associated pertussis outbreak

We describe parental attitude towards mass antimicrobial prophylaxis and adolescent booster vaccination to prevent pertussis. A survey was distributed to parents at a large suburban high school where an outbreak of pertussis was occurring. A total of 314 surveys were received among 450 distributed. If antimicrobial prophylaxis was recommended for all students and faculty as a method of controlling a pertussis outbreak in their child's school (i.e. mass antimicrobial prophylaxis), 40% of parents would have their child take the medication and 49% might have their child take the antibiotic but would first consult their child's physician. Having > or =2 children attend the high school (OR 2.2, 95% CI 1.10-4.59) and generally favouring immunizations (OR 1.7, 95% CI 0.99-2.87) were predictors of likely compliance with mass antimicrobial prophylaxis. These findings underscore the importance of communicating the rationale of public health intervention efforts to physicians in order to help ensure their success.     

Adherence to antimicrobial inhalational anthrax prophylaxis among postal workers,Washington, D.C., 2001

In October 2001, two envelopes containing Bacillus anthracis spores were processed at the Washington, D.C., Processing and Distribution Center of the U.S. Postal Service; inhalational anthrax developed in four workers at this facility. More than 2,000 workers were advised to complete 60 days of postexposure prophylaxis to prevent inhalational anthrax. Interventions to promote adherence were carried out to support workers, and qualitative information was collected to evaluate our interventions. A quantitative survey was administered to a convenience sample of workers to assess factors influencing adherence. No anthrax infections developed in any workers involved in the interventions or interviews. Of 245 workers, 98 (40%) reported full adherence to prophylaxis, and 45 (18%) had completely discontinued it. Anxiety and experiencing adverse effects to prophylaxis, as well as being <45 years old were risk factors for discontinuing prophylaxis. Interventions, especially frequent visits by public health staff, proved effective in supporting adherence.     

Call-tracking data and the public health response to bioterrorism-related anthrax

After public notification of confirmed cases of bioterrorism-related anthrax, the Centers for Disease Control and Prevention's Emergency Operations Center responded to 11,063 bioterrorism-related telephone calls from October 8 to November 11, 2001. Most calls were inquiries from the public about anthrax vaccines (58.4%), requests for general information on bioterrorism prevention (14.8%), and use of personal protective equipment (12.0%); 882 telephone calls (8.0%) were referred to the state liaison team for follow-up investigation. Of these, 226 (25.6%) included reports of either illness clinically confirmed to be compatible with anthrax or direct exposure to an environment known to be contaminated with Bacillus anthracis. The remaining 656 (74.4%) included no confirmed illness but reported exposures to "suspicious" packages or substances or the receipt of mail through a contaminated facility. Emergency response staff must handle high call volumes following suspected or actual bioterrorist attacks. Standardized health communication protocols that address contact with unknown substances, handling of suspicious mail, and clinical evaluation of suspected cases would allow more efficient follow-up investigations of clinically compatible cases in high-risk groups.     

First case of bioterrorism-related inhalational anthrax in the United States,Palm Beach County,Florida, 2001

On October 4, 2001, we confirmed the first bioterrorism-related anthrax case identified in the United States in a resident of Palm Beach County, Florida. Epidemiologic investigation indicated that exposure occurred at the workplace through intentionally contaminated mail. One additional case of inhalational anthrax was identified from the index patient's workplace. Among 1,076 nasal cultures performed to assess exposure, Bacillus anthracis was isolated from a co-worker later confirmed as being infected, as well as from an asymptomatic mail-handler in the same workplace. Environmental cultures for B. anthracis showed contamination at the workplace and six county postal facilities. Environmental and nasal swab cultures were useful epidemiologic tools that helped direct the investigation towards the infection source and transmission vehicle. We identified 1,114 persons at risk and offered antimicrobial prophylaxis.     

Molecular subtyping of Bacillus anthracis and the 2001 bioterrorism-associated anthrax outbreak,United States

Molecular subtyping of Bacillus anthracis played an important role in differentiating and identifying strains during the 2001 bioterrorism-associated outbreak. Because B. anthracis has a low level of genetic variability, only a few subtyping methods, with varying reliability, exist. We initially used multiple-locus variable-number tandem repeat analysis (MLVA) to subtype 135 B. anthracis isolates associated with the outbreak. All isolates were determined to be of genotype 62, the same as the Ames strain used in laboratories. We sequenced the protective antigen gene (pagA) from 42 representative outbreak isolates and determined they all had a pagA sequence indistinguishable from the Ames strain (PA genotype I). MLVA and pagA sequencing were also used on DNA from clinical specimens, making subtyping B. anthracis possible without an isolate. Use of high-resolution molecular subtyping determined that all outbreak isolates were indistinguishable by the methods used and probably originated from a single source. In addition, subtyping rapidly identified laboratory contaminants and nonoutbreak-related isolates.     

某院急诊儿科抗菌药物处方干预效果分析

目的:通过对急诊儿科抗菌药物处方抽样点评,分析处方干预效果,为进一步提高抗菌药物合理应用水平提供参考.方法:随机等间距抽取某三甲医院2016年5月-7月急诊儿科抗菌药物处方750张作为干预前研究对象,按照相关规定和方法进行初评和终评,并进行适当干预.再随机等间距抽取2016年8月-10月及2016年11月-2017年1月急诊儿科抗菌药物处方各750张作为第1、2次干预后资料,进行处方点评,观察干预效果.结果:干预前急诊儿科抗菌药物处方合理率为46.0％,第一、二次干预后合理率分别提升至63.9％(P=0.0062)、82.5％(P=0.0020).结论:急诊儿科抗菌药物处方经持续点评干预后合理率明显提升,但仍有部分不合理使用现象,应不断加强医务人员抗菌药物使用规范化培训,提高合理用药水平.     

Facilitation of risk communication during the anthrax attacks of 2001: the organizational backstory

The anthrax attacks of 2001 created risk communication problems that cannot be fully understood without appreciating the dynamics among organizations. Case studies of communication in New Jersey, consisting of interviews with a range of participants, found that existing organizational and professional networks facilitated trust among decisionmakers. This interpersonal trust improved communication among agencies and thereby risk communication with the public. For example, "white powder scares" were a problem even in places without contamination. Professionals' trust in each other was vital for responding productively. Conversely, organizational challenges, including conflict among agencies, hindered communication with key audiences. Although centralization and increased control are often seen as the remedy for communicative confusion, they also can quash the improvisational responses needed during crises.     

Antimicrobial postexposure prophylaxis for anthrax: adverse events and adherence

We collected data during postexposure antimicrobial prophylaxis campaigns and from a prophylaxis program evaluation 60 days after start of antimicrobial prophylaxis involving persons from six U.S. sites where Bacillus anthracis exposures occurred. Adverse events associated with antimicrobial prophylaxis to prevent anthrax were commonly reported, but hospitalizations and serious adverse events as defined by Food and Drug Administration criteria were rare. Overall adherence during 60 days of antimicrobial prophylaxis was poor (44%), ranging from 21% of persons exposed in the Morgan postal facility in New York City to 64% of persons exposed at the Brentwood postal facility in Washington, D.C. Adherence was highest among participants in an investigational new drug protocol to receive additional antibiotics with or without anthrax vaccine--a likely surrogate for anthrax risk perception. Adherence of <60 days was not consistently associated with adverse events.     

Immunogenicity and safety of four different dosing regimens of anthrax vaccine adsorbed for post-exposure prophylaxis for anthrax in adults

Background

Strategies to implement post exposure prophylaxis (PEP) in case of an anthrax bioterror event are needed. To increase the number of doses of vaccine available we evaluated reducing the amount of vaccine administered at each of the vaccinations, and reducing the number of doses administered.

Methods

Healthy male and non-pregnant female subjects between the ages of 18 and 65 were enrolled and randomized 1:1:1:1 to one of four study arms to receive 0.5 mL (standard dose) of vaccine subcutaneously (SQ) at: (A) days 0, 14; (B) days 0 and 28; (C) days 0, 14, and 28; or (D) 0.25 mL at days 0, 14, and 28. A booster was provided on day 180. Safety was assessed after each dose. Blood was obtained on days 0, 7, 14, 21, 28, 35, 42, 49, 56, 63, 70, 84, 100, 180, and 201 and both Toxin Neutralizing antibody and anti-PA IgG antibody measured.

Results

Almost all subjects developed some local reactions with 46–64% reported to be of moderate severity and 3.3% severe during the primary series. Vaccine groups that included a day 14 dose induced a ≥4 fold antibody rise in more subjects on days 21, 28, and 35 than the arm without a day 14 dose. However, schedules with a full day 28 dose induced higher peak levels of antibody that persisted longer. The half dose regimen did not induce antibody as well as the full dose study arms.

Conclusion

Depending on the extent of the outbreak, effectiveness of antibiotics and availability of vaccine, the full dose 0, 28 or 0, 14, 28 schedules may have advantages.     

AMS对消化内镜围操作期预防性使用抗菌药物的干预效果

目的探讨抗菌药物科学化管理(AMS)策略对消化内镜诊疗操作患者围操作期抗菌药物预防使用的干预效果。方法以某附属医院2019年1—6月行消化内镜诊疗操作的1 006例患者为研究对象,采用AMS策略对患者围操作期预防使用抗菌药物进行管理和干预,措施包括成立组织、完善制度、优化信息系统、宣教与培训、持续干预和监督等。以2017年1—6月行消化内镜诊疗操作的822例患者为对照组,对比分析两组患者围操作期预防性抗菌药物使用率、抗菌药物使用强度(AUD)、抗菌药物品种、联合用药以及用药时长的变化;同时比较预防性抗菌药物不合理应用情况以及术后感染情况。结果干预前预防性抗菌药物使用率为24.82%(204/822),干预后为17.10%(172/1 006),干预前后比较,差异具有统计学意义(P0.001);AUD方面,干预后为2.18,低于干预前的14.95;联合用药比例、用药时长与干预前相比亦明显下降。AMS策略实施后,抗菌药物预防性应用的不合理率低于实施前(P0.001);而操作后感染发生率则无明显变化(P0.05)。结论 AMS策略能够优化消化内镜围操作期预防性抗菌药物的应用。     

Azithromycin prophylaxis during a hospitalwide outbreak of a pertussis-like illness.

A questionnaire regarding tolerability and adherence was administered for 5 days to hospital employees who received azithromycin prophylaxis during a hospitalwide outbreak of a pertussis-like illness. Analysis of the 239 responses from those having received prophylactic azithromycin determined that it was well tolerated and accounted for a minimal loss of days worked; 81.5% were fully adherent with the regimen.     

An ounce of prevention is a ton of work: mass antibiotic prophylaxis for anthrax,New York City, 2001

Protocols for mass antibiotic prophylaxis against anthrax were under development in New York City beginning in early 1999. This groundwork allowed the city's Department of Health to rapidly respond in 2001 to six situations in which cases were identified or anthrax spores were found. The key aspects of planning and lessons learned from each of these mass prophylaxis operations are reviewed. Antibiotic distribution was facilitated by limiting medical histories to issues relevant to prescribing prophylactic antibiotic therapy, formatting medical records to facilitate rapid decision making, and separating each component activity into discrete work stations. Successful implementation of mass prophylaxis operations was characterized by clarity of mission and eligibility criteria, well-defined lines of authority and responsibilities, effective communication, collaboration among city agencies (including law enforcement), and coordination of staffing and supplies. This model can be adapted for future planning needs including possible attacks with other bioterrorism agents, such as smallpox.     

Uncertain science and certain deadlines: CDC responses to the media during the anthrax attacks of 2001

This paper presents a study in which communication personnel for the U.S. Centers for Disease Control and Prevention (CDC) provided first-hand accounts of the experience of responding to media inquiries during the 2001 anthrax attacks. In-depth interviews were conducted with 19 communication professionals who worked either at the CDC headquarters in Atlanta or at field locations in the U.S. where persons were exposed to anthrax. The interviews sought CDC staff viewpoints on how the CDC handled a historically unprecedented level of press activity in terms of work locations and equipment, information flow and clearance, and staff roles. Staff reported that the situation led to new work practices, tools for performing the work, and an enhanced understanding of what it takes to be prepared for and to handle communication work during a terrorism-related health crisis. The paper provides a discussion of implications of the findings for CDC and for other public health organizations developing systems for communication response during health-related crises.