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Mass Gatherings and Public Health Mass gatherings are highly visible events with the potential for serious health and political consequences if not managed carefully and effectively.¹⁻⁴ Mass gatherings have been reported to have significant impact upon public health systems throughout the world.⁵⁻¹⁰ International mass gathering events, such as those associated with the Olympic Games, often carry high political significance and have a historical risk for terrorist attacks.² Mass gatherings ranging from the subnational level to international the level have also been associated with outbreaks and subsequent spread of communicable diseases. These events have included outbreaks of foodborne shigellosis occurring at an outdoor music festival in the United States.⁵,⁶ The annual Hajj pilgrimage in Saudi Arabia has been plagued by public health threats such as fires, stampedes and an outbreak of meningitis.⁷,⁹ Influenza outbreaks were also reported during the 2008 World Youth Day mass gathering in Australia.¹⁰ Local, provincial and national public health and medical agencies are frequently involved before, during and after a major event. Therefore, disaster risk reduction is a key element for the effective management of mass gatherings. Disaster Risk Reduction Throughout the world, the overall approach to emergencies and disasters has recently shifted from post-impact activities (i.e., ad hoc relief and reconstruction) to a more systematic and comprehensive process of risk management.¹¹ Disaster risk management includes pre-impact disaster risk reduction (i.e., prevention, preparedness and mitigation) as well as post-impact response and recovery).¹² While planners may not always have the ability to prevent health hazards from occurring at mass gathering events, the health sector can play an important role in preventing the public health impact of such hazards. This manuscript describes a comprehensive approach for disaster risk reduction as implemented by those entities responsible for health security associated with the 2010 Shanghai World Exposition (Shanghai Expo).
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Reports of health issues related to mass gatherings around the world have indicated a potential for public health and medical emergencies to occur on a scale that could place a significant impact on business continuity for national and international organisations. This paper describes a risk assessment process for business continuity management that was performed as part of the planning efforts related to the World Expo 2010 Shanghai China (Expo), the world's largest mass gathering to date. Altogether, 73 million visitors attended the Expo, generating over US$2bn of revenue. During 2008 to 2010, the Shanghai Municipal Center for Disease Control and Prevention performed a dynamic series of four disaster risk assessments before and during the Expo. The purpose of this assessment process was to identify, analyse and evaluate risks for public health security during different stages of the Expo. This paper describes an overview of the novel approach for this multiple and dynamic process of assessment of health security risk for ensuring business continuity.
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Intelligence fusion centers have grown rapidly in the last few years as state, local, and tribal law enforcement agencies have attempted to find the best way to share information about threats to their communities. The Department of Homeland Security and the Information Sharing Environment of the Office of the Director of National Intelligence embraced fusion centers as being an important mechanism to aid them in their missions to share terrorism information among law enforcement, the private sector, and the intelligence community. The development and management of fusion centers have received significant guidance from the Justice Department, via the Global Intelligence Working Group, by developing standards for structure and processes. Critics, however, are concerned that the centers have inadequate protections for privacy and civil rights. This article examines issues in the development of fusion centers and provides an examination of the support for and criticisms of such agencies.
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The 2010 World Exposition in Shanghai China (Expo) was the largest mass gathering in world history, attracting a record 72 million visitors. More than 190 countries participated in the Expo, along with more than 50 international organizations. The 2010 Expo was six months in duration (May 1 through October 30, 2010), and the size of the venue site comprised 5.28 square kilometers. Great challenges were imposed on the public health system in Shanghai due to the high number and density of visitors, long duration of the event, and other risk factors such as high temperatures, typhoon, etc.As the major metropolitan public health agency in Shanghai, the Shanghai Municipal Center for Disease Control and Prevention (SCDC) implemented a series of actions in preparing for, and responding to, the potential health impact of the world's largest mass gathering to date, which included partnerships for capacity building, enhancement of internal organizational structure, risk assessment, strengthened surveillance, disaster planning and exercises, laboratory management, vaccination campaign, health education, health intervention, risk communication and mass media surveillance, and technical support for health inspection. The clear-cut organizational structures and job responsibilities, as well as comprehensive operational and scientific preparations, were key elements to ensure the success of the 2010 World Exposition. H Yi, Y Zheng'an, W Fan, G Xiang, D Chen, H Yongchao, S Xiaodong, P Hao, M Mahany, M Keim. Public health preparedness for the world's largest mass gathering: 2010 World Exposition in Shanghai, China. Prehosp Disaster Med. 2012;27(6):1-6.
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To facilitate rapid detection of a future bioterrorist attack, an increasing number of public health departments are investing in new surveillance systems that target the early manifestations of bioterrorism-related disease. Whether this approach is likely to detect an epidemic sooner than reporting by alert clinicians remains unknown. The detection of a bioterrorism-related epidemic will depend on population characteristics, availability and use of health services, the nature of an attack, epidemiologic features of individual diseases, surveillance methods, and the capacity of health departments to respond to alerts. Predicting how these factors will combine in a bioterrorism attack may be impossible. Nevertheless, understanding their likely effect on epidemic detection should help define the usefulness of syndromic surveillance and identify approaches to increasing the likelihood that clinicians recognize and report an epidemic.
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The Epidemic Intelligence Service (EIS) was created in 1951 to provide epidemiologists to investigate natural and intentional disease epidemics. From an initial class of 23 U.S. citizens, the program has evolved into a globally recognized, hands-on learning experience, accepting approximately 65 to 75 new officers each year. The first U.S. military epidemic intelligence service officer (EISO) was accepted into the program in 1994. Since that time, 12 such officers have completed, or have begun, EIS training. They have comprised 2.1% of all EISOs from 1994 to 2001 and 0.47% of all EISOs. This total has included nine Air Force veterinarians, one Army veterinarian, one Army physician, and one Navy physician. Each military EISO had the opportunity to lead investigations of significant public health events (e.g., Ebola, monkeypox, malaria, Nipah virus, West Nile fever, and anthrax outbreaks). All graduates from the military returned to active duty assignments in operational medical units, research institutes, or the intelligence community.
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The threat of biological terrorism and warfare may increase as the availability of weaponizable agents increases, the relative production costs of these agents decrease, and, most importantly, there exist terrorist groups willing to use them. Therefore, an important consideration during the current period of heightened surveillance for emerging infectious diseases is the ability to differentiate between natural and intentional outbreaks. Certain attributes of a disease outbreak, although perhaps not pathognomonic for a biological attack when considered singly, may combine to provide convincing evidence of intentional causation. These potentially differentiating criteria include proportion of combatants at risk, temporal patterns of illness onset, number of cases, clinical presentation, strain/variant, economic impact, geographic location, morbidity/mortality, antimicrobial resistance patterns, seasonal distribution, zoonotic potential, residual infectivity/toxicity, prevention/therapeutic potential, route of exposure, weather/climate conditions, incubation period, and concurrence with belligerent activities of potential adversaries.
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Context. —This large outbreak of foodborne disease highlights the challenge of investigating outbreaks caused by intentional contamination and demonstrates the vulnerability of self-service foods to intentional contamination.Objective. —To investigate a large community outbreak of Salmonella Typhimurium infections.Design. —Epidemiologic investigation of patients with Salmonella gastroenteritis and possible exposures in The Dalles, Oregon. Cohort and case-control investigations were conducted among groups of restaurant patrons and employees to identify exposures associated with illness.Setting. —A community in Oregon. Outbreak period was September and October 1984.Patients. —A total of 751 persons with Salmonella gastroenteritis associated with eating or working at area restaurants. Most patients were identified through passive surveillance; active surveillance was conducted for selected groups. A case was defined either by clinical criteria or by a stool culture yielding S Typhimurium.Results. —The outbreak occurred in 2 waves, September 9 through 18 and September 19 through October 10. Most cases were associated with 10 restaurants, and epidemiologic studies of customers at 4 restaurants and of employees at all 10 restaurants implicated eating from salad bars as the major risk factor for infection. Eight (80%) of 10 affected restaurants compared with only 3 (11%) of the 28 other restaurants in The Dalles operated salad bars (relative risk, 7.5; 95% confidence interval, 2.4-22.7; P<.001). The implicated food items on the salad bars differed from one restaurant to another. The investigation did not identify any water supply, food item, supplier, or distributor common to all affected restaurants, nor were employees exposed to any single common source. In some instances, infected employees may have contributed to the spread of illness by inadvertently contaminating foods. However, no evidence was found linking ill employees to initiation of the outbreak. Errors in food rotation and inadequate refrigeration on icechilled salad bars may have facilitated growth of the S Typhimurium but could not have caused the outbreak. A subsequent criminal investigation revealed that members of a religious commune had deliberately contaminated the salad bars. An S Typhimurium strain found in a laboratory at the commune was indistinguishable from the outbreak strain.Conclusions. —This outbreak of salmonellosis was caused by intentional contamination of restaurant salad bars by members of a religious commune.
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Public health investigators have successfully carried out epidemiologic investigations of outbreaks of disease for many years. By far the majority of these outbreaks have occurred naturally. With the recent illnesses resulting from deliberate dissemination of B. anthracis on an unsuspecting population, public health investigation of diseases must now include consideration of bioterrorism as a potential cause of outbreaks of disease. The features of naturally occurring outbreaks have a certain amount of predictability in terms of consistency with previous occurrences, or at least biological plausibility. However, with a deliberately introduced outbreak or infection among a population, this predictability is minimized. In this paper, the authors propose some epidemiologic clues that highlight features of outbreaks that may be suggestive of bioterrorism. They also describe briefly the general process of involvement of agencies at various levels of government, public health and non-public health, depending on the extent of an outbreak or level of suspicion. Language: en
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Homeland security fusion centres serve to gather, analyse and share threat-related information among all levels of governments and law enforcement agencies. In order to function effectively, fusion centres must employ people with the necessary competencies to understand the nature of the threat facing a community, discriminate between important information and irrelevant or merely interesting facts and apply domain knowledge to interpret the results to obviate or reduce the existing danger. Public health and medical sector personnel routinely gather, analyse and relay health-related inform-ation, including health security risks, associated with the detection of suspicious biological or chemical agents within a community to law enforcement agencies. This paper provides a rationale for the integration of public health and medical personnel in fusion centres and describes their role in assisting law enforcement agencies, public health organisations and the medical sector to respond to natural or intentional threats against local communities, states or the nation as a whole.
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Currently, there is no standardized curriculum for training of emergency physicians about the health hazards related to weapons of mass destruction. Opportunities for the widespread teaching of this material have remained limited, and the range of knowledge regarding even general disaster medical care is also variable among most residency training programs in the United States. We developed a survey to ascertain whether any formal training in biological weapons is conducted in emergency medicine programs; to determine the overall subjective ability of program directors or residency directors to recognize and clinically manage casualties of biological weapons agents; and to identify which resources might be used by emergency physicians to identify and treat biological warfare casualties. We also document a baseline of current practices regarding biological weapons training in emergency medicine residency programs.
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Biological terrorism is a threat to the United States that public health laboratories cannot afford to ignore. With the ability to recognize unusual strains of organisms, or an increase in test requests or isolation of specific organisms, the public health laboratory can detect the beginning of an outbreak. The laboratory can also facilitate appropriate response measures with rapid diagnostic testing and by determining antibiotic resistance patterns. Public health laboratory personnel need to assess their capabilities, improve them where indicated, and know where to turn for assistance. As improvements in bioterrorism detection occur in the civilian sector, military laboratories must integrate with local, state, and federal health department systems. Laboratories are essential components in surveillance, recognition, and response for both bioterrorism and naturally occurring disease outbreaks.
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The events of 11 September and the subsequent anthrax outbreaks in the USA have opened the world's eyes to the threat posed by terrorist groups, criminal organizations and lone operators who will stop at nothing to achieve their goals. The open or covert use of pathogens and toxins as biological warfare agents can no longer be ruled out. Against this background, the appearance of an unusual disease must be studied in order to clarify whether it is a natural or artificially caused occurrence. This issue was recently raised in discussions with local representatives and relief organizations during a tularemia epidemic in Kosovo from October 1999 to May 2000. This paper will present a procedure which attempts to use certain criteria to identify or rule out the use of biological warfare agents in the event of an unusual outbreak of disease. Data and findings gathered by routine epidemiologic and microbiological studies often provide only an indirect answer to this problem. For this reason, various criteria were formulated and points allocated to represent their importance, allowing us to deduce in a semiquantitative manner the degree of possibility of an artificial genesis of outbreaks. The significance and characterization of each criterion are discussed. An analysis of the tularemia epidemic in Kosovo based on the procedure described here indicates that a deliberate release of the causative agent of tularemia, Francisella tularensis, as a biological warfare agent is doubtful. In this paper, an approach is described to discriminate between the intentional use of biological warfare agents and natural outbreaks of infectious diseases. The developed model is flexible and considers the political, military and social analysis of the crisis-afflicted region, the specific features of the pathogen, and the epidemiologic and clinical characteristics of the epidemic.
Estimating the size of bioterror attack
  • Walden
Biological and chemical terrorism: strategic plan for preparedness and response; recommendations of the CDC strategic planning workgroup
  • Centers for Disease Control and Prevention