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1.  Bacillus anthracis Aerosolization Associated with a Contaminated Mail Sorting Machine 
Emerging Infectious Diseases  2002;8(10):1044-1047.
On October 12, 2001, two envelopes containing Bacillus anthracis spores passed through a sorting machine in a postal facility in Washington, D.C. When anthrax infection was identified in postal workers 9 days later, the facility was closed. To determine if exposure to airborne B. anthracis spores continued to occur, we performed air sampling around the contaminated sorter. One CFU of B. anthracis was isolated from 990 L of air sampled before the machine was activated. Six CFUs were isolated during machine activation and processing of clean dummy mail. These data indicate that an employee working near this machine might inhale approximately 30 B. anthracis-containing particles during an 8-h work shift. What risk this may have represented to postal workers is not known, but the risk is approximately 20-fold less than estimates of sub-5 micron B. anthracis-containing particles routinely inhaled by asymptomatic, unvaccinated workers in a goat-hair mill.
PMCID: PMC2730297  PMID: 12396913
Bacillus anthracis; anthrax; risk assessment; occupational exposure
2.  Factors Associated with Intention to Receive Influenza and Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccines during Pregnancy: A Focus on Vaccine Hesitancy and Perceptions of Disease Severity and Vaccine Safety 
PLoS Currents  2015;7:ecurrents.outbreaks.d37b61bceebae5a7a06d40a301cfa819.
BACKGROUND: Improving influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccine coverage among pregnant women is needed. PURPOSE: To assess factors associated with intention to receive influenza and/or Tdap vaccinations during pregnancy with a focus on perceptions of influenza and pertussis disease severity and influenza vaccine safety. METHODS: Participants were 325 pregnant women in Georgia recruited from December 2012 – April 2013 who had not yet received a 2012/2013 influenza vaccine or a Tdap vaccine while pregnant. Women completed a survey assessing influenza vaccination history, likelihood of receiving antenatal influenza and/or Tdap vaccines, and knowledge, attitudes and beliefs about influenza, pertussis, and their associated vaccines. RESULTS: Seventy-three percent and 81% of women believed influenza and pertussis, respectively, would be serious during pregnancy while 87% and 92% believed influenza and pertussis, respectively, would be serious to their infants. Perception of pertussis severity for their infant was strongly associated with an intention to receive a Tdap vaccine before delivery (p=0.004). Despite perceptions of disease severity for themselves and their infants, only 34% and 44% intended to receive antenatal influenza and Tdap vaccines, respectively. Forty-six percent had low perceptions of safety regarding the influenza vaccine during pregnancy, and compared to women who perceived the influenza vaccine as safe, women who perceived the vaccine as unsafe were less likely to intend to receive antenatal influenza (48% vs. 20%; p < 0.001) or Tdap (53% vs. 33%; p < 0.001) vaccinations. CONCLUSIONS: Results from this baseline survey suggest that while pregnant women who remain unvaccinated against influenza within the first three months of the putative influenza season may be aware of the risks influenza and pertussis pose to themselves and their infants, many remain reluctant to receive influenza and Tdap vaccines antenatally. To improve vaccine uptake in the obstetric setting, our findings support development of evidence-based vaccine promotion interventions which emphasize vaccine safety during pregnancy and mention disease severity in infancy.
PMCID: PMC4353696  PMID: 25789203
Influenza; maternal vaccination; pertussis; vaccination; vaccine hesitancy
3.  Changes in Immunization Program Managers' Perceptions of Programs' Functional Capabilities During and After Vaccine Shortages and pH1N1 
Public Health Reports  2014;129(Suppl 4):42-48.
We surveyed U.S. immunization program managers (IPMs) as part of a project to improve public health preparedness against future emergencies by leveraging the immunization system. We examined immunization program policy and Immunization Information System (IIS) functionality changes as a result of the Haemophilus influenzae type B (Hib) vaccine shortage and pandemic influenza A(H1N1) (pH1N1). Evaluating changes in immunization program functionalities and policies following emergency response situations will assist in planning for future vaccine-related emergencies.
We administered three consecutive surveys to IPMs from 64 state, city, and territorial jurisdictions in 2009, 2010, and 2012. We compared IPMs' responses across either two or three years (e.g., changes in response or consistent responses across years) using McNemar's test.
Immunization programs maintained increases in functionality related to communication systems with health-care providers during this period. Immunization programs often did not maintain changes to IIS functionalities made from 2009 to 2010 (e.g., identifying high-risk and priority populations, tracking adverse events, and mapping disease risk) in the post-pandemic period (2010–2012). About half of IPMs reporting additional IIS functionality in identifying high-risk populations from 2009 to 2010 reported no longer having this function in 2012. There was an 18% decline in respondents reporting geographic information systems risk-mapping capability in IIS from 2010 to 2012.
Because of the Hib vaccine shortage and pH1N1, immunization program needs and efforts changed to address evolving situations. The lack of sustained increases in resources or system functions after the pandemic highlights the need for comprehensive, sustainable public health emergency preparedness systems and related resources.
PMCID: PMC4187306  PMID: 25355974
4.  Vaccine Providers’ Perspectives on Impact, Challenges, and Response during the California 2010 Pertussis Outbreak 
Introduction: California has experienced its worst outbreak of pertussis in 50 y. In preparing for such outbreaks of pertussis, vaccine providers in the state play a key role in educating patients about the public health implications of vaccination, explaining the benefits to immunization, and facilitating patients' receipt of recommended immunizations.
Methods: We conducted a survey of 800 California vaccine providers to investigate provider level response to recent pertussis outbreaks and regulation by provider type and geography.
Results: Sixty-nine percent (533/777) of vaccine providers within the state of California responded to the survey. Fifty-three percent (278/527) of vaccine providers indicated that it was part of standard care at their practice or pharmacy location to ask adult patients about pertussis vaccine (Table 1) and this varied across practice types (P < 0.0001). Fifty-seven percent of providers (270/476) indicated that the information they received from the state about pertussis during the 2010 California pertussis outbreak was very useful or useful, while 52% of providers indicated this information was neutral, not useful, not at all useful. Vaccine administration, patient groups seen, and challenges varied by provider type however meaningful differences among subpopulations to which the vaccine was administered were found between provider types (P < 0.001, Table 2).
Conclusion: The 2010 pertussis outbreak in California challenged vaccine providers in a way that changed the preparation, promotion, and planning for future outbreaks and emergency situations. Adaptability to the new state law and increased awareness of pertussis in the physician community were important in the number of patients receiving the vaccine. Also, forming partnerships with schools and health agencies were important in facilitating and promoting wide spread vaccination.
PMCID: PMC4181007  PMID: 24045304
pertussis; vaccine providers; preparedness; California
5.  Partners in Immunization: 2010 Survey Examining Differences Among H1N1 Vaccine Providers in Washington State 
Public Health Reports  2013;128(3):198-211.
Emergency response involving mass vaccination requires the involvement of traditional vaccine providers as well as other health-care providers, including pharmacists, obstetricians, and health-care providers at correctional facilities. We explored differences in provider experiences administering pandemic vaccine during a public health emergency.
We conducted a cross-sectional survey of H1N1 vaccine providers in Washington State, examining topics regarding pandemic vaccine administration, participation in preparedness activities, and communication with public health agencies. We also examined differences among provider types in responses received (n=619, 80.9% response rate).
Compared with other types of vaccine providers (e.g., family practitioners, obstetricians, and specialists), pharmacists reported higher patient volumes as well as higher patient-to-practitioner ratios, indicating a broad capacity for community reach. Pharmacists and correctional health-care providers reported lower staff coverage with seasonal and H1N1 vaccines. Compared with other vaccine providers, pharmacists were also more likely to report relying on public health information from federal sources. They were less likely to report relying on local health departments (LHDs) for pandemic-related information, but indicated a desire to be included in LHD communications and plans. While all provider types indicated a high willingness to respond to a public health emergency, pharmacists were less likely to have participated in training, actual emergency response, or surge capacity initiatives. No obstetricians reported participating in surge capacity initiatives.
Results from this survey suggest that efforts to increase communication and interaction between public health agencies and pharmacy, obstetric, and correctional health-care vaccine providers may improve future preparedness and emergency response capability and reach.
PMCID: PMC3610072  PMID: 23633735
6.  Perspectives of Immunization Program Managers on 2009-10 H1N1 Vaccination in the United States: A National Survey 
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.
PMCID: PMC3316479  PMID: 22360580
7.  Biosafety Training and Incident-reporting Practices in the United States: A 2008 Survey of Biosafety Professionals 
Concern over the adequacy of biosafety training and incident-reporting practices within biological laboratories in the United States has risen in recent years due to the increase in research on infectious diseases and the concomitant rise in the number of biocontainment laboratories. Reports of laboratory-acquired infections and delays in reporting such incidents have also contributed to the concern. Consequently, biosafety training and incident-reporting practices are being given considerable attention by both the executive branch and Congress. We conducted a 51-question survey of biosafety professionals in June 2008 to capture information on methods used to train new laboratory workers within biosafety level 2 (BSL-2) laboratories, animal biosafety level 2 (ABSL-2) laboratories, biosafety level 3 (BSL-3) laboratories, and animal biosafety level 3 (ABSL-3) laboratories. The survey results suggest nearly all senior scientists, faculty, staff, and students working in these biocontainment laboratories are required to have biosafety training, and three-quarters of respondents indicated a biosafety or environmental health and safety professional provides explicit instructions on reporting incidents to each new lab worker. Only half of the respondents with BSL-2/ABSL-2 laboratories at their institution and 59% of respondents from institutions with BSL-3/ABSL-3 laboratories indicated custodial or maintenance workers are required to receive biosafety training at the BSL-2/ABSL-2 and BSL-3/ABSL-3 levels, respectively. Opportunities for targeted improvement such as providing training to non-traditional laboratory workers (e.g., custodians, maintenance workers) and posting laboratory incident-reporting protocols on institutional environmental health and safety websites may exist. Variations in biosafety training requirements, incident-reporting practices, and attitudes towards laboratory safety revealed through this survey of biosafety professionals also support the development of core competencies in biosafety practice that could lead to more uniform practices and robust safety cultures.
PMCID: PMC2947438  PMID: 20890389
8.  Business and public health collaboration for emergency preparedness in Georgia: a case study 
BMC Public Health  2006;6:285.
Governments may be overwhelmed by a large-scale public health emergency, such as a massive bioterrorist attack or natural disaster, requiring collaboration with businesses and other community partners to respond effectively. In Georgia, public health officials and members of the Business Executives for National Security have successfully collaborated to develop and test procedures for dispensing medications from the Strategic National Stockpile. Lessons learned from this collaboration should be useful to other public health and business leaders interested in developing similar partnerships.
The authors conducted a case study based on interviews with 26 government, business, and academic participants in this collaboration.
The partnership is based on shared objectives to protect public health and assure community cohesion in the wake of a large-scale disaster, on the recognition that acting alone neither public health agencies nor businesses are likely to manage such a response successfully, and on the realization that business and community continuity are intertwined. The partnership has required participants to acknowledge and address multiple challenges, including differences in business and government cultures and operational constraints, such as concerns about the confidentiality of shared information, liability, and the limits of volunteerism. The partnership has been facilitated by a business model based on defining shared objectives, identifying mutual needs and vulnerabilities, developing carefully-defined projects, and evaluating proposed project methods through exercise testing. Through collaborative engagement in progressively more complex projects, increasing trust and understanding have enabled the partners to make significant progress in addressing these challenges.
As a result of this partnership, essential relationships have been established, substantial private resources and capabilities have been engaged in government preparedness programs, and a model for collaborative, emergency mass dispensing of pharmaceuticals has been developed, tested, and slated for expansion. The lessons learned from this collaboration in Georgia should be considered by other government and business leaders seeking to develop similar partnerships.
PMCID: PMC1676007  PMID: 17116256
9.  Immunoglobulin M Antibody Responses to Mycobacterium ulcerans Allow Discrimination between Cases of Active Buruli Ulcer Disease and Matched Family Controls in Areas Where the Disease Is Endemic 
Buruli ulcer disease (BUD) is an emerging disease caused by Mycobacterium ulcerans. In the present study we have characterized the serological reactivities of sera from volunteer case patients with laboratory-confirmed BUD and controls living in three different regions of Ghana where the disease is endemic to determine if serology may be useful for disease confirmation. Our results showed highly reactive immunoglobulin G (IgG) responses among patients with laboratory-confirmed disease, healthy control family members of the case patients, and sera from patients with tuberculosis from areas where BUD is not endemic. These responses were represented by reactivities to multiple protein bands found in the M. ulcerans culture filtrate (CF). In contrast, patient IgM antibody responses to the M. ulcerans CF (MUCF) proteins were more distinct than those of healthy family members living in the same village. A total of 84.8% (56 of 66) of the BUD patients exhibited strong IgM antibody responses against MUCF proteins (30, 43 and 70 to 80 kDa), whereas only 4.5% (3 of 66) of the family controls exhibited such responses. The sensitivity of the total IgM response for the patients was 84.8% (95% confidence interval [CI], 74.3 to 91.6%), and the specificity determined with sera from family controls was 95.5% (95% CI, 87.5 to 98.4%). These studies suggest that the IgM responses of patients with BUD will be helpful in the identification and production of the M. ulcerans recombinant antigens required for the development of a sensitive and specific serological assay for the confirmation of active BUD.
PMCID: PMC371217  PMID: 15013992
10.  Inactivation of Bacillus anthracis Spores 
Emerging Infectious Diseases  2003;9(6):623-627.
After the intentional release of Bacillus anthracis through the U.S. Postal Service in the fall of 2001, many environments were contaminated with B. anthracis spores, and frequent inquiries were made regarding the science of destroying these spores. We conducted a survey of the literature that had potential application to the inactivation of B. anthracis spores. This article provides a tabular summary of the results.
PMCID: PMC3000133  PMID: 12780999
Bacillus anthracis; sporicidal efficacy; heat inactivation; chemical sterilization; gaseous sterilization; and radiation; synopsis
11.  Histopathologic Features of Mycobacterium ulcerans Infection 
Emerging Infectious Diseases  2003;9(6):651-656.
Because of the emergence of Buruli ulcer disease, the World Health Organization launched a Global Buruli Ulcer Initiative in 1998. This indolent skin infection is caused by Mycobacterium ulcerans. During a study of risk factors for the disease in Ghana, adequate excisional skin-biopsy specimens were obtained from 124 clinically suspicious lesions. Buruli ulcer disease was diagnosed in 78 lesions since acid-fast bacilli (AFB) were found by histopathologic examination. Lesions with other diagnoses included filariasis (3 cases), zygomycosis (2 cases), ulcerative squamous cell carcinomas (2 cases), keratin cyst (1 case), and lymph node (1 case). Thirty-seven specimens that did not show AFB were considered suspected Buruli ulcer disease cases. Necrosis of subcutaneous tissues and dermal collagen were found more frequently in AFB-positive specimens compared with specimens from suspected case-patients (p<0.001). Defining histologic criteria for a diagnosis of Buruli ulcer disease is of clinical and public health importance since it would allow earlier treatment, leading to less deforming sequelae.
PMCID: PMC3000137  PMID: 12780997
Mycobacterium ulcerans; Buruli ulcer; histopathology; PCR; culture; acid-fast bacilli; research
12.  Analysis of an IS2404-Based Nested PCR for Diagnosis of Buruli Ulcer Disease in Regions of Ghana Where the Disease Is Endemic 
Journal of Clinical Microbiology  2003;41(2):794-797.
Mycobacterium ulcerans causes Buruli ulcer disease (BUD), an ulcerative skin disease emerging mainly in West Africa. Laboratory confirmation of BUD is complicated as no “gold standard” for diagnosis exists. A nested primer PCR based on IS2404 has shown promise as a diagnostic assay. We evaluated the IS2404-based PCR to detect M. ulcerans DNA in tissue specimens from 143 BUD patients diagnosed according to the World Health Organization BUD clinical case definition in Ghana. Comparisons were made with culture and histopathology results. Variables influencing detection rate tested in this PCR protocol included the amount of tissue used and the stage of disease. The nested PCR was repeated on DNA extracted from a different part of the same biopsy specimen of 21 culture-positive samples. Of all 143 specimens, 107 (74.8%; 95% confidence interval, 68 to 82%) showed the presence of M. ulcerans DNA by PCR. Of the 78 histology-confirmed BUD patient samples, 64 (83%) were PCR positive. Detection rates were influenced neither by the amount of tissue processed for PCR nor by the stage of disease (preulcerative or ulcerative). Taken together, the two nested PCR tests on the subset of 21 culture-positive samples were able to detect M. ulcerans DNA in all 21 culture-confirmed patients. For future studies, small tissue samples, e.g., punch biopsy samples, might be sufficient for case confirmation.
PMCID: PMC149660  PMID: 12574285
13.  Leptospirosis: Skin Wounds and Control Strategies, Thailand, 1999 
Emerging Infectious Diseases  2002;8(12):1455-1459.
After an outbreak of leptospirosis in workers who participated in cleaning a pond during September 1999 in Thailand, a serologic survey was conducted. Among a cohort of 104 persons from one village who participated in pond cleaning activity, 43 (41.3%) were seropositive for immunoglobulin M antibodies against Leptospira, indicating recent infection. Only 17 (39.5%) of 43 seropositive persons reported a recent febrile illness; the remaining seropositive persons were considered asymptomatic, suggesting that asymptomatic leptospirosis infection may be common where leptospirosis is endemic. Multivariable logistic regression indicated that wearing long pants or skirts was independently protective against leptospirosis infection (ORadjusted = 0.217), while the presence of more than two wounds on the body was independently associated with infection (ORadjusted = 3.97). Educational efforts should be enhanced in areas where leptospirosis is endemic to encourage the use of protective clothing. In addition wound management and avoidance of potentially contaminated water when skin wounds are present should be included in health education programs.
PMCID: PMC2738501  PMID: 12498663
Leptospirosis; Leptospira; skin wounds; control strategies; Thailand

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