George W. Christopher

Immunization against Potential Biological Warfare Agents

The intentional release of biological agents by belligerents or terrorists is a possibility that has recently attracted increased attention. Law enforcement agencies, military planners, public health officials, and clinicians are gaining an increasing awareness of this potential threat. From a military perspective, an important component of the protective pre-exposure armamentarium against this threat is immunization. In addition, certain vaccines are an accepted component of postexposure prophylaxis against potential bioterrorist threat agents. These vaccines might, therefore, be used to respond to a terrorist attack against civilians. We review the development of vaccines against 10 of the most credible biological threats.

Will We Be Ready for the Next War

TO THE EDITOR—The title of Dr Schooley’s editorial, “All’s (Almost) Quiet on the Western Front: Will We Be Ready for the Next War?” [1] raises a key question: What is the role of the US Department of Defense (DoD) in the Ebola outbreak response? Because Ebola is a biological warfare threat, theDoDhas been developingmedical countermeasures through its biological defense program for more than a decade. Six DoD-sponsored candidates, intended for biological defense under field conditions, were accelerated in collaboration with civilian partners to support outbreak response. The US Food and Drug Administration (FDA) granted Emergency Use Authorizations to 2 DoD-sponsored polymerase chain reaction–based diagnostic assays, EZ-1 and BT-E. DoD provides test kits to support African and US treatment centers; >20 000 kits are pre-positioned

Evaluation of Pertussis in U.S. Marine Corps Trainees

tious diseases specialists in the United States. Although we do not George W. Christopher, Julie A. Pavlin, and Mark A. Bustamante believe physicians should abdicate their fundamental primary role Operational Medicine Division, U.S. Army Medical Research Institute of in medical care just because times are changing, we welcome fresh Infectious Diseases, Fort Detrick, Maryland; and ideas on how appropriately trained pharmacists can collaborate St. Claire Shores, Michigan with infectious diseases specialists to improve patient care.

Ebola Virus Causes Intestinal Tract Architectural Disruption and Bacterial Invasion in Non-Human Primates

In the 2014–2016 West Africa Ebola Virus (EBOV) outbreak, there was a significant concern raised about the potential for secondary bacterial infection originating from the gastrointestinal tract, which led to the empiric treatment of many patients with antibiotics. This retrospective pathology case series summarizes the gastrointestinal pathology observed in control animals in the rhesus EBOV-Kikwit intramuscular 1000 plaque forming unit infection model. All 31 Non-human primates (NHPs) exhibited lymphoid depletion of gut-associated lymphoid tissue (GALT) but the severity and the specific location of the depletion varied. Mesenteric lymphoid depletion and necrosis were present in 87% (27/31) of NHPs. There was mucosal barrier disruption of the intestinal tract with mucosal necrosis and/or ulceration most notably in the duodenum (16%), cecum (16%), and colon (29%). In the intestinal tract, hemorrhage was noted most frequently in the duodenum (52%) and colon (45%). There were focal areas of bacterial submucosal invasion in the gastrointestinal (GI) tract in 9/31 (29%) of NHPs. Only 2/31 (6%) had evidence of pancreatic necrosis. One NHP (3%) experienced jejunal intussusception which may have been directly related to EBOV. Immunofluorescence assays demonstrated EBOV antigen in CD68+ macrophage/monocytes and endothelial cells in areas of GI vascular injury or necrosis.

Interagency cooperation is the key to an effective pandemic response.

We read with interest the Comment by Lawrence Gostin and James Hodge in The Lancet Infectious Diseases. Although the focus of their Comment was on Zika virus, we are in agree ment that for certain pandemic threats, characterising them, when appropriate, as national or global security threats can help galvanise interest and resources to mitigate the threats. We view this from the perspective of the interface between the military and civilians under the umbrella of a whole-government approach. A large outbreak does more than cross international borders; the response requirements frequently cross interagency boundaries. Therefore, having ongoing communication and cooperation between agencies, long before an emerging threat surfaces, is paramount for preparedness and effective response. This allows us to be proactive rather than reactive. If we consider the 2014–15 west Africa Ebola outbreak as an example, decades of research cooperation by the US Department of Defense and National Institutes of Health provided a countermeasure platform from which to launch. Military-civilian cooperation with organisations such as the US Food and Drug Administration and pharmaceutical companies during the outbreak led to the acceleration of both therapeutic and prophylactic countermeasures, emergency use authorisation of diagnostics, and timely preclinical and clinical research. Thinking ahead on developing containment care facilities at the University of Nebraska, Emory University, and National Institutes of Health, based on a Department of Defense model, years before the outbreak, allowed us to flip the switch when those facilities were needed at short notice. Early cooperation not only has the potential to reduce cases during an outbreak but also can reduce the accompanying disease sequelae, such as the neurological disorders associated with Zika virus or chronic illnesses recognised in Ebola survivors. Such sequelae could lead to second or third order consequences, both economically and politically, that in and of themselves can be destabilising.

Bioterrorism Alert for Health Care Workers

When the agent used in a biological attack is known, response to such an attack is considerably simplified. The first eight chapters of this text deal with agent-specific concerns and strategies for dealing with infections due to the intentional release of these agents. A larger problem arises when the identity of an agent is not known. In fact, in some cases, an attack may be threatened or suspected, but it may remain unclear as to whether such an attack has actually occurred. Moreover, it may be unclear whether casualties are due to a biological agent, a chemical agent, or even a naturally occurring infectious disease process or toxic exposure. Recent experience with West Nile Virus (Fine and Layton, 2001), Severe Acute Respiratory Syndrome (SARS) (Lampton, 2003), and monkeypox highlight this dilemma. In each of these cases, the possibility of bioterrorism was raised, and rightly so, although each outbreak ultimately proved to have a natural origin. This chapter provides a framework for dealing with outbreaks of unknown origin and etiology. Furthermore, it addresses several related concerns and topics not covered elsewhere in this text.