Bioterrorism: Field Guide to Disease Identification and Initial Patient Management

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Accordingly, to establish whether issues related to WMD such as bioterrorism agents, radiation-based weapons and chemical weapons are currently being considered by those responsible for organising and delivering undergraduate medical teaching in the UK and Ireland, and if the degree programmes they offer currently include any time spent on these issues, a cross-sectional survey has been undertaken of all medical schools in the UK and the Republic of Ireland.

The specific questions posed to the medical schools are both contained in the figures as well as being listed in the Results section. Respondents were not under any obligation to answer any or all of the questions, or to provide free text responses. A Part 1 of original questionnaire emailed to undergraduate schools of medicine. B Part 2 of original questionnaire emailed to undergraduate schools of medicine.

Preparing for and Preventing Bioterrorism

All individually listed schools of medicine providing undergraduate medical degree courses in the UK and the Republic of Ireland were identified by visiting the individual websites of all universities and Royal Colleges in the two countries, and establishing whether they offered such courses. In August , a hyperlink to the survey questionnaire was sent by email to the persons identified from the internet as being the Dean or equivalent person in charge of undergraduate medical teaching at each of the identified schools of medicine in the UK and the Republic of Ireland totalling 32 in the UK and 6 in Ireland.

Depending upon whether or not replies were received, at least three emails were sent out to the identified contacts at each medical school. The emails invited the recipients to click on the hyperlink and to look at the questionnaire and to complete and return it. They were advised of the names, status and place of work of the researchers. They were advised that it was intended that the results would be published, and that they had the option to choose anonymity for the institution.

A positive response from a respondent was, in itself, considered as the evidence of consent. The survey was terminated in mid-December Question 1 figure 1 A of the questionnaire gave undergraduate schools of medicine the choice of either identifying the name of the medical school or remaining anonymous.

Beyond this, no assurances of anonymity were given. Questions 2—7 figure 1 A,B dealt with bioterrorism.


Question 2 asked, in the present tense, if the organisation has included any specific teaching on bioterrorism. If the answer to question 2 was no, question 3 explored their future plans, asking if there were any plans in place to introduce such teaching. Questions 4 and 5 asked, in the present tense, if certain areas of knowledge were covered and if the organisation had specific teaching experience in place to deliver such teaching. Questions 5 and 6 were included to help establish whether a decision should be made in the future to include new teaching on bioterrorism, the necessary expertise was already present among the existing teaching staff.

Opportunities were given within the questionnaire to provide free text replies, to allow for comments to be made by the participants if they should wish to do so. Such comments could, for example, provide insight into the reasoning and motives behind the answers given to the questions, and perhaps even provide wider insights which had not hitherto been recognised, or highlight if there had been any difficulty with interpreting and answering the questions.

Question 8 figure 1 B asked about chemical weapons and question 9 explored the issue of radiation utilised for the purposes of aggression. With respect to piloting, given that the aim of the piloting process is to detect any flaws in the questioning and to correct these prior to the main survey being started, the questionnaire was first tested on a small group of colleagues, which confirmed that it was clearly written in plain English, and was comprehensible.


The objective of the survey was to obtain, if possible, completed questionnaires from all medical schools;. If a subgroup was to be subjected to a pilot study, and those participants were then excluded from the main study, this would have left an even smaller—and incomplete—dataset.

Formal ethical approval was not considered necessary and therefore not sought. This was because the survey was considered to be more akin to a service review, with no experimentation being involved, no sponsorship being involved and no patients being involved or approached. The sample under study was made up of large mature well-resourced organisations, rather than individual people. Of a total of 38 undergraduate schools of medicine who were contacted, 34 A total of 28 were from the UK and 6 from the Republic of Ireland.

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A total of 32 respondents provided the name of their organisation. Of the remaining 6, 2 completed the questionnaire, but chose to remain anonymous. Accordingly, there were 4 medical schools all in the UK which did not provide any information for the study. The detailed breakdown is in table 1. Undergraduate Schools of Medicine approached breakdown of responders and non-responders.

Because of subsequently receiving further information, one undergraduate school of medicine asked for its original response to be withdrawn and replaced with a revised response, which was achieved. These responses relate to questions 2—6 listed in the original questionnaire illustrated in figure 1 A,B.

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The following data were obtained from the 34 respondents. The chances therefore of a doctor having to deal with a case are vanishingly small. These responses relate to questions 8—9 listed in the original questionnaire illustrated in figure 1 B. It is clear from these results that few undergraduate medical students in the UK and the Republic of Ireland currently receive any teaching about biological weapons and bioterrorism. There may be some similarities to the situation that has already been recognised at the United Nations level with respect to the wider scientific research community, namely that there are widespread deficiencies in the education of scientists, including life scientists, with respect to their background knowledge about and understanding of bioterrorism and biowarfare and how scientific research into this field might lead to adverse consequences.

The importance of recognising such diseases in the field has been acknowledged in the UK. This is because if genuine instances of bioterrorism are not identified as soon as possible, valuable time is lost that might help to ensure that the overall impact of such incidents is minimised and possible repeat events prevented. However, the first place where persons suffering from the effects of biological weapons are likely to interact with doctors is in accident and emergency departments or primary care, and the doctors who initially encounter such persons in those settings may be likely to be relatively junior or may have spent only a short time training within specialist hospital settings.

Accordingly, if one was to wish to ensure that the highest possible proportion of qualified doctors working in the UK or the Republic of Ireland have acquired at least a basic knowledge of biological weapons, bioterrorism and related matters by the time they start working as doctors with the public and to avoid a knowledge vacuum in this area, the only way this could be guaranteed would be for there to be some teaching incorporated into the undergraduate curriculum.

Leaving such training entirely to the postgraduate stages, unless it is mandatory and robustly enforced, means that a significant number of medical graduates may never receive any training about biological weapons and bioterrorism, which in turn may seriously hamper their abilities to recognise such events for what they are as early as they might be and alert the appropriate authorities. There exists evidence from British accident and emergency departments that postgraduate training and preparedness in this field is currently not as strong as it could be.

We have no knowledge as to why four of the organisations approached did not wish to participate. Duplicate responses seem unlikely. Virtually, all schools of medicine that chose to respond were happy to provide the name of their organisation, and only two chose to remain anonymous. Given that situation, even if there were to be any duplicate responses, their overall impact on the results would be small. The issue of whether or not there could have been any ambiguity in the questionnaire leading to confusion among respondents must be considered. Questions 1, 2, 7, 8 and 9 are very clear in their intent and virtually all respondents provided answers.

In the case of question 3, five respondents gave no answer, which, given the clarity of the wording of the question, suggests that, at the time of answering, they did not know if there were any plans in place, an option which was not given to them, while they had elected not to make further enquiries within their own medical school in order to establish if there were any such plans in place or not—as if they had, one would have anticipated that they would have been able to provide a yes-or-no answer. It is not known why respondents would not have sought to establish the internal situation within their own organisation more clearly rather than failing to provide an answer.

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  5. Eleven respondents provided answers to question 4, which is of interest as only six had stated in question 2 that they provided some specific teaching on bioterrorism and just four had answered in question 3 that there were plans in place to introduce some teaching. These are two main interpretations for this. Physicians must know whom to call and be confident that their call will contribute to the overall goal of providing information, guidance, and support to the medical community. Health care professional organizations, academic medical institutions, and public health officials must come together to develop appropriate training curricula, informational guidelines, and most important, the working partnerships that are critical to success.

    This will require careful advance planning since most hospitals are operating at or near capacity right now. Systematic examination of local capabilities and how they can be rapidly augmented by state and federal assets must be part of this effort. Federal health leadership will be important in this effort to define needs and provide model guidelines and standards; federal resources may also be essential to support planning efforts and to create the incentives necessary to bring the voluntary and private health care sector fully on board. However, the final planning process must be undertaken on the local or regional level, engaging all the essential community partners and capabilities.

    It is critical to remember that the front line of response, even in a national crisis, is always local.

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    4. Thus, across all these domains of activity, we must make sure that we have adequate capacity locally and regionally, which can then be supplemented as needed. Another important example of this involves access to essential drugs and vaccines. A large-scale release of a biological weapon may require rapid access to quantities of antibiotics, vaccines, or antidotes that would not be routinely available in the locations affected.

      Given that such an attack is a low probability and unpredictable event in any given place, it would hardly be sensible or cost effective to stockpile supplies at the local level.

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      As we ramp up our public health and medical capacity to respond to bioterrorism, we should continue to strengthen our national pharmaceutical stockpile so that vital drugs and equipment can be rapidly mobilized as needed. The federal Centers for Disease Control and Prevention CDC has the responsibility to maintain and oversee use of this stockpile, which currently represents a cache of supplies located in strategic locations across the country that can be delivered within 12 hours to any place in the nation.

      Current concerns make it clear that the nature and quantities of materials maintained in the stockpile must be enhanced, and the stockpile contents should be periodically reviewed and adjusted in response to intelligence about credible threats. Beyond simply having the drugs and vaccines available, we must develop plans for how those critical supplies will be distributed to those who need them.

      CDC needs to provide strong leadership and support for state and local health departments to undertake contingency planning for distribution. We must also think about the broader mobilization of essential drugs, vaccines, or other materials in the event that they are needed outside the United States. Although this may raise complex diplomatic issues, especially when the necessary pharmaceutical is in short supply, addressing potential global need is essential for political and disease-control reasons.

      To make sure that the United States can remain strategically poised, further investments must be made in biomedical research to develop new drugs, vaccines, rapid diagnostic tests, and other medical weapons to add to the arsenal against bioterrorism. We must learn more about the fundamental questions of how these organisms cause disease and how the human immune system responds so that we can develop better treatments and disease-containment strategies.

      It is also essential that we improve technologies to rapidly detect biological agents from environmental samples and develop new strategies and technologies to protect the health of the public. Scientists will need the full support and encouragement of the public and the government confront this threat. Success will entail research endeavors and collaboration involving numerous government agencies, universities, and private companies. Looking to the future, an effective, well-funded research agenda may give us the tools to render the threat of biological weapons obsolete. Stopping a biological attack before it happens is obviously the most desirable way to avoid a crisis. The first step in blocking the proliferation and use of biological weapons is to significantly bolster our intelligence.

      The intelligence community could use additional scientific and medical expertise to help enhance the quality of data collection and analysis. This will require greater partnership and trust between the intelligence community, law enforcement, and public health and biomedical science. These disciplines do not routinely work together, and their professional cultures and practices are not easily merged.

      Sadly, we must recognize that the possibility of bioweapons threats emerging from legitimate biological research is certainly real and embedded in the very science and technology that we herald in laboratories around the world. It would be made available under an IND in case of a smallpox emergency in circumstances where ACAM is depleted, not readily available, or contraindicated [73].

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      It should be noted that although these vaccinations are called "smallpox vaccinations," they do not contain any smallpox virus and cannot transmit the disease. However, the vaccines can transmit vaccinia and can produce life-threatening adverse events in some cases [64]. The FDA has required "black box" warnings to be included with the smallpox vaccines due to the possibility of encephalitis, myopericarditis, ocular complications, and skin and systemic infections i.

      The goal of the third-generation vaccine is to provide complete protection from the disease i. In a safety study of an earlier version of MVA conducted in Germany, , people were given the vaccine with few observed complications. The "ring vaccination" strategy will be the first-line strategy in a smallpox emergency. It vaccinates the contacts of patients with confirmed smallpox and also those who are in close contact with those contacts.