Jennifer B. Nuzzo

Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the Working Group on Emergency Mass Critical Care‡

The Working Group on Emergency Mass Critical Care was convened by the Center for Biosecurity of the University of Pittsburgh Medical Center and the Society of Critical Care Medicine to provide recommendations to hospital and clinical leaders regarding the delivery of critical care services in the wake of a bioterrorist attack resulting in hundreds or thousands of critically ill patients. In these conditions, traditional hospital and clinical care standards in general, and critical care standards in particular, likely could no longer be maintained, and clinical guidelines for U.S. hospitals facing these situations have not been developed. The Working Group offers recommendations for this situation.

Public health and medical responses to the 1957-58 influenza pandemic.

As the U.S. prepares to respond this fall and winter to pandemic (H1N1) 2009, a review of the 1957-58 pandemic of Asian influenza (H2N2) could be useful for planning purposes because of the many similarities between the 2 pandemics. Using historical surveillance reports, published literature, and media coverage, this article provides an overview of the epidemiology of and response to the 1957-58 influenza pandemic in the U.S., during which an estimated 25% of the population became infected with the new pandemic virus strain. While it cannot be predicted with absolute certainty how the H1N1 pandemic might play out in the U.S. this fall, lessons from the 1957-58 influenza pandemic provide useful and practical insights for current planning and response efforts.

Assessment of Serosurveys for H5N1

BACKGROUND It has been suggested that the true case-fatality rate of human H5N1 influenza infection is appreciably less than the figure of approximately 60% that is based on official World Health Organization (WHO)-confirmed case reports because asymptomatic cases may have been missed. A number of seroepidemiologic studies have been conducted in an attempt to identify such missed cases. METHODS We conducted a comprehensive literature review of all English-language H5N1 human serology surveys with detailed attention to laboratory methodology used (including whether investigators used criteria set by the WHO to define positive cases), laboratory controls used, and the clades/genotypes involved. RESULTS Twenty-nine studies were included in the analysis. Few reported using unexposed control groups and one-third did not apply WHO criteria. Of studies that used WHO criteria, only 4 found any seropositive results to clades/genotypes of H5N1 that are currently circulating. No studies reported seropositive results to the clade 2/genotype Z viruses that have spread throughout Eurasia and Africa. CONCLUSIONS This review suggests that the frequency of positive H5 serology results is likely to be low; therefore, it is essential that future studies adhere to WHO criteria and include unexposed controls in their laboratory assays to limit the likelihood of false-positive results.

Community Resilience Roundtable on the Implementation of Homeland Security Presidential Directive 21 (HSPD-21)

269 ON APRIL 23, 2008, THE CENTER for Biosecurity of the University of Pittsburgh Medical Center (UPMC) convened an invitational meeting to discuss community resilience for catastrophic health events and to help inform implementation planning for Homeland Security Presidential Directive 21 (HSPD-21). Released in October of 2007, HSPD-21 identified community resilience as one of the “four most critical components of public health and medical preparedness” alongside biosurveillance, countermeasure distribution, and mass casualty care, and the directive also asserted “the important roles of individuals, families, and communities” in managing public health emergencies.1 Meeting attendees (listed in the sidebar) included officials who authored HSPD-21 and those charged with its execution, grassroots leaders who have prioritized disaster management in their hometowns and among vulnerable populations, public health and emergency management practitioners, scholars of disasters and resilience, and staff to members of Congress with jurisdiction over homeland security and public health matters. Individual comments made during the event were not for attribution. The day’s agenda was organized into 3 structured discussions: roundtable participants considered which definition(s) of community resilience best advanced the policy agenda, they reviewed prior public participation programs for disasters for relevant lessons, and they made recommendations for federal program and budget priorities in keeping with the value placed on resilience by the presidential directive. The organization of this report reflects the 3-part agenda. Opening each conversation was a presentation from the Center for Biosecurity and invited speakers, accompanied by the results of a brief survey circulated in advance of the meeting to spur discussion. Among the issues polled were attendees’ own concepts of community resilience, concrete techniques for building resilience, and the role of the federal government in helping state and local authorities promote resilient communities. A majority of participants (n 20) completed the survey. The following report is an overview of prepared remarks, pre-event survey findings, and the major themes that arose in the roundtable discussions. We first provide some brief background knowledge on HSPD-21.

Gain-of-Function Research and the Relevance to Clinical Practice

Abstract The ongoing moratorium on gain-of-function (GOF) research with highly pathogenic avian influenza virus, severe acute respiratory syndrome coronavirus, and Middle East respiratory syndrome coronavirus has drawn attention to the current debate on these research practices and the potential benefits and risks they present. While much of the discussion has been steered by members of the microbiology and policy communities, additional input from medical practitioners will be highly valuable toward developing a broadly inclusive policy that considers the relative value and harm of GOF research. This review attempts to serve as a primer on the topic for the clinical community by providing a historical context for GOF research, summarizing concerns about its risks, and surveying the medical products that it has yielded.

Triumphs, trials, and tribulations of the global response to MERS coronavirus.

22 months after its discovery, and despite extensive investigation and research, the source and origin of the Middle East Respiratory (MERS) coronavirus remain unknown. As of April 26, 2014, 261 laboratory-confi rmed cases of MERS coronavirus infection have been reported, including 93 deaths. Although sustained human-tohuman transmission has not been reported, a global concern remains that the virus could become more contagious and deadly. An overabundance of caution is certainly prudent, but with the latest discovery—that the virus was documented in dromedary camels as long ago as 1992—interpretation of the epidemiology has become more diffi cult. Are the recently identifi ed cases in Jordan, Qatar, the United Arab Emirates, and Saudi Arabia new, or a part of a long series of human disease? Improved collaboration between clinicians, scientists, and public health authorities will be necessary to understand the epidemiology and defi ne the sources and modes of transmission. Lessons from the SARS coronavirus outbreak in 2003 and the infl uenza H1N1 pandemic in 2009 suggest that eff ective, collaborative public health research in support of outbreak investigation and comprehensive risk management is encouraged by mutual respect—for others, authority, governance, information, and property (both intellectual and physical)—and a solid agreement. But the meaningful collaboration that helped the scientifi c community to rapidly identify the SARS coronavirus has not been seen recently. Collaborative research into MERS coronavirus has been scarce, with investigations marked by bitter disagreements between public health authorities and scientists about the virus’ discovery and the ensuing publications, processes, and patenting of products. The recent disagreements played out in the media raise several issues that should be addressed. Key among them is the absence of a consensus-built governance agreement for public health investigation and research when an event is recognised as a global public health emergency. Such an agreement would include the controversial issues of how to share animal and human specimens, investigational products (eg, pathogens and viral isolates), and intellectual property (eg, public health surveillance data and scientifi c publications). Without agreement about the mutually benefi cial roles, responsibilities, and legitimate contributions of clinicians, scientists, and public health authorities, parties end up either encroaching on one another or not communicating—both of which are happening now with respect to MERS coronavirus. Public health authorities and academic scientists must work together to discover and pursue investigation of emerging or re-emerging infectious diseases, and clinicians and scientists must fulfi l their legal responsibility to report relevant data to public health authorities through offi cial mechanisms. Such reporting enables public health authorities to undertake their legitimate and crucial role in investigating, preventing, and controlling future transmission. Successful examples of this delicate yet important balance include the recognition, reporting, and research around Legionnaires’ disease and Lyme disease—outbreaks that were reported appropriately, while public health research ensued. Four considerations are pertinent to an agreement: the immediate need to control the spread of disease by public health authorities; the intellectual curiosity of clinicians and scientists; the long-term commercial interests of the pharmaceutical industry; and the economic wellbeing of the farming and ranching communities. Governance should be built around One Health, an interdisciplinary collaboration between human and veterinarian medicine and health, because economic loss is an important consideration (as can be seen from the negative economic eff ect of the present infl uenza H7N9 outbreak). Additional steps should be taken to protect the economic interests of farmers and livestock owners. Livestock insurance schemes, already used for protection against drought, could be used for reimbursement. The development of a global biological risk management fund to share the burden of economic loss would enhance the mission of the 2005 International Health Regulations (IHRs). The sovereign rights of IHR state parties must be respected. National ministries of health are responsible for the detection, assessment, reporting, and response to public health issues that threaten their populations. The willingness of states to collaborate on comprehensive risk assessments is dependent on the perception that doing Lancet Respir Med 2014

Biosurveillance Where It Happens: State and Local Capabilities and Needs

In recent years, improved biosurveillance has become a bipartisan national security priority. As has been pointed out by the National Biosurveillance Advisory Subcommittee and others, building a national biosurveillance enterprise requires having strong biosurveillance systems at the state and local levels, and additional policies are needed to strengthen their biosurveillance capabilities. Because of the foundational role that state and local health departments play in biosurveillance, we sought to determine to what extent state and local health departments have the right capabilities in place to provide the information needed to detect and manage an epidemic or public health emergency-both for state and local outbreak management and for reporting to federal agencies during national public health crises. We also sought to identify those policies or actions that would improve state and local biosurveillance and make recommendations to federal policymakers who are interested in improving national biosurveillance capabilities.

Travel Bans Will Increase the Damage Wrought by Ebola

Cases of Ebola that have turned up in Dallas and New York City have prompted calls for a travel ban to prohibit travelers from Sierra Leone, Liberia, and Guinea from entering the US during the ongoing Ebola outbreak. But travel bans have not worked in past epidemics and will not stop Ebola from spreading. Banning travel would slow the movement of people and goods to those countries, harm the international response to the outbreak in West Africa, and increase the prospect of ongoing global spread of Ebola. In addition, travel bans could lead to complete isolation of those 3 countries and would further worsen the economic and humanitarian toll of this crisis. US travel bans would also run counter to international agreements and could encourage other countries to impose their own bans against the United States and other countries in future outbreaks. The occurrence of secondary cases in 2 US nurses who treated the first Ebola patient in Dallas, and the corresponding lack of secondary cases occurring among members of the broader community, underscores the importance of focusing our Ebola control efforts on US hospitals and ensuring that clinicians in these settings have all of the training and protective equipment necessary to safely diagnose and treat Ebola patients.

Compliance with Postexposure Screening and Treatment of Latent Tuberculosis Infection among Healthcare Workers in a Tertiary Care Hospital in Saudi Arabia

BACKGROUND Controlling tuberculosis (TB) infection among occupationally exposed healthcare workers (HCWs) may be challenging. METHODS We retrospectively reviewed clinical records of HCWs who were exposed to patients diagnosed with infectious TB at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 2008 and 2010. The collected data included baseline tuberculin skin test (TST) status, potential predictors of TST positivity, postexposure diagnosis of latent TB infection (LTBI), and postexposure compliance with LTBI therapy. RESULTS Thirteen patients were diagnosed with infectious pulmonary TB during the study period. A total of 298 HCWs met our definition for exposure. Exposed HCWs tended to be female (62.9%), non-Saudi (83.9%), nurses (68.6%), or respiratory therapists (24.0%) working in critical care locations (72.8%). Baseline (preemployment) TST documentation existed for 41.3% (123/298). Among those with documented baseline TSTs, 51.2% (63/123) were positive, representing 21.1% (63/298) of all HCWs. Only 48.9% (115/235) of exposed HCWs who had negative or unknown preexposure TST status had their TST tested after exposure. Approximately 46.1% (53/115) of them were diagnosed with postexposure LTBI, and 92.5% (49/53) of them were prescribed LTBI therapy. Among those, 93.9% (46/49) started LTBI therapy; however, 82.6% (38/46) failed to complete the recommended course. CONCLUSIONS We found low rates of baseline TST documentation and postexposure screening among exposed HCWs. Compliance with initiating postexposure isoniazid prophylaxis among HCWs was fair, but only a small fraction of those who started prophylaxis completed the recommended course of therapy. These findings suggest substantial opportunities to implement administrative measures to enhance LTBI management among HCWs.

Acting on the Lessons of SARS: What Remains To Be Done?

On November 16, 2002, a man was admitted with a diagnosis of atypical pneumonia to People’s Hospital #1 in Foshan City, Guangdong Province, People’s Republic of China. Although it was not recognized at the time, he was the earliest known case of a new human infectious disease, Severe Acute Respiratory Syndrome, or SARS. Within 4 months SARS was global, eventually infecting 8,098 people in 29 countries on 6 continents and killing 774 of them. Even more concerning than these numbers is the fact that in many locations most of the victims were infected in hospitals and 21% of the victims were healthcare workers. At the time, SARS caused great alarm in the public health and medical preparedness communities. National and international guidance was issued, many health departments and hospitals created SARS plans, personal protective equipment was purchased, and healthcare workers were trained in respiratory precautions. In the months following the SARS pandemic, a number of conferences were held and reports issued on lessons learned from SARS. Now, from the vantage point of 8 years’ distance, what did we really learn? What are the remaining unanswered questions? What remains to be done?