2002 Richard J. Duma/NFID Annual Press Conference and Symposium on Infectious Diseases
Please Choose a Presenter
» Scott P. Layne, M.D.
» Stuart B. Levy, M.D.
» Michael T. Osterholm, M.D.
» Lance E. Rodewald, M.D.
Technological Advances in the Rapid Detection of Bioweapons And Emerging Infectious Agents
By Scott P. Layne, M.D.
September 11th serves as a wake up call. We must face the fact that biological weapons pose a real challenge to homeland and international security, that small attacks are more likely than large ones and have the capacity to overwhelm emergency responses, and that further attacks will undermine our trust in leadership and government.
The development of biological weapons requires three key elements: knowledge, equipment, and infectious agents. These elements are relatively easy to obtain and thereby pose serious challenges to our security. It costs roughly $1,000,000 to kill a person with a nuclear weapon, $1,000 to kill a person with a chemical weapon, and $1 to kill a person with a biological weapon. Such economy emphasizes that biological weapons can be made by an organized "bio Bin Laden" and lone "bio Kaczynski."
The biggest issue is that the United States must devise a broader plan to prevent, deter, and respond to the long-term threats of biological terrorism. How could we do this? The means exist to create a high-speed laboratory and molecular forensic database against germs like anthrax. Such a laboratory would provide for positive identification and source tracing for anthrax and many other "select germs" identified by Congress.
Proposed laws to strengthen homeland security call for more guards, padlocks, record-keeping and personnel checks at laboratories that handle select germs. Such measures would be expensive and time-consuming. Yet forensic security can ease the burdens of physical security.
Here is how it might work: Researchers would be required to periodically submit samples of their labs' select germs for high-speed fingerprinting. This practice would automatically maintain a list of institutions and investigators who have handled select germs (something that does not exist currently) and an up-to-date forensic database on them. If germs from a legitimate institution were used in a biological attack, we would uncover this quickly, perhaps overnight.
The 1972 Biological Weapons Convention, agreed to by 162 nations, bans the maintenance of offensive bioweapons programs but offers no provisions for verification and compliance.
The high-speed laboratory could provide a new technical foundation for sensitive and effective inspection procedures based on molecular forensics. For example, if an insecticide plant was inspected and found to contain traces of anthrax, we would take action. That is prevention.
There are about 20 rogue countries and organizations with secret offensive biological weapons programs, and the number is growing. If we had a high-speed laboratory, it would help in the covert monitoring of their capabilities and in fingerprinting their germs. And we could put such states on notice that, if their weapons were ever used against us, we would pinpoint their origins and act with guaranteed force. That is deterrence.
In the event of a biological attack, the high-speed laboratory could test thousands of samples each day. It would help public health officials to save lives, reduce confusion and speed recovery operations. That is response.
The United States has plans for other complex and evolving problems. For example, it seeks to limit the proliferation of ballistic missile technology by gathering intelligence information, enacting export laws, and focusing diplomatic pressure. Nevertheless, if an enemy ever fired a missile at the United States, we would immediately pinpoint its origin with our "eyes in the sky" and act with guaranteed force. That is prevention, deterrence, and response rolled into one.
Now we need a plan for biological attacks. Every dollar spent on a high-speed system would save much more.
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Community-Acquired Antimicrobial Resistance: From Emerging Threat to Reality
By Stuart B. Levy, M.D.
- An eleven-month-old girl is hospitalized for an ear infection resistant to six different antibiotics.
- Urinary tract infection in women is no longer treatable by the first line agents.
- Four children die from a methacillin-resistant Staphylococcus aureus in the community.
We have witnessed the gamut of ways that bacteria cope with and avoid both synthetic and natural antibiotics designed to kill them. Treatment of virtually all major infectious disease bacteria is curtailed by drug resistance, often multidrug resistance. Until recently, the community has been spared from the antibiotic resistance problem, which has long been focused primarily in hospitals. This finding made sense during the early decades of antibiotic usage since such use was largely in the hospitals. Today, resistance plagues the community as well.
Probably the first clinical indication of resistance entering the community was the appearance of penicillin-resistant Hemophilus influenzae and Neisseria gonorrhoeae, (the cause of gonorrhea), in the mid-1970s. These respiratory and sexually-transmitted disease agents were, up to then, totally susceptible to penicillin and other commonly-used antibiotics.
As community use increased, bacteria involved in community infections emerged resistant to multiple different antibiotics. The pneumoccocus, a common respiratory tract agent and one that can cause fatal meningitis and pneumonia, began to thwart penicillin in the 1990s. Towards the end of the decade, these organisms appeared resistant to multiple antibiotics. Originally appearing in less than 1% of clinical pneumococcal isolates, today penicillin resistance overall in the U.S. has reached over 20%. Most recently, a strain of pneumococcus resistant to six different antibiotics was the cause of refractory ear infection in an 11-month-old child in Georgia.
Resistance in other common bacteria has made them difficult-to-treat infections in the community. Of particular note are methacillin-resistant Staph aureus (MRSA) which bear resistance to first-, second-, and third-generation penicillins and cephalosporins. These organisms cause grave morbidity and mortality in hospitals, but only recently appeared in the community. E.coli, with resistance to more than 6 different drugs, may be the cause of urinary tract infection. Up to 20% are resistant to the first line of therapy, trimethoprim/sulfamethoxazole, provoking a shift towards more expensive drugs, namely the fluoroquinolones. These were formerly reserved for the hard-to-treat infections and are also our first line agents against multidrug resistant bacteria which threaten the lives of cancer and organ transplant patients.
Gastrointestinal infections caused by Salmonella and Campylobacter have become more prevalent as resistant, community-acquired diseases. These reflect another aspect of the community problem, namely, food-borne disease. Resistant strains of bacteria are being propagated through the use of antibiotics in animal husbandry.
Thus, through the 1990s and the new decade see a change in the profile of community infections, from that of being largely susceptible to that of being increasingly multidrug resistant. Wide public awareness and control of the problem is urgently needed.
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The Anthrax Attack on the United States: The Investigation and Ongoing Preparedness Efforts
By Michael T. Osterholm, M.D.
The concept and implications of bioterrorism have taken on new meaning following the events of September 11 and the subsequent anthrax attack on the U.S. Postal Service. Although the Anthrax episode resulted in 22 cases, including five deaths, it represented a "tragic dry run" compared to a major bioterrorist attack. Future events could involve other infectious diseases, including smallpox, plague and botulism, as well as, covert releases through aerosols that expose thousands of unsuspecting individuals.
Several critical lessons were learned as a result of the Anthrax attack. First, there is a critical need for public health infrastructure capable of responding to future attacks. This includes the means to rapidly detect bioterrorism-related illnesses, the ability to provide necessary vaccines and antimicrobial treatment to large segments of the population, and the system to present clear and concise information to the public health and medical communities, law enforcement, policy makers and the general public. Second, there is a need for public health officials to work closely with law enforcement and intelligence officials. Finally, support for public health resources must be long-term in nature as part of national security and the concurrent prevention and control of naturally occurring infectious disease problems.
This presentation will review the lessons learned from the Anthrax attack and current efforts at the Federal, state and local level to prepare for future attacks.
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Ensuring A Stable United States Vaccine Supply -- Issues and Potential Solutions
By Lance E. Rodewald, M.D.
Routine childhood vaccination is a major public health success story. Because of vaccines administered throughout the 20th century to children and adults, an estimated half a billion cases of disease and 3 million premature deaths were prevented in the United States alone. Childhood immunization rates are at record high levels, and vaccine preventable disease rates are at record low levels. These successes are dependent on the ready availability of vaccines in sufficient quantities to allow health professionals to reach every child in need of vaccination when they present to the office.
Over the past year and a half, the supply of the five vaccines against 8 of the 11 diseases prevented through routine vaccination has been insufficient to meet the needs of the nation's children. The affected vaccines are diphtheria, tetanus, and pertussis (DTaP); tetanus and diphtheria (Td); measles, mumps, and rubella (MMR); varicella; and pneumococcal conjugate vaccines.
Vaccine shortages are causing children to be turned away from their doctors' office or clinic unprotected. State immunization programs have been forced to suspend the highly effective school immunization laws because of the lack of vaccine. Parents and their children's immunization providers have been upset and disappointed over the inability to supply these vaccines.
Unlike the shortages of DTP vaccine in the early to mid 1980s that had the single cause of liability, the current shortages have several different causes that vary from vaccine to vaccine and manufacturer to manufacturer.
This talk will describe (1) the extent of the vaccine shortages, (2) our current understanding of the causes of the shortages, (3) management strategies being used to ration vaccine as effectively as possible, (4) projections about future vaccine supply, and (5) potential strategies to prevent future supply disruptions. The National Vaccine Advisory Committee has made recommendations to the Department of Health and Human Services on strategies to prevent shortages, and these recommendations will also be discussed.