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BICHAT GUIDELINES* FOR THE CLINICAL MANAGEMENT OF HAEMORRHAGIC FEVER VIRUSES AND BIOTERRORISM-RELATED HAEMORRHAGIC FEVER VIRUSES

Haemorrhagic fever viruses (HFVs) are a diverse group of viruses that cause a clinical disease associated with fever and bleeding disorder. HFVs that are associated with a potential biological threat are Ebola and Marburg viruses (Filoviridae), Lassa fever and New World arenaviruses (Machupo, Junin, Guanarito and Sabia viruses) (Arenaviridae), Rift Valley fever (Bunyaviridae) and yellow fever, Omsk haemorrhagic fever, and Kyanasur Forest disease (Flaviviridae). In terms of biological warfare concerning dengue, Crimean-Congo haemorrhagic fever and Hantaviruses, there is not sufficient knowledge to include them as a major biological threat. Dengue virus is the only one of these that cannot be transmitted via aerosol. Crimean-Congo haemorrhagic fever and the agents of haemorrhagic fever with renal syndrome appear difficult to weaponise. Ribavirin is recommended for the treatment and the prophylaxis of the arenaviruses and the bunyaviruses, but is not effective for the other families. All patients must be isolated and receive intensive supportive therapy.

BICHAT GUIDELINES* FOR THE CLINICAL MANAGEMENT OF BRUCELLOSIS AND BIOTERRORISM- RELATED BRUCELLOSIS

Interest in Brucella species as a biological weapon stems from the fact that airborne transmission of the agent is possible. It is highly contagious and enters through mucous membranes such as the conjunctiva, oropharynx, respiratory tract and skin abrasions. It has been estimated that 10-100 organisms only are sufficient to constitute an infectious aerosol dose for humans. Signs and symptoms are similar in patients whatever the route of transmission and are mostly non-specific. Symptoms of patients infected by aerosol are indistinguishable from those of patients infected by other routes. Regimens containing doxycycline plus streptomycin or doxycycline plus rifampin are effective for most forms of brucellosis. Isolation of patients is not necessary. Trimethoprim-sulfamethoxazole and fluoroquinolones also have good results against Brucella, but are associated with high relapse rates when used as monotherapy. The combination of ofloxacin plus rifampicin is associated with good results. Even if there is little evidence to support its utility for post-exposure prophylaxis, doxycycline plus rifampicin is recommended for 3 to 6 weeks.

Bichat guidelines for the clinical management of tularaemia and bioterrorism-related tularaemia.

Francisella tularensis is one of the most infectious pathogenic bacteria known, requiring inoculation or inhalation of as few as 10 organisms to initiate human infection. Inhalational tularaemia following intentional release of a virulent strain of F. tularensis would have great impact and cause high morbidity and mortality. Another route of contamination in a deliberate release could be contamination of water. Seven clinical forms, according to route of inoculation (skin, mucous membranes, gastrointestinal tract, eyes, respiratory tract), dose of the inoculum and virulence of the organism (types A or B) are identified. The pneumonic form of the disease is the most likely form of the disease should this bacterium be used as a bioterrorism agent. Streptomycin and gentamicin are currently considered the treatment of choice for tularemia. Quinolone is an effective alternative drug. No isolation measures for patients with pneumonia are necessary. Streptomycin, gentamicin, doxycycline or ciprofloxacin are recommended for post-exposure prophylaxis.

West Nile virus outbreak in humans, Greece, 2012: third consecutive year of local transmission

In 2010, the first outbreak of West Nile virus (WNV) infection in Greece was recorded, the largest in Europe since 1996. After 2010, outbreaks continued to occur in different areas of the country. Enhanced surveillance was implemented during transmission periods (June to October). We investigated the 2012 outbreak to determine its extent and identify risk factors for severe disease using regression models. Of 161 cases recorded in 2012, 109 had neuroinvasive disease (WNND). Two outbreak epicentres were identified: the southern suburbs of Athens in July and a rural area in East Macedonia T 95% CI: 2.2-22) and chronic renal failure (adjusted RR: 4.5; 95% CI: 2.7-7.5) were independently associated with WNND-related death. In three PCR-positive samples, sequencing revealed WNV lineage 2 identical to the 2010 strain. The occurrence of human cases in three consecutive years suggests that WNV lineage 2 has become established in Greece. Raising awareness among physicians and susceptible populations (elderly people and persons with co-morbidities) throughout Greece is critical to reduce the disease impact. .

Bichat guidelines for the clinical management of glanders and melioidosis and bioterrorism-related glanders and melioidosis.

Glanders and melioidosis are two infectious diseases that are caused by Burkholderia mallei and Burkholderia pseudomallei respectively. Infection may be acquired through direct skin contact with contaminated soil or water. Ingestion of such contaminated water or dust is another way of contamination. Glanders and melioidosis have both been studied for weaponisation in several countries in the past. They produce similar clinical syndromes. The symptoms depend upon the route of infection but one form of the disease may progress to another, or the disease might run a chronic relapsing course. Four clinical forms are generally described: localised infection, pulmonary infection, septicaemia and chronic suppurative infections of the skin. All treatment recommendations should be adapted according to the susceptibility reports from any isolates obtained. Post-exposure prophylaxis with trimethoprim-sulfamethoxazole is recommended in case of a biological attack. There is no vaccine available for humans.

A case of imported Middle East Respiratory Syndrome coronavirus infection and public health response, Greece, April 2014

On 18 April 2014, a case of Middle East Respiratory Syndrome coronavirus (MERS-CoV) infection was laboratory confirmed in Athens, Greece in a patient returning from Jeddah, Saudi Arabia. Main symptoms upon initial presentation were protracted fever and diarrhoea, during hospitalisation he developed bilateral pneumonia and his condition worsened. During 14 days prior to onset of illness, he had extensive contact with the healthcare environment in Jeddah. Contact tracing revealed 73 contacts, no secondary cases had occurred by 22 April.

BICHAT GUIDELINES* FOR THE CLINICAL MANAGEMENT OF ANTHRAX AND BIOTERRORISM-RELATED ANTHRAX

The spore-forming Bacillus anthracis must be considered as one of the most serious potential biological weapons. The recent cases of anthrax caused by a deliberate release reported in 2001 in the United States point to the necessity of early recognition of this disease. Infection in humans most often involves the skin, and more rarely the lungs and the gastrointestinal tract. Inhalational anthrax is of particular interest for possible deliberate release: it is a life-threatening disease and early diagnosis and treatment can significantly decrease the mortality rate. Treatment consists of massive doses of antibiotics and supportive care. Isolation is not necessary. Antibiotics such as ciprofloxacin are recommended for post-exposure prophylaxis during 60 days.

Bichat guidelines for the clinical management of plague and bioterrorism-related plague.

Yersinia pestis appears to be a good candidate agent for a bioterrorist attack. The use of an aerosolised form of this agent could cause an explosive outbreak of primary plague pneumonia. The bacteria could be used also to infect the rodent population and then spread to humans. Most of the therapeutic guidelines suggest using gentamicin or streptomycin as first line therapy with ciprofloxacin as optional treatment. Persons who come in contact with patients with pneumonic plague should receive antibiotic prophylaxis with doxycycline or ciprofloxacin for 7 days. Prevention of human-to-human transmission via patients with plague pneumonia can be achieved by implementing standard isolation procedures until at least 4 days of antibiotic treatment have been administered. For the other clinical types of the disease, patients should be isolated for the first 48 hours after the initiation of treatment.

Mapping Environmental Suitability for Malaria Transmission, Greece

During 2009–2012, Greece experienced a resurgence of domestic malaria transmission. To help guide malaria response efforts, we used spatial modeling to characterize environmental signatures of areas suitable for transmission. Nonlinear discriminant analysis indicated that sea-level altitude and land-surface temperature parameters are predictive in this regard.

Development of a matrix to evaluate the threat of biological agents used for bioterrorism.

Abstract.Adequate public health preparedness for bioterrorism includes the elaboration of an agreed list of biological and chemical agents that might be used in an attack or as threats of deliberate release. In the absence of counterterrorism intelligence information, public health authorities can also base their preparedness on the agents for which the national health structures would be most vulnerable. This article aims to describe a logical method and the characteristics of the variables to be brought in a weighing process to reach a priority list for preparedness. The European Union, in the aftermath of the anthrax events of October 2001 in the United States, set up a task force of experts from multiple member states to elaborate and implement a health security programme. One of the first tasks of this task force was to come up with a list of priority threats. The model, presented here, allows Web-based updates for newly identified agents and for the changes occurring in preventive measures for agents already listed. The same model also allows the identification of priority protection action areas.