Abstract

In June and July 2010, we conducted a national internet-based survey of 64 city, state, and territorial immunization program managers (IPMs) to assess their experiences in managing the 2009-10 H1N1 influenza vaccination campaign. Fifty-four (84%) of the managers or individuals responsible for an immunization program responded to the survey. To manage the campaign, 76% indicated their health department activated an incident command system (ICS) and 49% used an emergency operations center (EOC). Forty percent indicated they shared the leadership of the campaign with their state-level emergency preparedness program. The managers' perceptions of the helpfulness of the emergency preparedness staff was higher when they had collaborated with the emergency preparedness program on actual or simulated mass vaccination events within the previous 2 years. Fifty-seven percent found their pandemic influenza plan helpful, and those programs that mandated that vaccine providers enter data into their jurisdiction's immunization information system (IIS) were more likely than those who did not mandate data entry to rate their IIS as valuable for facilitating registration of nontraditional providers (42% vs. 25%, p<0.05) and tracking recalled influenza vaccine (50% vs. 38%, p<0.05). Results suggest that ICS and EOC structures, pandemic influenza plans, collaborations with emergency preparedness partners during nonemergencies, and expanded use of IIS can enhance immunization programs' ability to successfully manage a large-scale vaccination campaign. Maintaining the close working relationships developed between state-level immunization and emergency preparedness programs during the H1N1 influenza vaccination campaign will be especially important as states prepare for budget cuts in the coming years.

The authors conducted a study of state and local immunization program managers to assess their experiences in managing the 2009-10 H1N1 influenza vaccination campaign. Results suggest that incident command and emergency operations center structures, pandemic influenza plans, collaborations with emergency preparedness partners during nonemergencies, and expanded use of immunization information systems are important in successfully managing a large-scale vaccination campaign.

The use of tabletop exercises as a tool in emergency preparedness and response has proven to be an effective means of assessing readiness for unexpected events. Whereas most exercise developers target a population in a defined space (eg, state, county, metropolitan area, hospital), the Southeastern Center for Emerging Biologic Threats (SECEBT) conducted an innovative tabletop exercise involving an unusual foodborne outbreak pathogen, targeting public health agencies and academic institutions in 7 southeastern states. The exercise tested the ability of participants to respond to a simulated foodborne disease outbreak affecting the region. The attendees represented 4 federal agencies, 9 state agencies, 6 universities, 1 nonprofit organization, and 1 private corporation. The goals were to promote collaborative relationships among the players, identify gaps in plans and policies, and identify the unique contributions of each organization—and notably academic institutions—to outbreak recognition, investigation, and control. Participants discussed issues and roles related to outbreak detection and management, risk communication, and coordination of policies and responsibilities before, during, and after an emergency, with emphasis on assets of universities that could be mobilized during an outbreak response. The exercise generated several lessons and recommendations identified by participants and evaluators. Key recommendations included a need to establish trigger points and protocols for information sharing and alerts among public health, academic, and law enforcement; to establish relationships with local, state, and federal stakeholders to facilitate communications during an emergency; and to catalogue and leverage strengths, assets, and priorities of academic institutions to add value to outbreak responses.

A tabletop exercise simulated a foodborne outbreak and involved representatives from federal and state agencies, universities, a nonprofit organization, and a corporation. The exercise pointed up the need to establish working relationships before an emergency and suggested that the resources of academic institutions could be used to good advantage.

Two epidemic modeling studies of inhalational tularemia were identified in the published literature, both demonstrating the high number of potential casualties that could result from a deliberate aerosolized release of the causative agent in an urban setting. However, neither study analyzed the natural history of inhalational tularemia nor modeled the relative merits of different mitigation strategies. We first analyzed publicly available human/primate experimental data and reports of naturally acquired inhalational tularemia cases to better understand the epidemiology of the disease. We then simulated an aerosolized release of the causative agent, using airborne dispersion modeling to demonstrate the potential number of casualties and the extent of their spatial distribution. Finally, we developed a public health intervention model that compares 2 mitigation strategies: targeting antibiotics at symptomatic individuals with or without mass distribution of antibiotics to potentially infected individuals. An antibiotic stockpile that is sufficient to capture all areas where symptomatic individuals were infected is likely to save more lives than treating symptomatic individuals alone, providing antibiotics can be distributed rapidly and their uptake is high. However, with smaller stockpiles, a strategy of treating symptomatic individuals alone is likely to save many more lives than additional mass distribution of antibiotics to potentially infected individuals. The spatial distribution of symptomatic individuals is unlikely to coincide exactly with the path of the dispersion cloud if such individuals are infected near their work locations but then seek treatment close to their homes. The optimal mitigation strategy will depend critically on the size of the release relative to the stockpile level and the effectiveness of treatment relative to the speed at which antibiotics can be distributed.

The authors analyzed publicly available data and reports of inhalational tularemia cases to better understand the epidemiology of the disease. They then simulated an aerosolized release of the causative agent, using airborne dispersion modeling to demonstrate the potential number of casualties and the extent of their distribution. Finally, they developed a public health intervention model that compares 2 mitigation strategies: targeting antibiotics at symptomatic individuals with or without mass distribution of antibiotics to potentially infected people.

Michigan's unique geological features and highly variable climatic conditions make distribution of medical countermeasures during a public health emergency situation very challenging. To enhance distribution during these situations, the Civil Air Patrol (CAP) has agreed to support the state of Michigan by transporting life-saving medical countermeasures to remote areas of the state. The Michigan Strategic National Stockpile (MISNS) program has successfully developed, exercised, and enhanced its partnership with the CAP to include distribution of federally provided Strategic National Stockpile (SNS) assets. The CAP has proven to be a reliable and valuable partner, as well as a cost-effective and time-efficient means of transporting vital resources during a public health emergency.

Michigan's unique geological features and highly variable climate make distribution of medical countermeasures during a public health emergency situation challenging. The Civil Air Patrol agreed to transport life-saving medical countermeasures to remote areas of the state. The program was successfully developed and exercised.

In the United States, filoviruses (ebolaviruses and marburgviruses) are listed as National Institute of Allergy and Infectious Diseases (NIAID) Category A Priority Pathogens, Select Agents, and Centers for Disease Control and Prevention (CDC) Category A Bioterrorism Agents. In recent months, U.S. biodefense professionals and policy experts have initiated discussions on how to optimize filovirus research in regard to medical countermeasure (ie, diagnostics, antiviral, and vaccine) development. Standardized procedures and reagents could accelerate the independent verification of research results across government agencies and establish baselines for the development of animal models acceptable to regulatory entities, such as the Food and Drug Administration (FDA), while being fiscally responsible. At the root of standardization lies the question of which filovirus strains, variants, or isolates ought to be the prototypes for product development, evaluation, and validation. Here we discuss a rationale for their selection. We conclude that, based on currently available data, filovirus biodefense research ought to focus on the classical taxonomic filovirus prototypes: Marburg virus Musoke in the case of marburgviruses and Ebola virus Mayinga in the case of Zaire ebolaviruses. Arguments have been made in various committees in favor of other variants, such as Marburg virus Angola, Ci67 or Popp, or Ebola virus Kikwit, but these rationales seem to be largely based on anecdotal or unpublished and unverified data, or they may reflect a lack of awareness of important facts about the variants' isolation history and genomic properties.

Standardized procedures and reagents could accelerate the independent verification of research results across government agencies and establish baselines for the development of animal models acceptable to regulatory entities. At the root of standardization lies the question of which filovirus strains, variants, or isolates ought to be the prototypes for product development, evaluation, and validation. The authors discuss a rationale for selection and conclude that filovirus biodefense research ought to focus on the classical taxonomic filovirus prototypes.

Reaerosolization or resuspension—that is, the reintroduction of previously airborne particles into the atmosphere—is a complex phenomenon. Microbial reaerosolization is particularly poorly understood because few studies have been done in this area, and many of the studies that have been performed are not in the peer-reviewed literature. The reaerosolization of Bacillus anthracis in outdoor environments is of particular concern because of its stability and potential for use as a biological weapon. This review pulls together data from more than 30 publications, spanning field and laboratory experiments, to summarize the current state of our understanding of Bacillus spp. reaerosolization in outdoor environments.

Reaerosolization or resuspension—that is, the reintroduction of previously airborne particles into the atmosphere—is poorly understood because few studies have been done in this area, and many of the studies that have been performed are not in the peer-reviewed literature. The reaerosolization of Bacillus anthracis in outdoor environments is of particular concern because of its stability and potential for use as a biological weapon. This review pulls together data from more than 30 publications to summarize the current state of our understanding of Bacillus spp. reaerosolization in outdoor environments.

The authors surveyed life science journals to determine how many have a policy concerning dual-use research. Of the 155 journals that responded, only 7.7% stated that they had a written dual-use policy and only 5.8% said they had experience reviewing dual-use research in the past 5 years.

To address biosecurity issues, government agencies, academic institutions, and professional societies have developed policies concerning the publication of “dual-use” biomedical research—that is, research that could be readily applied to cause significant harm to the public, the environment, or national security. We conducted an e-mail survey of life science journals to determine the percentage that have a dual-use policy. Of the 155 journals that responded to our survey (response rate 39%), only 7.7% stated that they had a written dual-use policy and only 5.8% said they had experience reviewing dual-use research in the past 5 years. Among the potential predictors we investigated, the one most highly associated with a journal having a written dual-use policy was membership in the Nature Publishing Group (positive association). When considered individually, both previous experience with reviewing dual-use research and the journal's impact factor appeared to be positively associated with having a written dual-use policy, but only the former remained significant after adjusting for publishing group. Although preventing the misuse of scientific research for terrorist or criminal purposes is an important concern, few biomedical journals have dual-use review policies. Journals that are likely to review research that raises potential dual-use concerns should consider developing dual-use policies.

To ensure that biomedical research is performed in the safest and most responsible manner possible, the NIH established the Biological Surety Program (BSP) in 2006 to reflect the unique human and security factors associated with biosafety level 4 (BSL-4) laboratories. The program sets forth control measures to ensure there is a trained, responsible, and reliable workforce, with rigorous procedures to protect employee health and maintain a safe work environment.

The events and aftermath of September 11, 2001, accelerated a search for personnel reliability test measures to identify individuals who could pose a threat to our nation's security and safety. The creation and administration of a behavioral health screen for BSL-4 laboratory workers at the National Institutes of Health represents a pioneering effort to proactively build a BSL-4 safety culture promoting worker cohesiveness, trust, respect, and reliability with a balance of worker privacy and public safety.

The National Institute of Allergy and Infectious Diseases (NIAID) Radiation/Nuclear Medical Countermeasures Development Program has developed an integrated approach to providing the resources and expertise required for the research, discovery, and development of radiation/nuclear medical countermeasures (MCMs). These resources and services lower the opportunity costs and reduce the barriers to entry for companies interested in working in this area and accelerate translational progress by providing goal-oriented stewardship of promising projects. In many ways, the radiation countermeasures program functions as a “virtual pharmaceutical firm,” coordinating the early and mid-stage development of a wide array of radiation/nuclear MCMs. This commentary describes the radiation countermeasures program and discusses a novel business model that has facilitated product development partnerships between the federal government and academic investigators and biopharmaceutical companies.

Public health experts from a county health department and a school of public health in Texas collaborated to establish a simple, functional surveillance system to monitor 2009 H1N1 influenza virus as it crossed from Mexico into a Texas border community. They used GIS mapping and reports of school and daycare absences to guide their response to the outbreak.

Public health experts from a county health department and a school of public health collaborated to establish a simple, functional surveillance system to monitor swine-origin influenza virus as it crossed from Mexico into a Texas border community during the 2009 pandemic. The draft national and state preparedness plans were found to be cumbersome at the local level, so a simple, more practical real-time surveillance and response system was developed, in part by modifying these documents, and immediately implemented. Daily data analyses, including geographical information system mapping of cases and reports of school and daycare absences, were used for outbreak management. Aggregate reports of influenzalike illness and primary school absences were accurate in predicting influenza activity and were practical for use in local tracking, making decisions, and targeting interventions. These simple methods should be considered for local implementation and for integration into national recommendations for epidemic preparedness and response.

The intentional and controlled release of an aerosolized bacterium provides an opportunity to investigate the implications of a biological attack. Since 2006, Los Alamos National Laboratory has worked with several urban areas, including Fairfax County, VA, to design experiments to evaluate biodefense concepts of operations using routine spraying of Bacillus thuringiensis var. kurstaki (Btk). Btk is dispersed in large quantities as a slurry to control the gypsy moth, Lymantria dispar. Understanding whether personnel and equipment pick up residual contamination during sampling activities and transport it to other areas is critical for the formulation of appropriate response and recovery plans. While there is a growing body of literature surrounding the transmission of viral diseases via fomites, there is limited information on the transport of Bacillus species via this route. In 2008, LANL investigated whether field sampling activities conducted near sprayed areas, post-spray, resulted in measurable cross-contamination of sampling personnel, equipment, vehicles, and hotel rooms. Viable Btk was detected in all sample types, indicating transport of the agent occurred via fomites.

Anecdotal evidence has indicated that microbial collections have been destroyed in the U.S. following the imposition of the regulations associated with the Select Agents and Toxins List. The authors confirmed, by means of a questionnaire, that this has occurred in at least 13 cases.

In this study we have followed up on anecdotal and hearsay evidence that microbial collections were destroyed in the United States following the imposition of the regulations associated with the Select Agents and Toxins List, to validate or refute that information. Using a questionnaire, we documented 13 episodes of microbial collection destruction involving viral, bacterial, and fungal strains, which we believe is almost certainly an underestimate of the number of collections destroyed. In every case, the motivation for the destruction of the collection was a desire to avoid the perceived burdens of the regulatory environment associated with operating under the Select Agent Regulations. Some institutions that destroyed isolates considered, and in some cases tried, transferring their collections to registered institutions prior to collection destruction but desisted when confronted with transport regulations. Destruction of microbial collections represents a loss of strains and biological diversity available for biomedical research and future mechanistic, forensic, and epidemiologic investigations. Given the rapid evolution of microbial strains, the destruction of archival collections is a potentially irretrievable loss that was an unintended consequence of regulations to protect society against the nefarious use of biological agents. Furthermore, unregistered institutions continue to destroy newly acquired clinical isolates, thus preventing the establishment of new repository collections. We recommend that government agencies develop plans to ensure that microbial collections are preserved when considering future additions to microbial threat lists under which the possession of certain microbes is criminalized.

This article synthesizes and extends discussions held during an international meeting on “Surveillance for Decision Making: The Example of 2009 Pandemic Influenza A/H1N1,” held at the Center for Communicable Disease Dynamics (CCDD), Harvard School of Public Health, on June 14 and 15, 2010. The meeting involved local, national, and global health authorities and academics representing 7 countries on 4 continents. We define the needs for surveillance in terms of the key decisions that must be made in response to a pandemic: how large a response to mount and which control measures to implement, for whom, and when. In doing so, we specify the quantitative evidence required to make informed decisions. We then describe the sources of surveillance and other population-based data that can presently—or in the future—form the basis for such evidence, and the interpretive tools needed to process raw surveillance data. We describe other inputs to decision making besides epidemiologic and surveillance data, and we conclude with key lessons of the 2009 pandemic for designing and planning surveillance in the future.

This article synthesizes discussions held during an international meeting, “Surveillance for Decision Making: The Example of 2009 Pandemic Influenza A/H1N1,” held at Harvard School of Public Health in June 2010. It defines the needs for surveillance in terms of the key decisions that must be made in response to a pandemic: how large a response to mount and which control measures to implement, for whom, and when. The article describes the sources of surveillance and other population-based data that can form the basis for such evidence, and the interpretive tools needed to process raw surveillance data. It concludes with key lessons of the 2009 pandemic for designing and planning surveillance in the future.

The October 2001 anthrax attacks heralded a new era of bioterrorism threat in the U.S. At the time, little systematic data on mental health effects were available to guide authorities' response. For this study, which was conducted 7 months after the anthrax attacks, structured diagnostic interviews were conducted with 137 Capitol Hill staff workers, including 56 who had been directly exposed to areas independently determined to have been contaminated. Postdisaster psychopathology was associated with exposure; of those with positive nasal swab tests, PTSD was diagnosed in 27% and any post-anthrax psychiatric disorder in 55%. Fewer than half of those who were prescribed antibiotics completed the entire course, and only one-fourth had flawless antibiotic adherence. Thirty percent of those not exposed believed they had been exposed; 18% of all study participants had symptoms they suspected were symptoms of anthrax infection, and most of them sought medical care. Extrapolation of raw numbers to large future disasters from proportions with incorrect belief in exposure in this limited study indicates a potential for important public health consequences, to the degree that people alter their healthcare behavior based on incorrect exposure beliefs. Incorrect belief in exposure was associated with being very upset, losing trust in health authorities, having concerns about mortality, taking antibiotics, and being male. Those who incorrectly believe they were exposed may warrant concern and potential interventions as well as those exposed. Treatment adherence and maintenance of trust for public health authorities may be areas of special concern, warranting further study to inform authorities in future disasters involving biological, chemical, and radiological agents.

On April 26, 2009, the United States declared a public health emergency in response to a growing but uncertain threat from H1N1 influenza, or swine flu. In June, the World Health Organization declared a pandemic. In the U.S., hospitalizations due to swine flu numbered 6,506 on August 6, 2009, with 436 deaths; all 50 states have reported cases. The declaration of a public health emergency, followed by the approval of multiple Emergency Use Authorizations (EUAs) by the Food and Drug Administration, allowed the distribution of unapproved drugs or the off-label use of approved drugs to the public. Thus far, there are 2 antiviral medications available to the public as EUA drugs. It is possible that an H1N1 vaccine will be initially released as an EUA in the fall in the first large-scale use of the EUA mechanism. This study explores the public's willingness to use a drug or vaccine under the conditions stipulated in the FDA's nonbinding guidance regarding EUAs. Using Knowledge Networks' panel, we conducted an internet survey with 1,543 adults from a representative sample of the U.S. population with 2 oversamples of African Americans and Spanish-speaking Hispanics. Our completion rate was 62%. We examined willingness to accept an EUA drug or an H1N1 vaccine, the extent of worry associated with taking either, the conditions under which respondents would accept an EUA drug or vaccine, and the impact of language from the EUA fact sheets on people's willingness to accept a drug for themselves or their children. We also examined the association among these variables and race/ethnicity, education level, trust in government, previous vaccine acceptance, and perceived personal consequences from H1N1 influenza. These results provide critical insights into the challenges of communicating about EUA drugs and vaccine in our current pandemic.

This report describes Pennsylvania’s 9-year experience in implementing training programs to strengthen public health response to emerging infectious diseases. During the biannual 3–5-day-long Pennsylvania Public Health Institute (PHI) events, which have been held since 2000, courses have covered topics such as emerging infectious disease outbreaks, monitoring of antimicrobial-resistant pathogens in retail food, and zoonotic diseases commonly associated with companion animals. Core competency courses include the legal basis for public health and epidemiology for nonepidemiologists. Emerging infectious disease seminars offered to clinicians since 2005 have focused on the emergence of community-associated methicillin-resistant Staphylococcus aureus and Clostridium difficile antibiotic-associated diarrhea. Complementing the PHI, the Pennsylvania Department of Health’s monthly Epidemiology Journal Club offers additional interactions with presenters from academic institutions and federal agencies. Lunch-time forums also provide a venue for health department staff to share their work with colleagues. Innovative use of modern communication technology increases participation of frontline health workers in Journal Club events, and video conference capability offers flexibility in the selection of presenters. Pennsylvania’s experience over the past 9 years demonstrates that with political will, commitment from content experts, and adequate administrative support, modest state and federal resources can be used to sustain public health training programs tailored to local needs.

The recent expansion of biocontainment laboratory capacity in the United States has drawn attention to the possibility of occupational exposures to BSL-3 and -4 agents and has prompted a reassessment of medical management procedures and facilities to deal with these contingencies. A workshop hosted by the National Interagency Biodefense Campus was held in October 2007 and was attended by representatives of all existing and planned BSL-4 research facilities in the U.S. and Canada. This report summarizes important points of discussion and recommendations for future coordinated action, including guidelines for the engineering and operational controls appropriate for a hospital care and isolation unit. Recommendations pertained to initial management of exposures (ie, immediate treatment of penetrating injuries, reporting of exposures, initial evaluation, and triage). Isolation and medical care in a referral hospital (including minimum standards for isolation units), staff recruitment and training, and community outreach also were addressed. Workshop participants agreed that any unit designated for the isolation and treatment of laboratory employees accidentally infected with a BSL-3 or -4 pathogen should be designed to maximize the efficacy of patient care while minimizing the risk of transmission of infection. Further, participants concurred that there is no medically based rationale for building care and isolation units to standards approximating a BSL-4 laboratory. Instead, laboratory workers accidentally exposed to pathogens should be cared for in hospital isolation suites staffed by highly trained professionals following strict infection control procedures.

This report describes Pennsylvania's 9-year experience in implementing training programs to strengthen public health response to emerging infectious diseases. During the biannual 3-5-day-long Pennsylvania Public Health Institute (PHI) events, which have been held since 2000, courses have covered topics such as emerging infectious disease outbreaks, monitoring of antimicrobial-resistant pathogens in retail food, and zoonotic diseases commonly associated with companion animals. Core competency courses include the legal basis for public health and epidemiology for nonepidemiologists. Emerging infectious disease seminars offered to clinicians since 2005 have focused on the emergence of community-associated methicillin-resistant Staphylococcus aureus and Clostridium difficile antibiotic-associated diarrhea. Complementing the PHI, the Pennsylvania Department of Health's monthly Epidemiology Journal Club offers additional interactions with presenters from academic institutions and federal agencies. Lunch-time forums also provide a venue for health department staff to share their work with colleagues. Innovative use of modern communication technology increases participation of frontline health workers in Journal Club events, and video conference capability offers flexibility in the selection of presenters. Pennsylvania's experience over the past 9 years demonstrates that with political will, commitment from content experts, and adequate administrative support, modest state and federal resources can be used to sustain public health training programs tailored to local needs.

Over the past several years, the primary focus of emergency preparedness has been on terrorism, and how a CBRNE event would directly affect human health. Limited emphasis has been placed on the direct (eg, zoonotic infections) and indirect (eg, mental health, financial loss) effects that an agricultural emergency event can have on human health outcomes, and how they relate to emergency preparedness. We critically reviewed the resources and information readily accessible to our target audience, emergency responders; the resources included military and civilian books, personal communications, internet sites, GAO reports, and peer-reviewed journals. Among more than 2,000 bioterrorism-related articles, we found 51 that addressed either agroterrorism and/or veterinary public health: 2 cross-sectional studies, 28 review papers, and 21 commentary papers. In order to properly respond to future agriculture emergencies, emergency response professionals need to understand the nature and implications of the event as well as their roles and responsibilities, but the availability of educational and training opportunities is limited. The results of our review are consistent with the hypothesis that more resources, education, and training opportunities should be available to responders as well as to producers, importers and shippers, international travelers, and the general public. Increased education and training will raise awareness among these groups of the relationship between animal and human health.

Through an online survey, the authors determined the readiness and confidence of paramedics in New South Wales, Australia, to respond to a CBRNE incident, which may differ from their “routine” emergency work. They identified some specific occupational and dispositional factors, which may help in designing future training.

Paramedics play a pivotal role in the response to major emergencies. Recent evidence indicates that their confidence and willingness to respond to chemical, biological, radiological, nuclear, and explosives-related (CBRNE) incidents differs from that relating to their “routine” emergency work. To further investigate the factors underpinning their readiness to respond to CBRNE incidents, paramedics in New South Wales (NSW), Australia, were asked to complete a validated online survey instrument. Univariate and multivariate analyses were performed to examine associated factors determining readiness. The sample of 663 respondents was weighted to reflect the NSW paramedic population as a whole. The univariate analysis indicated that gender, length of service, deployment concern, perceived personal resilience, CBRNE training, and incident experience were significantly associated with perceived CBRNE response readiness. In the initial multivariate analysis, significantly higher response readiness was associated with male gender, university education, and greater length of service (10-15 years). In the final multivariate model, the combined effect of training/incident experience negated the significant effects observed in the initial model and, importantly, showed that those with recent training reported higher readiness, irrespective of incident experience. Those with lower concern regarding CBRNE deployment and those with higher personal resilience were significantly more likely to report higher readiness (Adjusted Relative Risk [ARR] = 0.91, 95% CI: 0.84-0.99; ARR = 1.40, 95% CI: 1.11-1.72, respectively). These findings will assist emergency medical planners in recognizing occupational and dispositional factors associated with enhanced CBRNE readiness and highlight the important role of training in redressing potential readiness differences associated with these factors.

Natural outbreaks of multidrug-resistant microorganisms can cause widespread devastation, and several can be used or engineered as agents of bioterrorism. A key challenge is the ability to detect and then efficiently control, within hours, the spread and the potential effects of an emergent outbreak, without recourse to either antibiotics or vaccines. The authors describe phage engineering as a potentially highly flexible and effective means to both detect and eradicate threats from emergent bacterial strains.

Natural outbreaks of multidrug-resistant microorganisms can cause widespread devastation, and several can be used or engineered as agents of bioterrorism. From a biosecurity standpoint, the capacity to detect and then efficiently control, within hours, the spread and the potential pathological effects of an emergent outbreak, for which there may be no effective antibiotics or vaccines, become key challenges that must be met. We turned to phage engineering as a potentially highly flexible and effective means to both detect and eradicate threats originating from emergent (uncharacterized) bacterial strains. To this end, we developed technologies allowing us to (1) concurrently modify multiple regions within the coding sequence of a gene while conserving intact the remainder of the gene, (2) reversibly interrupt the lytic cycle of an obligate virulent phage (T4) within its host, (3) carry out efficient insertion, by homologous recombination, of any number of engineered genes into the deactivated genomes of a T4 wild-type phage population, and (4) reactivate the lytic cycle, leading to the production of engineered infective virulent recombinant progeny. This allows the production of very large, genetically engineered lytic phage banks containing, in an E. coli host, a very wide spectrum of variants for any chosen phage-associated function, including phage host-range. Screening of such a bank should allow the rapid isolation of recombinant T4 particles capable of detecting (ie, diagnosing), infecting, and destroying hosts belonging to gram-negative bacterial species far removed from the original E. coli host.

During the 2001 anthrax attacks, public health agencies faced operational and communication decisions about the use of antibiotic prophylaxis and the anthrax vaccine with affected groups, including postal workers. This communication occurred within an evolving situation with incomplete and uncertain data. Guidelines for prophylactic antibiotics changed several times, contributing to confusion and mistrust. At the end of 60 days of taking antibiotics, people were offered an additional 40 days' supply of antibiotics, with or without the anthrax vaccine, the former constituting an investigational new drug protocol. Using data from interviews and focus groups with 65 postal workers in 3 sites and structured interviews with 16 public health professionals, this article examines the challenges for public health professionals who were responsible for communication with postal workers about the vaccine. Multiple factors affected the response, including a lack of trust, risk perception, disagreement about the recommendation, and the controversy over the military's use of the vaccine. Some postal workers reacted with suspicion to the vaccine offer, believing that they were the subjects of research, and some African American workers specifically drew an analogy to the Tuskegee syphilis study. The consent forms required for the protocol heightened mistrust. Postal workers also had complex and ambivalent responses to additional research on their health. The anthrax attacks present us with an opportunity to understand the challenges of communication in the context of uncertain science and suggest key strategies that may improve communications about vaccines and other drugs authorized for experimental use in future public health emergencies.

The UK government sees increasing individual preparedness as a priority, but the level of preparedness of people in the UK for a large-scale emergency is not known. The London bombings of July 7, 2005, affected many Londoners and may have altered their sense of vulnerability to a future terrorist attack. We used a longitudinal study design to assess individual preparedness within the same sample of Londoners at 2 points in time: immediately after the bombings (T1) and 7 to 8 months later (T2). A demographically representative sample of 1,010 Londoners participated in a phone interview at T1. Subsequently, at T2, 574 of the same people participated in a follow-up phone interview. At T1 51% of Londoners had made 4 or more relevant emergency plans; 48% had gathered 4 or more relevant supplies in case of emergency. There was evidence of increased preparedness at T2, by which time 90% had made 4 or more emergency plans. Ethnicity, low social status, and having felt a sense of threat during the bombings predicted increased preparedness between T1 and T2. Women in general, and women of low social status in particular, perceived themselves to be unprepared in the event of a future terrorist attack. In summary, Londoners show moderate levels of emergency preparedness, which increased following the London bombings. Although we cannot know whether this association is causal, the prospective nature of the study increases the likelihood that it is. However, preparedness is still patchy, and there are important demographic associations with levels of preparedness and perception of vulnerability. These findings have implications for future development of individual and community emergency preparedness policy.

The recent expansion of biocontainment laboratory capacity in the United States has drawn attention to the possibility of occupational exposures to BSL-3 and -4 agents and has prompted a reassessment of medical management procedures and facilities to deal with these contingencies. A workshop hosted by the National Interagency Biodefense Campus was held in October 2007 and was attended by representatives of all existing and planned BSL-4 research facilities in the U.S. and Canada. This report summarizes important points of discussion and recommendations for future coordinated action, including guidelines for the engineering and operational controls appropriate for a hospital care and isolation unit. Recommendations pertained to initial management of exposures (ie, immediate treatment of penetrating injuries, reporting of exposures, initial evaluation, and triage). Isolation and medical care in a referral hospital (including minimum standards for isolation units), staff recruitment and training, and community outreach also were addressed. Workshop participants agreed that any unit designated for the isolation and treatment of laboratory employees accidentally infected with a BSL-3 or -4 pathogen should be designed to maximize the efficacy of patient care while minimizing the risk of transmission of infection. Further, participants concurred that there is no medically based rationale for building care and isolation units to standards approximating a BSL-4 laboratory. Instead, laboratory workers accidentally exposed to pathogens should be cared for in hospital isolation suites staffed by highly trained professionals following strict infection control procedures.