Public health in the time of bioterrorism. (Bioterrorism-Related Anthrax).On Thursday, October 4, 2001, just 24 days after the tragic events of September 11, the Florida Department of Health Florida Department of Health is a category of Government of Florida. Orange County Health Department is one of the branches of Florida Department of Health and Government of Florida. and the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation ) confirmed the first case of inhalational anthrax anthrax (ăn`thrăks), acute infectious disease of animals that can be secondarily transmitted to humans. It is caused by a bacterium (Bacillus anthracis in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. in more than 25 years. Recognition of this unexpected case is attributed to the alertness of local infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. physician Larry Bush, who promptly notified Jean Malecki, director, Palm Beach County Health Department (1,2). By Saturday, October 6, a team of federal, state, and local public health and local law enforcement investigators identified intentional Bacillus anthracis Bacillus anthracis Infectious disease A gram-positive organism which causes often fatal infections when its endospores–resistant to heat, drying, UV light, gamma radiation, and many disinfectants–enter the body and cause septicemia Military medicine spore contamination at the patient's workplace. These events marked the beginning of the first U.S. outbreak of bioterrorism-related anthrax and (for many of us in clinical medicine, public health, and law enforcement) ushered in the transition from tabletop bioterrorism exercises to real-world investigation and response.
Contingency plans to mitigate bioterrorism-related anthrax outbreaks go back to August 1998, when CDC hosted the "Workshop on Improving Public Health Response to Possible Acts of Bioterrorism." This workshop brought together state and local health departments, public health professional organizations, the U.S. Department of Defense, and the U.S. Department of Justice to examine ways of improving public health preparedness for bioterrorism (CDC, unpub. data). Two investments made as a result of this workshop were the Laboratory Response Network for Bioterrorism and the National Pharmaceutical Stockpile. These early investments were key components of the public health response to the 2001 bioterrorism-related anthrax outbreak.
The Laboratory Response Network was created at the recommendation of the 1998 Workshop's "Diagnosis Working Group," the then Association of State and Territorial Public Health Laboratories (now Association for Public Health Laboratories), and CDC. The Laboratory Response Network is a tiered system of laboratories with capacities defined in an A (lowest tier) through D (highest) pyramid structure (3,4). In support of this structure, procedures for identification of B. anthracis, and other Category A biologic agents, were validated, and in some instances developed (or redeveloped) de novo [Latin, Anew.] A second time; afresh. A trial or a hearing that is ordered by an appellate court that has reviewed the record of a hearing in a lower court and sent the matter back to the original court for a new trial, as if it had not been previously heard nor decided. on the basis of older methods. Protocols were written into standard laboratory procedure manuals. Reagents for testing were standardized, produced, and distributed by CDC to participating laboratories. State health department laboratory scientists were trained to use these methods for identifying B. anthracis, Yersinia pestis Yersinia pes·tis
A bacterium that causes plague and is transmitted from rats to humans by the rat flea Xenopsylla cheopis. Also called Pasteurella pestis. (causative agent of plague), and Francisella tularensis Francisella tu·la·ren·sis
A bacterium of the genus Francisella that causes tularemia in humans. (causative agent of tularemia tularemia (tlərē`mēə) or rabbit fever, acute, infectious disease caused by Francisella tularensis (Pasteurella tularensis). ) in the fall and winter of 2000. Capacity for specialized or more developmental diagnostic and other tests for B. anthracis (e.g., real time polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is [PCR PCR polymerase chain reaction.
polymerase chain reaction
Polymerase chain reaction (PCR) ] , direct fluorescent-antibody assay , immunohistochemical testing, molecular subtyping , and antimicrobial susceptibility testing ) were established at CDC and (in some instances) at a small number of other advanced U.S. laboratories (e.g., U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, Maryland; Department of Biological Sciences, Northern Arizona University Northern Arizona University (NAU) is a public university in Flagstaff, Arizona in the United States.
As of Fall 2007, the university has 21,352 students, 13,989 of these are situated in the main Flagstaff campus<ref name="Enrollment" />. , Flagstaff, Arizona). For serologic testing, which was found to be invaluable in identifying anthrax cases during the investigation, existing tests developed for vaccine evaluation were adapted for diagnostic purposes (9). All these laboratory measures were in place before the 2001 anthrax outbreak.
During the acute phase of the outbreak, Laboratory Response Network laboratories processed >121,700 specimens for B. anthracis (the bulk from environmental specimens from areas of suspected or confirmed contamination). Public Health Laboratories (other than CDC) tested 84,000 (69%) specimens; the Department of Defense tested 30,200 (25%) specimens; and CDC tested 7,500 (6%) (CDC, unpub. data). Handling the unusual surge of demand without the support of the Laboratory Response Network is difficult to imagine and would have likely compromised the investigation.
The National Pharmaceutical Stockpile was another investment made as a result of the 1998 Workshop and put in place before the 2001 outbreak. During the outbreak, the pharmaceutical stockpile team transported not only antibiotics, anthrax vaccine, clinical and environmental samples, and B. anthracis isolates but also epidemiologists, laboratory scientists, pathologists, and specialized teams of researchers. Under extreme pressure, the team made 143 sorties to 9 states and delivered 3.75 million antibiotic tablets from October 8, 2001 to January 11, 2002 (CDC, NPS NPS National Park Service
NPS Naval Postgraduate School
NPS Net Promoter Score (customer management)
NPS Non-Point Source pollution
NPS Native Plant Society
NPS Norfolk Public Schools (Virginia) Program Logistics Log, Oct 2001-Jan 2002).
Other earlier public health investments that paid off during the anthrax outbreak investigation were CDC's more than 50-year-old applied epidemiology training program, Epidemic Intelligence Service The Epidemic Intelligence Service is a program of the United States' Centers for Disease Control and Prevention. Established in 1951 due to biological warfare concerns arising from the Korean War, it has become a hands-on two-year postgraduate training program in epidemiology, with , and other academic, state and local health department, and CDC efforts to develop the seasoned cadre of field epidemiologists (10,11) that make up the core of public health investigation and response. These epidemiologists, who work in established networks and make up and often lead complex partnerships, comprise the public health front lines of the bioterrorism response team.
The complexity of the 2001 anthrax investigation and response challenged even experienced field epidemiologists. At the state and federal levels, "incident command"-style management structures were used to address the constant emergence of new information, pursue many public health activities simultaneously across multiple investigations, and communicate effectively. These management structures, which have been adopted by the disaster management and law enforcement communities, are less familiar to public health workers. With some variation from site to site, a typical field investigation structure included local, state, and federal public health partners working on the following teams: Epidemiologic Investigation (what happened?), Intervention (post-exposure prophylaxis and follow-up), Surveillance (identify additional cases), Clinical Evaluation clinical evaluation Medtalk An evaluation of whether a Pt has symptoms of a disease, is responding to treatment, or is having adverse reactions to therapy (rapidly evaluate suspect cases), Environmental Assessment (environmental sampling and processing), Remediation (working with the Environmental Protection Agency Environmental Protection Agency (EPA), independent agency of the U.S. government, with headquarters in Washington, D.C. It was established in 1970 to reduce and control air and water pollution, noise pollution, and radiation and to ensure the safe handling and ), and Communication (with the public, partners, and press). These teams were sometimes complemented with Federal Bureau of Investigation Federal Bureau of Investigation (FBI), division of the U.S. Dept. of Justice charged with investigating all violations of federal laws except those assigned to some other federal agency. (FBI) liaisons; in some cases, public health officials were assigned to FBI investigation teams (12). A senior epidemiologist was also posted to FBI Headquarters in Washington, D.C.
After the October 12 recognition of cutaneous anthrax in New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of (13), an emergency operations center The Emergency Operations Center, or EOC, is a central command and control facility responsible for carrying out the principles of emergency preparedness and emergency management, or disaster management functions at a strategic level in an emergency situation, and ensuring was established at CDC, Atlanta, Georgia, to coordinate the outbreak investigation and response. The center tasked more than 2,000 employees (in the field or at headquarters in Atlanta) (CDC unpub. data) to specific functions, including 24-hour response capacity with telephone information and call-triage services and other specialized teams (14). CDC/Atlanta-based teams led by senior epidemiologists supported each field investigation team in involved jurisdictions (Florida, New York Florida is the name of some places in the U.S. state of New York:
Many unknowns confronted the public-health response team during the anthrax investigation (26). The basics about exposure to B. anthracis-contaminated envelopes specifically sent to media outlets and government leaders were understood quickly, given the events in Florida, New York, and then Washington, D.C. (13). Difficulties arose in characterizing anthrax risk to individuals and groups with suspected or confirmed exposure to B. anthracis-contaminated envelopes or environments (27). Challenges also arose in the evaluation of B. anthracis-containing powders, epidemiologic investigation (28), environmental assessment (29,30) and remediation, surveillance (31,32), diagnosis, treatment, and post-exposure prophylaxis (33-35).
Work with B. anthracis-contaminated goat hair in textile mills more than 40 years ago provided some data about the risk of B. anthracis spore-containing particles in naturally contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object. occupational environments. These data suggested that relatively high levels of B. anthracis spores were "not necessarily or consistently dangerous" in this setting (36). Biologic warfare experts considered it unlikely that terrorists could produce a B. anthracis spore powder for use in an envelope that would be capable of generating substantial primary (or secondary) aerosol threats for human infection or widespread contamination of environments. Yet, in Senator Daschle's office, in the Hart Senate Office building The Hart Senate Office Building, the third U.S. Senate office building, was built in the 1970s. First occupied in November 1982, the Hart Building is the largest of the Senate office buildings. It is named for Philip A. Hart, long-time senator from Michigan. , in the room where the letter was opened (as well as outside the room) exposed persons' nasal mucosa nasal mucosa,
n See mucosa. were almost immediately contaminated (37). Re-aerosolization (secondary aerosol) at a level consistent with potential transmission was demonstrated off the implicated im·pli·cate
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.
2. high-speed sorter in the Brentwood Processing and Distribution Facility (38). Recent research using simulates of B. anthracis spores from the Canadian Defense Establishment Suffield suggests that contaminated envelopes can cause heavy aerosol contamination (39). New understanding is accumulating, and this should improve public health response in the future.
The decision-making involved in closing the U.S. Postal Service's Brentwood Processing and Distribution Facility, Washington, D.C., has been criticized. The risk to Brentwood facility employees by contaminated envelopes in transit was not recognized in time to prevent illness in four employees, two of whom died (40). Decisions concerning the Brentwood facility were based on epidemiologic observations in Florida and New York, where no disease occurred among postal workers. A possible explanation for the differential risk is that the B. anthracis spore preparation in the October 9 envelopes had a higher potential for aerosolization than the preparation in the September 18 envelopes or that the two mailings were made under or exposed to different environmental conditions (e.g., amount of moisture) that created a different potential for aerosolization. A different aerosolization potential is supported by the epidemic curve in the manuscript by Jernigan et al. (13), which shows a higher proportion of inhalational (versus cutaneous cutaneous /cu·ta·ne·ous/ (ku-ta´ne-us) pertaining to the skin.
Of, relating to, or affecting the skin.
Pertaining to the skin. ) anthrax cases associated with the October 9 mailing. In naturally occurring disease, once risk is understood, it generally remains constant; however, in intentional contamination, risk may be altered by the perpetrator A term commonly used by law enforcement officers to designate a person who actually commits a crime. (s).
During the anthrax investigation, the public health response team was better prepared in some areas than in others. Five deaths were not prevented, but widespread illness and death was averted through early recognition of threats and prompt intervention. We applied what we knew and learned what we did not know. We gained new appreciation for communication and partnerships. For the first time, on November 8, 2001, a sitting President of the United States of America PRESIDENT OF THE UNITED STATES OF AMERICA. This is the title of the executive officer of this country.
2. The constitution directs that the executive power shall be vested in a president of the United States of America. Art. 2, s. 1. , George W. Bush, visited CDC to support the efforts of public health professionals and others who participated in the anthrax investigation and response. Leaders and individual heroes rose in the ranks of public health, clinical medicine, and law enforcement (41). The substantial role of public health in the 2001 anthrax investigation and response suggests that strong public health infrastructure supported by applied public health and basic-science research are key elements to the control and prevention of future bioterrorism threats.
The guest editors of this special issue of Emerging Infectious Diseases thank all colleagues who participated in the 2001 bioterrorism investigation and response and all who contributed to articles in this issue.
(1.) Traeger MS, Wiersma ST, Rosenstein NE, Malecki JM, Shepard CW, Raghunathan PL, et al. First case of bioterrorism-related inhalational anthrax in the United States, Palm Beach County, Florida Palm Beach County is a county located in the state of Florida. As of 2007, the county had a population of 1,351,236 according to the University of Florida, Bureau of Economic and Business Research. , 2001. Emerg Infect Dis 2002;8;1029-34.
(2.) Maillard J-M J-M Jelinski-Moranda (reliability model) , Fischer M, McKee KT Jr, Turner LF, Cline JS. First case of bioterrorism-related inhalational anthrax, Florida, 2001: North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. investigation. Emerg Infect Dis 2002;8;1035-8.
(3.) Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 2000;49:1-26.
(4.) Khan AS, Morse S, Lillibridge S. Public-health preparedness for biologic terrorism in the USA. Lancet 2000;356:1179-82
(5.) Hoffmaster AR, Meyer RF, Bowen M, Marston CK, Weyant RS, Barnett GA, et al. Evaluation and validation of a real-time polymerase chain reaction In Molecular Biology, real-time polymerase chain reaction, also called quantitative real time polymerase chain reaction (QRT-PCR) or kinetic polymerase chain reaction assay for rapid identification of Bacillus anthracis. Emerg Infect Dis 2002;8;1178-82.
(6.) De BK, Bragg SL, Sanden GN, Wilson KE, Diem LA, Marston CK, et al. A two-component direct fluorescent-antibody assay for rapid identification of Bacillus anthracis. Emerg Infect Dis 2002;8;1060-5.
(7.) Hoffmaster AR, Fitzgerald CC, Ribot E, Mayer LW, Popovic T. Molecular subtyping of Bacillus anthracis and the 2001 bioterrorism-associated anthrax outbreak, United States. Emerg Infect Dis 2002;8;1111-6.
(8.) Mohammed MJ, Marston CK, Popovic T, Weyant RS, Tenover FC. Antimicrobial susceptibility testing of Bacillus anthracis: comparison of results obtained by using the National Committee for Clinical Laboratory Standards broth microdilution reference and Etest agar gradient diffusion methods. J Clin Microbiol 2002;40:1902-7.
(9.) Quinn CP, Semenova VA, Elie CM, Romero-Steiner S, Greene C, Li H, et al. Specific, sensitive, and quantitative enzyme-linked immunosorbent assay enzyme-linked immunosorbent assay
Enzyme-linked immunosorbent assay (ELISA)
A diagnostic blood test used to screen patients for AIDS or other viruses. for human immunoglobulin G immunoglobulin G
n. Abbr. IgG
The most abundant class of antibodies found in blood serum and lymph and active against bacteria, fungi, viruses, and foreign particles. Immunoglobulin G antibodies trigger action of the complement system. antibodies to anthrax toxin protective antigen. Emerg Infect Dis 2002;8;1103-10.
(10.) Thacker SB, Dannenberg AL, Hamilton DH. Epidemic intelligence service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology. Am J Epidemiol 2001;154:985-92.
(11.) Bales ME, Dannenberg AL, Brachman PS, Kaufmann AF, Klatsky PC, Ashford DA. Epidemiologic response to anthrax outbreaks: field investigations, 1950-2001. Emerg Infect Dis 2002;8;1163-74.
(12.) Butler JC, Cohen cohen
(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. ML, Friedman CR, Scripp RM, Watz CG. Collaboration between public health and law enforcement: new paradigms and partnerships for bioterrorism planning and response. Emerg Infect Dis 2002;8;1152-6.
(13.) Jernigan DB, Raghunathan PL, Bell BP, Brechner R, Bresnitz EA, Butler JC, et al. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis 2002;8;1019-28.
(14.) Mott JA, Treadwell TA, Hennessy TW, Rosenberg PA, Wolfe MI, Brown CM, et al. Call-tracking data and the public health response to bioterrorism-related anthrax. Emerg Infect Dis 2002;8;1088-92.
(15.) Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis 2001;7:933-44.
(16.) Centers for Disease Control and Prevention. Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep 2001;50:909-19.
(17.) Centers for Disease Control and Prevention. Update: Investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR Morb Mortal Wkly Rep 2001;50:941-8.
(18.) Centers for Disease Control and Prevention. Updated recommendations for antimicrobial prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine among asymptomatic pregnant women after exposure to Bacillus anthracis. MMWR Morb Mortal Wkly Rep 2001;50:960.
(19.) Centers for Disease Control and Prevention. Update: interim recommendations for antimicrobial prophylaxis for children and breastfeeding mothers and treatment of children with anthrax. MMWR Morb Mortal Wkly Rep 2001;50:1014-1016.
(20.) Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the prophylaxis, diagnosis, and treatment of anthrax. Emerg Infect Dis 2002 8:222-5.
(21.) Barakat LA, Quentzel HL, Jemigan JA, Kirschke DL, Griffith K, Spear SM, et al. Fatal inhalational anthrax in a 94-year-old Connecticut woman. JAMA JAMA
Journal of the American Medical Association 2002;287:863-8.
(22.) Centers for Disease Control and Prevention. Update: Investigation of bioterrorism-related anthrax, 2001. MMWR Morb Mortal Wkly Rep 2001;50:1008-10.
(23.) Polyak CS, Macy JT, Irizarry-De La Cruz M, Lai JE, McAuliffe JF, Popovic T, et al. Bioterrorism-related anthrax: international response by the Centers for Disease Control and Prevention. Emerg Infect Dis 2002;8;1056-9.
(24.) Tengelsen L, Hudson R, Barnes S, Hahn C. Coordinated response to possible anthrax contamination, Idaho, 2001. Emerg Infect Dis 2002;8;1093-5.
(25.) Centers for Disease Control and Prevention. Selected articles. Special issue. MMWR Morb Mortal Wkly Rep 2001; 50:877;889-897;909-919; 941-948;960;961;962;973-976;984-986;987-990;991;1008-1010; 1014-1016;1049-1051;1051-1054.
(26.) Perkins BA, Ashford DA. Meeting summary: bioterrorism-related Bacillus anthracis public health research priorities. Emerg Infect Dis 2002;8;1183.
(27.) Centers for Disease Control and Prevention. Interim guidelines for investigation and response to Bacillus anthracis exposures. MMWR Morb Mortal Wkly Rep 2001;50:987-90.
(28.) Greene CM, Reefhuis J, Tan C, Fiore AE, Goldstein S, Beach MJ, et al. Epidemiologic investigations of bioterrorism-related anthrax, New Jersey, 2001. Emerg Infect Dis 2002;8;1048-55.
(29.) Sanderson WT, Hein MJ, Taylor L, Curwin BD, Kinnes GM, Seitz TA, et al. Surface sampling methods for Bacillus anthracis spore contamination. Emerg Infect Dis 2002;8;1145-51.
(30.) Teshale EH, Painter J, Burr GA, Mead P, Wright SV, Cseh LF, et al. Environmental sampling for spores of Bacillus anthracis. Emerg Infect Dis 2002;8;1083-7.
(31.) Tan CG, Sandhu HS, Crawford DC, Redd SC, Beach MJ, Buehler J, et al. Surveillance for anthrax cases associated with contaminated letters, New Jersey, Delaware, and Pennsylvania, 2001. Emerg Infect Dis 2002;8;1073-7.
(32.) Williams AA, Parashar UD, Stoica A, Ridzon R, Kirschke DL, Meyer RF, et al. Bioterrorism-related anthrax surveillance, Connecticut, September-December, 2001. Emerg Infect Dis 2002;8;1078-82.
(33.) Shepard CW, Soriano-Gabarro M, Zell ER, Hayslett J, Lukacs S, Goldstein S, et al. Antimicrobial postexposure prophylaxis Postexposure prophylaxis (PEP)
Any treatment given after exposure to a disease to try to prevent the disease from occurring. In the case of rabies, PEP involves a series of vaccines given to an individual who has been bitten by an unknown animal or one that is for anthrax: adverse events and adherence. Emerg Infect Dis 2002;8;1124-32.
(34.) Jefferds MD, Laserson K, Fry AM, Roy S, Hayslett J, Grummer-Strawn L, et al. Adherence to antimicrobial inhalational anthrax prophylaxis among postal workers, Washington, D.C., 2001. Emerg Infect Dis 2002;8;1138-44.
(35.) Williams JL, Noviello SS, Griffith KS, Wurtzel H, Hamborsky J, Perz JF, et al. Anthrax postexposure prophylaxis in postal workers, Connecticut, 2001. Emerg Infect Dis 2002;8;1133-7.
(36.) Brachman PS, Plotkin SA, Bumford FH, Atchison MM. An epidemic of inhalation anthrax inhalation anthrax Pulmonary anthrax, woolsorter's disease Pulmonology Occupational anthrax caused by inhalation of Brucella anthracis spores, affecting those exposed to aerosols during early processing of goat or other infected animal hair Clinical : the first in the twentieth century. Am J Hyg 1960:72:6-23
(37.) Hsu VP, Lukacs SL, Handzel T, Hayslett J, Harper S, Hales T, et al. Opening a Bacillus bacillus (bəsĭl`əs), any rod-shaped bacterium or, more particularly, a rod-shaped bacterium of the genus Bacillus. Some bacterium in the genus cause disease, for example B. anthracis-containing envelope, Capitol Hill, Washington, D.C.: the public health response. Emerg Infect Dis 2002;8;1039-43.
(38.) Dull PM, Wilson KE, Kournikakis B, Whitney EAS (Electronic Article Surveillance) A security system for preventing theft in retail stores that uses disposable label tags or reusable hard tags attached to the merchandise. , Boulet CA, Ho JYW JYW Junk Yard Wars
JYW Just You Wait
JYW Just You Wish , et al. Bacillus anthracis aerosolization associated with a contaminated mail sorting machine. Emerg Infect Dis 2002;8;1044-7.
(39.) Koumakakis B., Armour SJ, Boulet CA, Spence M, Barsons B. Risk assessment of anthrax threat letters. DRES Technical Report TR 2001-048. September, 2001.
(40.) Dewan de·wan
Any of various government officials in India, especially a regional prime minister.
[Hindi d PK, Fry AM, Laserson K, Tierney BC, Quinn CP, Hayslett JA, et al. Inhalational anthrax outbreak among postal workers, Washington, D.C., 2001. Emerg Infect Dis 2002;8;1066-72.
(41.) Gerberding JL, Hughes JM, Koplan JP. Bioterrorism preparedness and response: clinicians and public health agencies as essential partners. JAMA 2002;287:898-900.
Bradley A. Perkins, Guest Editor
Dr. Perkins is chief, Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic mycotic /my·cot·ic/ (mi-kot´ik)
1. pertaining to mycosis.
2. caused by a fungus.
1. Relating to mycosis.
2. Diseases, Centers for Disease Control and Prevention (CDC), which has technical responsibility for the CDC epidemiologic and laboratory aspects of Bacillus anthracis, and selected other bacterial agents of public health importance. Dr. Perkins led the field team in the investigation of the index case of inhalational anthrax in Florida and participated broadly in the 2001 anthrax investigation and response. His research interests include vaccine evaluation, bacterial meningitis bacterial meningitis Acute bacterial meningitis Neurology Meningeal inflammation caused by bacteria which, if untreated, is often fatal, or associated with significant sequelae Epidemiology 60% are community-acquired–CM, 40% nosocomial–NM Predisposing , bioterrorism and emerging infectious diseases. He has worked extensively on the control and prevention of meningococcal disease in the United States, Africa, and around the globe.
Tanja Popovic, Guest Editor
Dr. Popovic is chief, Epidemiologic Investigations Laboratory, Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention. As the subject matter expert on laboratory aspects of B. anthracis and anthrax at CDC, she and her staff trained laboratory scientists in all 50 states to isolate and identify B. anthracis using standard methodologies in the fall of 2000, and have performed thousands of tests for isolation of B. anthracis, its confirmatory identification and molecular subtyping during the 2001 anthrax investigation. In addition to bioterrorism preparedness and response, her research focuses on laboratory diagnosis and molecular epidemiology molecular epidemiology Molecular medicine An evolving field that combines the tools of standard epidemiology–case studies, questionnaires and monitoring of exposure to external factors with the tools of molecular biology–eg, restriction endonucleases, of bacterial meningitis and diphtheria diphtheria (dĭfthēr`ēə), acute contagious disease caused by Corynebacterium diphtheriae (Klebs-Loffler bacillus) bacteria that have been infected by a bacteriophage. It begins as a soreness of the throat with fever. .
Kevin Yeskey, Guest Editor
Dr. Yeskey is director, Bioterrorism Preparedness and Response Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). He has served as deputy director of Emergency Public Health in the Division of Emergency and Environmental Health Services health services Managed care The benefits covered under a health contract , National Center for Environmental Health, CDC. His previous assignments include associate professor and vice chair, Department of Military and Emergency Medicine, Uniformed Services University School of Medicine, and chief medical officer, U.S. Public Health Service Office of Emergency Preparedness. Dr. Yeskey's experience with disaster response includes work on hurricanes, earthquakes, floods, mass migrations, and terrorist bombings.
Bradley A. Perkins, * Tanja Popovic, * Kevin Yeskey *
* Center, for Disease Control and Prevention, Atlanta, Georgia, USA