Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats [1 ed.] 9781607504924, 9781607500865

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PANDEMICS AND BIOTERRORISM

Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

NATO Science for Peace and Security Series This Series presents the results of scientific meetings supported under the NATO Programme: Science for Peace and Security (SPS). The NATO SPS Programme supports meetings in the following Key Priority areas: (1) Defence Against Terrorism; (2) Countering other Threats to Security and (3) NATO, Partner and Mediterranean Dialogue Country Priorities. The types of meeting supported are generally “Advanced Study Institutes” and “Advanced Research Workshops”. The NATO SPS Series collects together the results of these meetings. The meetings are co-organized by scientists from NATO countries and scientists from NATO’s “Partner” or “Mediterranean Dialogue” countries. The observations and recommendations made at the meetings, as well as the contents of the volumes in the Series, reflect those of participants and contributors only; they should not necessarily be regarded as reflecting NATO views or policy. Advanced Study Institutes (ASI) are high-level tutorial courses to convey the latest developments in a subject to an advanced-level audience. Advanced Research Workshops (ARW) are expert meetings where an intense but informal exchange of views at the frontiers of a subject aims at identifying directions for future action. Following a transformation of the programme in 2006 the Series has been re-named and reorganised. Recent volumes on topics not related to security, which result from meetings supported under the programme earlier, may be found in the NATO Science Series. The Series is published by IOS Press, Amsterdam, and Springer Science and Business Media, Dordrecht, in conjunction with the NATO Public Diplomacy Division.

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Sub-Series A. Chemistry and Biology B. Physics and Biophysics C. Environmental Security D. Information and Communication Security E. Human and Societal Dynamics

Springer Science and Business Media Springer Science and Business Media Springer Science and Business Media IOS Press IOS Press

http://www.nato.int/science http://www.springer.com http://www.iospress.nl

Sub-Series E: Human and Societal Dynamics – Vol. 62

ISSN 1874-6276

Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

Pandemics and Bioterrorism Transdisciplinary Information Sharing for Decision-Making against Biological Threats

Edited by

Andrey Trufanov Irkutsk State Technical University, Irkutsk, Russian Federation

Alessandra Rossodivita San Raffaele Hospital Scientific Foundation, Milan, Italy and

Matteo Guidotti Copyright © 2010. IOS Press, Incorporated. All rights reserved.

Institute of Molecular Science and Technologies, CNR, Milan, Italy

Published in cooperation with NATO Public Diplomacy Division Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

Proceedings of the NATO Advanced Study Institute on Preparing Regional Leaders with Knowledge, Training and Instruments for Information Sharing & Decision-Making Against Biological Threats and Pandemics Milan, Italy 30 November – 8 December 2008

© 2010 The authors and IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 978-1-60750-086-5 (print) ISBN 978-1-60750-492-4 (online) Library of Congress Control Number: 2009941880

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Publisher IOS Press BV Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected]

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Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

Pandemics and Bioterrorism A. Trufanov et al. (Eds.) IOS Press, 2010 © 2010 The authors and IOS Press. All rights reserved.

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Preface

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“ Either we work together to rise to the challenges or we condemn ourselves to irrelevance” José Manuel Barroso, President of the European Commission

The history of human civilization and the development of the modern world is inextricably linked to various types of emergencies and disasters: epidemics, earthquakes, floods, hurricanes, extreme heat and cold, fires etc.; societies have continuously been subjected to natural and man-man disasters. This preface begins with a few examples of the historic and prehistoric natural disasters known to us which can teach us important lessons about disaster preparedness and mitigation. The Italian volcano Mt. Vesuvius erupted on August 24, 79 AD, killing thousands of people and smothering the towns of Pompeii, Stabiae, and Herculaneum with ash. The volcano is still a threat and the area is much more densely populated today than it was two thousand years ago. The plague of Athens, which occurred in the fifth century BC, is the best known of the ancient plagues and another important example of a historical disaster. Two more devastating ancient plagues were the Athenian of 430 BC (to which Pericles succumbed during the Peloponesian War) and the Justinian of AD 542. Malaria is a disease that has threatened humankind with frequent outbreaks throughout the last several thousand years, another is shistisomiasis, a disease caused by parasitic blood flukes. Cholera may have been the reason for the Assyrian forces suddenly abandoning their siege of Jerusalem in 700 BC and polio was present in isolated cases in ancient Egypt. Biological weapons have been in use since at least the seventh century BC, when Scythian archers dipped their arrows in blood, dung or decomposing bodies to stop the invading Assyrians. We have some information on the development of inoculation and vaccination: pock sowing is recorded in a sanskrit text of the second or third century AD. Scientists argue that most diseases have presented a more serious threat as civilization has advanced. Nowadays, disasters disrupt hundreds of thousands of lives and leave thousands more homeless every year. Statistics of injuries suffered due to disasters are rarely taken into account, but for earthquakes, the rate is about 30 people injured for every death; for hurricanes it is closer to 50 to 1. The impact of a disaster is felt far beyond the immediate area affected. More than 95 percent of all deaths caused by disasters occur in developing countries. Industrialized countries, on the other hand, tend to suffer more from economic damage: the financial impact of natural and man-made disasters totals hundreds of billons of US dollars. GNP (Gross National Product ) lost due to disasters tends to be 20 times greater in developing countries than in their developed neighbors, however, hurricane Katrina in the US entailed the highest total damage by far, at $135 billion. Here are a few examples of natural and man-made disasters that took place in 2009.

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Man-made disaster: more than 70 people perished in the accident of August 17 which destroyed three out of 10 turbines at RusHydro’s Sayano-Shushenskaya plant in southern Siberia, Russian Federation, and limited electricity supply to manufacturers. It has not been made clear whether it was due to human error or a technical failure. The repairs will cost 40 billion roubles ($1.28 billion) over four to five years. Natural disasters: in the early morning (01:32) of Monday, April 6, central Italy was struck by an earthquake of 6.3 magnitude. The L’Aquila earthquake caused serious damage to several medieval hill towns in the region, killing over 260 residents, injuring over 1,000 and leaving 28,000 homeless. The 2009 flu pandemic is a global outbreak of a new strain of an influenza: a virus subtype H1N1, first identified in April 2009, in Mexico. In early June, as the virus spread worldwide, the World Health Organization (WHO) declared the outbreak to be a pandemic. It has not been established where the virus originated. Threats to mankind are constantly evolving, and national and international experts are examining and reviewing new plans and priorities applicable to today’s threats. The chemical, biological, radiological, nuclear, and explosives (CBRNE) threats have recently come to the forefront of international discussions. Traditionally, natural disasters and industrial accidents have posed the greatest threat to people worldwide, but CBRNE emergencies present new challenges, with the potential to become global threats affecting the developing and developed world alike. Srgjan Kerim, president of the U.N. General Assembly, called on the international community in Sept, 2008 to implement a “new way of thinking” to enable greater cooperation around the world to better counter global terrorism. The U.S./Russia Working Group on Counterterrorism (CTWG) met for its 16th session in June, 2008 in Moscow to update current plans and initiate new areas of cooperation in countering terrorist threats. But governments alone cannot protect people from terrorism. A complete counter-terrorism strategy requires cooperation between governments, businesses, scientists, communities, and civil society in general. For centuries, the field of international peace and security was the province of politicians only, but times have changed, with academics, scientists, business, industry and the arts becoming more educated, knowledgeable, sophisticated, penetrative, and democratic in their diversity than ever before. Because disasters are a global issue, the study of how to counter them is also a global issue. Counter-terrorism requires the cooperation and collaboration of multidimensional groups such as academics; representing the theoretical and research areas, policymakers; representing coordination and authorization aspects and professionals; representing practical and real life experiences. A key obstacle to any human scientific, technical or social process is inefficient or non-existent information sharing mechanisms. It is not evident that everyone benefits by sharing information, but those who must act to counter global threats do. As information sharing implies education and training, these are necessary if we are to respond effectively to global threats. The body of knowledge and experience being developed in these fields is so immense that a new information-sharing paradigm is required for the various disciplines in different societies to understand each other better. New technologies have given the counter-emergency community an opportunity to build a collaborative, innovative, and knowledge sharing culture that will continue to engage in learning and research. The only impediment is the will to understand rather

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than to suppress each other. Everyone knows of outstanding scientific and academic initiatives such as the LHC (Large Hadron Collider, CERN) and the ISU (International Space University), famous for their incredible information sharing infrastructure. But countering global threats is not limited to science and education. The challenge of disaster preparedness and mitigation inevitably involves other sectors: politics, the military, medicine, law and law enforcement, industry, commerce, and grass roots approaches. Key emergency countering forces should not be alone in their activity. They need help from other professionals. Moreover, the process requires social control and social interaction, as government structures are not always optimally positioned to effectively manage disasters. The international project known as The Global Health Network Supercourse (University of Pittsburgh, Pittsburgh, PA, USA) is considering the use of media outlets for effective information sharing among societies around the world. The North Atlantic Treaty Organization (NATO) is one of the global actors which supports collaboration of world leaders in science, politics, technology, and other areas financially. In his important paper, delivered at ‘Technology in Society’ 23(3), 2001, Prof. Fernando Carvalho-Rodrigues, director of the human and societal dynamics panel, Science for Peace and Security (SPS) program section of NATO, declared that the aim of NATO science programs is “putting scientists and politicians in the same loop”. The idea of holding a multidimensional cross-silo meeting (Prof. Carvallo-Rodrigues’ “loop”) has been the subject of discussion and design by a 4 member team: E. Gursky (USA), A. Rossodivita (Italy), E. Stikova (FYR Macedonia), and A. Trufanov (RF) since 2006. As a rule, actions and instruments for countering global threats are multi or interdisciplinary, however, the meeting held in Milan, Italy, in 2008 was different. Its aim was to be cross-disciplinary (not only interdisciplinary and multidisciplinary but transdisciplinary as well), a term usually applied to the spheres of education and research. According to the definitions of Stokol and Rosenfield, transdisciplinary conceptual frameworks are characterized as reflecting a higher degree of integration than is achieved through interdisciplinary collaboration. The least-integrative forms of cross-disciplinary research or education activity, are multidisciplinary projects in which participating scholars remain conceptually and methodologically anchored in their respective fields Moreover this meeting has been conceived as a cross-silo collaborative effort. That means cross-disciplinary, cross-national, cross-agency, cross-departmental, crosslevel…, and cross- society concepts for diverse groups of pertinent actors. The initiative was inspired by our distinguished colleagues, who developed the Supercourse effort, including Ronald LaPorte, Faina Linkov and Eugene Shubnikov, as well as by editors of the Journal Disaster Medicine and Public Health Preparedness, AMA (J. James, I. Subbarao). Eventually, the project, entitled “Preparing regional leaders with the knowledge, training and instruments for information sharing and decision making against biological threats and pandemics” was selected by the NATO SPS program for financial and organizational support. Developing the key NATO SPS events – ARW in Kaunas, Lithuania, 2005 and ASI in Skopje, FYR Macedonia, 2006, which focused of the ever-increasing frequency and severity of natural and man-made emergencies and disasters, the third pertinent meeting, ASI, was convened on Nov 29–Dec 10, 2008, in Milan. This initiative was

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aimed at further supplementing the efforts to transfer technology and knowledge and so help decrease the vulnerability of the population to natural, technogenic, and anthropogenic threats. As foreseen by expert analysis, the follow-up ASI tried to unify the efforts of the scientific, academic and practical communities, creating a greater understanding and information sharing in the field of countering biological threats. The venue of the ASI was originally to be in Irkutsk, RF in early October, 2008, however the 2008 South Ossetia war, also known as the Russia–Georgia war, forced a change to the scheduling and venue of this event.

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The conference was held in Milan in December 2008. Italy has a prominent history in the field. For example: the first world conference on health emergencies in technological disasters was organized by the Italian Department of Civil Protection in Rome, May, 1992. Continuing this tradition, the ASI Italian team; specifically A. Rossodivita, A. Caruso, M. Guidotti, and M. Ranghieri and their assistants, prepared to launch this as a prestigious event. We would like to thank the team for their organization skills, especially given the time pressures involved in planning this event. Their efforts to support the sessions, meetings and visits technically and spiritually were more than successful and in accord with the ideal of cross-silo cooperation. All those attending felt welcome and were given the opportunity to work, network, attend site visits, and interact with colleagues. We have been greatly impressed by and are grateful for the help that Italian organizations and their officials provided to the ASI. Specifically, we wish to thank: - San Raffaele Hospital, in particular its President Don L. Verzè and the Supervisor for Health Policy: Dr. G. Zoppei - The Sovereign Military Order of Malta in particular Col. M. Terrasi - The Italian Association of Alpine (ANA) in particular Prof. P. Losapio - The Italian Air Force Medical Service in particular Gen. O. Sarlo, Gen. N. Barale and Col. L. Oliva - The Military Hospital of Milan in particular Gen. S. Valentino - The Italian Association For Solidarity Among People (AISPO) in particular Dr. G. Zoppei and Dr. R. Corrado. All the participants appreciated the attention of Italian civil and military circles. The audience was greatly inspired by a letter of greeting from the President of the Italian Republic, Giorgio Napoletano. We all appreciated Adm. Vincenzo Martines (Italy) for his speech at the opening ceremony of the conference, and the leader of the Russian delegation, Prof. S. Kolesnikov, Vice- Chairman of the Committee on Public Health, State Duma, Federal Assembly - Parliament of the Russian Federation, who posed key questions of international cooperation in the field of epidemics and pandemics; Dr. James, Director of the Center for Public Health Preparedness and Disaster Response, American Medical Association (AMA) for his interest in the ASI and Prof. Di Paolantonio, who presented on behalf of the Italian chapter of International Physicians for the Prevention of Nuclear War. Throughout, the environment of the ASI was one of mutual support and of learning from one another, and genuinely cooperative. The organizers proposed, and attendees accepted, a wide range of activities focused on a creative a friendly atmosphere and

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plenty of networking opportunities. The choice of topic was timely and proactive as it occurred on the eve of the swine flu outbreak. The agenda consisted of numerous lectures, seminars, and discussions, addressing a wide range of information sharing regimes and concomitant issues. The principal focus (preemptively, for infection diseases) was on how cooperation and the sharing of data in disasters can affect both the prevention and mitigation environments. The conferences of Kaunas and Skopje were excellent in terms of multidisciplinary and international efforts. But the Milan meeting actually initiated cross-disciplinary and cross-border collaboration, bringing politicians, scientists, and the military closer to each other. ASI succeeded in expanding the information sharing territory with politicians, the military, doctors, scientists and the media. The main benefit for attendees was the creation of a bridge from science to application in the collaborative pursuit of better outcomes. The list of 65 ASI contributors we would like to thank reflects the extensive experience in the participating countries (15 NATO + partners) in the field of combating natural and man-made disasters, as well as their secondary impact on democratic processes and the understanding between societies at different levels in and across the countries. Undoubtedly this material, on the topic of information sharing while countering biohazards, will be of great value to a wider circle of readers. The audience for publication includes specialists within various areas of research and teaching plus those working in the field who are responsible for mitigation, preparedness, response, or recovery actions. This ASI served to put representatives of diverse circles “into the same loop” and the discussions that took place at the event covered some of the following: improving cooperation among different groups, actors, and organizations and using lessons learned to improve impact, and how to reduce communication barriers between diverse silo circles. The mix of papers highlights strategic enablers that will allow countering communities to prevent disasters and emergencies, protect against global threats and recover should an event take place. These enablers are cross-disciplinary information sharing, international outreach and partner activities, public diplomacy and strategic communication. To be in line with the discussed approaches, all anti-emergency entities must foster cooperation with partners from other countries and international and regional organizations in order to develop a common understanding of global threats. This collection of ASI papers serves as a showcase of disaster preparedness and mitigation work from various nations, and demonstrates how and to what extent experts form different countries and fields understand and collaborate with each other. Collaboration between researchers and consumers of research in this translational approach is critical to reduce the threat burden for nations and consequential damage, the ultimate measure of benefit to all people. This concept of sharing information on the scope, content, and goals within threat countering is based on the work of those who have come to the ASI. The collection of papers recounts a volume of interaction between research, education and practice that has resulted in the current expertise in the field of global disasters and emergencies. New synergy outputs and outcomes might be anticipated from such cross-silo scope. This concept had been central in the editing and realization of this book and we

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cannot help emphasizing the energetic and decisive cooperative contribution of the editorial board. In our opinion, both the ASI and the book are modest but robust steps towards a new era of genuine cross-silo information sharing and cooperation in an atmosphere of trust. However, the next steps must be innovative and aggressive, and we hope the NATO SPS program will continue to regard its efforts in support of this direction as being of paramount value.

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Alessandra Rossodivita and Andrey Trufanov, ASI co-directors

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Acknowledgements We would like to thank all of those who helped us in preparing this book, in particular, the managing editors and the editorial board for their valuable work reviewing, editing and providing critical feedback:

Managing Editors Massimo Ranghieri Faina Linkov Elin Gursky Editorial Board

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Sergey Kolesnikov Ron LaPorte Steve Photiou Eugene Shubnikov Italo Subbarao Irina Shurygina Ray Swienton Natalia Vynograd

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In addition, we would like to thank the following Institutions for their strong support to the BioHaza-Milan 2008 NATO-ASI Conference “Preparing regional leaders with the knowledge, training and instruments for information sharing and decision-making against biological threats and pandemics” held in Milan (Italy) from November 30 to December 8, 2008:

Fondazione Centro S. Raffaele del Monte Tabor Istituto di Ricovero e Cura a Carattere Scientifico Università “Vita – Salute” San Raffaele Irkutsk State Technical University

Stato Maggiore dell’Esercito

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Corpo Militare del Sovrano Militare Ordine di Malta Speciale Ausiliario dell’Esercito Italiano

Regione Lombardia

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Associazione Nazionale Alpini

Associazione Italiana per la Solidarietà tra i Popoli

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Alessandra Rossodivita Andrey Trufanov Matteo Guidotti

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Scientific Committee NATO-ASI BioHaza-Milan 2008 “Preparing regional leaders with the knowledge, training and instruments for information sharing and decision-making against biological threats and pandemics ”

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CO-DIRECTOR - Alessandra Rossodivita (“San Raffaele” Hospital Scientific Foundation, Milan, ITA) CO-DIRECTOR - Andrey Trufanov (Irkutsk State Technical University, Irkutsk, RUS) MEMBERS: Liviu Galatchi (Ovidius University of Constanta, ROM) Victor Gulevich (Dep. Chief, Baikal Rescue Corp., EMERCOM, RUS) Elin Gursky (Dep. Director of Biodefense, ANSER/Analytic Service Inc., USA) Evgeniy Kononov (Irkutsk State Technical University, Irkutsk, RUS) Ron LaPorte (WHO Collaborating Centre, Pittsburgh, USA) Faina Linkov (University of Pittsburgh Cancer Institute, USA) Evgeniy Shubnikov (Novosibirsk, RUS) Elisaveta Stikova (University "St. Cyril and Methodius" Faculty of Medicine, Skopje, MKD) Italo Subbarao (Center of Public Health Preparedness and Disaster Response- AMA, Chicago, USA) Natalia Vynograd (Chief of Epidemiology Dept., L’viv National Medical University, UKR) LOCAL ORGANIZING COMMITTEE Matteo Guidotti (EI-SMOM, Milan, CNR-ISTM, Milan, ITA) Pantaleo Lucio Losapio (Director of ANA Field Hospital, ITA) Massimo C. Ranghieri (EI-SMOM, Milan, ITA) Maria Teresa Cibelli (“San Raffaele” Hospital Scientific Foundation, Milan, ITA) Luise Welman (“San Raffaele” Hospital Scientific Foundation, Milan, ITA) ADMINISTRATIVE SECRETARY Adriana Fusè

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Contents Preface Alessandra Rossodivita and Andrey Trufanov

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Acknowledgements Alessandra Rossodivita, Andrey Trufanov and Matteo Guidotti

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Scientific Committee of NATO-ASI BioHaza-Milan 2008

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1. Introduction The Need of Preparing Regional Leaders with the Knowledge, Training and Instruments for Information Sharing and Decision-Making against Biological Threats and Pandemics. Preparing for the Next Pandemic Alessandra Rossodivita and Andrey Trufanov

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2. Information-Sharing for Counteracting Biological and Other Global Threats

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Information Sharing in Knowledge Society 15 Fernando Galindo, Matteo Guidotti, Viktor Gulevich, Elin Gursky, Sergey Kolesnikov, Sergey Koptilov, Ron LaPorte, Faina Linkov, Massimo Ranghieri, Alessandra Rossodivita, Eugene Shubnikov, Elisaveta Stikova, Andrey Trufanov and Natalya Vynograd Learning from Catastrophe: Lessons for Pandemic Planning Elin A. Gursky and Sweta R. Batni

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Governance in Counteracting Natural and Man-Made Disasters: The LEFIS Network as Example Fernando Galindo

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Legal and Political Implications of a Pandemic and Biological Threats. Ethical Dilemmas in Disasters Antonio Caruso and Alessandra Rossodivita

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The Economic and Systemic Impacts of a Pandemic William I. Hancock

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3. Improving Preparedness through Education and Awareness Health “Security” Systems Raymond E. Swienton, Italo Subbarao and Elin A. Gursky

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Tools against Terrorist Threats: Considerations on How to be Prepared Massimo Ranghieri, Matteo Guidotti and Alessandra Rossodivita

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The Viewpoint of ED Personnel about Avian Flu: Do Emergency Department Healthcare Professionals Feel Ready to Face Epidemics/Pandemics? Efstratios Photiou Bioterrorism and Pandemics: A New World Order of Civil Defence David Alexander

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4. Multidisciplinary Approaches to Address Biological and Nonconventional Threats Nanosystems and CBRN Threats: A Resource Worth Exploiting, a Potential Worth Controlling Matteo Guidotti, Massimo Ranghieri and Alessandra Rossodivita Modern Biooptical Instruments for the Express Control of Total Toxicity, Individual Chemicals, Viral and Bacterial Infections to Prevent Bio- and Medical Threats Nickolaj F. Starodub

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Behavior of Some Pathogenic and Genetically Modified Bacteria in Groundwater Samples 134 Zdenek Filip and Katerina Demnerova Geological Environment as a Factor of Natural and Man-Made Disasters Evgeniy E. Kononov

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Mass Destruction Weapons and their Contribution to Pandemic Effects Alberto Breccia Fratadocchi

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Significance of Noninvasive Cardiology Care in Present-Day Peculiarities of Hazardous Regions M.G. Shurygin

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5. Modeling Information-Sharing and Communication The Supercourse: Former Soviet Union Countries Practice Eugene Shubnikov, Faina Linkov, Andrey Trufanov and Ronald LaPorte Globalization of Public Health Communication: Preparing Local Leaders using the Supercourse Faina Linkov, Eugene Shubnikov and Ronald LaPorte

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Model of the Adaptive Hierarchical Information Security System A.L. Antipov and A.I. Trufanov

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6. Case Studies and Regional Threats Cooperation between Civilian and Military Organizations during an Emergency: A Case Study Evaluation of the 2008 Reentry of an Uncontrolled U.S. Government Satellite Contaminated with Hydrazine 181 Chuck Tomljanovich, Conrad Volz, Sandra Quinn, Andrey Trufanov and Alessandra Rossodivita Counterterrorism: The First Italian Drill Alessandra Rossodivita, Marzia Spessot and Gianna Zoppei

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Crimean-Congo Hemorrhagic Fever in Turkey (2002–2008) Etem Akbas

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The Anopheles Mosquitoes: Their Role in Malaria Transmission in Georgia George Babuadze, Merab Iosava and Lela Bakanidze

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The Problem of Preventing Natural Foci Infections during the Development of New Territories Irina A. Shurygina

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Pseudotuberculosis – Epidemiology, Clinic and Prevention Measures Irina A. Shurygina

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Subject Index

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Author Index

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Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

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1. Introduction

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The Need of Preparing Regional Leaders with the Knowledge, Training and Instruments for Information Sharing and Decision-Making against Biological Threats and Pandemics. Preparing for the Next Pandemic Alessandra ROSSODIVITAa, Andrey TRUFANOVb Department of Cardiothoracic and Vascular Diseases, Disaster Specialist, San Raffaele Hospital Scientific Foundation, University of Medicine of San Raffaele “Life and Health”, Milan, Italy b Irkutsk State Technical University, Irkutsk, Russian Federation

a

Chance favors a prepared mind Luis Pasteur

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It is better to understand a little than misunderstand a lot Anatole France Revolt of Angels, Ch 1 They can because they think they can Vergil, Aeneid , Bk, v, 1. 231

1. Are the Populations Protected from Biothreats? Today mankind is facing unprecedented challenges. Contemporary geopolitical and cultural conflicts, biology and natural disasters pose enormous strains on social order and economic stability, particularly in developing and underdeveloped, resource-poor nations and even in developed countries. Along with anthropogenic and technogenic threats the natural ones shake regions and the world in whole from time to time. Incredible flows of human migrations and changing environmental factors have contributed to the emergence and dissemination of tens of new pathogens over the past thirty years, such as the human immunodeficiency virus, West Nile virus, E. coli 0157:H7, hantavirus, viral hemorrhagic fevers (such as Marburg, Ebola, dengue, and yellow fevers), highly pathogenic avian influenza, new form of pandemics and,

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A. Rossodivita and A. Trufanov / Preparing Regional Leaders against Biological Threats

Staphylococcus aureus. Global climate changes has added to a cluster of natural disasters and hazards including heat waves in Europe, and a series of flooding and mudslides, earthquakes, tsunamis, and hurricanes throughout Asia and North America that have caused death, disability, and population displacement affecting more than 7 million people worldwide. Globalization of goods, food, and people introduces a host of emerging pathogens to all corners of the world threatening the collective security of populations and their food supplies. In recent years, outbreaks of diseases such as severe acute respiratory syndrome (SARS), food and mouth disease, the Ebola virus, and bovine spongiform encephalopathy (mad cow disease) have halted global tourism and trade, and contributed to large economic losses, and disrupted stable diplomatic relations. Global economic crisis has played its role at the scenario complexity of the issue. In addition, over the last decade terrorism, related emergencies and conflicts have represented a new resurgence involving a complex pattern of global changes and imbalances. Throughout the globe, healthcare providers are increasingly challenged with the spectre of terrorism and the fallout from weapons of mass destruction. Recent acts of terrorism have ranged from the dissemination of anthrax spores to the intentional contamination of food, from the release of chemical weapons to suicide attacks using explosives. The prediction of such events is difficult, if not impossible. The prediction of future man-made disasters or a terrorist attack could drive the efforts of the public policy and government funding. The medical and healthcare infrastructure must be prepared to prevent and treat illness and injury that would result from chemical, biological, radioactive, nuclear or explosive terrorism (CBRNE). Terrorist attacks are of great concern to policy–makers, disaster managers and communities around the world. The attacks on 11 September 2001, the terrorist events of the past few years highlighted by the World Trade Center, the Pentagon catastrophe (11/09/2001), the further Madrid, London and Mumbai attacks place another risk on the table, changing forever the mindset of antiterrorism responses. The world now understands that terrorists are continually innovative in planning new terrorist operations. The question of the fight against this phenomenon is very crucial and deeply felt by the international community. Over the years “natural and man-made disasters” could be interpreted in terms of human failings; this concept is strictly related to the concept and definition of terrorism as intimidation, coercion, and direct violent action or engenderment of fear to attain goals that are political, religious or ideological in nature. Terrorism and other forms of disaster overlap one another quite substantially both as destructive phenomena and as management problems. Natural hazards or man–made hazards have the same potential to became harmful, real events. Knowing human man-made hazards, identifying hazards can mitigate or prevent a possible future disaster like terrorism. In the Globalization era disasters might concern any human being. Today these complex disasters have led to a dramatic increase in demand for disaster and emergency medical care and the concomitant critical infrastructures which have been rapidly overwhelmed, as evidenced during the response to these global catastrophic health events. The Center for Research on the Epidemiology of Disasters defines a disaster as “a situation or event which overwhelms local capacity, necessitating a request to a national or international level for external assistance”. The field of disaster medicine is the study and collaborative application of various health disciplines – epidemiology, public health, infectious disease and vector control,

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nutrition, pediatrics, emergency surgery, social and psychological medicine, community care, resource area management and education, hygiene and sanitation, and international health applied to the prevention and immediate response and rehabilitation of health problems arising following a disaster. Most of the world’s senior political, health, researchers and agricultural leaders must now prepare for a potential disaster in the form of a pandemics such avian influenza pandemic or other new influenza events, like Influenza A H1N1 or a biological threat. In 1918, a subtype of avian flu caused an estimated 50-100 million deaths, including 675,000 deaths in the United States. It is estimated that as much as 50% of the human population was infected, with a mortality rate of 2-5% [1-3]. In 1997, an avian flu strain of H5N1 subtype was identified in human patients. First identified in 1997 and responsible for widespread, unprecedented outbreaks in poultry in South East Asia in 2003, H5N1 has since rapidly spread to over 50 countries throughout Asia, Africa, and Europe and has resulted in the death of more than 200 people1 [4]. Estimates suggest that an epidemic may kill about 60 million people worldwide. Though it cannot be determined with certainty what virus will be responsible for the next pandemic, or when the next pandemic will strike, many experts hypothesize that the H5N1 avian influenza virus is a likely candidate to incite global disaster. Evidence from the WHO now suggests an escalating pandemic threat from the H5N1 viral subtype or now with H1N1. This suggests to the global community that the virus could further re-assort to a strain capable of sustained human-to-human transmission. Now we are fighting with the hazard of H1N1, a new evolution of a pandemic [6]. What is known is that logistical aspects of pandemic influenza and planning are still incomplete. In an age of potential biological terrorism, outbreaks of severe acute respiratory syndrome, and fears of an avian flu or a new pandemic, there is an increased need for frontline clinicians to have adequate education and training to meet these threats. Ethical dilemmas now represent a new chapter in managing these threats. Preparedness from pandemic injuries is an essential component for every nation and for every public health system, which is designed to protect the population against any unusual public health event. Preparing the nation to address these dangers is a major challenge to public health systems and health-care providers. The fundamental issues are: preparedness education, prevention, detection and surveillance, diagnosis and characterization of a biological agent, response communication. To be effective, an integrated training program must also include disaster drills, and address management and response plans to ensure core competency in public health preparedness. Recent studies and events suggest that public health system is not adequately prepared to deal with large-scale biological threat events [7, 8]. Infectious pandemics represent some of the most catastrophic events in human history, and pose serious and difficult ethically based questions that will arise and test the moral background of the society. These challenges drive new priorities in terms of solidarity, and common responses on the basis of jointly defined norms. The global fight against a biological 1 To the spring, 2008 there have been about 400 reported human cases of H5N1 infections including approximately 250 deaths. Aggressive poultry containment measures have resulted in the culling of over 140 million H5N1 infected birds at a cost in excess of $10 billion [5].

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agent requires efforts in many areas and directions, from strengthened border controls to better coordination among numerous government agencies at local, national and international levels, with an integrated training work program in terms of management, plans and drills to ensure core competency in public health preparedness and security to provide the highest panel of scientists and expertise among local, state and federal and international partners, by suggesting a robust military and civilian cooperation. But we would also like to stress the importance of incorporating ethics into pandemic planning and response [4, 5].

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2. The Role of Health Information, Secure Exchange Systems and Infrastructure in Pandemic Preparedness With the advent of computers, computers networks, the Internet, e-mail, the World Wide Web, and the cell and satellites phones, we now have a lot of tools to communicate beyond traditional social boundaries. Information is needed to support humanitarian responses in every phase of a disaster. Since 1970s and 1980s, a robust literature has developed around the crucial role of information to support disaster response. Information is needed to assess the key contextual elements relating to the health, environment, and culture of the affected population; to select and monitor appropriate interventions; and to encourage accountability among the agencies, donors and government involved [9-11]. Timely and adequate Information Technology (IT) and Telecommunication resources are critical for disaster mitigation and relief efforts. Information technology and telecommunication systems should be strategic element in the development of comprehensive preparedness plans. Information and communication technology applications, deployment strategies, and operational procedures should be developed as a part of preparedness planning. Counteracting to Disasters and Emergences always has need for cooperation and collaboration among all entities and actors. Advanced Internet technologies enable users to share information easily among themselves in a variety of formats. Diverse National and International Networks of Disaster and Emergency Medicine (DEM) have been launched by workgroups of users to support their work efforts. But Global International and Interdisciplinary Networks usually are not robust enough and new difficulties or threats jeopardize the fragile networks of medical and public health preparedness at local state and national and international levels. A good prevention program and measures in case of disasters may include accurate information and a data collection to allow a correct and immediate decision-making process. We must also be well prepared to minimize the human and economic consequences of terrorist attack. Epidemiological data are well recognized as essential to understand, manage and defend against global threats and disasters, to allow a progressive improvement in the ability of health system to respond more effectively and efficiently to such events. A good disaster management requires more accurate information and data collection analysis to allow an immediate and balanced decision making-process. The medical and healthcare infrastructure must be prepared to prevent and treat illnesses and injuries that would result from a biological threats or a pandemic event. Epidemiological data are well recognized as essential to understand and to manage a disaster and to support an adequate response and preparedness planning, to allow a

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progressive improvement in the ability of health system to respond more effectively and efficiently to such events. Studies of disaster impact on public health have suffered from the lack of these data, especially the lack of real time. Furthermore, we suffer from the lack of a systematic data collection. The analysis of hazards and vulnerabilities represent the key to manage and mitigate a possible terrorist attack or a man-made disaster. Planners, policy-makers, authorities and all forces engaged in emergency have all expressed need of these data. Communication remains the vital paradigm between two different operational paradigms, as the military world means command, control, computers, communications and intelligence, instead in the humanitarian-civil field it means cooperation, coordination, consensus, communication and assessment. Good disaster management requires accurate information and must be linked with a data collection and analysis of an immediate decision-making process. Epidemiological data are well recognized as essential to understanding and to managing a disaster, and to allowing a progressive improvement in the ability of health system to respond more effectively and efficiently to disasters. Studies of disaster impact on public health have suffered from the lack of these data, especially the lack of real time data. Furthermore, we suffer from the lack of systematically-collected data. Data are collected for a purpose: to improve emergency decisions and to provide more effective planning of relief and recovery. Data collection is ongoing. Incorrect or non-exact time-scale data can lead to erroneous conclusions and wasted time and resources. Information must be found when it is needed. Defining and obtaining security remain the other main issue. Security is strictly linked to communication (collecting, storing, dissemination, etc.). Security for the military means force protection by arms and weapons, which leads to displays of overwhelming force in everything it does. Security for civilian interveners represents legitimacy of acting in a humanitarian manner that creates a willingness to engage a situation on the humanitarian merits. All disaster assessment processes require coordination in terms of communication, data collection and security. The United Nations (UN), Red Cross, and governmental and non-governmental organizations (NGOs) have developed different mechanism to make it effective. The importance of coordination between these issues continues to be emphasized in numerous contemporary international agencies; nevertheless it reveals different variables and non-standardized approaches. To be correct, Information Security is not on computers: it is on people. The legal aspects of creating, collecting, storing, processing and sharing valuable information should be taken into account by actors while counteracting biological threats. These actors represent all levels of human groups: individuals, societies, local, and global. The responsibility for Information Security does not rest upon computers but, rather, upon those who use them. The legal issues associated with creating, collecting, storing, processing, analyzing and sharing data is a prime responsibility of the entities engaged in counteracting biological threats. These entities include individuals, governments and societies from the local to the global levels. It is crucial to have access to collect all data on disasters, including the so-called “perishable data” and all previous data not available due to a “lack of access”, in order to create a future evolution of the National and International Networks of Disaster and Emergency Medicine (DEM) Information Sharing Networks and the way to make that sustainable, to improve information technology research applied to disaster medicine,

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in terms of preparedness, teaching and response in case of biological threats and pandemics. Counteracting to Disasters and Emergencies always has a need for cooperation and collaboration among all entities and actors. DEM have been launched by workgroups of users to support their work efforts. But Global International and Interdisciplinary Networks usually are not robust enough and new difficulties or threats jeopardize these fragile networks. This paper focuses on what impedes evolution of the DEM Information Sharing Networks and how to make that sustainable.

3. Aim of the Project and Recommendations The project and the book are multi-purpose, as:

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to improve the sharing of the public health information; to foster and balance the different countries security and communication scenarios related to a disaster from a pandemic event, in terms of preparedness, mitigation and prevention programs; to rationalize the decision making process; to serve the purpose of humanitarian action to national and international levels, with the tight cooperation of civilian and military forces in terms of peace-keeping process and sharing information and security programs related to population health well-being; to increase collaborative global cooperation and partnerships in disease control and containment to global threats such as that posed by avian influenza. The general idea is to create a permanent international working group and a global network with a panel of experts, from different fields and nations. The Group will consist of experts from different fields of medicine, public health, university, epidemiology, toxicology, engineering, emergency planning and management, fire brigades, civil protection, anthropology, economics, military corps, volunteers groups and any discipline that deals with the impact of a pandemic or anthropogenic disaster on security and health of human population. This working group will be organized and work in the name of claimed principles of honesty, trust, integrity, consistency, balance of confidentiality and accessibility, accountability and with the objective to maintain a strict collaboration with other relevant national and international organisations as the National Health Service, the Centre for Diseases Control and Prevention (CDC), World Health Organization (WHO) and the International Red Cross (IRCS), World Association of Disaster and Emergency Medicine (WADEM). The pertinent are: - Creating a permanent forum of free discussion between experts to assess medical, epidemiological, economic, and socio-psychological impacts to populations from pandemic threats; to study the political and economic impacts on critical infrastructure and various sectors from pandemic threats; - Discussing medical countermeasures and non-pharmaceutical strategies to prevent and respond to pandemic threats;

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- Improving public relations and risk communication strategies with media; - Discussing legal and ethical considerations in pandemic preparedness and response; - Improving existing teaching methods on scientific, clinical, and epidemiological principles for detection and containment of new and emerging disease threats; - Designing and disseminate new teaching methods for scientific, clinical, and epidemiological principles and applications of new and emerging disease threats; - Improving training programs on pandemic disease threats; - Conducting future tabletop exercises and drills as useful tools to manage disasters and pandemics; - Disseminating and develop an after action report (AAR), lessons learned, and best practices to improve preparedness and response across the health and disaster medicine infrastructures against a pandemic threat; - Improving existing health information system infrastructures and technologies applied to monitor, detect, and track new and emerging biological threats; - Developing a common operational platform for dynamic and secure flows of scientific and health information to improve global health response in emergency; - Developing secure information security infrastructures. This network will concentrate its actions on applied science and on methods of planning in order to obtain a continuous improvement of methods used to estimate the number , the type and location of injuries caused by a pandemic; with the study of the means of reducing vulnerability to injuries during a disaster.

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4. NATO-ASI Resolution and Future Perspectives The ASI Conference BioHaza-Milan 2008 entitled: Preparing regional leaders with the knowledge, training and instruments for information sharing and decision-making against biological threats and pandemics (30 November–8 December 2008 in Milan), demonstrated how a Multidisciplinary, Trans-disciplinary approach jointly related with new form of international cooperation, collaborative dialogue in civilian and military cooperation with a theoretical and practical approach on the field, that could represent the key words of a global response in disaster, and imply a severe pluralism of the actors and the fact that the society should be constantly updated. The final resolution of BioHaza-Milan 2008 was a common proposal to create an International Association for international cross-disciplinary Networked Information Sharing in Disasters and Global Threats (NISHADA), in order to improve effectiveness and efficiency of counteracting disasters, CBRNE, and other threat to global and local scale was discussed as the corner stone of a new evolution idea of networking and international civilian and military cooperation in information technology, information health security, disaster response, research and public health management. The aim of the future Network will be to improve the sharing of public health information, to improve and to balance the Different Countries Security and Communication scenario, related to any disaster, global threat, CBRNE, terrorism, humanitarian medicine, Information-sharing and technology, civilian and military cooperation in terms of preparedness, mitigation and prevention programmes, to rationalize the decision-making process; to serve the purpose of humanitarian action at

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national and international levels, in terms of peace-keeping process or peace-making process, and to serve as a template for other countries. There is no general definition of the term “information sharing”, but the premise gained vast popularity after 9/11 when it was recognized that the United States government had poor information interaction prior to a planned terrorist attack on the New York City World Trade Center. The ASI emphasized that better cooperation implies better Information Sharing. Knowledge or Information Societies possessing current technologies need not be constrained by geographic proximity. Current technology offers much more possibilities for sharing, archiving, processing and retrieving knowledge than before. Providing timely and reliable Information Sharing during crises is critical to improve response, maximize resources and minimize human suffering. The ability to work well with others is a requirement for virtually every job, but this skill becomes crucial in the hectic and demanding healthcare work environment. The authors will discuss about the responsibility for Information Exchange, which does not rest upon computers but, rather, on those who use them, and what impedes knowledge sharing for those who want to cooperate. Barriers occurs when actors encounter lack of tools and equipment, and insufficiencies in moral, political, legislative, organizational, technical, didactic, psychological, physical, financial and geographical support. Cooperation is complex. The word Globalization today indicates a new philosophy to interact and consider the world and the future events that could happen and the possible response. Too much cooperation can lead to “group-think”, “yes-man syndrome”, or inappropriate conformity. It was emphasized that many of us are locked into silos, narrowly focused on our occupations and gaining little trans-disciplinary work. The authors would like to stress the role of information sharing in counteraction to Disasters, focusing particular attention on CBRNE, terrorism and humanitarian emergency. Preparedness to mitigate any disaster or global threat consequences is an essential component for every nation and for every public health system, which bears the responsibility to protect its populations in times of catastrophic events. Preparing nations to address these dangers is a major challenge to public health systems and health-care providers on the national and international levels. The fundamental issues are: preparedness and prevention, detection, surveillance, diagnosis, and characterization of a disaster response and communication. These challenges drive new priorities in terms of solidarity, and common responses on the basis of jointly defined norms. Being in line with a strong information-sharing approach, the proceedings includes the issues on Medicine, Biology, Chemistry, Radiation Physics, IT, Information Sciences, Politics, Economics to set cross-silo links for professionals who combat with biological threats. Based on the approach the next step in the Biological emergency medicine is to deploy intensive information sharing activity by implementing pertinent transdisciplinary international sites, centers and labs in NATO and Partner countries and all over the world. Working together in the global fight against Disasters, Pandemics, CBRNE, and terrorism requires efforts in many areas and directions with the main objective to protect the population, to support human rights, civil liberties and to improve knowledge especially in poor developed countries. Saving lives, livelihoods, promoting human security, attention to human dignity and rights, no-discrimination and

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administrative coherence should represent some crucial points which should be discussed still further and developed in the years to come in a common language and in a plural society. We have the responsibility to find new frontiers and knowledge to preserve humankind. Every country, society and group has the fundamental obligation to provide the nation security and to protect people. Knowing the past, this study may help to understand, in order to contribute to reduce the loss of human lives, injuries and the suffering of populations.

References NPAS Johnson, J. Mueller, Updating the accounts: Global mortality of the 1918-1920 “Spanish” Influenza pandemic, Bull Hist Med 76 (2002), 105-115. [2] J.K. Taubengerger, D.M. Morens, 1918: the mother of all pandemics, Emerg Inf Dis 12(1) (2006),15-22. [3] M.E. Pena, C.B. Irvin, R.B. Takla, Ethical Consideration for emergency care providers during a pandemic influenza - Ready or not, Prehosp Disast Med 24 (2) (2009), 115-119. [4] Cumulative Number of Confirmed Human Cases of Avian Influenza A (H5N1), Reported to “WHO” http://www.who.int/csr/disease/avian_influenza/country/cases_table_2007_10_08/en/index.html [5] Writing Committee of Second World Health Organization Consultation on Clinical Aspects of Human Infection with Avian Influenza A (H5N1) virus, Update on Avian Influenza A (H5N1) virus infection in humans, N Engl J Med 358 (2008), 261-273. [6] S.M. Zimmer and D.S. Burke, Historical Perspective - Emergence of Influenza A (H1N1) viruses, N Engl J Med 361 (2009), 279-285. [7] G. Stone, et al., Data collection and communications in the public health response to a disaster: rapid population estimate surveys and the daily dashboard in post-Katrina New Orleans, J Public Health Manag Pract 13(5) (2007), 453 -460. [8] A. Macyntyre, G. Christopher, E. Eitzen Jr, et al., Physicians preparedness for bioterrorism recognition and response: A Utah-based needs assessment, Disast Manag Response 2(3) (2004), 69-74. [9] M.S. McDonell, et al., Information for Disasters, Information Disasters, and Disastrous Information, Prehosp Disast Med 22(5) (2007), 406-413. [10] N. Banatvala and A.B. Zwi, Public Health and humanitarian interventions: Developing the evidence base, BMJ 321(7253) (2000), 101-105. [11] P. Salama, P. Spiegel, L. Talley, et al., Lesson learned from complex emergencies over past decade, Lancet, 364 (2004), 1801-1813. Copyright © 2010. IOS Press, Incorporated. All rights reserved.

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2. Information-Sharing for Counteracting Biological and

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Other Global Threats

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Information Sharing in Knowledge Society Fernando GALINDOa, Matteo GUIDOTTIb,Viktor GULEVICHc, Elin GURSKYd , Sergey KOLESNIKOVe, Sergey KOPTILOVf, Ron LaPORTEg, Faina LINKOVh, Massimo RANGHIERIi,Alessandra ROSSODIVITAj, Eugene SHUBNIKOVk, Elisaveta STIKOVAl, Andrey TRUFANOVf,1 and Natalya VYNOGRADm a University of Saragossa, Saragossa, Spain b CNR-Institute of Molecular Science and Technologies, Milan, Italy c Baikal Search and Rescue Squad of EMERCOM, Irkutsk, RF d ANSER/Analytic Services, Inc., Arlington, USA e Committee of Public Health, The State Duma, Moscow, RF f Irkutsk State Technical University, Irkutsk, RF g University of Pittsburgh, Pittsburgh, USA h University of Pittsburgh Cancer Institute, Pittsburgh, USA i Comando 1Rep.to E.I. S.M.O.M., Milan, Italy j San Raffaele Hospital Scientific Foundation University, Milan, Italy k Institute of Internal Medicine, Novosibirsk, RF l University “St. Cyril and Methodius”, Skopje, Macedonia m Danylo Halytski Lviv National Medical University, Lviv, Ukraine

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Abstract. Within this study a qualitative review has been conducted leading to a clarifying finding of Cooperation and Information Interaction in the field of counteracting biological threats. Three cornerstone incentives of Information Sharing have been highlighted: Psychological, Technological and Economical. The proposals to use the architecture experience of CERN; strategy of ISE, USA; standards, rules and formats of NIEM, USA; practice of EMERCOM, RF for building a Global Anti-Terrorism Information Sharing Infrastructure are presented. Keywords. Information Sharing: psychological, technological and economical aspects, international, transdisciplinary and cross-level cooperation, biological threats

Introduction Competition and Cooperation All life is primarily competitive. Within human societies, various actors (e.g., individuals, groups, tribes, societies, and nations) have tried to apply some form of Information Security to gain advantage in social contests. Simultaneously, people often cooperate when facing common problems and troubles. At every new stage of mankind’s development there was a demand for new principles and technologies of information exchange to support pertinent cooperative actions. 1 Corresponding Author: Elisaveta Stikova, Irkutsk State Technical University, Lermontova 83, 664074 Irkutsk, RF; E-mail: [email protected].

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Numerous studies demonstrate that cooperation surely brings out the “best” in us [1]. There is no doubt that a cooperative strategy increases the number of ideas, improves the quality of outcomes, and facilitates a better working environment. But Why do Actors not Cooperate? One common impediment to cooperation is lack of trust. Lack of trust often results when the actors do not know each other and when they have conflicting interests and problems. If an actor perceives that cooperation will do him harm so that the outcome of co-working is misery, the actor will reject such collaboration. Moreover, in all aspects of life, including business, decision makers want to know that a proposed expenditure is financially justified. Cooperation, Security, and Information Sharing are no different – these have to make “business sense”. What decision-makers need are pertinent metrics that show how the expenditures impact the bottom line. There is no point in implementing an action if its true cost is greater than the prospective advantages. Definition of Knowledge Society Discussion in contemporary sociology on the character of contemporary society and the role that technologies, information, communication, and co-operation play in it are reflected in concepts such as knowledge society, information society, network society, and postindustrial society. Meanwhile experts use diverse definitions of data, information, and knowledge [2]. Data is often considered the result of collecting different facts; information means literally “to put form to”; and knowledge comes from the same root as the word “cunning” which suggests application, not collection. Thus, for example, laboratory sample results are data; a robust theory of the cause of a disease, stemming from that data, is information; and a vaccine for the disease is knowledge. Nevertheless, all may be viewed as information.

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Definition of Information Sharing There is no general definition of “information sharing”, but after 9/11 this term gained vast popularity as it was concluded that the United States government had poor just-intime (JIT) information sharing in response to the planned terrorist attack on the New York City World Trade Center, prior to the event. We may define the term as: The collaborative management, control, and use of information resources aimed to increase effectiveness and efficiency of the collaborative efforts.

1. Better Cooperation Implies Better Information Sharing 1.1. Three Corner-Stone Incentives of Information Sharing Knowledge or Information Societies need not be constrained by geographic proximity. Current technologies enable sharing, archiving, processing and retrieving knowledge. Providing timely and reliable Information Sharing during crises is critical to improving response, maximizing resources, and minimizing human suffering. The ability to work well with others is a requirement for virtually every job, but this skill is crucial in the

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hectic and demanding healthcare work environment. Thus the responsibility for Information Exchange does not rest upon computers, but, rather, upon the people who use them. So we may highlight three corner-stone incentives of Information Sharing: Psychological, Technological and Economical ones (Figure 1). 1.2. What Impedes Knowledge Sharing Even for Those Who Want to Cooperate? •

•

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•

Diverse sources have concluded that the greatest impediment to the sharing of information is our personal and shared culture [3], i.e. psychology. Cooperation is complex, and communication can be problematic even when sharing information among people who know each other well. As with everything, too much of a good thing can be a problem. In the case of cooperation, as psychologists point out, too much can lead to “group-think”, “yes-man syndrome”, or inappropriate conformity [4]. We often operate within occupational silos (e.g., a Discipline, Business, or Agency) with little transdisciplinary work. Within-silo cooperation and information sharing (px2px) might be comforting, expected, or even mandatory for the actors. Thus even effective and efficient within-silo cooperation does not automatically lead to tight cross-silo (X-Y) interactions (px2py). Barriers occur when conditions are not favorable for actors to convene and get to know one another. These conditions can be: moral, political, financial, legislative, organizational, technical, didactic, psychological, physical and geographical. Fortunately technologies exist today that enable effective and efficient information sharing in spite of such unfavorable conditions. Information is essential for the functioning of every social system, but especially with professionals in knowledge-intensive organizations. Since individuals rarely if ever possess all of the work-related knowledge that they require, they turn to others in search of that knowledge. To measure Return of Information Sharing Investments, and to make the case for further such investments, most entities have relied on qualitative assessments, as valid quantitative methods are lacking.

2. Information Sharing in Counteraction to Biological Threats Preparedness for pandemics is essential for all nations and presents a major challenge to public health systems and health care providers. The fundamental issues are: preparedness and prevention, detection and surveillance, diagnosis and characterization of a biological agent, response, and communication. These issues elevate the priorities of solidarity and a common response based on jointly defined norms. A global fight against a biological agent requires efforts in many areas, including strengthened border controls, better coordination among numerous government agencies at the local, national and international levels. It requires integrated plans, training, and drills, to ensure core competency in public health preparedness. Security and legal issues associated with creating, collecting, storing, processing, analyzing and sharing data are key responsibilities of local, state, federal and international entities, including individuals, governments and societies, who are engaged globally in counteracting biological threats.

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2.1. Model of Cross-Boundary Information Sharing: Interdisciplinary, International, and Inter-Level Ideally, critical information and communication systems would allow timely and accurate sharing of information horizontally and vertically, without barriers. Horizontal sharing takes place between organizations at the same level, such as between research institutes or rescue teams. Vertical sharing takes place between entities at different levels, such as between different tiers inside an organization or government, or between national research institutes and local emergency divisions. Experts noted the problems of building networks with two-way flows of information and it is not a question of horizontal information sharing: practice need better vertical-inter-level (or inter-tire) information sharing [5]. An assumption in transdisciplinary, cross-level and international cooperation is significant heterogeneity of the actors. In this study a qualitative review was conducted leading to a critical finding. The current scope is based mainly on national, discipline and tier traditional limitations for cooperation and information sharing. Even the global financial crisis of 2008–2009 might be explained in terms of divergent interests of the parties and lack of deep collaboration and information sharing. We declare the critical need to identify and implement greater homogeneity across actors and institutions in order to establish effective and efficient counteracting environment. Such increased homogeneity might be reached through applying modern technological, economical and psychological tools. Even Linguistics have accepted psychological needs and directed its efforts to define diverse terms that denote cross-boarder information exchange for different fields. We found the semantic shift from multi- to inter- and now to cross- and transdisciplinary activity that in some ways reflect the tasks of modern societies (Figure 2).

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2.2. Science Breaks through Boundaries and is not Limited by Borders Contrary to practice, science has always annihilated national borders and continental boundaries, as the laws of Nature are the same throughout the Universe. Advances of science and its understanding have no ownership: for example, the rules of arithmetic, or the laws of quantum physics, belong to nobody and everybody. Curiosity plus striving for survival have advanced civilization since it began. The desire to understand our Universe and the forces that operate upon it is common to all races. Given the universality and openness of science, particularly basic science, it is natural that scientific research be carried out in international collaborations, not limited by borders or cultures.

3. Good Examples of Cooperation and Information Sharing to Solve Common Problems 3.1. CERN The European Organization for Nuclear Research (CERN) is the world's largest particle physics laboratory. Established in 1954, it is situated in the northwest suburbs of Geneva on the Franco-Swiss border. The organization has twenty European member states, and it is currently the workplace of thousands of employees, representing 500 universities and 80 nationalities. Recently, CERN inaugurated the Large Hadron

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Collider (LHC), the world’s largest and most complex scientific instrument [6]. With regard to information sharing, one should note that the World Wide Web began as a CERN project. It was based on the concept of hypertext, the project was aimed at facilitating information sharing among researchers. Professor Gago, Minister of Science and Technology of Portugal, highlighted the importance of CERN as a model for scientific cooperation that has achieved a unique success in attracting to Europe scientists and resources from the world at large [7]. 3.2. ISE, USA In response to 9/11, the Intelligence Reform and Terrorism Prevention Act of 2004, Section 1016 called for the creation of an Information Sharing Environment and defined it as “an approach that facilitates the sharing of terrorism information”. The Implementation Plan for the Information Sharing Environment sets forth the following vision: “A trusted partnership among all levels of government in the United States, the private sector, and our foreign partners, in order to detect, prevent, disrupt, preempt, and mitigate the effects of terrorism against the territory, people, and interests of the United States by the effective and efficient sharing of terrorism and homeland security information”. It was emphasized that the ISE is not about building a massive new information system. Rather, its intent is to align and leverage existing information sharing policies, business processes, technologies, systems, and promote a culture of information sharing through increased collaboration [8].

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3.3. NIEM, USA The National Information Exchange Model, NIEM [9], is a partnership of the U.S. Department of Justice and Department of Homeland Security. It is designed to develop, disseminate and support enterprise-wide information exchange standards and processes that can enable jurisdictions to effectively share critical information in emergency situations, as well as to support the day-to-day operations of agencies throughout the nation. 3.4. The National Center for Crisis Control (NCCC), EMERCOM, RF Focused on setting the information environment NCCC [10] has planned to create a specialized automated system. NCCC also supports information interaction with the crisis centers of foreign countries. Organizing of the NCCC was due to the current expansion of the scope of the EMERCOM, RF, and to essential need of transition to new technology and efficiency of interagency cooperation. Based on JIT information from field sites (including photos and video materials), and on rapid prognosis the evaluation of further development of emergency is envisaged to elaborate the pertinent control decisions. Special software modeling scenarios will be prepared to “play” various options for control decisions in high alert and standby emergencies. 3.5. Supercourse Supercourse [11] is a project designed to create a free library of PowerPoint prevention lectures. To date, over 55,000 academic faculty from approximately 174 countries with Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

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over 3,500 available free Power Point Lectures have participated in order to bring Internet-based education into prevention of all forms of diseases and terrorism/bioterrorism. The Supercourse collection of lectures shows that terrorism/bioterrorism has had a long history, demonstrates that bioterrorism has occurred worldwide, and concludes that terrorism/bioterrorism, while it is terrifying, is also rare. The Supercourse asks that we be concerned but not paralyzed with fear, and it encourages us to be ready to fight all forms of terrorism/bioterrorism. 3.6. LEFIS The Legal Framework for the Information Society (LEFIS) Network [12] is an infrastructure to introduce the information and communication technologies in the faculties and schools of law, and to promote the study of regulations and practice codes in the polytechnic centers. LEFIS elaborates policies on law and new technologies coming from discussions originated in the different regions of the European Union and other countries.

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3.7. NATO SPS Programme The aim of the Science for Peace and Security (SPS) Programme is to contribute to security, stability and solidarity among nations by applying the best technical expertise to problem solving. Collaboration, networking and capacity-building are means used to accomplish this end [13]. “Business and Science, working together with Government, can provide solutions to the new problems that face us” according to Prof. Fernando Carvalho Rodrigues, Programme Director, Threats and Challenges Section, NATO Public Diplomacy Division [14]. Civil science has proved to be a highly effective vehicle for international dialogue, due to its universality and dependence upon international networks. Science is both a means of finding answers to critical questions and a way of connecting nations. The Programme provides a paramount forum for the sharing of knowledge and experience on technical, scientific and policy aspects of social and environmental matters in both the civilian and military sectors among NATO and Partner countries.

4. Where should we go from here? The above patterns of experience demonstrate that international collaboration has many benefits, the combination of intellectual forces being even more important than the combination of financial resources. Working together, academics, researchers and patricians (civil and military), trained in accordance with diverse national and discipline-based traditions to look at problems from different perspectives, often come up with new, unexpected ideas and solutions to problems. Furthermore, experienced professionals are enriched by working in multinational and multi-disciplinary environments, and in doing so they become less inhibited by cross-tier barriers. The experience of collaborating in highly motivated, multicultural teams working at the frontiers of knowledge, technology, and education is important. This will also be unique training for the students and young experts who will constitute the majority of actors counteracting future biological, as well many other, threats.

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It makes sense for those who will counteract various chemical, biological, radiological, nuclear, and high yield explosive (CBRNE) threats to use the architecture experience from many that lead in knowledge, technology, and education. Many notable agencies and entities are important to include such as CERN (e.g., an incomparable cooperator with its fantastic project of Large Hadron Collider); ISE, USA (e.g., for strategic strength); NIEM, USA (e.g., for standards, rules and formats); and the practices of EMERCOM, RF. Collaboratively aligned to organize an International Center of Emergency Information Sharing, to support Global AntiTerrorism Information Sharing Infrastructure. The foundation could be built from cooperation with existing programs (e.g., such as the Supercourse, LEFIS, NATO ASIs and ARWs), as well as, enhanced with diverse interested global institutes and individuals, from all sectors, military and civilian. This multinational, multidisciplinary approach will form the starting point. Will this cross a starting threshold, or tipping point? It may depend upon the will of governmental leaders or politicians.

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Economical

Psychological

Technological

Figure 1.

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transcrossdisciplinary disciplinary 1% 12% interdisciplinary 52%

multidisciplinary 35%

Figure 2.

References

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[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14]

D.W. Johnson, R.T. Johnson, M.L. Krotee, The relation between social interdependence and psychological health on the 1980 U.S. Olympic ice hockey team, Journal of Psychology, 120 (1986) 279-291. http://blogs.salon.com/0002007/2005/09/19.html#a1278 http://chronicle.uchicago.edu/070301/commonknowledge.shtml http://www.charleswarner.us/articles/competit.htm http://www.fao.org/rdd/pnetwork_en.asp http://public.web.cern.ch/public http://www.eurekalert.org/pub_releases/2006-07/c-cca071406.php http://www.ise.gov/ http://www.niem.gov/ http://www.ncuks.ru http://www.pitt.edu/~super1/disasters/disasters.htm http://www.lefis.org/ http://www.nato.int/science/index.html http://www.nato.int/science/news/2003/n031111b.htm

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Pandemics and Bioterrorism A. Trufanov et al. (Eds.) IOS Press, 2010 © 2010 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-60750-086-5-23

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Learning from Catastrophe: Lessons for Pandemic Planning a

Elin A. GURSKYa and Sweta R. BATNIb Fellow and Principal Deputy for Biodefense, ANSER/Analytic Services, Inc. b Analyst, ANSER/Analytic Services, Inc.

Abstract. Twenty-first-century natural and deliberate catastrophic health events have demonstrated their potential to strain existing medical and public health systems’ capacities. Changing climates, the emergence of new diseases, globalization, and limited global health governance each has the potential to further challenge the delivery of public health and medical care in the coming decades. World leaders must now prepare for the threat of an influenza pandemic that could disrupt lives, devastate communities, and destroy economies. NATO has extensive experience in planning and conducting multinational operations and is uniquely positioned to guide nations’ pandemic preparedness efforts. From November 30, 2008, to December 8, 2008, the NATO Science for Peace and Security Program sponsored an Advanced Studies Institute in Milan, Italy, to help regional leaders to better prepare for pandemic threats. Over the course of two weeks, 60 participants from almost 20 countries collaborated and shared knowledge and training learned from current pandemic planning efforts. This paper attempts to summarize some of the major critical lessons from past catastrophes – lessons that are intended to inform future NATO pandemic preparedness efforts by member countries.

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Keywords. NATO, pandemic influenza preparedness, planning, response, global health security, public health

Introduction Twenty-first-century challenges to health security have the capacity to strain medical and public health systems and ultimately limit efforts to minimize levels of morbidity and mortality during catastrophes. Evidence of this has already been demonstrated. The 2004 Southeast Asia earthquake and tsunami illustrated the demands placed on medicine and public health to mobilize rapid response and recovery efforts. A December 2004 earthquake at a magnitude between 9.1 and 9.3 [1]1 triggered a tsunami in the Indian Ocean. In its immediate wake, water and sanitation were targeted as the most immediate health risks when water supplies and sanitation facilities were disrupted and contaminated. Fear of diarrheal disease outbreaks – salmonellosis, typhoid, cholera, and hepatitis – in survivor camps was combined with concern over injury-related tetanus and mosquito-borne diseases. Additional concerns included measles and other vaccine-preventable diseases, childhood injuries and trauma, adult injury, and mental health issues [2, 3]. Much of the health care facilities’ infrastructure 1

The Richter magnitude scale is used to quantify the amount of seismic energy released by an earthquake.

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was badly damaged, and almost 700 of the 9,800 health care workers in the region were reported dead or missing. The region was ill equipped to deal with mass casualties for an event that ultimately would claim the lives of 229,866 persons across 11 countries. The 2003 spread of severe acute respiratory syndrome (SARS) from Guangdong Province, China, caused global economic losses estimated at $54 billion (U.S.) in foreign trade, travel, tourism, and health care to affected countries [4]. SARS, a highly infectious, rapidly progressive viral respiratory illness, was first reported in Asia in February 2003. Over the course of a few months, SARS spread to more than two dozen countries in North America, South America, Europe, and Asia, infecting 8,098 people, 774 of whom died as a result of infection [5]. The health care environment itself became a crucial vector in the early spread of infection in both Toronto and Taiwan, as hospitals were responsible for initiating and maintaining outbreaks of SARS [6]. The SARS outbreak pushed Toronto’s health care system to its limits as staffing shortages, hospital-based infection control, and the influx of critically ill SARS patients challenged critical care services [7]. Nosocomial precautions exceeded public health officials’ expectations and were both resourceintensive and difficult to sustain over long periods: large numbers of health care workers were required to wear gowns, gloves, N95 or higher respirators, and eye protection for hours [6]. When possible, isolation or negative-pressure rooms were reserved for SARS patients. Alternative approaches included grouping SARS patients in private rooms on dedicated wards with modified ventilation systems and using plastic sheeting and taped barriers to restrict access and airflow from the rest of the hospital [6]. Successful containment of the epidemic required close collaboration with the World Health Organization (WHO), international partners, and over 800 medical officers, epidemiologists, and other specialists from the U.S. Centers for Disease Control and Prevention (CDC) [5]. The 2001 anthrax attacks in the United States were the result of the deliberate dissemination of Bacillus anthracis through letters in the U.S. mail. Twenty-two individuals were infected: 11 inhalational infections and another 11 cutaneous. There were five deaths [8]. Though the 2001 anthrax attacks were relatively small in scale, their impact on American society was far-reaching. Parts of the federal government and U.S. postal operations were shuttered. Billions of dollars were expended for cleanup and decontamination [9]. To address the crisis, more than 1,000 physicians, epidemiologists, public health officials, and medical practitioners were mobilized to investigate cases, trace contacts, evaluate exposure levels by screening and history, assist with clinical patient evaluations, provide counseling, and carry out environmental sampling [9]. Federal, state, and local public health authorities quickly advised those who might have been exposed to tainted letters or workplaces to take oral postexposure prophylactic antibiotics for up to 60 days. More than 10,000 people were advised to follow this course due to known or potential risk for inhalational anthrax. More than 20,000 others started treatment until the investigation determined that exposure was unlikely and treatment unnecessary [10]. Furthermore, thousands more were victims of hoaxes or false alarms, and still more were worried coworkers, friends, and family members of those directly affected. The impact was not limited to the United States. Hoaxes involving threatening letters or envelopes containing powder were reported from other countries. Cross-contaminated mail with B. anthracis was distributed to some U.S. embassies, and persons in remote corners of the world were advised to take prophylactic antimicrobial treatment. Over 121,700 specimens were tested for B. anthracis by the Laboratory Response Network.

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The large-scale death, destruction, and population displacement caused by Category 4 Hurricanes Katrina and Rita on the U.S. Gulf Coast in August 2005 demonstrated the speed with which the U.S. medical and public health systems can be overwhelmed. Coupled with the displacement and loss of medical personnel, the vacuum in health care almost eliminated all acute, primary, and tertiary medical services in the period immediately after the hurricane hit land. The New Orleans hospital system was devastated by Katrina: One year after the event, 80% of the hospitals’ pre-Katrina bed capacity remained lost. More than 1,600 people were killed [11]. The storm affected more than 2.5 million households, left more than 500,000 homeless, and forced the unprecedented displacement of an entire metropolitan area [12]. Extensive physical damage to the medical infrastructure severely limited access to hospitals and their emergency departments, private clinics, public community health centers, dental and mental health clinics, pharmacies, and many other health-related facilities. The medical facility at the Houston Astrodome – Reliant Complex Center, known as the Katrina Clinic, was established to provide patient care for the waves of evacuees and populations that sought shelter within the complex. After days without adequate food, water, or rest, many of the 27,000 Katrina evacuees arrived at the Houston Astrodome/Reliant Complex Center dehydrated, delirious, and in need of medical management for their chronic medical and psychiatric conditions. The public health concerns following Katrina’s devastation included sanitation and hygiene, water safety, infection control, surveillance, immunizations, environmental health, and access to care. Also of concern were the risk of communicable disease spread and the presence of vast stands of stagnant water, suggesting the potential for vector-borne diseases, particularly viral encephalitis [13]. Treatment of chronic conditions among the displaced, already complicated by a legacy of limited health care access and limited medication reserves, was more difficult in Katrina’s wake [13, 14]. From September 1 to 19, 11,245 patients visited the clinic, 16,622 prescriptions were written, 382 X-rays and 155 ultrasounds were ordered, and 6,318 vaccines were administered [13–15]. Since it was first detected in Hong Kong in 1997, H5N1 influenza virus has rapidly evolved, spreading to 67 countries and resulting in the culling or killing of over 200 million birds. Despite the implementation of strict biosecurity measures, the virus remains circulating in flocks throughout Asia, Africa, and Europe [16]. Though the H5N1 virus has not risen to the level of instigating efficient and sustained human-tohuman transmission2, as a zoonotic disease it has infected 411 humans and has caused 256 deaths since 2003. Its high pathogenicity has contributed to a 62% case fatality rate [17]. Regional efforts to contain further spread are under way. For example, the Indonesian Ministry of Health formulated an avian flu strategy that focused on research and information dissemination, active surveillance and protection of high-risk groups, and patient management (such as preparing a wide range of referral hospitals). Many East Asian governments have attempted to increase access to antiviral drugs and safety equipment, but insufficient stockpiles and poor interagency collaboration continue to 2 Isolated clusters of person-to-person transmission of H5N1 among family members had been detected in Southeast Asia from January 2004 through July 2005, according to the World Health Organization. Humanto-human transmission of H5N1 was first suspected in Thailand in 2004. Upon investigation, it was concluded that the disease in a mother and aunt probably resulted from person-to-person transmission of avian influenza. Similarly, three separate Indonesian clusters were detected in 2005. In all three, cases were detected among family members who had had close contact to the index case. Despite these clusters, the evidence still justifies the characterization of the current global phase of a pandemic at Phase 3: No or very limited human-to-human transmission.

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limit the effectiveness of such measures [18]. Currently, a regional Association of Southeast Asian Nations stockpile of antivirals has been established in Singapore with support from the Government of Japan [19]. WHO continues to monitor preparedness via tabletop exercises in the Lao People’s Democratic Republic, the Philippines, and Cambodia to test rapid response and containment strategies. Mobilization of in-country resources and medicine stockpiles has been the primary focal point of these simulations [20]. In cooperation with WHO and the U.S. Centers for Disease Control and Prevention (CDC), the most significant public health impacts of avian influenza have been the increase of disease surveillance and the development of techniques for agricultural reform to combat H5N1 spread in Asian nations [21]. Besides the overwhelming events that have captured media and political attention, over the past five years WHO has confirmed more than 1,100 epidemic events worldwide [22]. Outbreaks of multidrug-resistant tuberculosis, Ebola viral hemorrhagic fever, West Nile virus, foot-and-mouth disease, and mad cow disease in recent years have also disrupted global commerce, trade, and tourism; led to the use of embargos and bans on the imports of goods; contributed to large economic losses; strained diplomatic relations; and caused widespread public anxiety. Deliberate bioattacks or the use of biological weapons similarly have the potential to cause large-scale casualties, halt national medical and public health infrastructures, and shatter public confidence in the ability of political leaders and governments to protect populations. These epidemics can also confound medical and public health professionals as the science to develop new therapeutics for treatment of new and emerging diseases often lags far behind their emergence. Characterizing and identifying new and emerging disease outbreaks is a slow and difficult process for the medical and public and health communities. The West Nile virus outbreaks were an example of scientific uncertainty and confusion as public health and medicine worked to piece together the epidemiological puzzle [23]. Dealing with new disease threats may require the development and implementation of new strategies for disease control, diagnosis, and prevention for which the public health and medical sectors may be largely unprepared.

1. Global Health Problems in the Decades Ahead Changing climates and rising global temperatures have altered vector habitats and environments, expanded the geographic range and transmission of many vector-borne diseases [24], and increased the frequency and intensity of natural disasters. Absent a catastrophe, climate changes may further burden health systems by increasing rates of malnutrition, diarrheal diseases and water-borne infections, injury, and overall disease and death rates [24]. New diseases are emerging, in large part because of climate and habitat changes, at an unprecedented rate and are becoming more difficult to treat [22]. In the past 30 years, over 30 new infectious agents have been identified around the world3. Population growth, population movements, rapid urbanization, intensive farming practices, environmental degradation, and the misuse of antibiotics have also contributed to the emergence of new disease threats.

3 Examples of pathogens that have been identified in past 30 years include West Nile, E. coli O157:H7, viral hemorrhagic fevers, HIV, and Staphylococcus aureus [25].

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Accelerated rates of international travel, trade, migration, and commerce provide mechanisms for the global introduction and dissemination of new and emerging pathogens into populations, agricultural commodities, and food supplies. Each year, over 900 million passengers spend close to $600 billion (U.S.) on international travel [26]; by 2020, this number is predicted to increase to over 1.5 billion persons. The global movement of people parallels increases in the global movement of goods. In 2009 alone, the United States is projected to spend close to $81 billion (U.S.) on agricultural imports and approximately $98.5 billion (U.S.) on agricultural exports [27]. Globally, almost 15 million metric tons of meat is exported annually, while corn exports stand at 81.1 million metric tons [28]. Global governance is an additional 21st-century concern. Fundamental governance deficiencies are reflected by a relative absence of or decline in the capacity and will of states and state-based organizations to install an infrastructure that promotes the best interests of their citizens and protects them from diseases of global public health impact. Health crises are not limited by geopolitical borders and have profound impacts on the global community; thus sovereign-state governance is of little use when confronted with pandemic scenarios. Although global health actors such as WHO, the UN, UNICEF, and the United Nations Development Programme have established some legitimacy governing international public health crises, that legitimacy is often contested and constrained by the desire of nations to act as sovereign entities when public health crises emerge [29].

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2. Preparing for Pandemics At a time when infectious diseases are spreading faster than ever [22], global health leaders are preparing for an influenza pandemic that is predicted to be capable of infecting 40% of the world’s population, devastating lives, disrupting communities, and destroying economies [30]. Explosive and deadly outbreaks of influenza have occurred throughout history. In the 20th century alone, three influenza pandemics – the 1918 Spanish flu (H1N1), the 1957-1958 Asian flu (H2N2), and the 1968-1969 Hong Kong flu (H3N2) – reached around the globe and were responsible for large-scale morbidity and mortality worldwide. Of these three, the 1918 Spanish influenza stands out as the single greatest public health tragedy recorded in history. Circling the globe in three waves in 1918 and 1919, this pandemic infected approximately one-third of the world’s population and caused anywhere from 40 to 50 million deaths, killing more people than World War I [31]. Estimates predict that an influenza pandemic of the type that ravaged the globe in 1918-1919 could kill up to 62 million people today –96% of them in developing countries [32]. Additionally, it has been forecast that the economic impact of a severe pandemic on world gross domestic product would cause losses in output of up to $4.4 trillion (U.S.) [33]. It is unknown when or where the next influenza pandemic would take place or which strain would cause it; some scientists and public health experts believe that it could be the highly pathogenic strain of the H5N1 avian influenza virus. This belief stems from observing the virus’s unprecedented ability to cause multicountry simultaneous outbreaks in poultry; its capacity to infect a broad range of species, including pigs, rodents, and tigers; and its pathological similarities to the 1918 H1N1 influenza virus [34, 35].

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Population vulnerability to an H5N1 virus is universal [34]. While the entire world would experience similar levels of viral spread, the pattern of spread is likely to differ in striking ways [34]. The countries most likely to be adversely affected by a pandemic are those with the fewest resources [32]. Preparedness efforts in developing countries are hampered by a lack of funding, public health and medical infrastructure, and resources – the same variables that increase their vulnerability in a pandemic. Out of necessity, the current approach to pandemic planning for the world involves small groups of health officials, influenza scientists, and company executives – the bulk of whom come from industrialized countries [36], which face their own unique and difficult issues in pandemic planning [36].

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3. U.S. Public Health Preparedness Efforts in the New Century The impacts of the anthrax attacks of 2001 and Hurricane Katrina (2005) on U.S. preparedness efforts were profound. These events underscored the limited ability of federal and local health agencies to respond to acts of bioterrorism and naturally occurring disasters, exposed weaknesses in hospital surge capacity and intra- and interagency communications and information-sharing strategies, raised awareness in the federal government of the importance of preparedness in planning for and responding to novel health threats, and ushered in billions of dollars of federal funding to strengthen U.S. public health and medical infrastructures. Many of the lessons learned from the U.S. experience during the anthrax attacks and Hurricane Katrina have guided U.S. pandemic preparedness planning. In response to the growing concern that the H5N1 virus would mutate into a form capable of sustained human-to-human transmission, the federal Homeland Security Council issued planning and guidance documents and authorized billions of dollars in emergency and annual budget funds specific to planning for and responding to an influenza pandemic4. The first of these documents, the National Strategy for Pandemic Influenza (November 2005), outlined the federal government’s approach to pandemic preparedness planning and response and articulated expectations across governmental, nongovernmental, private-sector, and international partners and individual communities5. The U.S. Department of Health and Human Services awarded grants totaling $350 million (U.S.) to state and local governments to begin pandemic planning efforts [37] while agencies and organizations across the federal government and private sector developed and exercised individual pandemic preparedness plans. International pandemic influenza preparedness efforts gained momentum as several other nations announced similar commitments to plan, cooperate, and coordinate on increasing global preparedness for 4 President Bush submitted a request to Congress for a $7.1 billion emergency budget supplement to invest in international health surveillance and containment efforts, medical stockpiles, and the production of emergency supplies of vaccines and antiviral medications. The President’s Budget for fiscal year 2007 included an additional $2.3 billion allowance for implementing the next phase of the pandemic preparedness strategy. 5 The National Strategy for Pandemic Influenza is based on three pillars: preparedness and communication, surveillance and detection, and response and containment. The Implementation Plan for the National Strategy for Pandemic Influenza was intended to lay out broad implementation requirements and responsibilities among the appropriate federal agencies and clarify and define expectations for nonfederal entities. The plan includes 324 action items related to these requirements, responsibilities, and expectations. See the White House Implementation Plan for the National Strategy for Pandemic Influenza (May 2006) and the National Strategy for Pandemic Influenza (November 2005).

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a human influenza pandemic. The International Partnership on Avian and Pandemic Influenza was formed to enhance global pandemic preparedness [38, 39]. Despite these gains, critical issues remain unresolved in current U.S. preparedness planning efforts. Analyses have pointed to the lack of clarity in defining specific roles and responsibilities in pandemic preparedness and an absence of consideration of some key issues [37]. A recent assessment of states’ operating plans to combat pandemic influenza found that most states still have major gaps in key preparedness objectives, such as building surge capacity and rapid disease detection, and will continue to face formidable challenges to ensuring continuity of operations with respect to essential public health-oriented missions [40]. Furthermore, the progress made in many areas to better protect the country from disease threats is now at risk due to budget cuts and the economic crisis [41]. Budget cuts of up to 25% in federal support to protect Americans against diseases, disasters, and bioterrorism have already negatively impacted state preparedness efforts [41].

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4. Opportunities for NATO Over the past five decades, NATO has led efforts to foster cooperation, build collaborations, and strengthen consensus decision making to safeguard the freedom of its member countries against potential security threats. NATO has responded to the changing nature of threats by reorienting its capabilities to deal with the dynamic threat environment. In recent years, new NATO missions and concepts of operations have placed increased emphasis on joint military operations and have enhanced the coordination of medical support in peacekeeping, disaster relief, and humanitarian operations [42]. It has also stressed the importance of improving and expanding agreements between member countries for coordination, standardization, and interoperability in the medical field and in improving information exchange relating to organizational, operational, and procedural aspects of military medical services in NATO and Partner Countries [42]. NATO’s role specific to shaping pandemic preparedness efforts across its member countries is evolving. NATO has always placed great emphasis on the protection of civilian populations. Under Article 5 of the NATO Treaty, NATO’s roles in supporting civil emergency planning for Alliance operations are delineated, and NATO civil emergency planning has evolved into a pivotal area for practical engagement and coordination with NATO partners. For example, NATO Advisory Support Teams are designed to assist national authorities and international organizations in preparing for a response to natural and technological disasters. They can also offer expertise to nations to improve their preparedness plans and systems [43]. Such teams could be used to assist nations in their pandemic preparedness planning efforts. In May 2003, NATO sponsored an Advanced Research Workshop, “Strengthening Influenza Pandemic Preparedness Through Civil-Military Co-Operation,” in St. Petersburg, Russia, to discuss innovations in influenza surveillance and control for pandemic influenza. The workshop, hosted by NATO and WHO, with the support of the CDC and the U.S. Department of Defense-Global Emerging Infections System, brought together more than 60 civilian and military representatives from 18 countries to discuss global influenza surveillance and development of influenza pandemic response plans [44]. In January 2008, NATO became the first military agency to sign

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up for the Global Public Health Intelligence Network6, intended to strengthen its public health surveillance capacity [45]. However, while the NATO Military Policy on CivilMilitary Co-Operation addresses various aspects of NATO medical planning and preparedness, it fails to offer specific guidance on how NATO would react to a pandemic emergency [46], suggesting that efforts to improve NATO capabilities in support of pandemic influenza preparedness could be further enhanced. There is consensus among world public health and medical leaders that a pandemic will pose a serious threat to global stability, economy, and security. Responding to this threat necessitates urgent planning and international collaborative efforts within and across countries. From November 30, 2008, to December 8, 2008, the NATO Science for Peace and Security Program sponsored an Advanced Study Institute, “Preparing Regional Leaders with the Knowledge, Training, and Instruments for Information Sharing and Decision Making against Biological Threats and Pandemics”. Over the course of two weeks, 60 participants from almost 20 countries met in Milan, Italy, to learn and share their knowledge and experiences in current pandemic preparedness planning efforts. The following summarizes some of the critical lessons learned from past responses to global catastrophes in order to inform NATO pandemic preparedness efforts by member countries.

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4.1. Lesson One: Build a Competent Global Public Health Workforce The public health workforce is a diverse and largely undefined entity: inter- and intragovernmental variations, training requirements, and enumerating its troops across both the public and private sectors largely prevent accurately tracking the quantity and quality of the global public health workforce [47]. Deficiencies in the overall public health workforce complement reflect the varying levels of investments made globally to improve and maintain the medical and public health sectors. Countries with better human health outcomes tend to have higher levels of economic growth than countries with poor human health indicators. Good health promotes economic growth, as healthy populations have higher levels of human capital attainment and higher rates of workforce productivity, which contribute to higher rates of income. Conversely, high disease burden and lower population health status are both symptoms and determinants of poverty. Impoverished populations tend to live in areas where poor sanitation and infrastructure propagate further disease spread; high disease burden has negative impact on child development, pregnancy, and workforce productivity, all contributing to lower income. As was seen in the United States during Hurricanes Katrina and Rita, people with the lowest levels of health and socioeconomic status are disproportionately affected. Compounding limited health care capacity in poorer countries and their populations’ relatively greater vulnerability to pandemics and other health catastrophes is the shortage of healthcare workers from the brain drain that leeches skilled medicalsector professionals from the nations most in need. Worldwide there are an estimated 6 The Global Public Health Intelligence Network is an international initiative run by the Public Health Agency of Canada. It monitors media and other open-source material continuously for signs of emerging pandemics and other public health disasters. Its analysts monitor broadcast media and the Internet 24 hours a day, collating and translating material in seven languages. It has a broad scope, including tracking outbreaks of infectious diseases in humans and animals; incidents of food and water contamination; bioterrorism and accidental releases of chemical, biological, and radioactive materials; and natural disasters. See http://www. phac-aspc.gc.ca/media/nr-rp/2004/2004_gphin-rmispbk-eng.php.

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59.8 million health workers, with two-thirds providing direct health services and the other third providing management and support [48]. Fifty-seven countries, most in Africa and Asia, face a shortage of over 4 million health workers. This shortage is not simply characterized by the numbers, but is also indicative of inefficient use of the existing health workforce. Unbalanced disbursement frequently leaves rural areas and poverty-stricken nations suffering the most severe shortages, while low-quality training (for example, brain waste) and a lack of competitive salaries in poorer nations drives potential health care workers to leave (for example, brain drain) [48]. Key factors affecting the shortages in both developed and undeveloped nations include inadequate public health funding, uncompetitive salaries and benefits, a looming exodus of retiring workers, an insufficient supply of trained workers, and a lack of interest among students in pursuing public health careers [49]. To prepare for future natural disasters, emerging diseases, and pandemics, it is imperative that we assess the adequacy of the supply and skills of public health workers and devise a foundation of baseline competencies to assure global surge capacity. Should a mass-casualty event occur, a global health workforce must be a fluid body that can adjust to incorporate the numerous occupations that will be called upon to aid the public at large. Too, the level of commitment during high-stress, catastrophic situations must be validated. A 2006 survey of U.S. local public health workers’ perceptions of pandemic influenza response found that nearly half of local health department workers are likely not to report for duty [50].

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4.2. Lesson Two: Integrate Civilian and Military Resources In recent years, the U.S. military has been increasingly called upon to augment civilian capacities and provide logistical and operational support and humanitarian assistance in response to natural catastrophes at home and abroad. During South Asian tsunami relief operations, the U.S. Department of Defense deployed 16,000 military personnel throughout the areas most affected by the tragedy [51]. The U.S. Navy hospital ship Mercy was outfitted with special medical equipment and a robust multi-specialized medical team to support from 250 to 1,000 patients if necessary [51]; U.S. Pacific Command sent a forward command element to Utapao, Thailand, to serve as a regional support center for emergency and medical personnel throughout the region [52]. In response to the massive 7.6-magnitude earthquake that struck northern Pakistan in October 2005, U.S. troops were on the ground within 48 hours to provide aid [53]. The Defense Department response to Hurricane Katrina was the largest, fastest deployment of military forces for a civil-support mission in U.S. history [53]. Roughly 2,000 military medical personnel assisted with rescue and relief efforts, and medical assets set up field hospitals throughout the disaster zone to treat injuries and illnesses [53]. The U.S. Navy hospital ship Comfort treated nearly 1,500 patients on board, and medical staff worked alongside local civilian physicians to treat thousands of trauma patients in the field [53]. Recognizing the important role the U.S. military played in augmenting civilian response capabilities to past catastrophes, President George W. Bush announced that the military might have to assist in the event of an avian influenza outbreak [54]. The U.S. National Implementation Plan identified the U.S. Department of Defense as the lead and supporting agency on a number of action items to improve national preparedness. In response, the Defense Department issued department-wide planning and preparedness directions for an influenza pandemic and has established the Global Pandemic Influenza Working Group to develop the department’s global plan for

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pandemic influenza [55]. In response, each of the department’s nine combatant commands has developed pandemic influenza plans for its area of responsibility; some have tested these planning efforts through participation in pandemic or avian influenzaspecific exercises. For example, in June 2006 more than 100 participants representing partner nations, other federal agencies, and Defense Department and European Command components participated in an exercise, Avian Wind, designed to identify and enhance coordination of actions to plan for, respond to, contain, and mitigate the effects of avian influenza [55]. Additionally, in many regions the military has active surveillance programs that can help detect disease outbreaks. Pandemic influenza would likely also affect the armed forces. Reductions in troop strength and capacity of all armed forces worldwide would significantly impair the military’s readiness in carrying out both its ongoing domestic and overseas operations. During the 1918 pandemic, the virus swiftly spread to U.S. army camps and on troop ships, killing 43,000 military personnel in three months [30]. Another 1 million service members were hospitalized, which limited the military’s ability to continue its ongoing missions [55]. The U.S. War Department was so overwhelmed by influenza that the military was unable to assist in controlling civil disorder at home. Doctors, scientists, and lab technicians had been drafted to military service, leaving civilian operations woefully understaffed [30]. The military has unique capabilities, logistical capacities, resources, and personnel that could be used to augment civilian response during a pandemic. While local commanders are empowered to assist in civilian emergencies for up to 72 hours without special authorization [56], it is unrealistic to assume that military operations will not be impacted during a pandemic. The military faces certain circumstances, such as frequent deployments, many to areas with endemic transmission of H5N1, which may make the military uniquely vulnerable during a pandemic. Effective integration of civilian and military resources will thus be essential to ensuring continuity of operations and mission operational readiness during a pandemic. Civilian and military communities must work together to understand the limitations and expectations of each other, delineate roles and responsibilities, and achieve seamless integration of response efforts during a global epidemic. 4.3. Lesson Three: Improve Risk Communication Pandemics, like hurricanes or other catastrophic natural disasters, are recurring events. Unlike most natural disasters, however, pandemics are not confined to a single occurrence or time. Rather, they have the capacity to sweep the globe in simultaneous waves, devastating lives and disrupting entire communities. Decisions on how to allocate scare resources efficiently across communities for extended periods, how to sustain operations in the event of international disruptions to trade and travel, how to protect communities and mitigate disease spread, and how to honor international commitments for sharing of medical countermeasures and vaccines require leaders to be ready and able to make tough choices under tight time constraints. An influenza pandemic will generate immediate demand for health information from the public, health care providers, policy makers, international partners, and the news media. When health risks are uncertain, as they will likely be during an influenza pandemic, people need accurate and concise information as to the knowns and unknowns of the situation, as well as guidance on how to formulate decisions to protect their health and the health of others [57]. The failure to communicate a clear message

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to the public was one of the greatest problems observed during the anthrax attacks [9]; it caused stress and misunderstanding regarding the concepts of exposure and need for prophylaxis, drained already limited communication resources of public health departments, and incited drug-seeking behaviors in the private medical community. During the anthrax crisis, the public demanded up-to-date information on an ongoing basis throughout the emergency [58] – a demand that was not adequately met and one that will be replicated during future public health events. Additionally, in stressful situations, people have difficulty hearing, understanding, and remembering information [57]. An inadequate supply of information for public consumption compounded by stress-induced confusion can result in widespread panic and poor individual decision making. Addressing the requirements of adequate risk communication in preventing mass panic inevitably entails the recognition of risk communication as a two-way street. Hurricane Katrina provided an example of one-way risk communication: authorities attempted to communicate risks to the populace once the disaster was already under way without significant interest in public feedback. The citizens of New Orleans should have been kept abreast of the full range of emergency preparedness, response options, and evacuation plans prior to the landfall of Hurricane Katrina. Furthermore, the citizenry should have been seen as an integral part of risk communication via utilization of community knowledge to inform preparedness decision making [59]. Quality risk communication is central to quality decision making. Once decisions have been informed through proper two-way risk communication, information must then be shared with other countries and the public at large to efficiently manage scarce resources, ensure coordination of efforts within and across borders, mitigate further risks, and manage public expectations. Risk communication plans should be outlined and communicated in advance of an emergency to ensure quick and effective responses during an emergency. Risk communication messages must be honest, frequently updated, culturally and linguistically appropriate to the population of concern, and presented in a way to maximize understanding. 4.4. Lesson Four: Enhance Community Preparedness (Non-Pharmaceutical Interventions) Many of the non-pharmaceutical interventions that were utilized to successfully contain the SARS epidemic may not be effective against a pandemic that is far more contagious, has a very short incubation period, and can be transmitted prior to the onset of symptoms [34]. During past pandemics, quarantine and isolation were strategies used by the U.S. public health sector. However, these measures were generally found to be ineffective, as they did little to stop contagion [34]. While quarantine may have delayed viral spread, having no impact on reducing population susceptibility, it was not an effective tool for reducing the numbers who would fall ill [34]. Quarantines are very labor-intensive: they require the identification of key partners and personnel to implement movement restrictions; necessitate designation of a workforce to provide essential services and supplies, and demand the mobilization of public health and other community resources [60]. Social distancing strategies such as school closures and cancellation of public gatherings may also be considered as alternatives to quarantine. Yet these also require community diligence to ensure that they are effectively used to prevent further disease transmission.

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The most significant responsibility of a community is to educate its own members about disaster preparedness and help ensure safety in the event of a public health crisis [61]. Community preparedness relies heavily upon relationships across multiple communities: medical, emergency response, legal, citizens, and others. These groups must have strategies for real-time communication sharing, have experience working with one another through practices and exercises, and understand the chain of command during an event so that there is no question of responsibility for leadership. Training programs and drills must be exercised to ensure that supply chains and the provision of essential services such as food and water, shelter, medicines and medical consultations, mental health and psychological support services, other supportive services, and transportation to medical treatment remain operational [60].

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4.5. Lesson Five: Expand Biosurveillance, Detection, and Information-Sharing Capabilities International disease surveillance and detection comprise critical early warning strategies. Information collected from biosurveillance systems promotes situational awareness and real-time information sharing to enable the timely detection and response to a pandemic threat. Many efforts to bolster disease surveillance and detection of pandemic-related threats in humans and animals are under way. The U.S. Department of Defense, the U.S. Agency for International Development, and the CDC each received government funding to improve surveillance capacities for H5N1. Through expanding programs such as the Department of Defense-Global Emerging Infections Surveillance and Response System and the Global Avian Influenza Network for Surveillance, the United States has attempted to optimize its disease surveillance and monitoring networks in order to detect outbreaks before infection emerges in humans [62]. Additionally, the U.S. Department of Agriculture has developed several surveillance programs for testing samples in birds and poultry, and the National Avian Influenza Surveillance System links existing avian influenza surveillance data from the Department of Agriculture, industry, and other federal and state agencies [62]. Internationally, WHO, in coordination with its member states, tracks and monitors avian influenza through its Global Influenza Surveillance Network [63]. Similarly, regional efforts such as the European Influenza Surveillance Scheme collect and exchange timely information on influenza activity among European Union member states and partners7. However, efforts to improve domestic and international surveillance capacity could be improved. Many state health departments’ initiatives to enhance disease reporting remain incomplete, and the absence of national standards and interoperability hinders the information collection and data sharing necessary for outbreak detection [62]. Global surveillance of highly pathogenic avian influenza among domestic animals has serious shortfalls; only 75% of countries report having a surveillance system that is operational and capable of detecting it [62]. International cooperation and collaboration should be expanded to strengthen influenza surveillance reporting and control capabilities.

7 The European Influenza Surveillance Scheme collects and exchanges timely information on influenza activity from 26 European Union member states, plus Norway, Serbia, Switzerland, and the Ukraine. See http://www.eiss.org/.

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4.6. Lesson Six: Ensure International Cooperation Detecting and responding to a widespread influenza outbreak well prior to a pandemic result will require global cooperation and multilateral participation. During the 2004 Southeast Asia earthquake and tsunami, various organizations deployed health care workers to the hardest-hit nations: 116 to Indonesia, 129 to Sri Lanka, 77 to Thailand, and 54 to the Maldives. Germany, Australia, and the Red Cross set up stationary field hospitals, and around 130 foreign relief organizations arrived in the region within two weeks of the disaster to organize mobile field hospitals, deploy emergency healthcare staff, procure and distribute medical supplies, and establish vaccine and cold-chain systems [64]. The assistance was welcomed; the coordination was challenging. When confronted with the public health impact of the tsunami, most of which can be attributed to the crowded nature of camps for displaced persons, the logistics of aid coordination presented the greatest obstacle [65]. Ministries of health of the affected countries, UNICEF, the International Federation of Red Cross and Red Crescent Societies, the U.S. Agency for International Development, the Substance Abuse and Mental Health Services Administration, the U.S. Department of Health and Human Services, U.S. Pacific Command, the U.S. State Department, the CDC, the U.S. Defense Department, WHO8, and several other health actors had to be coordinated and dispatched to regions requiring assistance, and medical supplies9 had to be funneled to affected areas efficiently and promptly. This effort was mainly led by WHO; however, the CDC also contributed to coordination efforts. Health care provision requires the efficient coordination of financial resources, human resources, and medical supplies, as well as proficient delivery of those services. Good governance is essential to the formation of a system that can appropriately mobilize and distribute resources and adapt to emerging health threats, while implementing strict regulations is essential to articulating principles under which these new global health systems can be governed. International health law thus constitutes a core component of global communicable disease architecture [66]. The International Health Regulations (2005) are one such international legal instrument that binds 194 countries, including all member states of WHO, to work together to uphold a set of obligations that promote global public health security [67]. Specifically, the 2005 International Health Regulations establish a new set of rules to support existing global outbreak alert and response systems, to improve international surveillance and reporting mechanisms for public health, and to prevent, protect against, control, and respond to the international spread of disease [68]. Accountability, government effectiveness in resource allocation and decision making, and minimization of government corruption are key components of a well-governed society that can adequately respond to public health concerns [69]. Economic disparities present the largest obstacle to globalizing the governing landscape of public health; the poorest nations’ response to public health can be typified by a lack of transparency perpetuated by minimal accountability throughout all levels of government [70]. Growing recognition of health as a global public good facing a global risk has prompted the G8 and UN to increase investment in the health of comparatively 8

The list of aid organizations in the public and private sectors is included in the CDC’s press release “Emergency Preparedness and Response: CDC assists in public health response for tsunami recovery” (January 13, 2005) [3]. 9 Supplies included surgical kits, diarrhea kits, cars, telecommunication equipment, vaccines, and pharmaceuticals. WHO, Three Months After the Indian Ocean Earthquake-Tsunami: Health consequences and WHO’s response (2009) [2].

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poorer nations; however, the gaps in good health governance mechanisms in economically depressed nations continue to jeopardize global health safety [71]. In the construction of a global public health system, partnerships among governments, civil society, the private sector, and international institutions will be necessary to address the challenges in a world increasingly faced with the threats of emerging diseases, catastrophic natural disasters, and deliberate attacks [72]. In fact, response to a global epidemic of a communicable disease – a pandemic – will be labor- and resource-intensive to contain as quickly as possible the ravages of the disease and to mitigate mortality. It will be in each country’s best interest to share personnel and resources, such as vaccines; however, these commitments must be made in advance of a pandemic, and the sharing effort should be practiced and exercised to improve the timeliness and fluidity of the effort10.

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4.7. Lesson Seven: Develop New Medical Countermeasures Currently, the optimal treatment for patients with H5N1 infection is unknown [30]. Common anti-flu drugs used to treat seasonal flu – Tamiflu™, Relenza, and Rimantidine – are the closest available therapeutics against the H5N1 virus. According to initial studies, the H5N1 virus was found to be susceptible to the anti-flu drug oseltamivir phosphate. Manufactured under the brand name Tamiflu by Roche Pharmaceuticals, this drug was given to treat many cases of patients diagnosed with H5N1, and WHO has recommended that all countries stockpile Tamiflu to the best of their ability. Since 2004, Roche has more than doubled production capacity of Tamiflu to meet the needs of government stockpiling programs and has further increased its global manufacturing capacity to levels necessary to make 400 million treatment courses a year [74]. Currently, the U.S. Department of Health and Human Services has stockpiled 40 million treatment courses of Tamiflu, 10 million treatment courses of Relenza, and 2.8 million courses of Rimantidine [75]. Further, 5 million treatment courses (approximately 10 doses per patient) of Tamiflu have been donated to the WHO stockpile [36]. Yet, global supplies of the drug are both limited and uncertain [74]. WHO does not have any plans to dramatically increase the size of its antiviral stockpile [36], and in 2007, despite receiving orders from governments, health agencies, and corporations, Roche announced that it was scaling back production, as Tamiflu supply outweighed demand [74]. In the event of a deadly pandemic, it is doubtful that any one country will be able to meet the demands of its own citizens, let alone ensure that enough treatment courses will be available to resource poor and developing countries. Moreover, on March 2, 2009, the Journal of the American Medical Association published a report indicating that almost 100% of the year’s circulating H1N1 flu strains are immune to Tamiflu [76]. Tamiflu is approved by the Food and Drug Administration for the treatment of uncomplicated influenza in patients one year and older whose flu symptoms have not lasted more than two days, and it is widely recognized as the go-to 10

Indonesia stopped sharing virus samples of H5N1 with WHO because its Minister of Health voiced concerns that the subsequent production of vaccines would not be shared with the developing world. Without samples of Indonesia’s H5N1 viruses, scientists around the globe are at a great disadvantage in developing a possible pandemic vaccine. Indonesia signed a memorandum of understanding in 2007 with U.S. drug manufacturer Baxter Healthcare Corp. to develop an avian influenza (H5N1) vaccine. Under this agreement, Indonesia will provide H5N1 virus samples in exchange for Baxter’s expertise in vaccine production [73].

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antiviral for influenza infections [77]. Although almost 12% of H1N1 isolates were Tamiflu-resistant in the 2007–2008 season, such resistance was not expected to greatly increase, and it was hypothesized that resistance would actually make the virus less dangerous. Unfortunately, those initial beliefs did not pan out, and the resistant strains are equally as virulent as those that remain responsive [78]. This increasing resistance is not the result of overuse of Tamiflu, but of the natural evolution of viruses; thus, such resistance cannot be countered by varying treatment methodology [79]. The CDC’s Epidemic Intelligence Service has been unable to identify the reason Tamiflu-resistant infections are on the rise; however, the very real threat of a flu strain immune to the antiviral could render the massive efforts at stockpiling the drug void. The Biomedical Advance Research and Development Authority states that Tamiflu makes up almost 80% of the federal pandemic flu drug stockpile [75]. Serious discussion is under way to determine whether governments and private entities should invest in alternative antivirals, such as Relenza and Rimantidine, and vastly restructure their stockpiles based on the threat of a Tamiflu-immune flu pandemic [75]. Stockpiled by state, federal, and foreign governments as well as private corporations, Tamiflu had been seen thus far as the linchpin in preparedness against the threat of a flu pandemic [80]. Surveillance of resistance and research must be heightened to assure the utility of Tamiflu until other medical countermeasures for the H5N1 virus are developed.

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5. Closing Thoughts Globally, progress has been achieved in controlling H5N1 and preventing a pandemic. The U.S. government has worked with its international partners to develop an overall global strategy that fits with the U.S. National Strategy for Pandemic Influenza, and international efforts are under way to improve pandemic influenza surveillance and diagnostic capabilities for quick detection of outbreaks. As of April 2008, $2.05 billion (U.S.) had been committed by international agencies, organizations, and donors toward avian and pandemic influenza efforts [62]. Yet the persistence of the virus in parts of Asia, Africa, and Europe serves as a constant reminder that the H5N1 virus remains a global threat that requires close monitoring and strong control efforts [81]. While significant efforts to improve global pandemic preparedness have arisen in many countries, much work remains. National preparedness efforts aimed at increasing domestic surge capacities are exacerbated by the current global economic recession. Severe budget deficits and depreciating currencies have given way to tighter controls and regulations over borrowing, lending, and government spending – each of which will likely impact the availability of adequate funding for pandemic preparedness. As countries struggle to maintain preparedness for their own citizens, it is likely that they will also struggle to uphold their commitments to international preparedness efforts. While it remains the individual responsibility of every nation to ensure adequate preparations at local and national levels, it is the collective responsibility of all nations to ensure global health security. Pandemic preparedness necessitates recurrent advance planning, international cooperation, and multi-sector coordination to ensure an optimal response to what is certain to be an unpredictable, complex, and rapidly evolving public health emergency. NATO is one of the few international organizations with extensive experience in planning and conducting large, complex, rapidly evolving, multinational operations. Under NATO’s leadership and engagement with NATO’s

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political and military authorities, world leaders can understand the lessons learned from past responses to catastrophic health emergencies and can incorporate these key lessons into optimizing current and future pandemic preparedness efforts.

Acknowledgments The authors would like to acknowledge and thank Jean Folsom and Bryan Christensen, Ph.D., who provided research assistance for this paper.

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[18] The Avian Flu Challenge in Southeast Asia: The potential of public-private partnerships, B. Muchhala, ed., Asia Program Special Report No. 133, Woodrow Wilson International Center for Scholars (October 2006). Retrieved from http://www.wilsoncenter.org/topics/pubs/ASIA133.pdf [19] ASEAN [Association of Southeast Asian Nations] Stockpiles Bird Flu Drug in Malaysia (December 12, 2005). Retrieved from http://www.news-medical.net/?id=14950 [20] B. Phommasack, Lao PDR Tests Its Pandemic Preparedness, World Health Organization, Regional Office for the Western Pacific press release (December 6, 2007). Retrieved from http://www.wpro.who. int/media_centre/press_releases/pr_20071207.htm [21] D.C. Arias, Global Public Health Officials Keeping Tabs on Avian Influenza: Asian countries hit hardest by outbreak, American Public Health Association, Nation’s Health 35 (2005). Retrieved from http://www.medscape.com/viewarticle/502016 [22] World Health Organization, The World Health Report 2007 – A Safer Future: Global public health security in the 21st century. Retrieved from http://www.who.int/whr/2007/en/index.html [23] M. Stoto, D. Dausey, L. Davis, K. Leuschner, N. Lurie, S. Myers, S. Olmstead, K. Ricci, M.S. Ridgely, E.M. Sloss, and J. Wasserman, Learning from Experience: The public health response to West Nile virus, SARS, monkeypox, and hepatitis A outbreaks in the United State[s], RAND Technical Report (2005). http://www.rand.org/pubs/technical_reports/TR285/ [24] Intergovernmental Panel on Climate Change, Fourth Assessment Working Group II Report, Climate Change 2007: Impacts, adaptation, and vulnerability. Retrieved from http://www.ipcc.ch/ipccreports/ ar4-wg2.htm [25] J. Koplan, CDC Works in Global Environment, U.S. Medicine (January 2001). Retrieved from http://www.usmedicine.com/article.cfm?articleID=136&issueID=20 [26] U.N. World Tourism Organization. World Tourism Arrivals & Receipts (2002-2007), U.S. Department of Commerce (October 2008). [27] U.S. Department of Agriculture, Foreign Agricultural Service, Fiscal Year 2009 Trade Forecasts for Agricultural Products (December 1, 2008). [28] U.S. Department of Agriculture, Economic Research Service, USDA Agricultural Projections to 2016 (February 2007). Retrieved from http://www.ers.usda.gov/publications/oce071/oce20071fm.pdf [29] C. Huckel, Global Governance Institutions Managing Global Public Health: Opportunities and challenges, citing A. Price-Smith, The Health of Nations, Cambridge, MA, MIT Press (2002). Retrieved from http://www.allacademic.com/meta/p_mla_apa_research_citation/0/9/8/3/2/p98323_ index.html [30] L. Garrett, The Next Pandemic? Foreign Affairs (July/August 2005). [31] J.K. Taubengerger and D.M. Morens, 1918 Influenza: The mother of all pandemics, Emerging Infectious Diseases 12 (January 2006). Retrieved from http://www.cdc.gov/ncidod/EID/vol12no01/ pdfs/05-0979.pdf [32] D. Brown, World Death Toll of a Flu Pandemic Would Be 62 Million, Washington Post (December 22, 2006). Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2006/12/21/AR2006122 101466.html [33] M.T. Osterholm, Unprepared for a Pandemic, Foreign Affairs 86 (March/April 2007). [34] World Health Organization, Avian influenza: Assessing the pandemic threat (January 2005). Retrieved from http://www.who.int/csr/disease/influenza/WHO_CDS_2005_29/en/ [35] L.A. Perrone, J.K. Plowden, A. García-Sastre, J.M. Katz, and T.M. Tumpey, H5N1 and 1918 Pandemic Influenza Virus Infection Results in Early and Excessive Infiltration of Macrophages and Neutrophils in the Lungs of Mice, PloS [Public Library of Science] Pathogens 4 (August 2008). Retrieved from http://www.plospathogens.org/article/info:doi%2F10.1371%2Fjournal.ppat.1000115 [36] D. Fedson, Meeting the Challenge of Influenza Pandemic Preparedness in Developing Countries, Emerging Infectious Diseases 15 (March 2009). Retrieved from http://www.cdc.gov/eid/content/15/3/ 365.htm [37] U.S. Government Accountability Office, Influenza Pandemic: Further efforts are needed to ensure clearer federal leadership roles and an effective national strategy (August 2007). Retrieved from http://www.gao.gov/products/GAO-07-781 [38] World Health Organization, G8 Commitments to Infectious Disease Can Improve Global Health Security (July 17, 2006). Retrieved from http://www.who.int/mediacentre/news/statements/2006/s11/ en/print.html [39] U.S. Agency for International Development, Avian and Pandemic Influenza: Preparedness and response. Retrieved from http://www.usaid.gov/our_work/global_health/home/News/news_items/ avian_influenza.htm [40] Report to the Homeland Security Council: Assessment of States’ Operating Plans to Combat Pandemic Influenza (January 2009). Retrieved from http://www.pandemicflu.gov/plan/states/state_assessment. html

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[41] Trust for America’s Health, Ready or Not? Protecting the public’s health from diseases, disasters, and bioterrorism (December 2008). Retrieved from http://healthyamericans.org/assets/files/bioterror-report 2008.pdf [42] NATO, The Committee of the Chiefs of Military Medical Services in NATO (COMEDS). Retrieved from http://www.nato.int/issues/comeds/index.html [43] NATO/OTAN, Project on Minimum Standards and Non-Binding Guidelines for First Responders Regarding Planning, Training, Procedure and Equipment for Chemical, Biological, Radiological and Nuclear (CBRN) Incidents, Modalities for the Advisory Support Team, NATO Civil Emergency Planning Civil Protection Committee. Retrieved from http://nato-otan.org/docu/cep/cep-cbrn-responsee.pdf [44] DOD-GEISWeb, Strengthening Influenza Pandemic Preparedness through Civil-Military Cooperation: Report of a NATO-WHO workshop. Retrieved from http://www.geis.fhp.osd.mil/GEIS/Surveillance Activities/Influenza/NATOandWHOwrkshp.asp [45] S. Waterman, Analysis: NATO begins pandemic monitoring, United Press International (January 30, 2008). Retrieved from http://www.upi.com/Emerging_Threats/2001/01/30/Analysis_NATO_begins_ pandemic_monitoring [46] E. Gursky and J. Sandrock, Is NATO Ready for an Influenza Pandemic? NATO Review (Winter 2007). Retrieved from http://www.nato.int/docu/review/2007/issue4/english/analysis6.html [47] Public Health Workforce Study, U.S. Department of Health and Human Services, Health Resources & Services Administration, Bureau of Health Professions (January 2005). Retrieved from http://bhpr.hrsa. gov/healthworkforce/reports/publichealth/default.htm [48] World Health Organization, The Global Shortage of Health Workers and Its Impact, Fact Sheet 302 (April 2006). Retrieved from http://www.who.int/mediacentre/factsheets/fs302/en/index.html [49] D.A. Draper, R.E. Hurley, and J. Lauer, Public Health Workforce Shortages Imperil Nation’s Health, Research Brief No. 4, Center for Studying Health System Change (April 16, 2008). Retrieved from http://www.hschange.org/CONTENT/979/ [50] R.D. Balicer, S.B. Omer, D.J. Barnett, and G.S. Everly Jr., Local Public Health Workers’ Perceptions Toward Responding to an Influenza Pandemic, BMC Public Health 6(2006), 99. Retrieved from http://homelandsecurity.tamu.edu/framework/special-issues-hurricane-katrina-1/planning-andresponse/ local-public-health-workers2019-perceptions-toward-responding-to-an-influenzapandemic.html/ [51] USNS Mercy Arrives in 7th Fleet AOR [area of operations] to Aid in Tsunami Relief Efforts (January 2005). http://www.news.navy.mil/search/display.asp?story_id=16647 [52] U.S. Department of Defense news release, U.S. Military Support to Tsunami Relief Efforts (December 28, 2004). Retrieved from http://www.defenselink.mil/releases/release.aspx?releaseid=8090 [53] U.S. Department of Defense Year in Review 2005. Retrieved from http://www.defenselink.mil/home/ features/2006/2005yearinreview/ [54] Bush Proposes Military Fight Bird Flu Pandemic, Melbourne, Australia, Age (October 5, 2005). Retrieved from http://www.theage.com.au/news/world/bush-proposes-military-fight-bird-flupandemic/ 2005/10/05/1128191745626.html [55] U.S. Government Accountability Office, Influenza Pandemic: DOD [Department of Defense] combatant commands’ preparedness efforts could benefit from more clearly defined roles, resources, and risk mitigation, Report to the Committee on Oversight and Government Reform, House of Representatives (June 2007). Retrieved from http://www.gao.gov/highlights/d07696high.pdf [56] S.W. Casscells, U.S. Army Medical Command: Disasters, pandemics, and surprises, Military Medicine (July 2006). [57] V.T. Covello, Risk Communication: Principles, tools, and techniques, Maximizing Access and Quality Initiative (February 25, 2008). Retrieved from http://www.maqweb.org/techbriefs/tb49riskcomn.shtml [58] K.F. Gensheimer, Challenges and Opportunities in Pandemic Influenza Planning: Lessons learned from recent infectious disease preparedness and response efforts, International Congress Series, 1263 (2004), 809-812. [59] American Society of Civil Engineers, Hurricane Katrina: One Year Later – What must we do next? Retrieved from http://www.asce.org/files/pdf/Ch9_WhatMustWeDoNext.pdf [60] Centers for Disease Control, Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2/3 (May 3, 2005). Retrieved from http://www.cdc.gov/ncidod/sars/guidance/index.htm [61] Ready America, Ready.gov, U.S. Department of Homeland Security. Retrieved from http://www.ready. gov/america/index.html [62] U.S. Government Accountability Office, Influenza Pandemic: Sustaining focus on the nation’s planning and preparedness efforts, report to the Chairman, Committee on Homeland Security, House of Representatives (February 26, 2009). Retrieved from http://www.gao.gov/highlights/d09334high.pdf

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[63] World Health Organization, Influenza Virus Tracking System: Interim version launched (January 22, 2008). Retrieved from http://www.who.int/csr/disease/avian_influenza/aivirus_tracking_system/en/ index.html [64] M. Carballo, S. Daita, and M. Hernandez, Impact of the Tsunami on Healthcare Systems, Journal of the Royal Society of Medicine, 98 (2005), 390-395. Retrieved from http://jrsm.rsmjournals.com/cgi/content/ full/98/9/390 [65] M. VanRooyen and J. Leaning, Perspective: After the tsunami-facing the public health challenges, New England Journal of Medicine 352 (February 3, 2005). Retrieved from http://content.nejm.org/cgi/ content/full/352/5/435 [66] O. Aginam, International Law and Communicable Diseases, Bulletin of the World Health Organization (2002). Retrieved from http://www.who.int/bulletin/pdf/2002/bul-12-E-2002/80(12)946-951.pdf [67] World Health Organization, What Are the International Health Regulations? Retrieved from http://www.who.int/features/qa/39/en/index.html [68] World Health Organization, Frequently Asked Questions About the International Health Regulations (2005). Retrieved from http://www.who.int/csr/ihr/howtheywork/faq/en/index.html [69] M. Lewis, Governance and Corruption in Public Health Care Systems, Center for Global Development, Working Paper 78 (January 2006). Retrieved from http://www.cgdev.org/content/publications/detail/ 5967%20 [70] I. Kickbusch and L. Payne, Constructing Global Public Health in the 21st Century, Meeting on Global Health Governance and Accountability, Harvard University, Cambridge, MA (June 2-3, 2004). Retrieved from http://www.ilonakickbusch.com/global-health-governance/GlobalHealth.pdf [71] C.L.R. Bartlett, I. Kickbusch, and D. Coulombier, D4.3: Cultural and governance influence on detection, identification and monitoring of human disease, Foresight Project, Infectious Diseases: preparing for the future, UK Department of Trade and Industry (April 2006). Retrieved from http://www.foresight.gov.uk/Infectious%20Diseases/d4_3.pdf [72] Center for Strategic and International Studies, Global Strategy Institute, Seven Revolutions: Revolution 7 – Governance (2008), Retrieved from http://gsi.csis.org/index.php?option=com_content&task=view& id=32&Itemid=61 [73] Associated Press, WHO: Indonesia Won’t Share Bird Flu Vaccine Research (February 8, 2007). Retrieved from http://www.foxnews.com/story/0,2933,250909,00.html [74] Hoffmann-La Roche Inc., Pandemic Planning Toolkit, Will There Be Adequate Supply? Retrieved from http://www.pandemictoolkit.com/tamiflu-supplyordering/tamiflu-adequatesupply.aspx [75] J. Lite, Widespread Tamiflu Resistance Sparks New Look at Pandemic Flu Drug Stockpile, Scientific American (March 2, 2009). Retrieved from http://www.sciam.com/blog/60-second-science/post.cfm? id=widespread-tamiflu-resistance-spark-2009-03-02 [76] N.J. Dharan, L.V. Gubareva, J.J. Meyer, M. Okomo-Adhiambo, R.C. McClinton, S.A. Marshall, K. St. George, S. Epperson, L. Brammer, A.I. Klimov, J.S. Bresee, A.M. Fry, for the Oseltamivir-Resistance Working Group, Infections With Oseltamivir-Resistant Influenza A(H1N1) Virus in the United States, Journal of the American Medical Association 301 (2009), 1034-1041. Retrieved from http://jama.amaassn.org/cgi/content/full/2009.294 [77] U.S. Food and Drug Administration, Center for Drug Evaluation and Research, Tamiflu (Oseltamivir Phosphate) Information (April 7, 2008). Retrieved from http://www.fda.gov/CDER/Drug/infopage/ tamiflu/default.htm [78] J. Gever, Tamiflu-Resistant H1N1 Flu Virus Prevalence Increasing, MedPageToday (March 2, 2009). Retrieved from http://www.medpagetoday.com/InfectiousDisease/URItheFlu/13072 [79] Resistance to Tamiflu Growing, Forbes (March 2, 2009). Retrieved from http://www.forbes.com/feeds/ hscout/2009/03/02/hscout624591.html [80] M.B. Marcus, U.S. Firms Can Stockpile Tamiflu, USA Today (June 27, 2008). Retrieved from http://www.usatoday.com/money/industries/health/drugs/2008-06-26-Tamiflu_N.htm [81] Food and Agriculture Organization of the United Nations, New Avian Influenza Flare-ups: Virus remains a global threat – disease control strongly improved (January 24, 2008). Retrieved from http://www.fao.org/newsroom/en/news/2008/1000775/index.html

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Governance in Counteracting Natural and Man-Made Disasters: the LEFIS Network as Example Fernando GALINDO1 Philosophy of Law Department, University of Zaragoza, Spain

Abstract. The paper presents the most relevant characteristics, history and activities of the LEFIS network as possible model for the constitution of a network dedicated to counteract natural and man-made disasters. Keywords. Governance, network, web portals, PKI infrastructure

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Introduction The best form to foresee solutions for the disasters is the development of activities that propitiate the cooperation and dialogue: governance, in the daily life: before the emergence of the disasters. An example of these measures is constituted by those that the LEFIS (Legal Framework for the Information Society) Network develops. These activities are put in practice from the end of the ninety. This paper makes a short presentation on the establishment and activities of the LEFIS Network (www.lefis.org) as they can be reference to a possible constitution of another Network in the area of Prevention of Natural and Man disasters. The basic reason of the proposal resides in that the joint preparation of regional leaders with the adequate knowledge, training and instruments for information sharing and decision-making against biological threats and pandemics can be possible only thanks to the promotion of international cooperation and knowledge, basic requirements of governance today [1], made by Networks as LEFIS.

1. Objectives of the LEFIS Network The LEFIS Network (www.lefis.org) is constituted in these moments by 126 institutions, that are located in 44 countries. The countries are in Europe, specially, South America, Russia, USA, China and India. The Network has the name and address of 350 people that are included in its list of distribution of messages. The activities of the Network are guided to propose to governments, administration of justice: judicial power, companies and organizations of the civil society, technical mechanisms, communication infrastructures especially that allow to 1

Corresponding Author: Philosophy of Law Department, Faculty of Law, University of Zaragoza, 5009 Spain; Email: [email protected]. Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

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carry out respectful government initiatives with the governance and justice principles characteristic of the democratic State. This is centered so much in the realization of research and development projects like, the most important thing, in activities of lifelong learning attending to the proposals made by the European reforms of the Higher Education Space in coordination with the named reforms of Bologna. The activities are centered, lately, in the setting in practice of a Virtual Campus, denominated Law & ICT shared virtual campus [2], promoted by the European Union2, in which ten European Universities impart a combined program of learning on the characteristic matters of LEFIS. The studies have validity in the Universities and countries that integrate the campus. The project is open to the participation and inclusion of another Universities, institutions and interested companies, be part or not of the LEFIS Network. The heterogeneity of the initiatives and, for the same reason, the model possibilities of the Network can be best understood if we observe that members of the Virtual Campus are the Universities of Beja (Portugal), Belfast (UK), La Laguna (Spain), La Plata (Argentina), Montevideo (Uruguay), Münster (Germany), Rovaniemi (Finland), Santa Catarina (Brazil), Torun (Poland), Vaasa (Finland), Vilnius (Lithuania) and Zaragoza (Spain). The matters object of formation, to undergraduate, post-graduate degree and permanent formation levels, are those characteristic of Faculties and Schools of Law, Economics, Management, Documentation, Public Administration, Engineering and Polytechnics.

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2. What is LEFIS? LEFIS is a teaching and research Network that uses as communication tool a Web Portal located in a server that lets to certify that only accepted users access to the closed contents of the Web Portal developed by the group. The certificates are provided by the LEFIS informal organization itself. The public part of the Web Portal is focused to offer to every Internet user, in a reliable way, the information about the group activities: given courses, celebrated meetings, integrating research and development groups and another news. Several Web applications have been developed in parallel to the public part of the web page. These applications compose the Intranet, adding more advanced functionalities, related with communication mechanisms that support the work of the LEFIS members. From the beginning of the Web environment development, the design has been made under the idea of building it on a platform that would guarantee reliable and private communication operations, respectful with properties as confidentiality, identity, integrity, authenticity, basically. With this purpose the research and development team implement a Public Key Infrastructure (PKI) integrated with the necessities covered by the Intranet, guaranteeing this way the referred communication properties.

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This research is supported by the European Union, Lifelong Learning Programme 2007–2013, ref.: 133837-LLP-1-2007-1-ES-ERASMUS-EVC. Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

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F. Galindo / Governance in Counteracting Natural and Man-Made Disasters

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2.1. Comparison The idea of the LEFIS Web portal is not original and new. The references are several world initiatives directed to elaborate Web Portals that like to give access to all the people to all offices of the public Administrations in a country. Looking at Europe, we can see that every country has usually this kind of web sites. This is the situation, for example, in United Kingdom [3], Germany [4], France [5], Italy [6], Spain [7] or Austria [8]. The idea is, basically, to provide “one window” for every citizen to have access to all the Administrations of every country. The objective seems very ambitious and of difficult fulfillment: the truth is that every public Administration has different kind of functions in relation with every citizen. This requires dedicated resources and, of course, adequate technical solutions for every citizen. It also requires the establishment of the correspondent and adequate communication between every citizen and every Administration. In other words, it is important to know the user community and the relation of this community with the functions of every institution to design adequate portals and to give access to every public Administration. This is the only solution to a correct use of the portals; in another case, these will have scarce utility or will guide until no answer to many questions that users made to the portal: this is the situation that can be observed in the practice of every of the above mentioned portal. The portals of the public Administrations are supposed to solve the problems by different resources. It is usual, for example, to elaborate different versions of the portal in relation with the different kind of users: a design for citizens, another for industries or firms and another for public servants. The portals are also presented in different languages. These are first steps to solve the problems, of course. Anyway, the basic idea related with the presentation of an only portal for all the citizens of a country continues having the difficulty to be respectful with the different interests, needs and obligations of citizens and public Administrations. An interesting solution is has been made in the USA from several years. The solution is making only one portal of the public Administrations for citizens [9] and a common organization to build and develop this kind of portal attending to all possible requirements [10]. There is also a regulation on e-government directed to solve this problems that are related with putting into practice all the strategies referred to the implementation of e-government [11]. The problem of the solution for every European government is that they have not yet enough resources to implement this kind of policy. The resources in a country are limited and they must be assigned to many another objectives. The European Union develops initiatives to solve the problem establishing a joint initiative on the state of the art as Fact Sheets of each country [12], for example. As we have said before, an attempt to propose an experience and present a small solution to the referred problems is made by the group of partners working in LEFIS, by the construction of the thematic network dedicated to the teaching and research and development in the area of e government 3. The next paragraphs state explicitly the LEFIS proposals in relation with the elaboration of a web portal for the uses of the LEFIS community. The activities to fulfill this objective can be a good example for the design of similar portals for a Network in the area of Prevention of Natural and 3 See on the teaching objectives: Fernando Galindo “The LEFIS Network”, in Roland Traunmüller (Ed.), Electronic Government: Third International Conference, EGOV 2004, Zaragoza, Spain, August 30September 3, 2004, Proceedings (2004), 436-442.

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Man disasters and, of course, for the big portals for the public Administrations also having as specific reference the communication problems between every citizen and every public institution4. This paper is divided to this effect in several parts specified in the next paragraph. The next section (2) describes the principal characteristics and objectives of the LEFIS network. The third section explains the technological steps taken to build a portal with the different functions that the LEFIS community requires to use it. The fourth section establishes the basic technical requirements that the different programmes fulfil. The fifth section put forward the conclusion, setting the possibilities to use the LEFIS methodology as a specific reference for the development of another portal for the governance of another communities. 2.2. The LEFIS Network as a “Real” Virtual Community

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2.2.1. Rationale The advent of the knowledge society has deeply affected the cultural, political and social structures of our world. The technological, interconnected and decentralized character of this society constitutes a challenge to traditional legal paradigms, in particular as concerns the policy and regulation models we are moving towards. Legislative bodies and public agencies fail in establishing cross-national and even worldwide regulative tools ensure citizen’s basic rights, trust and security in electronic contexts, and appear to be incapable to cope with the fact that private self-regulation and regulation-by-technology approaches prove more efficient when legitimated political intervention is waived. Models of good governance are therefore needed which bring these diverging drives together. The new social and legal environment requires not only adequate regulative, political and theoretical responses but also specific teaching and learning methodologies which enable jurists and civil servants to deal with it. As legal experts are not the only actors steering the knowledge society, there is also an increasing need for appropriate educational models for non-legal professions dealing with ICT (e.g. technicians), as well as for training teaching staff which must be familiar with the European legal and technical ICT regulation. The underlying idea is that a shift is necessary from the teaching of IT law in legal faculties to the teaching of the Information Society Law (IS Law) in all institutions concerned, covering both legal and non-legal aspects of the knowledge society in a multidisciplinary approach. This shift must further cohere with the requirements of the European High Education Space and so be adapted to the societal needs and expectations (Tuning methodology). Neither those societal changes nor the corresponding legal, political and educational needs were unforeseeable a couple of years ago. A number of research projects and initiatives have been developed across Europe to explore the ongoing development of modern IT-based societies. Yet, they remain in a sense isolated initiatives, inasmuch as there is little contact and knowledge-transfer among them. Having regard to the tight intertwinement of theoretical, political, legal, technical and educational aspects of the knowledge society, there is actually a certain lack of coordinated and integrative initiatives. 4 See several realistic proposals to e Government according to the mix between legal and computer aspects in: Electronic Government, Special Issue, in International Review of Law Computer & Technology 18(1) (2004).

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In order to surmount this problem, it was desirable to promote a strong, consistent and comprehensive legal framework for the information society in which both educational and policy aspects of the ICT regulation flow together. This idea underlied the initial LEFIS-TN experience from 2003/04 until 2007, which under several EU and national support has emerged as a solid teaching and research infrastructure on IT & IS Law. Conclusions drawn there of point that the continuity and progress of this approach necessitates further work on its social and institutional impact, feasibility and acceptance5. It is no doubt that such an infrastructure requires a highly qualified and experienced group of participants. In this regard, the LEFIS-TN has taken advantage from several previous EU-granted projects and initiatives with like-minded, albeit narrower scope. 2.2.2. Background Three milestones may be underlined in this regard. First, LEFIS activities can be traced back to 1999, when nineteen universities from ten European countries joint together under coordination of the University of Zaragoza in order to develop and implement high-quality teaching models for both postgraduates and graduate courses on IT Law. This initiative was promoted by the SOCRATES/ERASMUS Programme, in particular through CDA, PROG and DISS actions. Secondly, the EULISP consortium [13] groups together eleven Universities from nine European countries and currently offers both postgraduate and undergraduate study programmes. Thirdly, in an attempt to bring together the academic, the industrial and institutional perspectives, the LEFIS Thematic Network has taken these efforts to a new level and has significantly extended the dissemination activities [see www. lefis.org]. It is worth high-lighting that these activities stretch worldwide through EU ALFA or TEMPUS programmes.

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2.2.3. Organisation The LEFIS-TN targets the teaching on the governance of the information and knowledge society (IS Law) which may be distributed into three major teaching areas: • • •

Teaching area 1 - Law and policy Teaching area 2 - Business and management Teaching area 3 - Informatics and telecommunications

From the thematic and research point of view, the working concept of IS Law addresses the legal and governance framework of the knowledge society, which covers topics formerly belonging to IT law as well as their related social, economical, and policy issues. In its turn, this legal framework may be split into three major thematic areas: • • •

Thematic area 1 - Telecommunications Governance Thematic area 2 - Legal and Policy Principles for Key Technical Issues Thematic area 3 - Ethics, Rights & Control

5 See summary of the LEFIS Final Report at: http://www.lefis.org/images/documents/management/ Progress_and_final_reports/lefis/memory.pdf.

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From an organizational and operative point of view, the LEFIS TN activities were conducted by five Working Groups, with the following denomination/field of work : • • • • •

Work Group 1 (WG1).- Graduate studies Work Group 2 (WG2).- Postgraduate studies Work Group 3 (WG3).- Continuous education Work Group 4 (WG4).- Public-Private relations Work Group 5 (WG5).- Quality

It has a consequence that the LEFIS (Legal Framework for the Information Society) be a network composed of one hundred twenty six public or private teaching institutions and companies. The network members come from every European Union members and applicant countries, as well as from United States of America, Russia, Argentina, Cuba, Chile and Uruguay. The number of participating people is about three hundred and fifty. 2.2.4. Objectives The LEFIS Thematic Network pursues from the begin to develop, implement and consolidate a cross-national teaching and research infrastructure which adequately responds to the needs and problems raised by the information and knowledge society. This overall goal may be split into three interwoven objectives, namely: •

•

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•

The design and development of coherent, common training and study programmes, providing for a teaching offer in IS Law and Governance (covering Law, ICT Law and related issues) which effectively matches the social needs and expectations according with the EU high education initiatives and the Tuning methodology. The development of a certification and implementation system, which assures the quality, consolidation, exploitation and dissemination of those programmes. The consolidation of a research and policy-making infrastructure capable of carrying out legal, economic and social studies and regulative proposals on ICT, ICT Law and the governance of the information and knowledge society.

These major objectives give to the LEFIS-TN an outstanding strategic dimension. In particular, its potential impact regards the following aspects: • • •

•

The development of modules in IS Governance for law, business, informatics and engineering students will have lasting impact inasmuch as they can be integrated into the standard training and teaching system. The extension of education and training in IS Law and Governance to professionals, stakeholders and actors involved in the governance of the knowledge society both on the public administration and in the private sector. The certification and implementation infrastructure will foster the systematic dissemination and extension of the best practices developed by LEFIS, as well as of the new materials and outcomes, to other universities and research centres outside the TN. The diffusion of good governance principles and practice both in European and non-European countries associated or connected with the LEFIS-TN.

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F. Galindo / Governance in Counteracting Natural and Man-Made Disasters

All in all, the dissemination work, diffusion and consolidation of the project outputs, shall warrant the creation and spreading of integrated knowledge which reflect into several paramount spheres for the development of the forthcoming society, such as the theoretical framework for e-governance, the increased human capacity in terms of lawyers with strong skills in the ICT legal issues and of better prepared civil servants and technicians work-force. This last impact will be mainly achieved through two conduits: on the one hand, ICT law trained lawyers who join the public administration and, on the other, special ICT law courses for professionals, public managers and experts. The project results thus will rein-force the EU education policies and initiatives and will enrich it with additional knowledge on the legal implications of the knowledge society. Moreover a common understanding will allow for a further integration of the processes, which in turn will result in more consistent European high education space. 2.3. The Need as Infrastructure of a Virtual Network From the beginning of the construction of the LEFIS network, it was observed that its putting into practice without the use, as infrastructure, of the possibilities that offer the different information and communication techniques was not possible. The followed steps were the initial development of a Web page, next the establishment of an Intranet, later the development of other procedures of communication and finally, so far, the establishment of a public key infrastructure that allows to use all the common resources at the same time that it guarantees the identification of emitters and receivers of information and system administrators.

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2.3.1. Web Site One of the initial activities was the development of a common Web site collecting information about the partners, the educational activities assumed by them, realized meetings and workshops, documentation generated in the meetings, joint activities developed by the network members (especially projects of research and development) and news. Given the heterogeneity of the participants in the network, the starting point was the design and implementation of the Web page, elaborating quickly a procedure that allows loading information in the own languages of each partner, maintaining a common information in English. The fact is that English is the dominant language until today. 2.3.2. Intranet From the beginning of the Web site development, the necessity of an Intranet for limited access to the network members was stated. A database was placed in the Intranet containing contact information on the partners and documents like requests or reports on stays or developments of the different projects, which were not considered to be open to the knowledge of any Internet user. The technical solution to build the Intranet was the establishment of a username and password that, integrated by words easy to remember, allowed acceding to this information to the LEFIS members.

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2.3.3. Communication The communication between the network members has been made by means of messages sent by electronic mail using a list of distribution of these messages. The list is moderated by the network coordination. 2.3.4. PKI An authority of public key certification (PKI) has been developed and proofed. The certification authority, denominated APTICE LEFIS (APTICE is a non governmental association integrated by individuals, public companies and organizations dedicated to the promotion of the electronic commerce and government) certifies the Web server, and emit certificates of public key to the members of the network. The certificates allow to the LEFIS members to access to the Intranet, with no need to use username and password, granting determined privileges to each one of the users, taking care of to their profile (administrator of the system, coordinator of the network, user, member of the Directive Committee of LEFIS, member of workgroup, etc.) and will allow to use certificated electronic mail or electronic signed shipment of messages and texts. There are certification policies of the PKI in coherent format with the norms that regulate PKIs and the use of electronic signature in the own countries of the LEFIS members.

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3. Possibilities of the LEFIS Methodology The steps followed in the LEFIS methodology go in a different way that the steps adopted by the Governments in relation with the “one window” or portal for all public Administrations in every country. The LEFIS methodology proposes to go from small and delimited problems, enough precise functionally and socially, to the computer solutions. The most important experienced steps are. • • • • •

the precise study of the problem and the social requirements the adoption of adequate technical resources for every need in the adequate moment the design of the prototypes attending to the security requirements the find of consent between the participants in the experience last but not least, the advances are made attending to a real problem that needs of a ICT solution

References [1] [2] [3] [4] [5]

Bruselas Communication, 25.7.2001, COM (2001) 428 final. http://courses.lefis.unizar.es http://www.direct.gov.uk/ http://www.deutschland-online.de http://www.service-public.fr

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http://www.italia.gov.it http://www.060.es/ http://www.help.gv.at/ http://www.usa.gov/ http://www.whitehouse.gov/omb/e-gov/ H.R. 2458, E-Government Act of 2002, § 3601, Definitions. Signed into law, Public Law No: 107-347, by the U.S. President on December 17, 2002. [12] http://www.epractice.eu/en/factsheets/ [13] www.eulisp.de

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[6] [7] [8] [9] [10] [11]

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Legal and Political Implications of a Pandemic and Biological Threats. Ethical Dilemmas in Disasters

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Antonio CARUSOa, Alessandra ROSSODIVITAb,1 a Italian Audit Office of Milan, Milan, Italy b Department of Cardiothoracic and Vascular Diseases, Disaster Specialist, San Raffaele Hospital Scientific Foundation , University “Life and Health”, Milan, Italy

Abstract. The emergence of life-threatening infections such as severe acute respiratory syndrome (SARS), viral hemorrhagic fevers (e.g. Ebola and Marburg viral infections), the new resurgence in terrorism after September 11, 2001, and the threat of bio-terrorism, highlighted the urgent need for efficient control practices in health care. A dramatic increase in the need to develop countermeasures including civilian protection against bio-terrorism and emergency preparedness drive the policy-makers to develop new strategy and management guidelines. New codes in ethics and laws for bio-terrorism and disaster emergencies and related research have been improved over the last five years. Failure to apply infection control measures favors the spread of pathogens, and the health care setting can act as amplifiers of outbreaks, with an impact on both hospital and community health. The recent pandemics and environmental emergencies suggest that it is necessary to redefine the roles of states, municipalities, and nations under the principles of federalism and on the national and international levels in different countries. In the era of globalization and international laws the authors would highlight and focus the attention of the new International Health Regulations (IHR), put forward by the WHO, in which it is underlined the importance of human rights principles linked with the concept and need to balance the effective response to risk of diseases compared to fundamental individual freedoms. The authors would like to focus the attention on human rights from an international perspective in order to better understand the international point of view on this matter, concerning the legal and political implications of a pandemic or a biological threat, terrorism and counter-terrorism health consequences and related issues. Keywords. dilemmas, disasters, human rights, international humanitarian law, pandemic, terrorism, UN charter

“To put the people at the centre of health care “ “The path to hell is paved with good intentions” “Thanks to words, we have been able to rise above the brutes; and thanks to words, we have often sunk to the level of demons” Aldous Huxley Adonis and the Alphabet, 1956 1 Corresponding Author: Alessandra Rossodivita, E-mail: [email protected], Phone: +39-0226437118; Fax: +39-02-26437125

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Introduction Disasters and in particular any infectious pandemic represent some of the most catastrophic events in human history. When a pandemic occurs emergency care providers will be on the frontiers caring for affected, and infected people, for potentially infected , and non infected patients. Logistically, the current emergency care system is not ready for a pandemic, but are the providers also ethically ready? Are the affected Governments ready to react in case of a disaster such as a pandemic event? Serious and difficult ethically-based questions will arise and will test the moral structure of society. Ethical questions and dilemmas associated with disasters and their management are numerous , complex and compound when international assistance is involved. Emergency care providers, will need to balance the utilitarian goal of caring for the greatest number of people against the libertarian goal of protecting the individual patient’s rights and privacy. During a disaster pandemic event, it is necessary to place social needs ahead of the individual’s needs, but sometimes we may forget the basilar human rights of every civil nation. The importance of considering ethics in the pandemic or disaster planning was brought to light most recently by the severe acute respiratory syndrome (SARS) outbreak. Some of the most difficult decisions did not have do to with logistical or scientific issues, but rather with ethical issues that were raised by the public health, government, and healthcare workers. Post–epidemic research of SARS found that the cost of not having previously agreed-upon guidelines included a loss of public trust, low morale, confusion about roles and responsibilities, stigmatization of vulnerable individuals and communities, misinformation, and public fear. Restriction of freedom in the interest of public health, quarantine, health care workers’ duty to provide care, resource allocations and global governance implications represent today the crucial topics of ethics dilemma applied in disaster or a pandemic event [1–4]. During a pandemic influenza crisis, public health measures such as isolation, quarantine, and social distancing, may be necessary to contain the spread of the disease. The extent to which this will impact on an individual’s freedom and privacy, as well as cause social or financial hardship, will vary from individual to individual. Middaugh states that social distancing measures could pose a threat to the social fabric of society and community resiliency [5]. Although decisions to implement these measures may violate individual or community rights, they are ethically acceptable and justified under these circumstances, if the consensus is that they are effective and for the common good. Isolation of those infected and the quarantine of exposed people are considered by some to be the most complex, legally and ethically controversial public health powers [6]. The current consensus is that pandemic planning decisions on these public health measures should demonstrate accountability, transparency, and stakeholders involvement, and should use the least restrictive measures necessary to protect the public. The use of ethical and equitable plans would provide safeguards against stigmatization or discrimination of groups of people, limit disproportionate burdens on certain individuals or communities, and increase public buy-in [1, 7, 8].

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This, in turn, can contribute positively to public compliance and understanding when these measures must be instituted. In this paper the authors would like to focus the attention on human rights from an international perspective in order to better understand the international point of view on this matter, concerning the legal and political implications of a pandemic or a biological threat, terrorism and counter-terrorism health consequences and related issues, the legal and policy questions faced by decision makers, identifying important aspects of international law concerning the balancing of individual liberties versus national security, the rights of nations and the role of the International Health Regulation (IHR), discussing on the emerging ethical dilemmas in our society with an overview on human rights. The discussion that follows is not meant to be an inclusive and comprehensive presentation of all of ethical issues that are part of disasters and disaster management. This paper is meant to raise awareness ad promote an important an ever-relevant discussion on this matter.

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1. Ethical Dilemmas Medical personnel should abide by an already endorsed ethical code that obliges them to assist in the relief of human suffering and alleviation of pain to the possible extent. This ethical code is the result of teaching and training, and has been inherent in the practice of medicine since the Oath of Hippocrates [9]. This professional responsibility does not apply automatically to other professions. Further, the extent to which these ethical obligations are universally applicable must be discussed. In addition, there are related issues that may call into question to what extent this is a moral duty or a devotion and dedication beyond which it can be demanded professionally [10]. After the Second World War, protection of human rights became a priority for the international community. The United Nations established “The Universal Declaration of Human Rights” on 10 December 1948, which means for the first time there was an international recognition of human rights by laws. It states: “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood”. With the hope to end discrimination: “Everyone is entitled to all the rights and freedom set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty” [11–14]. This declaration is important not only for its high moral value but for the future implications related to legal and political consequences in building a new ethic code, as well as health ethic codes.

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We also would like to remember the global relevance of some international treaties on human rights: 1) on 16 December 1966, approved by United Nations (UN) ( the first regarding economic, social and cultural rights, the second on civil and political rights); 2) on 1950 by European Convention on Human Rights and fundamental; 3) on 1969 in Costa Rica by The American Convention on Human Rights; 4) on 1981 in Nairobi “The African Charter of Human Rights of the People”; 5) on 1989 Convention on Defence of Children Rights; 6) in 2004 in Tunisia “The Arab Charter of Human Rights of the People”; [11–16].

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In addition, it is important to highlight the role of the European Convention of Human Rights as one of the most relevant and influential Treaties concerning Human Rights. It is the most advanced treaty in the world and the only that includes a legal mechanism of control and verification of the application of the law ( recognized by the European Community ) [12, 13, 15, 16]. Now in the European Court of Human Rights in Strasbourg there is a Department dedicated to the protection of all European Citizens, made up of a task force of judges from the Member States [15–17]. All International Human Rights laws have clauses to be applied only in case of emergency. The following clause is from The European Convention of 1950, regarding a situation of emergency and how the law may be changed. Art. 15 (Derogation in time of emergency) declares : “1. In time of war or other public emergency threatening the life of the nation any High Contracting Party may take measures derogating from its obligations under this Convention to the extent strictly required by the exigencies of the situation, provided that such measures are not inconsistent with its other obligations under international law. 2. No derogation from Article 2, except in respect of deaths resulting from lawful acts of war, or from Articles 3, 4 (paragraph 1) and 7 shall be made under this provision. 3. Any High Contracting Party availing itself of these rights of derogation shall keep the Secretary-General of the Council of Europe fully informed of the measures which it has taken and the reasons thereof. It shall also inform the Secretary-General of the Council of Europe when such measures have ceased to operate and the provisions of the Convention are again being fully executed” [18]. This disposition became a template for other international treaties. It’s important to underline that in the past, during “Emergency” or “Disaster “situations, the world assisted in many serious violations of Human Rights in the name of derogation. Another important point was analyzed by the Court of Strasburg that underlines how crucial it is to find an equilibrium between the Public’s interest, “the State Reason” and the vital safeguard of Human Rights. In this paper the authors will analyze, on an international level, the legitimate use of this clause, and how it is possible to apply this derogation. As previously said, all treaties contain a clause which allow all countries to derogate only in emergencies situations and under specific conditions.

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These specific conditions are: • •

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•

War or other danger to public safety that threatens the nation (see art. 15European Convention) Exceptional Public danger or threat that directly involves the nation, declared by the Government (e.g. “State Emergencies Declaration”), art. 4 War, public threat or a crisis situation which threatens the independence or security of a State (art. 27 of America convention) [17–19].

The first condition for the application of this clause is to verify the existence and the real imminent threat that could involve a State’s security and safety. Each Government which applies these measures of derogation to Human Rights is obliged to demonstrate the right balance between the ongoing countermeasures and the gravity of the situation (related to the emergency). Legality is an essential promise of fairness: there will be no arbitrary arrests, biased judges or oppressive procedures. Derogation from these rights may be permitted at times of “emergency” – when there is a war or a continuing terrorist threat or a natural disaster – but not disproportionately to the needs of the situation and never for the purpose of racial, religious or sexual discrimination. If the countermeasures are not effective, Governments are obliged to abolish or modify them immediately. The Government is obliged to maintain control of the countermeasures and continuously verify and review them, especially if the emergency situation has changed or is over. In case of emergency or disaster, the State is not authorized to derogate regarding “Unbreakable Rights” the rights which cannot be abolished, even in case of war, or in any threat of the public health concern. The European Convention and the American Convention define these rights as “essential to human dignity”: The right to life (Universal Declaration art. 8) The right not to be subjected to torture or to cruel, inhuman or degrading treatment or punishment (Universal Declaration art. 5) The right not to be held in slavery or servitude (Universal Declaration art. 4) Everyone has the right to recognition everywhere as a person before the law (Universal Declaration art. 6) No person may be convicted for an act which was not a crime at the time it was committed (Universal Declaration. Art. 11) [11–14]. Every “Emergency” or “Disaster” or Exceptional Situation of Public threat that directly involves a nation, and the consequential derogation to conventional obligations has to be officially declared by the Government (e.g. “State of Public Emergency Declaration”). The Government is also obliged to inform continuously the General Secretariat of United Nations and The European Council (art. 15 of the European Convention; art 4 of the 1966 Treaty) on the countermeasures taken and on the reasons that led to take them. They also must be informed as soon as the Government declares the ending of the “derogation’s state” and the renewal of conventional state measures. Its is essential, before suspending” Rights Guarantee”, to officially communicate the Derogation to the International Institutions [17–19].

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2. Terrrorism In the last decade, terrorist attacks and terrorism-related emergencies have involved the globe and have changed the medical and government response to these acts. These changes have included planning, management and response to: different harmful situations, clinical and health consequences, ethical and moral management, the care of patient and the involvement of all forces/organizations engaged in emergency on national and international level (including EMS personnel, fire-brigades, police, civil protection, hospital-based healthcare workers and volunteers and different government – institutions , e.g. CDC, FEMA, IRCR etc.). The terrorist attacks of the 2000s exemplified a new form of terrorism, a modern terrorism, and prompted many nations to review their safety measures in the event that they become a target. A new chapter in terrorism was written, the word International Terrorism now represents a global terrorism quite different from the Classical terrorism. This “Global International Terrorism”, born from the globalization of the terrorist attacks with the aim of destroying all aspects of the democratic system, is a corner stone of the international community. All western countries and populations or sympathizing countries became enemies to hit [20–25]. The objective is to destroy thousands of people by suicide attacks, with the objective of a unique political project, elaborated by a non state-actor, one powerful international crime organization. In the last decade, the increase of political and economic imbalances in poverty, social imbalances, wars, famine, deforestation, in different countries have represented a growing emergency concerning the development of religious fundamentalism, with the possibility to utilize weapons of mass destruction and with the globalization of communications and financial support. Globalization is characterized by the elimination of time and distance barriers and the increased popular access to information, technology and communications. These characteristics have been exploited by both legitimate and illegitimate enterprises. They have particularly benefitted terrorist groups by allowing the groups members and supporters to cross state borders, acquire and move equipments, obtain information, communicate with one other, and transfer funds trans-nationally with much greater ease, all the while relying on the worldwide media to broadcast both their message and the success of their operations. Globalization also allowed terrorist groups to develop strategic alliances with other groups engaged in trans-national criminality in order to develop synergetic connections and to maximize the respective capability and effectiveness [26, 27]. There is a growing awareness that now terrorism could represent one of the most dangerous phenomenon of this century, and in the era of globalization even the concept of terrorism has changed into global terrorism and global fight to terrorism, for terrorism itself has changed, becoming strongly different from the past. In particular, after the anthrax attacks in 2001, via mail in the US, the international institutions and the public opinion highlighted that the US and the Federal Government must provide better planning, coordination, and communication with the public, as well as better countermeasures in case of terrorist or conventional attacks, and who is responsible for responding in emergencies and to delineate more clearly the lines of authority involving “homeland security”. Today the most controversial issues and topics are whether we should give up any civil liberties in order to deal with this “different kind of war”.

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What steps should the Government take to prepare for a terrorist attack? - What steps should the Government take to prepare for a terrorist attack? - What steps should the Government take to prepare for a non conventional terrorist attack? - What steps should the Government take, when preparing to react to a possible attack, involving very dangerous substances- e.g. CBRNE ? - Who should take the lead in such a crisis? States? Government? Federal Bureau? or Regional Council? New aspects of the juridical analysis of the international terrorism and related consequences now represent a crucial key point of new application and interpretation of national and international laws on terrorism by governments and international community, in order to protect people and to guarantee homeland security [26–30]. The authors would like to focus the attention on Bioterrorism and CBRNE Terrorism and the possible future consequences, because they now represent acts of deliberate release of harmful agents to hit and intimidate civilians and their governments. This point constitutes “A Threat to Public Health “ that differs from any other public health threat. In this case, the Government may derogate on many statements of Human Rights, but only under the control of the international laws and International Institutions (e.g. the United Nations and the European Court). This is crucial as the possibility of evading the international laws could represent a real and extremely dangerous threat to the affected population. The debates about balancing the safeguard of human rights, civil liberties, public health safety against homeland security in case of “State of Public Health Emergency”, still represents a very complicated and intricate matter of discussion, with no easy solution. The European Court on Human Rights, regarding the jurisprudence in the field of Human Rights, elaborated a doctrine called “The Margin of Appreciation Doctrine” in the Dynamics of European Human Rights Jurisprudence” [31]. This doctrine proposes that in a “State of public emergency”, the Government’s primary responsibility is to act immediately to protect the public, and then to determine the level of threat and whether to introduce public countermeasures on homeland security and health protection. However “the Margin of Appreciation” does not signify an unlimited power to the Government. In case the population objects and refuse to respect the law Derogation, introduced by the Government, the International Institutions Representatives (e.g. the UN, the European Council), under international laws, have the power and the right to assess the situation and directly verify the Government ‘s actions. This is the procedure to follow in a “State Emergency”. However each situation is unique and therefore the process is not always applied [27, 29, 31].

3. International Health Regulation (IHR) In 2005 WHO promoted and adopted the new International Health Regulation (IHR) and its application on 2007 opens a new way in jurisprudence and in the field of public health security. This IHR is an instrument of the international law with the objective to guarantee the maximum security against the spread of diseases, in particular infectious diseases and to reduce the international impact on health emergencies [32, 33]. The IHR established the concept of increasing protection for the entire population, and to introduce quarantine not only for some diseases traditionally considered for “quarantine“ (e.g. variola, pestis, cholera, yellow fever, typhoid) but

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for all diseases (all infectious diseases e.g TBC, influenza or pandemics, and some CBRNE accidents or attacks) that could have international repercussion on public health. The purpose and objective of IHR (2005) is to “prevent, protect, control and provide a public health response to the international spread of diseases in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade” [32, 33]. The IHR (2005) contains a range of innovations, including: A scope not limited to any specific disease or manner of transmission, but covering “illness or medical condition, irrespective of origin and source, that presents or could present significant harm to humans”; State Party obligations to develop certain minimum core public health capacities. Obligations of State Parties to notify WHO events that may constitute a public health emergency of international concern according to defined criteria; Provisions authorizing WHO to take into consideration unofficial reports of public health events and to obtain verification from States Parties concerning such events: 1) Procedures for the determination by the Director–general of a “Public health emergency of international concern” and issuance of corresponding temporary recommendations, after taking into account the views of an Emergency Committee; 2) Protection of human rights of persons and travellers; 3) Establishment of National IHR Focal Points and WHO IHR contact Points for urgent communications between States Parties. Within the framework of IHR (2005), seven areas of work have been identified to achieve the goals described above. The first area of work aims to strengthen global partnerships; the second and third address countries’ capacities to meet IHR (2005) requirements; the fourth and fifth areas of work focus on surveillance, prevention, control and response systems on the international level; the sixth and seventh address awareness of the rules, legal aspects and measuring progress [32–34]. Under the IHR (2005) countries are required to notify WHO of all events “that may constitute a public health emergency of international concern (PHEIC)” [34]. There are three PHEIC groups. We wish to stress the importance of the first group, which includes all unusual or unexpected cases of diseases that may have serious public health impact, including human influenza caused by a new strain. The implementation of International Health Regulations, IHR (2005), requires monitoring and control of communicable diseases, including pandemic influenza, establishing well-functioning surveillance systems and developing effective early warning and response systems (EWARS) [34], the IHR Framework is complex, but if well applied by all governments, it could permit to implement the role of the international partnership, cooperation and support in global emergency responses, in the name of clear principles of common laws in the field of cooperation, preparedness and mutual aid.

4. Conclusions The juridical reflection on emergency and terrorism, and their relationship with the fundamental principles of democratic constitutionalism, has never ended in those countries whose form of state takes inspiration from such principles.

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In fact, the globalization era is the era of day-to-day lack of safety, and individual and public safety is pursued by any means, for disasters and catastrophes are ever-present in our world, and in every country the unresolved situations of political, ethnical and religious tensions spread dangers and risks not only for safety, but also for the safeguarding of fundamental rights and democratic constitutionalism. Every state has the duty to take measures against emergencies, and prevent and crush terrorism. However, every form of democratic state in today’s international community aims at protecting both human rights and international safety, which cannot disregard a systematic prevention of threat and violence uses, the promotion of a dialogue between different opinions, the prevention and pacific resolution of conflicts. They should never prevail over the safeguarding of democracy and the human being’s fundamental rights, but actually they must make the application of democracy and the protection of fundamental and every person’s rights more pliable and flexible, in the strenuous effort to reconcile the needs of safety and freedom. Even in the most dramatic situations, it is necessary to respect individual and minorities “Unbreakable Rights”, provided for by the constitutional and international norms, the parliamentary controls and the fair and supporting role played by the jurisdictional protection institutions. We should always remember that the democratic constitutionalism techniques and instruments to face emergencies or terrorism lead to complex and delicate situations, in which public powers often have to meet apparently insoluble dilemmas, in the urgent need of taking decisions quickly, which therefore not always can be error-free. However, even though with effort, with continual oscillations, contradictions and corrections, they can help to reach or develop reasonable and more balanced solutions, capable of reconciling and softening different needs, even in the hardest moments in the life of one or more countries. This paper aims at helping to expand on these complex subjects and this hard relationship, in the hope of making people appreciate the irreplaceable role of democracy principles and instruments to protect the essential conditions of cohabitations, even in the most dramatic moments of a person's or human society's life. Every country has the fundamental obligation to provide the nation security and to protect population. By knowing the past, studying the present and discussing new laws to protect people may help to understand to contribute in the reduction in loss of human lives, injuries and suffering associated to a disaster emergency or a terrorist attack. Disasters, conflicts, terrorism, oppression, and poverty do not excuse or justify the violation of human rights. According with Larkin and Rilke the authors would like emphasize the role of seven cardinal virtues and ethic in times of terror and emergency . “Prudence, courage, justice added to stewardship, resilience, vigilance and charity now represent the future basics virtues that would be join people involved in react in maxi-emergency and disaster”. These virtues inform an ethical basis for emergency management of any disaster and terrorism –related events [35]. “For one human being to love another human being: that is perhaps the most difficult task that has been entrusted to us, the ultimate task, the final test and proof, the work for which all other work is merely preparation” [36].

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References

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[1]

M.E. Pena, C.B. Irvin and R.B. Takla, Ethical considerations for emergency care providers during pandemic influenza-Ready or not, Prehosp Disast Med, 24(2) (2009),115. [2] M.J. Selgelid, Ethics and infectious diseases, Bioethics, 19(3) (2005) 272. [3] R.A. Cherry, M. Trainer, The current crisis in emergency care and the impact on disaster preparedness. BMC, Emerg Med, 8 (2008), 7. [4] M. Bernstein, L.Hawryluck, Challenging beliefs and ethical concepts : The collateral damages of SARS. Critical Care, 7(4) (2003), 269. [5] J.P. Middaugh, Pandemic Influenza preparedness and community resiliency, JAMA, 299 (5) (2008), 566. [6] L. Gostin et al., Ethics of public health measures in response to pandemic influenza, available to the web site http/ www. who.int/eth/ethics/PI_ethics_draft_paper_WG2_6_Oct_06.pdf. (accessed 17 Jan 2007). [7] K. Kinlaw, R. Levine, Ethical guidelines in pandemic influenza – Recommendations of the ethic subcommittee of the advisory committee the director, CDC, available at http//: www.cdc.gov/od/science/phec/panflu_ethic_guidelines.pdf (accessed 16 April 2007). [8] World health Organization: ethical consideration in developing a public health response to pandemic response to pandemic influenza.2007 available at http//: www.who.int/csr/resources/publications/WHO_CDS_ EPR_GIP_2007_2c.pdf. [9] L. Ludwig Edelstein, The Hippocratic Oat . Text, Translation and Interpretation, by Ludwig Edelstein. Baltimore: John Hopkins Press, (1943). Modern version: International Code of Medical Ethics of the World Medical Association (1949). Adopted by the third General Assembly of the World Medical Association at London in October 1949 (World Medical Association Bulletin, 1(3), 1949; 109–111). This was followed by the World Medical Association Declaration of Geneva Physician’s Oath (1948) adopted by the General Assembly of the World Medical association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968. [10] TFQCDM/WADEM: Health Disaster Management: Guidelines for Evaluation and Research in the “ Utstein Style”. Chapter 8: Ethical Issues. Prehosp Disast Med, 17(suppl 3) (2002) 128 [11] The Universal Declaration of Human Rights available to the web site http//: www.un.org/en/documents/udhr/ accessed 4 September 2009 [12] L. Pineschi, La Dichiarazione Universale dei Diritti Umani in “La Tutela Internazionale dei Diritti Umani, Eds Giuffrè 2003 [13] A. Cassese, I Diritti Umani Oggi Eds Laterza 2005. [14] United Nations General Assembly .Resolution 217 A(III) Art.1, 2, and 3. 10 December 1948. [15] http//: www.conventions.coe.int/Treaty/en/treaties/html/005.htm (accessed 4 September 2009) [16] B. Primicerio, Diritti Umani e Costituzione Italiana, in Dir San Mod 55 (2007) 183. [17] http: // www.coe.int (Accessed 10 September 2009) [18] G. Cataldi, “Le deroghe ai diritti umani in stato di emergenza”, (752-772) in L.Pineschi, “La Tutela Internazionale Dei Diritti Umani” Eds. Giuffrè, 2005. [19] http//: www.echr.coe.int., European Court of Human Rights (Accessed 10 September 2009). [20] D. Alexander, Terrorism, Disasters, and Security. Prehospital Disaster Medicine, 18(3) (2003) 165. [21] G. Ciottone et al., Terrorism and other Man Made Disasters. United Nations Disaster Management Programme for Terrorist Events (2005). [22] E.K. Noji, Consequences of Terrorism. Prehospital Disaster Medicine, 18(3) (2003) 163. [23] E.K. Noji, Public Health Issues in Disasters. Crit Care Medicine, 33(1S) (2005) 29. [24] G.J. Annas, “Bioterrorism, Publich Health and Civil Liberties”. N Engl Med, 346( 17) ( 2002) 1337. [25] J.L. Arnold et al., A proposed Universal Medical and Public Health Definition of Terrorism. Prehospital Disaster Medicine, 18(2) (2003) 47. [26] L.Quadrarella, Il Nuovo Terrorismo Internazionale come crimine contro L’umanità Editoriale Scientifica. Eds 2006. [27] P.Bonetti. Terrorismo, emergenza e costituzioni democratiche. Eds Il Mulino 2006. [28] M. Stohl. The mystery of the new global Terrorism: the other World War in C.W. Jr Kegley ed, The New Global Terrorism: Characteristics, Causes; Controls New Jersey 2003. [29] A. Cassese International Criminal Law, Oxford 2003. [30] Wendy E. Parmet, “Legal Power and Legal Rights- Isolation and Quarantine in the case of Drug Resistant Tubercolosis”, N Engl Med, 357; 5, pp 433-435, 2007. [31] Youzow The Margin of Appreciation Doctrine and Dynamics of European Human Rights Jurisprudence, Dordrecht, 1996. [32] World Health Report 2008, “Now More Than Ever”, WHO 2008. [33] International Health Regulations (2005), Geneva, World Health Organization 2006.

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[34] http//: www.who.int/ihr/en (Accessed 10 September 2009). [35] G.L. Larkin and J. Arnold. Ethical considerations in emergency planning, preparedness, and response to acts of terrorism . Prehosp Disast Med 18 (3) (2003): 170. [36] R. Rilke: In: Mitchell S (ed), The Enlightened Mind: An Anthology of Sacred Prose (1991) New York.

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The Economic and Systemic Impacts of a Pandemic William I. HANCOCK Adjunct Professor of Business & Homeland Security, Texas A&M University Adjunct Professor of Quality & Homeland Security, The National Graduate School of Quality Management

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Abstract. Part I of this article is a summary of some of the major economic effects of a pandemic, especially a pandemic entailing a severe strain of influenza. The study is mainly quantitative in nature and is based on several models created and run by government and private agencies in the United States and by international organizations involved in public health. The principle scenarios analyzed are based on the influenza pandemics of 1918 (“Spanish flu”), 1957, 1968 (“Hong Kong flu”), 2003 (SARS) and 2005-to-present (H5N1 avian flu). Both actual historical and forecast model data are included. Pandemic economics is a topic of research & teaching at Texas A&M University’s Integrative Center for Homeland Security. Part II of this article summarizes many of the nation-specific and multinational systemic effects of a pandemic, especially a pandemic entailing a severe strain of influenza. The study is mainly qualitative in nature and is a collection of information from a variety of sources from the US, other nations, and international organizations. Recent events have demonstrated the fragility of the major systems that civilization depends on. Natural disasters, terrorist attacks, and financial breakdowns may only be preludes to a systemic collapse precipitated by an uncontrollable pandemic. In today’s world, we are all dependent on the continuation of complex and interdependent systems that are the operational “machines” of societies, economies, governments, and businesses. Keywords. Pandemic, Economic Impact, Systemic Impact, H5N1, Avian Influenza, Spanish Flu, SARS, Morbidity, Mortality, GDP/Gross Domestic Product, Productivity, Demand, Hospitalization

Introduction to Part I – The Economic Impact of a Pandemic “Do not ask for whom the bell tolls, it tolls for thee.” John Donne Which nations are most at risk from a catastrophic pandemic? The answer is clear. We ALL are in danger, because we live in a world of globalized commerce and transportation. This paper covers both actual past experiences with pandemics and forecasts of future pandemics and their effects on society, economies, governments, and businesses. The historical information is based on the infamous 1918 “Spanish flu” pandemic, which was the worst health calamity in modern times. It was an international disaster which got its name from the fact that Spain’s press was one of the very few that were not censored by their government. Hence, much of the world’s knowledge about the pandemic dealt with Spain, and people thought it was a disease endemic to that country.

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Other historical examples of pandemics include the 1967 Avian flu which was among the least destructive, the 2003 SARS flu pandemic which hit Hong Kong and Toronto especially hard and was given much press coverage, and the current H5N1 Avian flu which has killed a few hundred people but to date has not jumped species to become transmittable from person to person. H5N1 is especially worrisome due to its extremely high mortality rate, which is well above 50%. The quality and quantity of data are of course much better for 1968 than for 1918. Data from developed countries like the United States and Western Europe are more complete and reliable than data from developing and less developing nations. This is despite enormous efforts by the World Health Organization and other United Nations bodies to improve the quality and quantity of health data from all countries. Most pandemic data comes from the health departments of individual nations, but some comes from international organizations such as the Organization for Economic Cooperation and Development (OECD), Asia-Pacific Economic Cooperation (APEC), the World Bank, the International Monetary Fund, United Nations Educational and Scientific and Cultural Organization (UNESCO). Also, one should not overlook the significant efforts of the North Atlantic Treaty Organization’s Science for Peace and Security (SPS) program that sponsors research and conferences. These efforts promote awareness and information dissemination about pandemics to support current and prospective NATO members. By far the most important reason for the dramatic increase in the danger of a pandemic today is the globalization of trade, investment, population movements, and transportation. The influenza pandemic of 1918 required months to spread around the world. A similar contagion today is anticipated to engulf the entire planet in less than two weeks. This is primarily the result of airline travel and the shipment of consumer goods among nations. The US alone receives over 10 million sea-land shipping containers of goods each year, most of which are for retail sale to Americans through store chains such as Wal-Mart. Today, almost every economy is fully integrated with and interdependent upon the manufacturing and distribution systems of other countries. Businesses today optimize internationally the sourcing of materials, product and service creation, shipping, and marketing/sales. All of these activities guarantee that diseases in one country will quickly be transmitted to many other countries.

1. Actual Economic Impacts of Past Pandemics The Spanish Flu Pandemic began in the United States, spread worldwide, and actually lasted from 1916 until 1920. It came in three waves, with the second wave being the most virulent. The movement of military forces during the First World War helped to spread the disease. Approximately 7 million people in the US became ill, 11% of the afflicted then died, and the country’s gross domestic product dropped slightly. This was the worst pandemic in recorded American history. By comparison, the 1968 “Hong Kong Flu” resulted in 34,000 deaths in the United States, or about .15% of the population. In 2003, the SARS epidemic impacted mainly Hong Kong and Toronto, Canada. It caused 800 deaths and a temporary drop in these nations’ GDP by approximately $20 billion or -2%. The H5N1 strain of Avian Flu so far has affected mainly Vietnam and East Asia. In the period 2004-2005, it sickened over 100 people who had direct contact with poultry and killed 52% of those who became ill.

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In addition to deaths and drops in GDP, pandemics have economic impacts through increased costs of government planning and preparation. The United States, for instance, spent $7 billion on such programs in the years 2006-2008. The US cost of medical preparedness, born heavily by businesses and local governments, has been in the area of $7 billion for vaccines and $5 billion for surveillance.

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2. Forecast of the Economic Impact of a Pandemic in the United States The probability of a pandemic in any given year is estimated to be 3-4%. In a mild scenario similar to the 1968 Hong Kong Flu, the US can expect to suffer a decline in GDP of -1% or about -$70 billion. By comparison, a severe pandemic such as the Spanish Flu of 1918 would result in a drop of -5% of GDP, or about -$250 billion. American states that are heavily dependent on tourism (e.g., Nevada and Hawaii) would experience more harsh economic declines of -7.5% [1]. The anticipated worldwide drop in production of goods & services in a 1918-style pandemic would be -$3 trillion. Asia alone would see a decline of -7.5% [2]. US productivity losses and medical costs would add up to $160 billion in a severe scenario, compared to $70 billion in a mild pandemic. A severe pandemic would permanently reduce the US labor force by -.075% and temporarily eliminate as much as 40% of workers. Even a mild pandemic would have up to half of this same impact on the work force [3]. Economic demand for products and services would drop, especially in industries such as entertainment, the arts, lodging, and restaurants, all of which would see temporary declines of up to -80%. Other industries would suffer at least -10% drops in purchasing. Meanwhile the medical industries would experience surges in demand of 15% or more, with these numbers constrained by the problem of increased medical personnel morbidity and mortality rates [4]. The United States can expect to see 75 million hospitalizations in a mild pandemic or 90 million in a severe one. A mild event would kill 100,000 Americans or 2 million people worldwide. A severe pandemic would kill 2.2 million in the US and at least 7.4 million worldwide [5, 6].

3. Input Variables Required in Order to Forecast Economic Impacts In order to create and run econometric forecasting models such as those used by the World Health Organization, US Centers for Disease Control, or Trust for America’s Health, accurate and reliable historical data must be collected. This data must include the number of deaths by age group, the average lifetime earnings lost, the number of hospitalizations by age group, average hospital costs, the average cost of drugs administered, the average number of days lost at work, and the average economic value of a day of lost earnings. Other required input variables are the number of outpatient visits by age group, the average patient payment or cost per visit, the average cost of prescribed drugs, the average number of days lost at work, and the average value of a day’s lost earnings due to outpatient visits.

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For patients who receive no medical care but are sick at home, we need to collect the value of non-prescription medicines purchased, the average number of days lost at work, and the average value of a day’s lost earnings.

Contacts for Econometric Modeling of a Pandemic Table 1. These are the individuals contacted by the author who volunteered to assist representatives of other nations in developing and running econometric models for use in forecasting the economic impact of a pandemic. Appropriate country representatives will be introduced to the persons listed below, if they contact the author of this article, Professor Bill Hancock at [email protected]. Expert

Organization

Location

Dr. Martin Meltzer

US Centers for Disease Control

Atlanta, Georgia

Dr. Robert Arnold

US Congressional Budget Office

Washington, DC

Warwick McKibbin

Brookings Institution

Washington, DC

Introduction to Part II – The Systemic Impact of a Pandemic

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“We must all hang together, or surely we will hang separately.” Benjamin Franklin Systemic impacts of a pandemic are subjective and not quantifiable like economic impacts. Their duration can be immediate which means days or weeks, or longer term meaning weeks or months. Permanent impacts can last for years. The analysis in this article generally omits the effects of a pandemic on the public health system, because such impacts are covered extensively elsewhere by other authors. There are four categories of systemic impacts from a pandemic. These four areas are societal, economic, government, and business. Part II of this article does not attempt to quantify the economic impacts, since this was done previously in Part I. Part II is divided into four sections, each describing one of the categories mentioned above. In each category there are several sub-categories. Each sub-category describes the two areas of impact that the author believes are the most important, one having immediate or short-term effects and the other having longer term or permanent effects. A large number of additional impacts under each sub-category have been identified and are available from the author upon request. 1. Major Systemic Impacts of a Pandemic on Society An immediate social effect of a pandemic is the widespread fear of the unknown. As President Franklin Roosevelt said, “Our only fear is fear itself”. In 1918 San Francisco leaders publicized the extent of the crisis, and people reacted well by putting themselves into voluntary quarantine and implementing other disease-prevention measures. Philadelphia, on the other hand, clamped down on all public information about the pandemic. The result was fear, panic, and chaos. In the longer term, a result of a pandemic is a drop in the overall level of public confidence in government that comes about when people see their leaders as powerless to do anything to mitigate the suffering and death.

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Concerning individual and family activities, there are many impacts. One of the short-term effects is the popular hoarding of food, medicine, money, and other valuables which people are fearful will be in short supply. Over the long run, however, people begin to rely on their family members, close friends, and neighbors for emotional and physical sustenance. Community activities are strongly impacted by a pandemic. Public meetings and gatherings of organizations are curtailed, shortened, or cancelled all together. As time goes by, we can expect to see an emigration of populations away from the cities to smaller towns and to the rural countryside. Educational activities are severely restricted, at least those that involve on-site classroom sessions and busing or other public transportation of students to and from facilities. This will mean the closing of many schools, discontinuing sports practices and events, and cutting back on other youth activities. On-line distance education by computer and the Internet is only a partial answer to this important problem. Over months and years, continued curtailment of educational activities will lead to a decrease in child literacy [7].

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2. Major Systemic Impacts of a Pandemic on the Economy An immediate impact of a pandemic will be the widespread drop in demand for businesses’ products and services. This will particularly hurt certain industries such as hotels, eating establishments, and airlines. Over all, there will be a disproportionately large negative impact on demand for business products, which of course is derived from the lowered amounts of purchases of consumer products. Exceptions to this may be found in the areas of hoarded products, such as bottled water, batteries, canned food, and cash. On the supply side, companies will be less able to produce outputs due to absenteeism and the inability to rely on quickly dwindling inventories of parts, supplies, components, and items for resale. This is due to increased reliance on modern JIT techniques, or Just-In-Time manufacturing. Companies today outsource or offshore many services such as telephone assistance and many products such as electronics. As the pandemic spreads worldwide, it affects the outsourced vendors, shipping lines, airlines, and port personnel. Companies will be forced to rely entirely on their own personnel and manufacturing. This may be difficult in a time of high absenteeism and fewer domestic production facilities. Labor will be in short supply, because of sickness, death, and fear of coming to work. Workers who are infected but nevertheless show up for work can be a special danger, since their “presenteeism” may spread the disease further among the work force. The overall population growth will slow down, creating worker shortages in the future similar to those in Europe and Russia after World War II. Some diseases such as H5N1 avian flu attack 2030 year old individuals the worst. The lack of younger, stronger, and cheaper employees will be a particular problem for businesses and other organizations in future years. In reference to government fiscal policy, there will be fewer tax revenues due to deaths and unemployed workers. However, the demand for increased government spending on health, public safety, welfare, and business subsidies will be huge. In the years to come, countries’ Gross Domestic Product will be lower, with a resulting diminished tax base. In the area of government monetary policy, there will be a need for a rapid increase in the money supply to provide economic liquidity. Every sale of a product or

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service results in a need for a financial payment. Without plenty of capital, commerce cannot continue. Due to the drop in a country’s exports, its currency value may weaken with an accompanying lowering of the people’s standard of living. On top of this, a weak currency may create ruinous price inflation at a time when the population has less money to spend for essential items [8].

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3. Major Systemic Impacts of a Pandemic on Government Local, provincial, and national government agencies will immediately experience a major shift in spending to support public health programs. This will probably come at the expense of other vital services that are normally provided. Political activities such as legislative meetings and judicial proceedings are halted or cut back. Few voters are willing to go to the polls for elections, with the result being deleterious shifts of power in the democratic process. In most countries, much of the critical infrastructure such as power and other utilities are owned and run by government agencies. Postal delivery and other essential government functions will be disrupted due to staff shortages and building closures. Electricity, water, and fuel may become unavailable intermittently or for extended periods of time. Government-run public services such as law enforcement, rescue and evacuation, and ambulance and emergency care may disappear or be overwhelmed by the increased need for these functions. Airports, train stations, and border crossings may lack sufficient personnel and hence be forced to close. Government agencies who administer insurance and other health-related programs will suffer from a surge in applications for benefits, such as the US Medicaid and Medicare programs. The US Social Security Administration and similar public departments will be stressed with the unusually large number of cases in which death and survivor payments must be processed expeditiously. VAT, sales, property, and income taxes will fall precipitously, causing financial crises for governments at levels. This will result from the drop in product sales and the inability of employers to pay their personnel. Both business and personal income tax revenues will drop, due to lowered business revenues, job losses, and worker deaths. In the legal arena, the populations of jails and prisons are especially vulnerable to disease outbreaks. More guards, medical personnel, and others will be needed quickly to maintain security and order. Courts, already backlogged, will be forced to shorten their hours, reduce their case loads, or shut down completely. This will be due to the lack of jurists, jury members, and attorneys who represent both the plaintiffs and defendants. In the international arena, there may be a positive surge in the awareness and support for greater multinational cooperation in disease surveillance, containment, and vaccine distribution. However, over time the lack of trade, investment, offshoring, and other vital economic activities will lead to fewer and weaker regional alliances, partnerships, and trade agreements. In the military arena, military organizations will focus on maintaining the health and continuity of their own personnel and missions. They will generally be unable to assist the civilian population in pandemic response efforts. Military deployments, especially to distant locations, may be curtailed. The inability of Kaiser Wilhelm’s German army to continue its earlier rapid advance due to onset of Spanish Flu in 1918 demonstrated the dramatic impact of a pandemic on military operations [9].

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4. Major Systemic Impacts of a Pandemic on Business On the wholesale side of business, industrial manufacturing of products and services will drop or stop. This may result from personnel absences or from the lack of essential supplies created by hoarding and black market activities. With shortages of key materials, manufacturers that stay in business will be forced to find alternative supplies and cut corners on quality. One can look at the former German Democratic Republic to see examples of plastic cars and beverages made with bovine urine. Both wholesalers and retail stores will be hurt by the hoarding of key items like food, fuel, and medicine. Shortages turn into customer resentment and occasional violence. Over time, governments and businesses will both institute rationing similar to what was done with petrol in Great Britain and the United States during World War II. Physical product distribution (logistics) will be hurt badly by the shortage of truck drivers, cargo airplane crews, and container port equipment operators. A recent study showed the vulnerability of the US electricity industry that is dependent on a small handful of healthy train engineers who bring massive amounts of coal daily to fuel key power generation plants. Today, containers and tankers bring most foreign-originated cargos into many countries such as the United States. Widespread sickness among a few crane operators will hobble this critical function, causing a back-up of ships at the principal seaports. Products from all over the world will not be able to begin their trips by road or rail to their ultimate destinations. In the area of agriculture, an avian flu outbreak will require the destruction of most poultry, the largest protein component of most diets worldwide. A side effect will be the lack of chicken eggs which are used to create vaccines necessary to prevent or lessen the pandemic. The cost of food will soar, due to shortages and due to the increased cost of testing and decontamination of edibles. In the financial system, banks and related firms will experience high demand for cash at a time when coin & currency distribution has been limited by personnel shortages. Over time, the investment industry will see a sharp drop in the value and prices for equities (stocks), debt instruments (bonds), real estate, and other assets. Meanwhile, the price and demand for gold and such valuables may go up dramatically. In countries like the US where much of the critical infrastructure is privately owned, there will be shortages of heating oil, gas, coal, gasoline, and other energy products. As the pandemic wears on, we can expect to see telecommunications disruptions due to the lack of maintenance and repair normally conducted by personnel affected by disease and related distractions. Privately owned and run health care facilities will run out of respirators, vaccines, and other critical medical items. The need to prioritize the distribution of drugs and treatments will cause friction and possible violent confrontations in communities. Governments in the long run may be forced to take over privately owned health care facilities such as hospitals, laboratories, and clinics. The insurance industry will be hit with huge increases in medical and death benefit claims resulting from hospitalization and mortality of pandemic victims. Many private insurance carriers will become insolvent and ultimately bankrupt. The news media will be deluged during the pandemic with an increased demand by the public for practical information about what to do and the comfort that comes from a sense of having some control over people’s own lives. Electronic media via the Internet will be preferred, since people will avoid potentially disease-carrying paper products such as newspapers. This will severely harm media revenues and their ability to

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continue to gather and disseminate the news. At the same time, the fear of travel and restrictions on population movements will make it more difficult for the news industry to collect information, especially from foreign sources [10].

5. Conclusions First, the possibility of a future pandemic is real. The question is not “If”? The question is “When”? A major pandemic is one of the largest potential threats to humankind today, on par with nuclear war or extreme global warming. Much work needs to be done to improve our assessment of both the quantitative and qualitative impact of future pandemics.

Endnotes

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[1]

“A Potential Influenza Pandemic: An Update on Possible Macroeconomic Effects and Policy Issues”, Congressional Budget Office, US Congress, Washington, D.C., July 27, 2006. [2] M.I. Meltzer, N.J. Cox and K. Fukuda, “The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention”, Centers for Disease Control and Prevention, Atlanta, GA, USA, 5(5) (September-October, 2004). [3] “Pandemic Flu and the Potential for U.S. Economic Recession”, Trust for America’s Health, Washington, DC, March, 2007. [4] “Economic Impact of Avian Flu”, World Bank, Global Program for Avian Influenza and Human Pandemic, 2008. [5] “Estimated economic impact of pandemic influenza”, World Heath Organization, Source: Oxford Economic Forecasting Group. [6] “Pandemic Impact”, International Federation of Pharmaceutical Manufacturers and Associations, www. ifpma.org/influenza [7] “Social Effects of H5N1”, Wikipedia, en.wikipedia.org [8] Avian Flu Working Group, “The Global Economic and Financial Impact of an Avian Flu Pandemic and the Role of the IMF”, International Monetary Fund, February 28, 2006. [9] “Emerging Risks in the 21st Century, An Agenda for Action”, Organization for Economic Co-operation and Development. [10] “What would be the impact of a pandemic?”, US Department of Health and Human Services, www. pandemicflu.gov.

References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13]

US Congressional Budget Office (CBO). US Centers for Disease Control (CDC). Trust for America’s Heath (TFAH). World Health Organization (WHO). World Bank (WB). Asian Development Bank (ADB). US Department of Health & Human Services (HHS). International Monetary Fund (IMF). Organization for Economic Cooperation & Development. J.M. Barry, The Great Influenza, Viking, New York, 2004. T.L. Friedman, The World is Flat, Farrar Straus & Giroux, New York, 2005. P.R. Cateora, J.L. Graham, International Marketing, McGraw-Hill Irwin, New York, 2005. C.W.L. Hill, Global Business Today, McGraw-Hill Irwin, New York, 2008.

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3. Improving Preparedness through Education

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and Awareness

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Health “Security” Systems Raymond E. SWIENTON a,1, Italo SUBBARAOb and Elin A. GURSKYc Section of EMS, Disaster Medicine & Homeland Security, Division of Emergency Medicine, University of Texas Southwestern Medical Center Dallas, Texas, USA b Director of the Public Health Readiness Office, Center of Public Health Preparedness and Disaster Response, “American Medical Association”, Chicago, IL, USA c Principal Deputy for Biodefense, ANSER/Analytic Services, Inc., Arlington, VA, USA a

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Abstract. Preserving health and medical care access during extreme demands on service delivery in a disaster or public health emergency is vital to the population and state, national and global security. Health security broadly encompasses the strategic, tactical, and operational infrastructure and hardening that ensures health system preparedness, the delivery of appropriate health and medical services, and swift recovery on behalf of impacted populations. This definition of heath security focuses on a measurable preparedness outcome by fostering resilience and meeting the critical and time-sensitive health and medical demands of affected communities. Health security as an inherent piece of quality health systems is a novel concept. Achieving health security in this manner requires a reengineered strategic approach. Responsibility and ownership for health security resides within the health care system. Like pieces of a puzzle, key health system components impacting disaster medicine and public health emergency readiness must be in place and include the following: planning, capacity & capability, public health preparedness, education & training, and scientific advancement. Utilization and integration of these components within the health system framework require excellence in the core tools of communication, collaboration and implementation. Health security, the often-missing piece of the health system, is now an inherent piece of the puzzle.

Keywords. Health security, health systems, disaster medicine, preparedness, public health emergency, biosecurity, pandemic

Introduction Today we face global threats to the health and safety of people in every nation. The recent declaration of the pandemic status for the H1N1 virus is a vivid reminder of the vulnerabilities facing all people [1]. The occurrence of large-scale natural disasters is commonplace. The headlines of the world’s media are filled with the tremendous destructive impact of ongoing-armed conflicts and terrorism. The demands for humanitarian assistance from the disruptive impact of political, social and economic events are significant.

1 Corresponding Author: Raymond E. Swienton, MD, FACEP, Associate Professor, Division of Emergency Medicine, Department of Surgery, University of Texas, Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd. Dallas, Texas 75390-8579. Email: [email protected].

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The threats and growing concern over weapons of mass destruction with potential catastrophic impacts are commonly discussed. The changing global climate on earth may become the greatest health challenge facing human civilization [2]. The recent history of large-scale disasters and the likelihood of public health emergencies place tremendous demands on the delivery of health and medical services. Many nations health care systems are fragile and sustaining service delivery during a large-scale event may not be possible. This would likely result in the collapse of the local health care infrastructure. No nation is immune from this risk. The impact of Hurricane Katrina, 2005 in the United States of America (USA) on the local health care infrastructure demonstrates this vulnerability may exist in any nation. Many leading authorities in global health have recognized the importance of health security. Recognizing that a quality health delivery system likely plays a role has been reported [3]. However, the conceptual definition and definable end points to achieving health security are historically lacking. Health security is the strategic, tactical, and operational infrastructure and hardening that ensures health system preparedness, the delivery of appropriate health and medical services, and swift recovery on behalf of impacted populations. This definition of heath security focuses on a measurable preparedness outcome by fostering resilience and meeting the critical and time-sensitive health and medical demands of affected communities. A minimum threshold of health security is demonstrated in the following:

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Health System > Health Demand Time A minimal threshold in achieving health security is present when the health system timely meets or exceeds the health and medical demands encountered. Meeting the population’s daily or routine service demands is fundamental to every nation’s health system. Meeting those demands during a disaster or public health emergency must also be a primary aim within each health system. Assurance to the at-risk populations, that an appropriate level of these services can be delivered during a surge in demand, or during a reduction in health system capacity or capability is vital to population wellbeing. These are the essence of health security. This definition of health security is simple, focusing on meeting the demands, a measurable outcome. Achieving health security in this model suggests that the following areas be addressed: (1) Responsibility and ownership for health security resides within the health care system. (2) A well-defined strategic approach is required. (3) Identifying the key components to address in the overall health system is crucial. (4) Utilizing proper tools is critical to the placement and utilization of these components within the health system framework. These concepts, strategies, components and tools will be explored. The concept of health security as an inherent piece within a health system is novel. This level of health security is achievable. It is essential to disaster medical readiness and public health emergency preparedness.

1. Health Security, Contained within the Health Care System Health security is a global issue. To ensure health security is an aim sought by every nation and region. It must be a tangible outcome based on achievable end points.

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However, all to often, discussions of health security more describe a quest, vaguely delineating a future state of health assurance desired, rather than an objective based reachable goal. To be achievable, the concept of health security must adopt the premise of a mission tasking. The achievable level of health security is largely dependant on the operational status of the overall health system. 1.1 Health “Security” Systems

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The title Health “Security” Systems denotes that health security should be contained within the existing health system. An ample health system is one that addresses the routine demands for services, and appropriately manages the scalable delivery of sufficient services during either times of a demand in surge or a reduction in available health and medical resources. Health security, as related to disaster preparedness and public health emergency readiness, is unfortunately often viewed as supplemental or external to the health systems routine demands for health and medical service delivery. The notion that meeting unexpected surge demands, or when facing a reduction in available health and medical resources, is the primary responsibility of entities outside of the core health system is perilous. Viewing external entities as responsible for assuring health security is in part accountable for the lack of overall disaster and public health preparedness in many nations and regions. When viewed as anything other than contained within the innate health care system, disaster preparedness becomes the casualty. It is predictable, when outside sources are considered responsible for health security, that progress and attention to disaster and public health preparedness will wax and wane. Seeing the episodic increase in attention and funding when a recent event has occurred followed by the wane of interest and funding when recent event memories fade. To achieve health security requires the health system accept responsibility and adopt fundamental principles that facilitate service delivery during routine and austere situations. 1.2 Local Preparedness, Global Response! Meeting the health and medical demands of a population during a large-scale disaster or public health emergency can be extremely difficult for any local, national or regional effort. The responsibility, especially during the early phases, resides with the local health system. Local Preparedness! Early outcomes in mortality and morbidity will in part be determined by the efficacy of health security that resides within the existing local health system. It is important that an appropriate sense of ownership locally be the operational paradigm (e.g. “it is our disaster”). Local empowerment is important. It is not a pursuit of independence but rather genuine collaboration with the state, nation or region within which this local area resides [4]. Global Response! The scale of the disaster will impact the sustainability of the local healthcare infrastructure. Catastrophic geographic destruction, widespread disruption in public works, law and social order disruption, are but a few of the many factors outside the control of the local health system. Any one of these could lead to the immediate or early collapse of the local healthcare infrastructure. Assistance from global partners, near and far, is appropriate and often essential during such austere times. Emphasizing again the need for genuine collaboration [4].

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This concept conveyed in “Local Preparedness, Global Response!” will be important in health and medical capacity and capability planning. 1.3 Inroads Inroads are an advance often at the expense of someone or something [5]. To often, the inroads or advancements achieved in disaster medicine and public health preparedness are at the expense of people affected by the disaster or public health event. Mortality, morbidity, failed healthcare infrastructure, community disruption and socioeconomic decline are some of the serious “expenses” paid by such affected people. It is important to invest in the establishment of health security so that our future inroads are not solely at the expense of the at-risk populations. This “expense”, investment, by the overall health system in assuring health security is important also to future generations and their culture.

2. Strategic Approach to Achieving Health Security A strategic approach that is reengineered on achieving health security as an innate piece of the health system is the objective. It must envelope principles that advance disaster medicine and public health preparedness. A well-designed strategic approach will facilitate the tactical planning, foster community level resilience, achieve health system hardening and include the organizational elements that result in effective operations, and hasten recovery. There are a multitude of issues to consider in such a comprehensive approach. A distillation of these many items, identifies three overarching principles essential to achieving health security:

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1. To rapidly identify the medical and health needs of affected populations 2. To coordinate, verify, and optimize local healthcare infrastructure 3. To deliver disaster medical and public health emergency services These principles are the results of conceptual design, modeling and operational concepts field-tested during multiple disaster events in the USA [6–9]. In the State of Texas, they are being used in the development of attaining a statewide-integrated disaster response system [10–11]. 2.1. To Rapidly Identify the Medical and Health Needs of Affected Populations Every health system has the core task of identifying the routine or usual medical and health needs of the overall population it services. Health security stresses that the system must be able to meet the at-risk population needs when a surge in demand occurs, or during a reduction in health system capacity or capability. During a disaster or public health emergency, the challenge is how adept is the health system in rapidly identifying the altered demands on the affected population. Health and medical hazard vulnerability assessment is vital to health security. Resilience, defined as the ability for a community to quickly recover from exposure to a disaster, is dependant upon the health system’s accurate assessment. Morbidity and mortality is impacted by the ability to meet the altered demands assessed. Vulnerability assessment is challenging and influenced by many variables including population

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density, socioeconomic demographics, disease prevalence, etc. Geographic vulnerability, for example, is a challenging issue as population migration is often towards coastlines and geographically seismic areas more susceptible to disasters. When a disaster occurs, there are predicable population subgroups at increased risk. These subgroups in the USA are often referred to as special populations or medical special needs patients. Collectively, this at-increased-risk group can be functionally defined by the following: The art and science of managing people with pre-existing disease, injuries or disabilities; or age related vulnerabilities; and their families, in a sufficiency of care environment caused by a disaster or public health emergency. The composition of this large group is highly diverse. Examples may include chronic renal disease dialysis-dependant patients, home oxygen dependency, insulin dependant diabetics, non-ambulatory, medical device required for mobility, extremes of age, mental illnesses, sensory or motor impairments, and an extensive list of many other chronic illnesses, disabilities, psychosocial and health limiting conditions. Simply said, it is caring for those at increased risk. This special needs population places a great strain on the healthcare infrastructure in the USA following disasters. Much of the mortality and morbidity is attributable to this population. The ability to rapidly identify the health and medical needs of this subgroup, and the overall at-risk population is important to the strategic planning process.

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2.2. To Coordinate, Verify, and Optimize Local Healthcare Infrastructure The value of the local healthcare infrastructure during a disaster or public health emergency is the focus of this strategic principle. Early response and ongoing sustained health and medical service delivery to the impacted area are largely dependent on the continuation of local healthcare infrastructure. Central to this strategic principle is the ability to sustain, reestablish or augment local healthcare. Historically, situational awareness and disease and injury surveillance is vital but often limited in accuracy in the early post-impact period following a disaster. Early on, information sharing is limited. Verification of information is difficult. Media coverage may be delayed due to challenges in accessing the local area. Eyewitness accounts by objective-based, mission-focused medical and health personnel are needed to improve decision-making and resource allocation, but are not always available. Modeling to improve accurate situational awareness based decision-making has been beneficial. Just-in-time use of rapid medical and public health assessment strike teams during H. Katrina and H. Rita, 2005 are an example [6]. In Louisiana, they were utilized to gain situational awareness by the senior medical strategic advisors reporting to state-level medical and health officials [9]. Field-testing of similar-purposed strike teams has been successful during multiple recent disaster events in Texas [8]. This collaborative effort of academic partners and state health leaders is now a recognized component of the state-level early response strategy in Texas. Optimizing local healthcare infrastructure when impacted by a disaster that increases surge demands or has reduced capabilities and capacities for service delivery requires a change in the care delivery model. The transition from a standard or usual manner of care delivery into a sufficiency or altered care delivery model is the mindset. Eyewitness accounts were gathered onsite from healthcare workers and administrators within the Texas Medical Center (TMC) in Houston, Texas during the

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early aftermath of Hurricane Ike, 2008 [12, 13]. This methodology allowed for the immediate raw data collection during an ongoing event by a prepared strike team when local communication and other methods of needs assessment were limited. Decisionmaking and resource allocation to assist the local healthcare infrastructure were improved. These accounts from multiple emergency departments within the TMC hospitals reported an immediate surge of more than doubling their usual daily census. These same facilities sustained approximately 25% increased surge for several days. This combined with a reduced workforce attendance raise issues of worker safety, patient safety and timely access to medical care [13]. A limited number of health and medical issues generated this surge. According to these eyewitness accounts the majority of surge clinical encounters were for medication refills, chronic and acute wound management, low acuity musculoskeletal injuries, chronic renal disease assessment for hemodialysis, need for continuation of home oxygen therapy, environmental stress due to lack of public services (e.g., electricity, potable water, etc.) and carbon monoxide toxicity [13]. This real-time situational awareness identified areas to improve surge management in three areas: (1). Medical supplies and pharmaceutical distribution (e.g., provide medical point-of-distribution (“Medical POD”) for medication refills, oxygen access, and chronic wound management supplies, etc.); (2). Improve access for point of care laboratory testing (e.g., for renal disease, diabetic screening, etc.); and (3). Provide health safety educational materials (e.g., carbon monoxide toxicity risks, etc.). It is important to notice that all of the needs identified in these three areas could be met in locations other than the hospital or emergency departments. The implementation of these altered-care delivery methods may reduce emergency department and hospital surge in future events. Obviously, measurable outcomes need to be demonstrated in a statistically valid manner. Optimizing local health care infrastructure must address the prompt return of local healthcare providers, reopening clinics and office based community medical practices in early disaster recovery. In the USA, this issue has not been adequately addressed to date. Improvements are underway through American Medical Association programs and other local initiatives. Operational incentives to encourage the return of local medical care community to service must be included. This could include financial incentives, housing assistance for healthcare workers and their families, early reestablishment of public services (e.g., electricity, potable water), medical equipment and supplies access, etc. While the continuation of the innate local healthcare infrastructure is most desired, historical events have demonstrated that this may not be possible. Complete disruption of the local healthcare infrastructure is not uncommon. A recent example from the USA would be Galveston Island, Texas resulting from Hurricane Ike in August 2008. Strategic planning for when the local healthcare infrastructure is non-sustainable or completely devastated is a challenging task. It requires excellent communication and identifies the collaborations necessary to utilize external, non-local, resources to meet the demands of the local affected population. It reinforces the sense of local event “ownership” and maintaining local responsibility even during times when overwhelming catastrophe will not allow the innate health system to operate. Simply, it is the guide to external sources on how to manage the affected population when local leadership and local management are incapacitated.

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2.3. To Deliver Disaster Medical and Public Health Emergency Services When the local impact has been substantial, a transition from a standard or usual manner of care delivery into a sufficiency or altered health care delivery is ongoing. Conditions such as these demand that additional, often non-local medical and public health emergency services and providers are used. Utilization of such resources to optimize remaining or reestablish local health care infrastructure is common. Strategic and tactical planning must address this altered care environment. In the USA this would include State-based, Federal, and other national level resource integration. Important considerations are the governing regulations and licensing practices. Legal declarations and proclamations have specific criteria that must be met before use of most Federal assets can be formally requested or utilized. Many local areas are not adequately knowledgeable or experienced in the use and integration of Federal or even State pre-established response teams, personnel acquisition, or external accessible resources during such austere times. The strategic approach must be formulated in a manner acceptable to the organizational structure of the designated incident command system and consistent with the unifying principles of emergency management. This will require a considerable level of system-specific understanding for domestic planning. The National Incident Management System (NIMS) is the nationally standardized model for the USA [14]. NIMS provides a nationwide template enabling government and non-governmental responders to functionally operate in domestic incidents. The National Response Framework (NRF) is the all hazards response guide for the USA [15]. The National Response Plan (NRP) was an important milestone is establishing this framework and it was replaced by the NRF in March 2008 [16]. These documents allow for coordination among Federal, State, local, tribal, nongovernmental, and private sector organizations. The Emergency Support Function (ESF) Annexes of NRF framework is a grouping of government and certain private-sector capabilities used to provide support, resources, program implementation, and services. ESFs are routinely utilized in USA domestic disaster response and recovery. Emergency Support Function (ESF) #6 – Mass Care, Emergency Assistance, Housing, and Human Services, coordinates the Federal delivery of these services when local, tribal, and State response and recovery needs exceed their capabilities [17]. ESF #8 is entitled the Health & Medical Services Annex [18]. It provides coordinated Federal assistance to supplement State and local resources in response to public health and medical care needs following a major disaster or emergency, or during a developing potential medical situation. Inherent challenges are created when integrating the wide-range of health care needs of affected populations, such as the special populations or medical special needs patients previously defined, into a rigidly structured operational management system such as the ESF annexes. During USA domestic responses it is common to encounter situations in a Federally declared event where this subgroup falls outside the ESF defined borders of mass care (ESF #6) and public health and medical services (ESF#8) [8]. Because of the magnitude of people in this special population subgroup, this is an issue of significant national concern. This highly vulnerable population remains at risk of not “fitting in” to the very system that was designed to provide their help. Challenges such as these are commonly managed within the NIMS-NRF. The local or regional Emergency Operations Centers (EOC) would address such issues. The use of a Health Emergency Operations Centers (HEOC) as a centralized coordinating

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center for disaster medical and public health information is a vital link in the emergency management operations [19]. Once identified at the HEOC or equivalent, the issue would be resolved or reported to the State EOC, and /or a request made to the Multi-Agency Coordination Center (MACC) for accessing additional resource allocation through coordination with state, national or global participating entities and agencies. The complexities of a strategic approach to deliver disaster medical and public health emergency services on a global level, involving the integration of international systems and regional guiding principles are significant. The criteria for valid requests and accessibility to assets from various nations, well-established global agencies, nongovernmental organizations (NGO), etc. must be incorporated into the strategic planning process if timely response from such entities is likely to occur. The conclusion of this particular strategic principle should be focused on the transition, from the necessity-demanded sufficiency or altered care delivery model, back towards the reestablishment of a standard or usual care delivery through a functional local healthcare infrastructure. Reestablishing surveillance and access to care for the community is inherent to ensuring recovery.

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3. Health System Components Essential to Health Security The success of even a well-defined strategic approach for disaster preparedness and public health emergencies is determined by the cooperative working of many pieces in concert. Recognizing the components that impact health security within the health system infrastructure is important. The health system is comprised of many component pieces that are required to meet the routine demands of health service delivery to their population. A description of all of these is beyond the scope intended for this work. Identifying those that greatly impact disaster preparedness and public health emergencies is the focus. Those that help establish a framework for assuring health security are the following: Health Systems Planning; Health Systems Capacity and Capability; Public Health Preparedness; Health & Medical Education and Training; and Health & Medical Scientific Advancement. It is important to recognize that each of these components is a piece of the overall health “security” system puzzle as depicted below (Figure 1). How does health security fit into these various pieces or components relevant to the health system? How do we assure that each important area is addressed to reduce overall vulnerabilities in the health system? These are important questions. In the USA, advancement of a given component often does not occur in a concerted planned strategic approach. Historically, it may occur from individual areas of self-interest by a given agency or institution without collaborative intent. Duplicative efforts, commonly encountered, when fostered in collaboration can be beneficial and provide for validation and best practice advancement. However, often these methodologies and efforts are motivated by selfinterest in an area determined by access to grant funding, academic niche pursuits, and political agendas. Additionally, inroads in a particular area often result from just-intime interests in response to a particular disaster or security-threatening event. The attention to one piece while seemingly lack of attention to another demonstrates the challenges in integrating these pieces. Establishing health security demands that all of

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Figure 1. Component pieces important for assuring health security.

these areas be addressed within the strategic approach established on the guiding principles identified.

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3.1. Health Systems Planning Efforts towards standardizing public health emergency and disaster preparedness planning should be commended. Through advancing a standardized approach we can improve seamless integration of resources and assistance between local, state, national, and global partners. This has significant challenges to implementation. As seen in the USA domestic efforts with NIMS, NRF, and the previous NRP, going from concept to operational success is a journey. The use of NIMS and NRP doctrine was utilized less than optimally during Hurricane Katrina and Rita in 2005. The reasons were manifold including unfamiliarity, inexperience, resistance to change, lacking implementation guidelines, and many other issues [20]. The improved implementation design post-Hurricane Katrina of NIMS and NRP was evident in Texas during August 2007. As Hurricane Dean was approaching the Texas coast, an Incident of National Significance was promptly declared by then Department of Homeland Security (DHS) Secretary Chertoff on 17 August 2007 [21]. Use of NIMS and NRP constructs by Texas State health and emergency management leadership in partnership with Federal agencies was accomplished effectively. This event was financially expensive but a valuable experience in testing many principles and organizational structure elements of NIMS and NRP. The operational utility of NIMS,

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prior NRP, and the new NRF based principles and structure has continued to be refined during the recent domestic USA events of Hurricanes Dolly, Gustav and Ike in 2008 [8]. The overarching desired outcome of this planning process is an organization well skilled at strategic and tactical planning, not simply a written plan. A written plan is a static description, while planning is a dynamic skill set. The static plan serves to help define a starting position and to manage initial resource allocation. However, an organization skilled at planning can implement, adapt, and just in time strive to meet new or changing demands placed upon it. Planning must also include community engagement and “buy-in”. It is at this level that resilience is fostered.

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3.2. Health Systems Capacity and Capability Health systems capacity and capability during a disaster is affected by many things such as identifying critical gaps in the quantitative healthcare workforce, the response effectiveness and the hardiness of the receiving facilities. A surge demand, or a significant increase in health service need that exceeds the usual resources available, may necessitate that external, supplemental local care delivery sites, or mass evacuation to remote care sites be implemented. One model for meeting this surge capacity need that exceeds the local medical facilities capabilities and capacities is the use of pre-planned field hospitals, augmented by using facilities of opportunity, and surge evacuation for utilization of distant medical facilities [6–9]. This model is built on the concepts of “Local Preparedness, Global Response!” previously described. Field hospitals are designed to supplement existing or replace nonfunctional innate health care facilities within the local disaster area. This pre-planned asset may have a variety of appearances and clinical service capabilities. From tent based structures to reconfigured sporting arenas are examples of such “field” hospitals [9]. During Hurricane Katrina, 2005, the Pete Maravich Assembly Center “PMAC”, which is a large sporting arena on the Louisiana State University (LSU) campus in Baton Rouge, Louisiana was utilized. The Joint Commission in 2006 reported that this was the largest acute care field hospital in USA history since the Civil War [9]. It is estimated that over 6,000 patients were treated or housed, and over 15,000 people were triaged at this site during its operation. The acuity of patients was significant as it was reported that at times up to 14-ventilator dependant patients were concurrently managed and its capacity included approximately 80 cardiac monitored beds [9]. When the pre-planned supplemental healthcare facilities are insufficient to meet the surge demands, using facilities of opportunity must augment them. Facilities of opportunity are just-in-time solutions and imply that the location, operations and use are uniquely determined as the need is identified. The use of an abandoned shopping center during Hurricane Katrina is one of several examples of these facilities [9]. Surge evacuation is the evacuation of disaster-affected people seeking healthcare services to distant facilities. It is necessary when the local medical surge capacity and capabilities become grossly exceeded in volume, acuity, or specific service need (e.g., hemodialysis, specialty surgery, etc.). The distance can be considerable and requires long-range aircraft and prolonged ground evacuation methods. The use of distant health care facilities places many challenges on the operations of this evacuation. Deterioration in clinical health status during prolonged transit times is likely. Appropriate observation by medical providers, on-board medical equipment, accessing emergency care in-transit, and routine dosing of essential medications are

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some of the operational challenges encountered. Even meeting the basic comfort care needs of temperature controlled evacuation vehicles, sufficient on-board food and water access, toilet / rest room access present challenges [6–8]. Ensuring safety is the primary operational challenge during evacuations. Vehicular accidents resulting in multiple deaths and severe injuries are encountered, such as the horrific bus accident near Dallas, Texas during Hurricane Rita in 2005. This bus fire accident claimed over 20 lives alone [22]. During Hurricane Katrina, the evacuation distance included states located several hundred miles away from the impacted local area. A published example of such a distant care site utilized was the Dallas Convention Center Medical Unit, in Dallas, Texas. During the 16 days of operations this medical delivery site treated over 10,000 emergent or acute care patients, averaging over 600 patients per day of operation. Only approximately 230 patients, less than 3% of the total volume seen, had to be transported to a higher level of care in the Dallas area. No deaths were reported during the facilities operations [23]. The use of distant facilities, as in Dallas, raises many discussion points. Clearly, the ability to manage 10,000 emergent and acute patients, averaging 600 per day, is a significant surge capacity asset. Sufficiency of care in an altered care environment (e.g., Dallas Convention Center) can be effectively delivered, and with minimal impact on the local healthcare infrastructure. This field hospital-equivalent protected the local Dallas health facilities. The Dallas area hospitals, medical centers and office-based sites continued usual operations during this tremendous surge in health care provided at the convention center to these evacuated guests. The legal, moral and ethical issues raised by the use of an alternate care facility during this situation are relevant. Issues of operating a large sufficiency of care delivery center while the usual standard of care continued in the same city, the value of preserving the local Dallas infrastructure for health care, etc. are interesting topics for future consideration. Surge evacuations for providing alternative access to health care is now commonplace during Gulf Coast hurricane experiences. Large-scale evacuations of health care facilities, nursing homes, and special needs patients from their home environment during Hurricanes Gustav and Ike, 2008, demonstrate this activity. The continued use of this domestic USA “global response” principle has truly global implications when one considers the potential for large-volume medical patient evacuations to accepting nations. Within a few hours any major city throughout the world could encounter a healthcare surge demand of significant magnitude from a regional disaster affected nation. 3.3. Public Health Preparedness The operational role of the public health system in a public health emergency such as a pandemic is critical. Public health preparedness for disasters has a broad scope and a multifaceted composition (e.g., syndromic surveillance, quarantine, isolation, triage, mass vaccination programs, laboratory screening, resource allocation, etc.). Pandemic preparedness is a timely example of the importance of public health and clinical medical collaboration. The emphasis on population-based decision-making, while overwhelmed with individual patient care needs, demonstrates this collaboration’s importance. Public health preparedness is a key component to health security. Defining an appropriate level of public health preparedness is challenging. In principle, it must be scalable and seamlessly integrated into the overall health and

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medical phases of disaster management. Additionally, it must address the issues unique to public health emergencies. It must also be effective in threat analysis, risk communication, situational awareness, and information sharing. These tasks would be coordinated through an HEOC within the incident management structure. Crucial to effective public health preparedness is the collaboration of the public health system with medical service providers and health care facilities. Historically in the USA, the relationship between public health and clinical medicine was not as strong or highly valued as it should have been. The good news is significant improvement is ongoing. Sentinel events, such as the Anthrax attacks, Hurricane Katrina, SARS, and H1N1 pandemic preparation, have fostered a new paradigm of cooperation and mutual respect. Anthrax attacks in 2001, for example, demonstrated this improvement through jointly managing challenges such as “white powder” events, laboratory screening dilemmas (e.g. nasal swabbing), and challenges with treatment and prophylaxis therapy. The collaborative efforts of leading organizations such as the American Medical Association (AMA) are also strengthening these bonds. Public health preparedness must focus on improving the operational delivery of health services during a disaster. As operationally experienced academic-based senior medical advisors, the need for improved accessible, deployable, modular public health and disaster medical teams was noted particularly in the post September 11, 2001 era. The limitations observed in Federal response assets (e.g., National Disaster Medical System [NDMS], Disaster Medical Assistance Teams [DMAT]) and the overall lack of State and local preparedness, clearly demonstrated that a critical gap was present. The need for a state-based emphasis on this team design was evident in the years leading up to Hurricane Katrina. Field-testing portions of this concept began during Hurricane Katrina and Rita and have continued to date [6–8]. In the USA, this need for a state-based emphasis rather than a disproportionate dependency on Federal assets has been recognized by leading State and National health officials in briefings provided by operationally field experienced senior medical advisors [10, 24]. In Texas, this is the conceptual framework for the development of an integrated statewide disaster response system. It is an ongoing collaboration with leaders from the Department of State Health Services (DSHS) and two academic health science centers the University of Texas Southwestern Medical Center at Dallas and the Texas A & M University Health Science Center in College Station. The Texas DSHS Commissioner of Health has provided opportunity for continued field-testing of these collaborative efforts with the founding senior advisory members, including use during Hurricanes Dean, Dolly, Gustav, Ike and other events. Modular component strike teams have been utilized in several capacities including rapid early response medical and public health assessment, incident management team augmentation, tactical-disaster medical operations, clinical support for facilities of opportunity, and triage. This Texas Disaster Medical and Public Health Assessment and Assistance Task Force (TxMAT) is a work in progress and represents a model for state-based improvement in supporting its own disasters and may better facilitate the integration of Federal disaster and public health assets during nationally declared disasters [10, 11]. 3.4. Health & Medical Education and Training To achieve an effective global-accepted approach to disaster medicine and public health emergency preparedness requires guidelines and standards for training and education in this discipline.

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In the USA, the National Disaster Life Support (NDLS) Foundation and Educational Consortium lead a comprehensive, nationally standardized family of all-hazards training programs [4, 25–29]. Ongoing domestic development and management is by a multidisciplinary consortium of academic, agency, state, and federal centers. Novel uses in educational design and methodologies, such as high fidelity simulation, have been published about these programs [30]. With a network of over 70 training centers throughout the USA, progress is being made to establish the desired standardized approach in disaster and public health emergency education and training [28]. Education and training programs must reflect pre-identified community hazard vulnerabilities. Community based programs (e.g., evacuation drills) must foster resilience and aim towards reducing morbidity and mortality. These programs need to address relevant ethical, moral and legal issues. Recent public health forums in New York City demonstrated the effectiveness of discussing a critical issue, the allocation of scarce resources such as ventilators in pandemic in order to develop an ethically accepted protocol [31]. Conducting disaster drills and exercises are essential to improving health security [32]. These are vital to achieving a prepared workforce and leadership personnel [32]. Drills and exercises that include the practical challenges inherent to obtaining accurate situational awareness will provide a greater test of the health system thereby ensuring health system hardening and improve health security. These must be included in a comprehensive education and training program. Globally, there are many examples of quality training and educational programs. Each of these programs is important to achieving global guidelines through the sharing of best practices, collaborative curriculum and competency design, and joint training educational initiatives. As an example, the NDLS program concepts and the Basic Disaster Life Support course was well received during the National Atlantic Treaty Organization (NATO) Advanced Study Institute (ASI) 2006 program held in Skopje, Republic of Macedonia [4]. Collaborations with several global partners, has now resulted in NDLS training centers established in multiple nations [28]. Multinational tabletops such as the NATO-ASI 2008 BioHaza program’s facilitated exercise held in Milan, Italy is an example of bringing nations together and to share common solutions and challenges. These collaborations show promise of mutually working together to establish global guidelines and standards in training and education in disaster medicine and public health preparedness. 3.5. Health & Medical Scientific Advancement “We are seeing the evolution of disaster medicine as its own body of knowledge,” [33]. The future of disaster medicine and public health preparedness demands that peerreviewed, evidence based information, identify the scientifically sound fundamental principles for health and medical providers. This focus on advancing the discipline of disaster medicine is occurring in many countries. The recent establishment of the journal of Disaster Medicine and Public Health Preparedness (DMPHP), an official publication of the American Medical Association is fostering this scientific advancement [34]. Recent articles in the Journal of DMPHP are helping to guide the future of disaster medicine as a discipline in the USA. A consensus-based approach that provides an educational framework and a comprehensive competency set is an important step in that process [35]. This article is an important, direction setting consensus for disaster medicine in the USA. The pursuit

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of valid curriculum content and continued refinement of standards in education and training will benefit from such publications. One of the ongoing challenges to the scientific advancement of this area is the difficulty in obtaining statistically valid data during or even after disasters. Situations of austere environments, limited communication options, and the shear volume of the human needs present will continue to challenge research and study design implementation during disasters. Yet, like in many disciplines of medicine, clinical providers and related scientists have overcome many challenges in conducting research. The future patients, injured or ill from a disaster or public health emergency, demand that we achieve these inroads. The importance of achieving excellence in all of these vital component pieces is obvious. Yet, like pieces of a puzzle, they must fit together in a meaningful manner. How does health security then “fit in” to this puzzle?

4. The “Tools” of Health Security In this model, health security is seen as an essential piece that helps complete the health system puzzle. It requires “tools” to meaningfully arrange these pieces and properly make the shape for a health security “fit”. The tools to assemble this puzzle are communication, collaboration and implementation.

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4.1. Communication Communication is often noted as the leading problem in disaster preparedness and response. The value of establishing and strengthening relationships among organizations, agencies, local, national, etc. cannot be overstated. The phrase “you never want to meet a stranger during a disaster” implies the need to establish effective lines of communication with the groups or individuals likely to be impacting disaster response and recovery outcomes prior to an occurrence. The ability to align these individual pieces requires appropriate communication be established. 4.2. Collaboration Collaboration could be described as two or multiple parties willfully working together for mutual benefit. Collaboration begins with effective communication. Although the strength and resolve of each component piece is important, it is the joining of strong pieces together that defines the system. Collaboration is essential to meaningfully establish health security. 4.3. Implementation Implementation is the action steps taken to solve needs and meet the objectives. Without effective implementation the best strategic and tactical planning will not be successful. Critical to successful implementation is good communication and collaboration. Evaluation methods must be in place to assess system readiness. Drills and exercises are important to functionally assess the implementation status. Objective

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based quantitative and qualitative assessment of performance measures is the root to meaningful outcomes from drills and exercises. In the USA, conducting realistic, meaningful drills and exercises are limited by the cost, concern of actual clinical care disruption, personnel utilization, and potential for negative performance reporting. Gaining inroads in implementation through proper drills and exercises is worth the investment and risks. These tools of communication, collaboration and implementation are essential to health security. They are the foundation or puzzle mat that holds the component pieces of the health system in place. When properly aligned, these essential components assure a fit for health security (Figure 2).

Figure 2. Assuring a “fit” for health security in the health system.

5. Conclusions Health security is definable. Health security broadly encompasses the strategic, tactical, and operational infrastructure and hardening that ensures health system preparedness, the delivery of appropriate health and medical services, and swift recovery on behalf of impacted populations. Heath security is an inherent piece of the health system. This definition and concepts on health security are derived from field experience and operational decision-making. Health security is measurable. This definition of heath security focuses on a measurable preparedness outcome by fostering resilience and meeting the critical and

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time-sensitive health and medical demands of affected communities. The expression, Health System > Health Demand Time describes a minimal threshold in achieving health security is present when the health system timely meets or exceeds the health and medical demands encountered. Assurance that an appropriate level of these services can be delivered routinely and during a surge in demand, or during a reduction in health system capacity or capability is vital to population well-being. Health security is achievable. Achieving health security in this model requires that the responsibility and ownership for health security reside within the local health care system. A well-defined strategic approach is required. It is crucial to identify and address key health system components that directly impact health security. Placement and integration of these components requires proper utilization of communication, collaboration and implementation as tools to position the puzzle pieces together to shape and fit health security. Health security is dynamic. In the figurative puzzle of health security, the ability to attach additional pieces surrounding all sides is important (Figure 2). The components essential to disaster medicine and public health preparedness may need to expand, encompassing a number of other pieces of the larger overall health system. This is the framework of a seamlessly integrated, scalable disaster and public health emergency prepared system. This is the heart of achieving health security. Vetting these concepts in health security to the global community is important. Presentations and discussions with multinational leaders on this concept and model to achieving health security have been well received [36–38]. Forums, such as NATO-ASI BioHaza-Milan 2008, provide an excellent milieu to discuss local, regional, and global health issues. This is highly valuable in the aim towards improving the overall health security of many nations. This particular forum allowed these concepts in health security to be presented and discussed relevant to a multinational, multidisciplinary approach to pandemics and bioterrorism [37]. As the world now faces the declared status of a pandemic, such a forum has proved to be quite timely and beneficial [1]. Each nation faces unique and shared challenges in attaining health security. This model may assist in providing the framework to address these challenges. The application of this concept in health security utilizing examples from domestic USA recent disasters affecting special populations was presented during an Institute of Medicine (IOM) of the National Academies forum workshop [38]. It was well received during this event. Through continued modeling and field-testing, inroads in health security are being achieved. Achieving health security is important to every nation and region. It is essential to disaster medical readiness and public health emergency preparedness. The ability to improve the health security for many nations is possible through working together. Let’s continue to work together!

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World Health Organization, World Health Day 2007: International Health Security. 29 March 2007. Geneva/Singapore. http://www.who.int/mediacentre/news/releases/2007/pr11/en/index.html R.E. Swienton, I. Subbarao, P.L. Coule, Healthcare Disasters: Local Preparedness, Global Response! National Atlantic Treaty Organization (NATO) 2006 Advanced Study Institute (ASI) Skopje, Republic of Macedonia: Strengthening National Public Health Preparedness and Response for Chemical, Biological, and Radiological Agents. C.E. Cummings, E. Stikova. IOS Press 2007; 11-14 Merriam-Webster, online dictionary http://www.merriam-webster.com/dictionary/inroad State Operations Center and field deployment: R.E. Swienton, M. Proctor, P. Pepe Serving as Senior Medical Advisors of Disaster Medicine, Public Health Preparedness and Emergency Management to the State of Louisiana, Dr. Jimmy Guidry, MD, State Health Officer. Hurricanes Katrina and Rita, September 2005. State Operations Center and field deployment: R.E. Swienton, P. Pepe Serving as Senior Medical Advisors of Disaster Medicine, Public Health Preparedness and Emergency Management to State of Texas, Eduardo Sanchez, MD, MPH, Commissioner of Health, Texas Department of Health. Hurricanes Katrina and Rita, September 2005. State Operations Center, Multi-Agency Coordination Center and field deployment: R.E. Swienton, S. Lillibridge, M. Proctor Senior Medical Advisors of Disaster Medicine, Public Health Preparedness and Emergency Management to the State of Texas, David Lakey, MD, MPH, Texas Commissioner of Health, Department of State Health Services. Hurricane Dean, 2007; Hurricanes Dolly, Gustav and Ike, 2008. Surge Hospitals: Providing Safe Care in Emergencies. The Joint Commission on Accreditation of Healthcare Organizations. 2006. http://www.jointcommission.org/NR/rdonlyres/802E9DA4-AE804584-A205-48989C5BD684/0/surge_hospital.pdf R.E. Swienton, S. Lillibridge, M. Proctor Invited white paper and briefing: Texas Disaster Medical System. Prepared for David Lakey, MD, MPH, Texas Commissioner of Health and Department of State Health Services (DSHS). Austin, Texas. April 2008. RE. Swienton, Cover photograph and summary of Texas Disaster Medical and Public Health Assessment and Assistance Task Force (TxMAT). J of Disaster Medicine and Public Health Preparedness. American Medical Association, Wolters Kluwer-Health, Lippincott Williams & Wilkins. Chicago. October 2008 Texas Medical Center: “About the Texas Medical Center”. http://www.texmedctr.tmc.edu/root/en/ GetToKnow/AboutTMC/About+the+TMC.htm Onsite interviews of B. King, W. Edwards, K. Mattox, et al., at The Methodist Hospital, Ben Taub General Hospital of the Harris County Hospital District, and Memorial Hermann - Texas Medical Center, Emergency Departments. Houston, Texas. Conducted by Swienton RE, Subbarao I, Moore P. September 16, 2008 National Incident Management System. U. S. Department of Homeland Security. December 2008. http://www.fema.gov/pdf/emergency/nims/NIMS_core.pdf National Response Framework. U. S. Department of Homeland Security. January 2008. http:// www.fema.gov/pdf/emergency/nrf/nrf-core.pdf National Response Plan. U. S. Department of Homeland Security. December 2004, with 2006 revisions. www.dhs.gov/xprepresp/committees/editorial_0566.shtm Emergency Support Function #6 – Mass Care, Emergency Assistance, Housing, and Human Services Annex. U. S. Department of Homeland Security. http://www.fema.gov/pdf/emergency/nrf/nrf-esf06.pdf Emergency Support Function #8 – Public Health and Medical Services Annex. U. S. Department of Homeland Security. http://www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf http://www.fema.gov/pdf/ emergency/nrf/nrf-esf-intro.pdf F.M. Jr Burkle, E.B. Hsu, M. Loehr, et al. Definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ICS. Disaster Med Public Health Prep. 2007 Nov;1(2):135-41. A Failure of Initiative. Final Report of the Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina. U. S. Government Printing Office, Washington 2006. http://www.gpoaccess.gov/Katrinareport/mainreport.pdf Feds Gear Up To Support Texas In Advance Of Hurricane Dean. U.S. Department of Homeland Security. Release Date: August 19, 2007. Release Number: HQ-07-16. http://www.fema.gov/news/ newsrelease.fema?id=38889 Texas Bus Fire Kills 24 Evacuees. Posted on: Friday, 23 September 2005. http://www.redorbit.com/ news/politics/249785/texas_bus_fire_kills_24_evacuees/index.html A.L. Eastman, et. al. Alternate Site Surge Capacity in times of Public Health Disaster maintains Trauma Center and Emergency Department Integrity: Hurricane Katrina. J. Trauma. 2007; 63:253-257

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[24] U.S. Department of Health and Human Services, Office of Preparedness and Response. Invited Briefing by Swienton RE. Experience modeling State-based concepts during Hurricane Ike in Texas 2008. Presented to RADM W. Craig Vanderwagen, M.D.; Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services. Washington, DC. 02 February 2009 [25] Advanced Disaster Life Support (ADLS). Coule PL, Schwartz R, Swienton RE (editors). Provider Manual. Versions 1.0, 2.0. AMA Press, Chicago. 2003 [26] Basic Disaster Life Support (BDLS). P.L. Coule, C. Dallas, J.J. James, S.R. Lillibridge, P.E. Pepe, R. Schwartz, R.E. Swienton (editors). Provider Manual. Version 2.5. AMA Press, Chicago. 2003 [27] Core Disaster Life Support (CDLS). P.L. Coule, R.L. Fowler, D. Lakey, R.G. Miller, R.E. Swienton (editors). Provider Manual. Version 1.5. AMA Press, Chicago. 2004 [28] National Disaster Life Support Foundation. http://ndlsf.org/ [29] National Disaster Life Support Educational Consortium. http://www.ama-assn.org/ama/pub/physicianresources/public-health/center-public-health-preparedness-disaster-response/national-disaster-lifesupport/ndlsec/executive-committee.shtml [30] J.D. Orledge, R.E. Swienton. Integration of High Fidelity Simulation into the Advanced Disaster Life Support (ADLS) Course. Trauma Care, The Official Publication of ITACCS; Vol. 16:1; 2006; 34-41 [31] Powell T., Christ K, Birkhead G, Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep. 2007 March. [32] E.A. Gursky. “Pivotal Steps to Building Global Health Security” in Strengthening National Public Health Preparedness and Response to Chemical, Biological, and Radiological Agent Threats C.E. Cummings and E. Stikova, Editors. IOS Press: 2007; 17-24. [33] Wall Street Journal: Disaster Medicine’ Becomes a Specialty. Laura Landro, Health Correspondent. Interview of Swienton, RE, published quote. WSJ. Thursday, August 12, 2004. Page D1 [34] AMA Journal of Disaster Medicine and Public Health Preparedness. http://www.dmphp.org/ [35] I. Subbarao et al. A Consensus-Based Educational Framework and Competency Set for the Discipline of Disaster Medicine and Public Health Preparedness. Disaster Med Public Health Preparedness. 2008;2; 57-68 [36] Central Asia Regional Health Security Workshop. Swienton RE. Keynote presentation: Health “Security” Systems, Local Preparedness, Global Response! Convened by George C. Marshall European Center for Security Studies. Co-organized with the Ministry of Defense, Kyrgyz Republic. Bishkek, Kyrgyz Republic. 11-14 March 2008 [37] NATO-ASI BioHaza-Milan 2008. Swienton RE. Presentation on Health “Security” Systems: Local Preparedness, Global Response! San Raffaele Hospital and Medical School Campus. Milan, Italy. 04 December 2008 [38] Institute of Medicine (IOM) of the National Academies. Board on Health Sciences Policy. Forum on Medical and Public Health Preparedness for Catastrophic Events. Medical Surge Capacity – A Workshop. Session VI: Vulnerable Populations: Behavioral health effects and medical needs for at risk populations. Discussion Panel: Enhancing the Health Care System’s Capacity to Care for those with Special Medical Needs. Swienton RE presented: Enhancing the Health Care System’s Capacity the Chronically Ill. The Keck Center of the National Academies, Room 100, 500 Fifth Street, Washington, D.C. 11 June 2009.

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Tools Against Terrorist Threats: Considerations on How to be Prepared Massimo RANGHIERIa,1, Matteo GUIDOTTIa,b and Alessandra ROSSODIVITAc a SMOM Auxiliary Corps of the Italian Army, 1st Field Unit, Milan, Italy b CNR-Institute of Molecular Sciences and Technologies, Milan, Italy c Department of Cardiothoracic and Vascular Diseases, San Raffaele Hospital, Milan, Italy

Abstract. While the availability and production of CBRN weapons cannot be controlled as in the case of conventional weapons, the increase in number of nuclear and petrochemical plants, as well as the developments in biological sciences, has increased the risk of non-conventional industrial disasters defined as ROTA events. Therefore, many countries have started to take serious measures for the protection of civilians and military against the effect of CBRN disasters. The use of special teams to organize Emergencies Preparedness Offices (EPO) is vital: this overview will explain duties and assessments of EPO in a modern society. Keywords. risk assessment, hazardous materials, non-conventional terrorist attack, disaster prevention plan for infectious diseases, psychosocial relief, forced clearance, evacuation, decontamination, education training and practice

Introduction

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In the evaluation of potential risks, it is necessary today to consider CBRN threats, that may come from one of the following major areas: • • • •

International terrorist groups Domestic terrorist groups Individuals Accidents: releases other then attack (ROTA events)

The objectives of such threats can be considered to be: • • • • • • •

Military or Police headquarters Airport and subways Railways station Industrial plants Nuclear and chemical plants Nuclear research centers Petrochemical plants

1 Corresponding Author: Massimo Ranghieri, 1st Field Unit, via Saint Bon 7, 20147 Milano, Italy; E-mail: [email protected] or [email protected].

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• • • • • •

Exhibitions and fairs Governmental and Public buildings Private companies Water reservoirs Hospitals Educational institutions

Today the danger from the use of chemical or other “non conventional” weapons will probably come from either countries with radical regimes or terrorist groups. It is widely accepted that radical regimes and terrorists have the means, the motivations, the opportunity and the knowledge to use CBR weapons. The probability of a N-type event is generally considered remote and, for this reason, the occurrence of such major event is not taken into account in detail in the present text. The availability of raw materials to be used as a CBR(N) weapon cannot be easily controlled as the case of conventional weapons. Thus, realizing this, many countries have started taking serious measure for the protection of civilians and military personnel, against the effect of CBR(N) contamination risks. Furthermore, the increased number of nuclear and petro-chemical plants, as well as developments in bio-sciences has augmented the risk of CBRN disasters. Therefore, preparedness and planning for this type of emergencies is vital for a well-organized community.

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1. Risk Assessment An effective Medical Emergency Preparedness and Planning Office (MEPPO) should aim at delivering a high quality medical response to emergencies. When a disaster happens, there is no time to discuss in details on how to operate. Health care workers and volunteers need to know what to do and they should be able to act immediately. In order to achieve this, the development of protocols evaluation of incidents and the training of care workers are important activities for any Emergencies Preparedness Organization (EPO). Additionally, by mapping the potential risks, the EPO officers are better prepared for possible calamities. Areas with a large number of chemical plants, storage places for chemicals or oil refineries, must suggest questions to EPO Officers, in order to identify how to deal with incidents with hazardous material. The main need and focus should be on the improvement of risk inventories and of risk evaluation tools, as well as the development of methods for risk assessment during unpredictable events. When incidents with chemical agents occur, the public expect a reliable answer to questions such as: “What are the risks?”, “Will it affect my health?” and “What should I do?”. In such cases, EPO Officers have to investigate the health issue: a trained officer has to interpret the results of measurements of air and water samples in order to assess the risk to the population. The process of interpretation, advising and communication includes close consultation with chemical experts of Environmental and Protection Agencies, Fire Services or other experts. The EPO Officers communicate the necessary information and advice to citizens, companies and health care workers. Typically, in each country, a series of National Laws regarding risk prevention, in the case of major industrial accidents, are applied. These laws define the safety

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demands for high-risk companies using or storing large quantities of hazardous materials. The obvious purpose is to prevent and limit the possibility of accidents with toxic or dangerous compounds. Local authorities have to draft a prevention plan to prepare a reaction against possible accidents at these companies and similarly have to prepare a prevention plan for local airport, or stadium or train/subways stations. The EPO Officers should provide information on the required level of medical assistance, including the possible number of victims and the characterization of injuries to be expected.

2. Hazardous Materials In case of accidents or disasters with hazardous materials, an EPO Officer needs to obtain information about the risks to the population and medical personnel, Cooperation among EPO Officers, Fire Service Department, Health Protection Agencies, is mandatory, to evaluate if short- or long-term health effect may be expected. The classification of hazardous materials according to CBR risks is simple: C B R

Chemical Agents (which can cause fire, explosion, intoxication) Biological Agents (micro-organisms, bacteria, virus and fungi, toxins) Radiological Sources (for example, iodine 131 or nickel 63)

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2.1. Chemical Events On a regular basis, any region could be affected by chemical events, from a simple type, such as an incident involving a tank vehicle, to a large one, such as a fire in an oil refinery or a petrochemical plant. All these events involve toxic clouds or fire. Smoke from fires may contain a variety of chemicals, depending on the object of fire, which upon inhalation can lead to intoxication or even death. Exposure to smoke may result in acute effects, such as cyanide or carbon monoxide intoxication. Therefore it is vital to determine quickly the possible effects on health. Chronic Obstructive Lung Disorders (COLD) effects can strike elderly and children, that are at risk, since they are particularly sensitive to toxic compounds. Long-term effects have to be put in evidence, to understand the need of protection and the tools to be used by responders and healthcare workers. EPO Officers should decide about triage, treatment and decontamination or the risk of contaminants and assess the health risks of exposure to chemical agents advising about quarantine or evacuation procedures. 2.2. Biological Events When a biological accident occurs, EPO Officers in consultation with Health Protection Agencies, Environment Protection Agencies and Fire Departments advise about treatment, decontamination, monitoring on further spreading, risk of infection as well as about selection and use of proper personal protective countermeasures. When a region is confronted with an infective disease outbreak, a Disaster Prevention Plan for Infectious Disease should be applied. This plan covers the prevention against general and specific infectious diseases (influenza, smallpox, swine

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flu, SARS, etc.). EPO Officers have also an important role in the treatment and protection of victims as well as of the medical staff, in case of biological events. In particular, they have to plan and provide decontamination, isolation, quarantine, and movements limitations of large numbers of citizens. They have also to evaluate and give advise on protective medical measures (vaccinations and/or medications). The decision about the countermeasures to be adopted always should be taken in close consultation with infectious disease specialists, in order to highlight possible long-term health risks. 2.3. Radiological Events The occurrence of a R-type event is not limited to the areas where atomic power plants are in use. Actually, Chernobyl disaster and the clouds derived from it that spread out for miles downwind, imposes a careful planning in this aspect too. A careful and capillary radiological surveillance system is needed over huge areas (sometimes covering different countries) according to the magnitude of the event.

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3. Disaster Prevention Plan for Infectious Diseases Large-scale infectious diseases control is needed when a large number of patients are expected to overload public health services and/or when the disease may pose a risk to public health. Disaster prevention plans also contemplates the suppression of diseases intentionally spread among the population by enemy forces or terrorists (bioterrorism). Why such a plan is desperately needed? A large-scale outbreak of infectious diseases has a great impact on society. Ten to twenty per cent of the population of a nation is expected to fall ill. This situation may lead to possible absences, creating vacancies in the functional social works with all consequences of it. If we consider the chain of consequences connected to a massive absence in the personnel of transportation, banking, post offices, fire brigade, police, hospitals and so on, the situation can be impressive: an entire society will be put down. Communities are greatly affected by the major measures that have to be taken to content or to suppress the disease. This is achieved by separating affected people from non-affected ones, closing schools, and canceling large events. These measures consequently also affect industry and the logistics of a country: it is vital, therefore, to be prepared. In general, the disaster prevention plan describes the all-purpose principles of prevention of large-scale infectious diseases outbreak, which are applicable to all pathogens. More in detail, we could consider three scenarios: 1) Influenza: Special measures have to be taken in order to suppress a new influenza virus which may be spread quickly and cause illness and death, when no vaccine is available. 2) Smallpox: Attention has to be paid onto massive infection of the population; vaccination programs must be organized, that may and impact a remarkable number of specialized manpower. 3) SARS: Specific countermeasures need to be taken for incidental cases of SARS or patients suspected to carry SARS virus, in order to prevent further spreading of the disease.

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A proper sequence of practical drills should be actuated in order to confirm preparedness or indicate mishaps in the emergency chain. The use of models to reproduce different scenarios is recommended and there is a large quantity of specific software now available from specialized enterprises.

4. Psychosocial Relief When confronted with a sudden life-threatening situation, the people’s thoughts are focused on one single priority: to be able to get their lives back to normal. Disasters are, of course, major events with enormous effects on individuals and society. The sooner the victims of an accident regain their self-control, the greater is the chance of being able to elaborate the event. The starting point for psychosocial relief is that medical and paramedical staff has to deal with individual normal reactions to abnormal situations. This requires a specific level of expertise, for which the personnel, including first responders, is trained continuously. While, fortunately, disasters do not occur on a daily basis, expert and specialized staff has to be on standby all the time. A great deal of time is then invested to train and maintain proper Psychosocial Relief Teams. The goal of such trained teams, immediately following a disaster is to provide shelters for the victims: • • •

To stimulate the recovery of the psychological balance (self-control) of the victims. To identify which victims require urgent psychiatric care and provide support. To identify as early as possible process disorders and adequate treatments.

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It is necessary to distinguish between two categories of disaster victims: • •

Direct Victims: people who experienced the event and found themselves in a life-threatening situation. Indirect Victims: people who did not directly experience the disaster, but that, through their relationship to direct victims (first responders, professionals, etc.) are connected or affected by the disaster.

The latter is a broad category that may include children, relatives, partners, neighbors, eye-witnesses, teachers, lifeguards, auxiliary and service staff, police crisis teams, and those whose psychological status is put in danger by the disaster. EPO should include and prepare adequate resources to cope with psychosocial emergencies arisen during a disaster situation: the size and the gravity of disaster itself determine how far the “psychosocial responders” staff has to be engaged and implemented.

5. Shelters, Forced Clearance, Evacuation In some major events, the effects of a disaster involving hazardous materials may stretch out for miles away from the original source of the accident. Therefore, the

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population that may be affected by the consequences is very numerous, with a remarkable concern for health problems over a wide area. EPO Officers must draft nationwide protocols about sheltering in place, or evacuation during unpredictable events with hazardous substances. Such protocols have to be carried out in cooperation with Health Agencies, Fire Department, Police and Environmental Agencies. Risky situations are defined by the duration, concentration and the route of exposure and by the vulnerability of the subjects exposed. Protocols, set up by EPO Officers must allow the crisis management teams to evaluate and select the countermeasures to be adopted for the population affected, such as staying indoors, clearance or evacuation. The crisis management staff is responsible for the final decision. When alarm signals indicate an emergency, the population is advised to stay indoors, seal windows and doors, listen to local radio instructions. A temporary shelter might be a room or a building offering protection against toxic clouds for a limited period of time: shelters are useful to protect people against gas releases or toxic clouds. Clearance means that people are forced to leave their homes for a short period of time. In general clearance involves a small-scale, short-time transfer of people and/or animals to a safer place: people are not only removed by their homes, but also from public places, offices and so on. Evacuation involves the involuntary transfer of people and/or animals. This includes registration, transfer, accommodation, care preparation for the return and follow up care. Evacuation is usually a long-term, large-scale measure (with an average timeframe of days), which may be forced by authorities and performed under supervision. It requires good preparation, thorough planning, analysis of resources, study of transports, subdivision of areas, analysis of the population composition, housing capabilities, industry involvement, evaluation of the hazardous materials, season, days of the week, time of the day and so on. A decision to evacuate will only be taken in case of a massive emergency, when no possible alternative can be considered, to save lives.

6. Decontamination When events with hazardous materials occur, EPO Officers assess the risks towards public health and determine, in accordance with the Fire Department, if decontamination is required. Contamination is defined as the amount of hazardous agent, which remains present on humans, animals or objects, after exposure to a hazardous material. Decontamination is thus defined as all measure needed to remove the hazardous agent from humans, animals, objects or environment, in order to eliminate or reduce further health risks. Considering, for instance, the case of a chemical accident followed by chemical contamination, as long as the toxic compound is present, it continues to spread and results in continuous exposure. This may increase chemical injuries and it is therefore vital that healthcare workers are adequately protected. Moreover, contaminated victims may pose a risk as a source of secondary contamination for other healthcare operators, for the material they use, for ambulance employed to move the contaminated victims and for the hospitals. Rapid decontamination is evidently crucial, at the site of the incident.

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When exposed to the contaminating agent, lungs (inhalation), skin (absorption), open wounds are the most important routes of entry to cause further internal tissue damage and intoxication. In these cases, Fire Departments, in cooperation with EPO officers, determines whether decontamination is required and how it should be carried out. According to international standards, the site of the event is divided in three areas: hot zone, warm zone and cold zone. Hot Zone: the area directly surrounding the source of pollution or where the event occurred. Only protected Firefighting personnel (or other professionals, according to local prescriptions) is allowed in this area. They determine: • •

The protective measures required for this area The size of the hot and warm zones, which depends on several parameters (e.g. type of hazardous material or wind direction and strength)

Victims are removed from the hot zone and taken, undressed, to the warm zone, by the Fire Service personnel. Warm Zone: the decontamination unit (shower area) is situated within this area. First responders and health care workers are permitted to enter and operate in this area, only if they are protected by personal protection devices, and properly trained. Only if inevitable, lifesaving treatments are performed here, followed by decontamination and redressing the victims. Cold Zone: Protective measures are not necessary. Victims are transferred from this zone to the on-site treatment facilities, after stabilization. Final destinations are usually hospitals, medical or paramedical teams or other organizations.

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7. Conclusions Education, Training and Practice are obvious conclusions to assure proper preparedness. EPO should dedicate a remarkable amount of time in training adequately their staff, considering that while terrorist attacks or ROTA events do not occur frequently, there is however a constant need of trained people to be ready to go into action at any moment. Staff should therefore operate on a “24/7 on call” system to assure rapid deployment when needed. To achieve this, training programs should be able to certify that people involved, and staff components, can perform a quality service, following rules and procedures properly defined and verified. The equipment should be tested as well as the communication protocols, to assure a safe flow of information and actions. Practice is important for the continuous exercise in order to prevent lack of communication in operative situations. It is important that all the mobilized staff is well trained and aware of each other’s function. Training is therefore arranged not only to cover specific and detailed competences, but also, at multidisciplinary level, to better develop a proactive understanding of each other’s role. Every training test should be completed with an evaluation to identify not only the weak areas in the process, but also the areas that work efficiently during practice. The results can be used to improve the service by adjustments and implementation of protocols and guidelines.

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A proper planning approach against major disasters and/or terrorist threats, will surely lead to lessen stress of operators and the population. Consequently, the public opinion will express the feeling of safety and protection by experienced professionals.

Acknowledgements M. C. Ranghieri and M. Guidotti acknowledge Dr. Rossodivita and Dr. Trufanov for the stimulating exchange of opinions in the field of CBRN issues. The authors also thank the Italian Association of the Sovereign Military Order of Malta, and Italian Army General Staff (Stato Maggiore Esercito), for the support given to BioHaza 2008.

References [1] [2] [3] [4] [5] [6] [7] [8]

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[9] [10] [11] [12] [13] [14] [15] [16]

A. Dwyer, J. Eldrige, M. Kernan, Jane's Chem-bio Handbook, Janes Information Group, Coulsdon, UK, 2003. London Emergency Services Liaison Support (LESLS), Major Incident Procedure Manual, 6th Edition, July 2004. http://consilium.europa.eu/uedocs/cmsUpload/EUplan16090.pdf, EU Plan of Actions on Combating Terrorism, Update 10 June 2005 (visited on August 21, 2009). http://www.consilium.europa.eu/uedocs/cmsUpload/ESDPdimension.pdf, Conceptual Framework on ESDP Dimension of Fighting Terrorism, June 2004 (visited on August 21, 2009). http://www.iss.europa.eu/uploads/media/rep05-03.pdf, G. Lindstron, The ESDP Contribution to the Fight Against Terrorism, 7 March 2005 (visited on August 21, 2009). L. E. Davis, T. LaTourrette, D. E. Mosher, L. M. Davis, D. R. Howell, Individual Preparedness and Response to CBRN Terrorist Attack, A Quick Guide, Rand, Santamonica (USA), 2003. http://www.scotland.gov.uk/Resource/Doc/47032/0014781.pdf, Guidance for the Emergency Services on Decontamination, Version 2, February 2006, (visited on August 21, 2009). Public health response to biological and chemical weapons: WHO guidance, World Health Organization, Geneva (Switzerland), 2004. Making the UK safer: detecting and decontaminating chemical and biological agents, The Royal Society, London (UK), 2004. http://www.consilium.europa.eu/uedocs/cmsUpload/78367.pdf, J. Solana, A Secure Europe in a Better World: European Security Strategy, Brussel 12 Dic. 2003 (visited on August 21, 2009). E. Croddy, Chemical and Biological Warfare, Springer–Verlag, Berlin, 2002. J. A. F. Compton, Military Chemical and Biological Agents, Telford Press, Caldwell (USA), 1987. A. J. Mauroni, Chemical and Biological Agents, Telford Press, Caldwell (USA), 1987. F. R. Sidell, E. T. Takafuji, D. R. Franz, Textbook of military medicine, Warfare Weaponry and the Casuality. Medical Aspects of Chemical and Biological Warfare, Borden Institute Walter Reed Army Medical Center, Washington (USA), 1997. J. B. Tucker, Toxic Terror. Assessing Terrorist Use of Chemical and Biological Weapons, MIT Press, Cambridge (USA), 2000. The Biological & Chemical Warfare Threat, US Central Intelligence Agency, Government Printing Office Washington, 1997.

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The Viewpoint of ED Personnel about Avian Flu: Do Emergency Department Healthcare Professionals Feel Ready to Face Epidemics/Pandemics? Efstratios PHOTIOU Senior staff member, Pronto Soccorso, Ospedale Sant’Antonio, Dipartimento di Pronto Soccorso e Medicina d’Urgenza, ULSS 16/Azienda Ospedaliera/Università di Padova, Italy

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Abstract. Influenza experts recognize the inevitability of an influenza pandemic, most probably an avian flu pandemic. Most indications suggest it is just a matter of time. Objective: To assess emergency department healthcare professionals’ (HCP) risk perception, possible affection of attendance pattern and willingness to work during a pandemic. Methods: An anonymous questionnaire was administered to physicians, nurses and auxiliary personnel of the Emergency Department, Short Observation Unit and Intensive Emergency Medicine Unit (Emergency Dept Unit, admitting patients with severe, acute medical conditions, excluding patients requiring invasive ventilation), employed in the Padova University Hospitals, Italy. Results: The overall response rate was: 69%; physicians 94%, nurses 73%, auxiliary personnel 56%. Conclusions: 1) there is a lack of the “culture of emergency” concerning epidemics/pandemics, which are emergencies ED personnel is not acquainted with; 2) in order to be able to cope with highly stressful situations like epidemics, the importance of timely, thorough information is paramount, regardless of the different methods; 3) periodic drills, continuous training, and active participation in acquiring information and training can create the sensation of making part of the whole system, thus increasing commitment. Keywords. avian flu, pandemic, Healthcare professionals, emergency department Abbreviations. ED: emergency department; HCPs: healthcare professionals; MCI: mass casualty incident; PPE: personal protective equipment.

Introduction Much is being said in these last years about the possibility of new epidemics. The reasons are globalization, re-presentation of diseases considered “past”, new flu strains, etc. For instance, microbiologists consider inevitable an avian influenza pandemic, on the basis of the increasing number of H5N1 infections in animals and humans. Two out of three prerequisites for an avian flu pandemic have already occurred: 1) presence of a novel virus (against which very low, if any, immunity exists); 2) H5N1 avian influenza virus is able to replicate in humans, while 3) avian flu virus is not yet clearly able to be transmitted from human to human.

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Facts To date, 90–100% of infected birds die of avian flu while, as of March 11, 2009, 411 humans were infected with a death toll of 256 deaths (62.28%, WHO). A new vaccine is being prepared, while its degree of protection is still unknown. Previsions are, however, that only a small percentage of the world’s population can be vaccinated. On the other hand, the interest of mass media has waned, especially in the Italian reality. Planning for a MCI, as a pandemic, should be on the agenda of every public health agency [1]. Emergency departments are high-risk, high-volume, problem-prone healthcare areas, and point of entry of infectious diseases. In EDs, the acceptance of the possibility of an infectious disease threat is paramount. The best blueprints available are: a) previous influenza pandemics; b) the 2003 SARS epidemic in Canada, China, Hong Kong, Vietnam etc.

1. Aim of the Study This survey aimed to assess how risk perception, in case of possible risk to self and family members and consequent stress, may affect attendance pattern and willingness to work during a biological mass casualty event, and to suggest means to reduce absentee impact through meeting HCPs’ needs/perceptions, by a) asking what HCPs suggest in order to better cope with an epidemic/pandemic; b) assessing how healthcare professionals consider the information, training and protective means concerning infectious diseases epidemics/pandemics. It is deemed that stress and fear may affect attendance pattern and willingness to work during epidemics/pandemics [2–5].

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will to report during bird flu pandemic 35 30 25 20 15 10 5 0

physicians nurses ward clerks yes

depends depends on certain on workpossibility related to contact issues family

no

no answer don't know

Figure 1. Will to report during bird flu pandemic.

The background for this survey is constituted by the results of a recent study, that was carried out in the Padova Hospitals Emergency Medicine Departments, concerning the will to report to work of the ED’s personnel (physicians, registered nurses and ward clerks) during a possible avian flu pandemic. This study (which is part of a multicentric trial, still ongoing, throughout several Northern Italian EDs) had disclosed that, while the majority of

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the personnel would report, a large percentage (especially nurses and clerks) does not know whether they would report, and others would present depending on certain issues: personnel: will to report 2% 5%

20%

yes depends/info depends/other do non know 58%

6%

no answer no

9%

Figure 2. Personnel: will to report.

2. Methods

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An anonymous questionnaire-based survey was administered to physicians, nurses and auxiliary personnel of the two Emergency Departments (together approximately 140,000 patients/year), the Short Observation Unit (28 beds) and the Intensive Emergency Medicine Unit (15 beds) of the Padova University Hospitals, Italy. The Padova University Medical School, one of the oldest worldwide, is considered a medical center of excellence in Italy – so EDs are expected to be heavily involved. 2.1. Supplementary Information City population 280,000. Catchment area 4,000,000. Two Emergency Departments (together approx.140,000 patients/year), the Short Observation Unit (tot. 28 beds) and the Intensive Emergency Medicine Unit (tot. 15 beds) 280 – 330 accesses/24 h one of the EDs is an NBCR management center. To limit exposure bias, anonymity was assured by having the questionnaires dropped in a sort of “ballot box”. Participation was voluntary. No incentives were offered.

3. Results Overall response rate was 69% (110 subjects out of 159). The percentages of the professional groups that participated where: physicians 94%; nurses 73%; auxiliary personnel 56%.

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E. Photiou / The Viewpoint of ED Personnel about Avian Flu

3.1. Question No. 1 “What do you suggest in order to improve your work during epidemics/pandemics?”. The answers were (Figure 3): a) 43% make no suggestions; b) 35% suggest periodic courses & rehearsals, with specific protocols and adequate protective means; c) 10% would like to receive timely information concerning upcoming epidemics; d) 8% suggest that epidemics should be faced by dedicated multidisciplinary groups in dedicated facilities; e) 2% would like to be paid according to risk; f) 1% suggests the possibility to potentiate personnel during epidemics; g) 1% proposes work quality control.

43% 46%

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2%

8%

no suggestions personnel potentiation dedicated personnel pay-per-risk courses/info

1%

Figure 3. Answers to question no.1

3.2. Question No. 2 “How would you like to be informed during upcoming/in-course epidemics/ pandemics?”. The answers were (Figure 4): a) 34% would like to receive specific epidemics’ management rehearsals; b) 29% prefer workshops/courses; c) 14% opt for board-written information; d) 14% would like to participate in risk assessment prior to crisis; e) 5% prefer obtaining up-to-date information through displays, f) 3% prefer obtaining up-to-date information through the web; g) 1% suggested other options.

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5%

103

3%1%

14%

34%

specific epidemics management rehearsals workshops/courses board-written updates participation in risk assessment prior to crisis display-written updates

14% Web updates other 29%

Figure 4. Answers to question no.2.

3.3. Question No. 3 “Do you trust your ED’s protective means?” The answers were (Figure 5): a) 21% feel fairly safe by using the protective gear present in the ED, b) 26% feels slightly safe, c) 27% does not know whether they feel really safe, d) 26% does not feel safe.

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26%

21%

fairly safe slightly safe do not know unsafe 26% 27%

Figure 5. Answers to question no.3

4. Discussion A very large percentage (43%) of participants that make no suggestions generates the idea of a lack of the “culture of emergency”: a big part of the personnel seems to have no ideas as to how to improve their working conditions under extraordinary

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circumstances. On the other hand, an equally big percentage (total 45%) suggests quite interesting ideas like timely information, specific protocols and periodic drills, in order to increase the system’s capability, as a whole, to face pandemics. The suggestion to create specific facilities manned with dedicated personnel could be an option; though, it may probably be a very expensive one (especially in an era of tight finances) that places risks in case of personnel shortage for any reason. A small percentage suggests a “pay-per-risk” policy; this could be a very innovative option, although it might seem poorly “moral”, talking about HCPs. Though, given the SARS experience aftermath, this option should not be completely discarded, if it can give the chance to obtain a lesser absence rate of HCPs during epidemics. Healthcare professionals would like to be informed (and thus, educated) about epidemics in different ways. The wide majority (total 63%) suggests workshops, courses and specific epidemics management drills, while a smaller group suggests to actively participate in risk assessment prior to crisis. Concerning mere information, a very small part would like to be informed through the Web (thus seeking information by themselves), while others prefer to obtain moment-by-moment updates though displays or blackboards; these data could be explained through a poor knowledge of computers use, “surfing” etc, and by the possibility to receive already elaborated, swiftly flowing news. Healthcare professionals appear almost equally distributed in the different option groups concerning PPE. It is remarkable, though, to notice the low rate of thorough safety deemed. Perhaps, healthcare systems should work on training the personnel on the proper use of PPE. This issue is very crucial, given that it is directly associated with the personnel’s education.

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5. Conclusions Probably, there is a lack of the “culture of emergency” concerning epidemics/pandemics, which are emergencies ED personnel may not be acquainted with. In order to be able to cope with highly stressful situations like epidemics, the importance of timely, thorough information is paramount, regardless of the different methods. Active participation in acquiring information and training can create the sensation of making part of the whole system, thus increasing commitment. Timely information, protocols, continuous training, periodic drills, adequate and well-known protection means are very important. A precise communication policy would give the opportunity to better educate the personnel, and to make clear the commitment of the healthcare system. Information is education. And, most of all, planning beforehand without underestimating the issue is paramount. References [1] [2] [3] [4] [5]

M.T. Osterholm, Preparing for the Next Pandemic, N Engl J Med, 352 (2005) 1839-1842. D. Sokol, Can doctors ever abandon their post? BBC News, August 16, 2006. J. Shiao Shu-Chu, D. Koh, L. Li-Hua, L. Meng-Kim, Y. L. Guo, Factors predicting Nurses’ Consideration of Leaving their Job during the SARS Outbreak, Nurs Ethics, 14 (1) (2007), 2007. C. Wiskow, The impact of Severe Acute Respiratory Syndrome (SARS) on health personnel, Sectorial Working Paper no 206. International Labour Office – Geneva, 2003. A. Nocum, SARS wreaks havoc on health workers’ health. Philippine Daily Inquirer, 25 April 2003, accessed through, http://global.factiva.com, 21 May 2003.

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Bioterrorism and Pandemics: A New World Order of Civil Defence David ALEXANDER1 CESPRO, University of Florence, Florence, Italy

Abstract. This chapter considers the process of preparing for a pandemic or major biological terrorism attack in terms of the organisational structure of civil defence and civil protection systems. The former are usually centralised at the national level and focus on security issues, while the latter tend to be devolved to the local level and to focus on public safety. Misconceptions about biological threats are discussed in the light of their potential impact upon preparedness. There are many incorrect or debatable assumptions about biological risks that need to be countered or at least fully discussed. For instance, anthrax is not a white powder, as is commonly supposed, panic is not a common reaction to threats, and at the world scale terrorism does not have a wildly fluctuating trend. The chapter ends with a modest classification of uncertainty and a discussion of its impact upon preparedness. Keywords. pandemic influenza, biological terrorism, emergency planning, misconceptions, civil defence, civil protection

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Introduction The aim of this chapter is to examine some of the implications of a potential biological terrorist attack or a pandemic for emergency preparedness and socio-economic systems. The chapter will begin by considering the nature and position of civil defence in modern emergency preparedness. This is relevant to the process of preparing for social crisis if it should occur as a result of terrorist attack or the spread of disease. It will then examine some of the foundations of strategy and contingency planning for bioterrorism and pandemics. Particular emphasis will be given to prevalent misassumptions about these two phenomena and how they might influence preparedness. Lastly the chapter will consider the impact of uncertainty on planning and readiness.

1. Civil Defence and Civil Protection: Evolution of Parallel Systems Civil defence can be defined as a system designed to protect civilian populations against armed aggression by a foreign power or groups of dissidents [1]. It is usually a function of national government. Although it has antecedents deep in the mists of time, modern civil defence probably began with the bombing of the Spanish Viscayan town of Guernica (population 7,000) in 1937, the first concerted aerial bombardment of an 1 CESPRO – Centre for Risk and Civil Protection Studies, University of Florence, Via G.B. Morgagni 58, 50134 Firenze, Italy. E-mail: [email protected].

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urban area [2]. It gave rise to quasi-spontaneous efforts to organise the protection of non-combatants. The following year preparations for war led to the diffusion and consolidation of civil defence systems, then known as air-raid precautions, in many cities of the world. The first phase of civil defence reached its apogee in the early 1940s with the mass bombardments of urban areas and the need to rescue survivors, care for the homeless, cordon off and search bomb-sites, and maintain public hygiene and order. After the cessation of hostilities in 1945, the 1930s model of civil defence was gradually abandoned. However, the invention of the nuclear bomb and its adoption by the Soviet Union caused civil defence to be reborn in a new form. Over the period of the Iron Curtain and bipolar world order, 1946–89, countries evolved sophisticated systems of civil defence designed to protect people (or society’s leaders) against a thermo-nuclear exchange [3]. The gradual introduction of détente, and perhaps also the demonstrable futility of many of the measures adopted, given the probable effects of nuclear war, led to the winding down of civil defence in the late 1980s. At the same time, under the duress of repeated natural disasters, a new system was rapidly evolving. Although the term is in common currency in many nations, civil protection is not known as such in all parts of the world (in the United States, for example, its broad synonym is emergency preparedness, while the French use civil security and the British civil contingencies). Civil protection exists to safeguard civilian populations and their assets and activities against harm and is thus similar to civil defence [4]. The principal difference is that civil protection is based on the local level, which may be endowed with a fair degree of autonomy [5]. It is thus a “bottom-up” system, although paradoxically it should be harmonised and co-ordinated by the activities of progressively higher levels of government in a complementary “top-down” manner. In contrast, civil defence is a nationwide concern that cannot be delegated to local authorities, for it is intimately connected with questions of national security [1]. In broad terms, civil defence declined in the 1990s while civil defence grew to fill the void. Although by 2001 many of the concerns had already been aired and the mechanisms of change were already in action, the events of 11 September (“9–11”) in the United States catalysed a process of change that led, somewhat convulsively, to a resumption of civil defence. In the United States it was termed Homeland Security, a sign that the scope had changed substantially since the Cold War [6]. The USA has in fact become the principal protagonist of a so-called ‘war on terrorism’ that has elements in common with the Cold War. It is not a war as such because, however violent it may be, terrorist activity does not constitute a war against the United States [7]. The whole process of homeland security could be viewed as a means of reintroducing militarism into civilian life, and perhaps also to codify and justify huge expenditures on security apparatus. Hence in 60 years, civil defence underwent a metamorphosis from protecting civilians against armed aggression on the part of states to doing the same against armed aggression on the part of groups of dissidents. In the second half of that period civil protection grew, initially as a response to natural disasters, although it rapidly had to broaden its scope to include technological incidents (transportation crashes, toxic spills, etc.), social disasters (crowd crushes, mass demonstrations, etc.) and emerging risks (SARS, mutating influenza, interruptions of fundamental services, intensified climatic phenomena, etc.). As a result it has broadened its outlook to embrace the concept of civil contingencies [8], based on highly generic disaster planning, and the creation of societal resilience, defined as ability to resist and absorb the shocks caused by crises

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and disasters in a robust, resistant manner [9]. The paradox is that civil protection has continually broadened its outlook, while civil defence has narrowed its scope. Civil defence and civil protection involve diametrically opposed tendencies. In some countries they are separate systems, although others tend to fuse them, with results that are not always optimal in terms of managing events. Civil defence has military and paramilitary origins and is based on command-and-control principles [10]. It is a proxy system in which the public is largely excluded (with the exception of the Swiss model, which is based on public participation in homeland defence activities). The role of intelligence gathering and covert monitoring tends to militate against public participation and in favour of secrecy. Indeed, in some ways the heavy accent on homeland security in the Western world has turned the citizen into a suspect. In contrast, civil defence is much more participatory, with greater emphasis on coordination and co-operation, than on command and control [11]. Modern information technology has tended to flatten the chain of command and thus permit greater autonomy among emergency response units. Modern forms of co-ordination, such as the incident command system, favour the delegation of responsibility to task forces and co-operative work through sharing data on problems to be solved in the field [12]. The open system characteristics of such a configuration make it suitable to involve and empower the public, especially through community emergency planning.

Figure 1. Role of civil protection and health services in counter-terrorism activity.

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The risks and incidents associated with terrorist activity are broadly the preserve of the field of civil defence. The role of civil protection in such events is somewhat limited. Intelligence gathering, surveillance and forensic analysis are associated with civil defence only; organisation, stockpiling of equipment and supplies and training activities are the preserve of both civil protection and civil defence. Health services are involved in the last three activities and also partly in forensic analysis and surveillance, especially of the population (Figure 1). 2. Shaky Foundations and Debatable Assumptions There is a tendency in civil protection to regard the field as stable and slowly evolving. This may be correct most of the time, but it should not be forgotten that there a possibility that change will be cataclysmic. The potential sources of profound, abrupt change fall into these categories: •

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• • • •

great geophysical events, such as major volcanic eruptions, earthquakes or extra-terrestrial impacts pandemics: epidemics, epizootics, epiphytotics large-scale radioactive emissions climate change and sea-level rise other emerging risks.

In reality, any major event from this list could change the civil protection outlook radically and abruptly over a period of days, weeks or months. The only solution is to encourage elastic thinking and flexible preparation, and to try to anticipate events before they become chronic or catastrophic [13]. In the 2000s there has been intense growth in academic, industrial and administrative interest in terrorism and pandemics. In northern Europe up to 70 per cent of emergency planning effort is going into preparing for a pandemic. This is not merely because of the potentially very high death tolls and rates of illness, but also because of the profound effect that the threat of disease would have on commerce and patterns of daily life, with widespread absenteeism and curtailment of socio-economic activities [14]. However, the process of preparing for pandemics and biological terrorist attacks is not one that can draw upon large reserves of detailed experience. Much of it remains speculative and tied to untested assumptions [15]. Some of the most debatable of these attain a level of improbability which endows them with the status of “myths” enduring misconceptions [16]. Some of these are widely and dearly held. They will be discussed forthwith. Myth: we are well organised to face a biological attack or pandemic. Unpublished studies in the United Kingdom suggest that a fair amount of cognitive dissonance exists in the population. People are worried about terrorism but are not taking action. In part this is because of an inherited culture of ‘leave it to the experts’, while the expert response has been to encourage a passive response, presumably in the hope that this will render the public easily manageable in the case of an emergency. It is summed up in the UK Government’s slogan “go in, stay in, tune in” – i.e. keep out of the way and wait for the mass media to relay orders [17]. Recent experience has shown that this is not always the most appropriate strategy. However, it has not been replaced by anything that would motivate the UK public to prepare in a more active way.

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Myth: prophylaxis will be effective and efficient. A study of decontamination protocols in relation to chemical terrorism [18] suggested that the following aspects are highly debatable: • • •

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•

the use of chemical agents to neutralise toxic substances (soap and water tend to be more effective) whether to strip naked before treatment (clothes can protect people against some aggressive chemical agents) what decontamination technique to use if the toxic agent has not been identified (there are thousands of chemical toxins that could potentially be used in an attack) how many people can be decontaminated per unit time (some manufacturers claim their systems can deal with a throughout of tens of people per hour, but the figures are highly debatable).

To my knowledge, no equivalent study has been carried out on evaluating decontamination procedures for biological toxins, but as they are smaller and more concentrated, as well as potentially highly communicable, the problem could easily be worse. Myth: in a CBRN attack or pandemic it will be easy to avoid contamination of hospitals. Again, with reference to chemical terrorism, the case of the Russian secret agent Alexander Litvnenko is instructive. He was poisoned in London in November 2006 with 210-polonium, a highly toxic substance that contaminates in amounts as small as traces. Litvinenko died within days of being poisoned in which was a small, concentrated attack that had only one person as its target. However, 30 localities in London had to be decontaminated. Tests had to be carried out on hundreds of people and the whole exercise put a strain on a wide variety of government agencies. The episode finished with a series problems about who was responsible for the high costs of the clean-up. Again, the high communicability of a pandemic disease or biological contamination could lead to analogous but far greater problems and would require Draconian measures of infection control [19]. Myth: it will be easy to identify the pathogen and apply appropriate remedies. It is widely held that in the first wave of a pandemic a vaccine would not be generally available as it would take time to develop and mass produce one. In a biological terrorism attack the first signs would be observed in very general symptoms. The pathogen would then have to be isolated, a process that might not be feasible in a normal ‘level-one’ diagnostic laboratory such as one might find in any large hospital. This could require special arrangements for transportation and analysis of samples, all of which could take 48 hours at a time when results are needed immediately in order to treat patients, maintain precautions against infection and decontaminate sites. Even the mere suspicion of biological contamination can cause loss of efficiency in emergency response: in the London Underground tunnels on 7 July 2005 rescue operations were delayed by 15–20 minutes by the need to ascertain whether CBRN contamination had occurred in the attacks [20]. Meanwhile, victims died of their injuries (although in truth they might have done so anyway if the intervention had been more rapid). Myth: anthrax is a white powder. Anthrax spores are more or less colourless, or at least of an indeterminate colour. However, in 2001–02, when anthrax was present in Washington, DC, the widespread belief that the spores are white led to endless scares in Europe and North America regarding white powders left in public places, most of which were talcum or cocaine [21].

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Myth: it is easy to design scenarios for future CBRN attacks and pandemics and thus create effective emergency plans to manage such events. Although the potential for an attack is considered to be very large, few examples of CBRN terrorism exist in the record that could be useful for building planning scenarios. Those events that have occurred may have had unexpected consequences. For example, the 1995 Aum Shinrikyo Sarin gas attack on the Tokyo subway killed 12 people and induced 4,900 people to go to hospital. Of these, only one in five was injured and the rest were suffering from multiple idiopathic physical symptoms – i.e. hypochondria [22]. Hence, the principal effect of a bioterrorist attack on the public might not be the infection of individuals with pathogens but instead could be very costly disruptions of daily life. In this context, blanket preventative measures are expensive, disruptive and of debatable effectiveness either as deterrents or as a means of discovering a deliberate infection [19]. Likewise, the principal effects of a pandemic could easily be the non-medical ones associated with curtailment of socio-economic activities on a massive scale [23]. At present it is difficult to ascertain what balance could be achieved between the effectiveness of clinical and sanitary measures in controlling a pandemic or bioterrorism attack and the seriousness of the non-medical impact upon the socioeconomic system. The potential effects upon society of a bioterrorism attack or a pandemic would be the following: • • • • •

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• •

massive demand for health services widespread fear and hypochondria absenteeism from work, including from critical basic services, which would then become inefficient shut-down of social interaction, with serious economic consequences, for example in the entertainment industry an economic slump caused by the curtailment of activities and the interruption of logistics heightened vulnerabilities and reduced coping and support mechanisms, especially of at-risk groups (the elderly, homeless, very young, etc.) overloading of the telecommunications system and fundamental mutation in the way people inform themselves (in order to avoid physical contact and potential contamination, print media would be eschewed)

The problem of bioterrorism contingency planning is that modern society is so interconnected and is evolving so fast that historical analysis may not be useful for scenario building. Despite the 35–40 year cycle of pandemics, and the enormous impact of the 1918 influenza outbreak, past events are too few and far between to be of much help with current planning scenarios. With both pandemics and biological terrorism, there is an infinity of possible attack scenarios, which may mean that ‘orthodox’ thinking offers little guidance to what may actually happen, especially in the fact of a clever terrorist’s creativity. Moreover, palliative and analytical capabilities are expensive but not necessarily effective [24]. Myth: a biological terrorism attack would necessarily be directed against people. In fact, it could easily be directed against animals or plants, provoking respectively an epizootic or epiphytotic, in order to damage the food chain. An attack on crops would be the most worrying strategy, as it would be directed at the base of the food chain. According to the World Health Organisation [25], at least ten different crop pathogens, mostly rusts and fungi, could potentially be used as terrorist weapons.

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Myth: terrorism has irregular trends over time. Despite the effect of terrorist attacks on places like New York, Madrid and London, the trends in worldwide terrorist activity are not particularly irregular. Some data sets show a slow upward trend, while others show no particular trend at all [26]. The shock impact of terrorism stems from the fact that the outrages occur in different parts of the world – i.e. the locus of terrorist activity is continually shifting (except for places such as Iraq and Afghanistan). Moreover, terrorists tend to be conservative in their strategies. In general, sufficient impact can be achieved without the complications of CBRN involvement. Hence, few CBRN events exist in the record, despite the immense potential for such activities. Myth: panic and irrational or egotistical behaviour are inevitable public reactions to a crisis situation such as a biological attack or a pandemic. Over the last 60 years sociological studies have repeatedly shown that panic is a rare and transient phenomenon that is constrained to particular situations [27]. Panic is an irrational, spontaneous form of individual self protection. It occurs only in very specific circumstances, such as heightened fear of entrapment, and lasts for a very short period of time. Hence, many other social phenomena have been misclassified as panic [28]. Often, what is happening is the sum of many different individual attempts to do the most rational and appropriate thing, perhaps with limited information on what is appropriate. Generally, the public will do what it thinks is prudent and appropriate, although patterns of mass behaviour (such as food hoarding) may occur and will be difficult to manage. Myth: the risk of a biological terror attack or pandemic is well understood. In theory it is possible to work out the impact and potential consequences of a future bioterrorist attack of pandemic by reference to past events and chains of causality. In practice the rapid rate of change in the modern world may invalidate attempts to extrapolate past events. Hence, the influenza outbreak of 1918 may be a very poor guide to pandemic influenza in the 2000s, when mass international travel is common, population levels are much higher, hygiene, health care and diagnostic medicine have made enormous progress and epidemiological surveillance has been established as a robust science. The ability of terrorists to mount a biological attack will depend on their ability to obtain a pathogen, transform it into a weapon, transport it to the point of deployment and launch the weapon in such a way as to cause substantial harm or chaos to the intended victims. There are many uncertainties in this process, to which must be added uncertainty about exactly what strategy the terrorists would devise [29]. In synthesis, all the ‘myths’ of pandemic and bioterrorism preparedness have potentially profound impacts upon civil protection and civil defence. The realisation that they are missassumptions needs to be built into both planning and training. Despite the fact that civil defence and civil protection come to the problem from diametrically opposite ends of the spectrum of public administration, there needs to be greater connection between them. This will require protocols for the management of national emergencies that fully involve local forces and resources, not merely in the response, but also in the decision-making processes [30].

3. Conclusions All of the problems discussed in the preceding sections need to be studied and debated thoroughly. Since the momentous events of 11 September 2001 there has been e huge increase in the number of studies of the terrorism problem. Outbreaks of SARS and avian influenza have led to large increases in work on the potential for an infectious

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disease to spread in the form of a major world pandemic. However, many aspects of these problems remain obscure. In terms of the response, much depends on the connections between civil defence, civil protection, intelligence services, health services and government - indeed, governance [31]. Not only must the function and role of each of these entities be defined clearly, so must the connections and interactions between them. Moreover, the public must be included as active protagonists with a role to play in both civil protection and civil defence activities. Elaborating on something that the former American Vice-President said about his countries strategies in the Middle East, we may create a “modified Rumsfeld classification”, as follows:

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• • • •

the known knowns are simply the things we know the known unknowns are the things we know we don’t know the unknown knowns are the things we don’t realise we know the unknown unknowns are the things we don’t know we don’t know

Pandemics and bioterrorism are spread across all categories but unfortunately a substantial measure occurs in category four. Because of its dependence on potentially unknown (or at least poorly understood) scenarios, any advance in understanding risks being speculative rather than scientific. The matter is summed up neatly by an observation that the economist Frank H. Knight made in his book Risk, Uncertainty and Profit, published in 1921: “If you can’t be sure about an event in the future, but you know the probability, that is risk. If you don’t know the probability, that is uncertainty.” Finally, what relationship might exist between bioterrorism and pandemics? The first and most obvious one is the presence of biological pathogens [32]. Moreover, both phenomena have the potential to overwhelm services and to induce profound shortterm mutation in social behaviour patterns. The highly specialised and reserved nature or laboratories and their diagnostic work mean that the response to either phenomena would probably be delayed while pathogens are identified and remedies devised [33]. In the light of all these considerations, it is as well to bear in mind that the safety and security outlook could change radically in a very short space of time. Hence both civil defence and civil protection should avoid “getting into a rut” of constrained thinking, conservative outlook and normalcy bias. In the laboratory and among health and emergency planners there is room for synergy in the study of both bioterrorism and pandemics [34]. Despite the dire warnings that are periodically issued regarding both pandemics and CBRN terrorism, nothing is inevitable and much can be done to prevent the worst.

References [1] [2] [3] [4] [5]

D. Alexander, From civil defence to civil protection – and back again, Disaster Prevention and Management, 11 (2002), 209-213. H. Thomas, The Spanish Civil War, Penguin, Harmondsworth, 1961, p. 624. B.W. Blanchard, American Civil Defense 1945-1984: The Evolution of Programs and Policies, National Emergency Training Center, Federal Emergency Management Agency, Emmitsburg, Maryland, 1984. T. Horlick-Jones, A. Amendola and R. Casale (eds.), Natural Risk and Civil Protection, E&FN Spon, Andover, Hants., UK, 1995. O.O. Aloyo, Emergency preparedness is all local, Journal of Emergency Management, 4 (2006), 11-12.

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[6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21]

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G. Woodbury, Emergency management and homeland security: exploring the gray area, Chapter 4 in Emergency Management in Higher Education: Current Practices and Conversations, Public Entity Research Institute, Fairfax, Virginia (2008). E.B. Abbott, Terrorism, freedom, and security: winning without war, Journal of Homeland Security and Emergency Management, 1 (2004), Article 306. P. Cornish, Domestic Security, Civil Contingencies and Resilience in the United Kingdom: a Guide to Policy, International Security Programme, Chatham House, London, 2007. H.B. Kaplan, Toward an understanding of resilience: a critical review of definitions and models, in M.D. Glantz and J.L. Johnson (eds.), Resilience and Development, Kluwer, New York, 1999, 17-83 K. Arbuthnot, A command gap? A practitioner’s analysis of the value of comparisons between the UK’s military and emergency services’ command and control models in the context of UK resilience operations, Journal of Contingencies and Crisis Management, 16 (2008), 186-194. M. Granatt and A. Pare-Chamontin, Cooperative structures and critical functions to deliver resilience within network society, International Journal of Emergency Management, 3 (2006), 52-57. D.A. Buck, J.E. Trainor and B.E. Aguirre, A critical evaluation of the incident command system and NIMS, Journal of Homeland Security and Emergency Management, 3 (2006), article 1. T.A. Birkland, Lessons of Disaster: Policy Change After Catastrophic Events, Georgetown University Press, Washington, DC, 2007. J. Barbera, A. Macintyre, L. Gostin et al., Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences, Journal of the American Medical Association, 286 (2001), 2711-2717. M. Basili and M. Franzini, Understanding the risk of an avian flu pandemic: rational waiting or precautionary failure? Risk Analysis, 26 (2006), 617-630. D.E. Alexander, Misconceptions as a barrier to teaching about disasters, Prehospital and Disaster Medicine, 22 (2007), 95-103. UK Government, Preparing for Emergencies: What You Need to Know, UK Cabinet Office, London, 2004. H.W. Levitin, H.J. Siegelson, S. Dickinson, P. Halpern, Y. Haraguchi, A. Nocera and D. Turineck, Decontamination of mass casualties: re-evaluating existing dogma, Prehospital and Disaster Medicine, 18 (2003), 200-207. R.J. Leggiadro, The threat of biological terrorism: a public health and infection control reality, Infection Control and Hospital Epidemiology, 21 (2000), 53-56. London Assembly, Report of the 7 July Review Committee, (3 vols.), Greater London Assembly, London, 2006. S. Ozeren, I.D. Gunes and D.M. Al-Badayneh (eds.), Understanding Terrorism: Analysis of Sociological and Psychological Aspects, NATO Science for Peace and Security Series, IOS Press, Amsterdam, 2007. J.F. Pilat, Chemical and biological terrorism after Tokyo: reassessing threats and response, Politics and the Life Sciences, 32 (1996), 213-215. S. Chen, R.R. Stough and A. Kocornik-Mina, Estimating the economic consequences of terrorist disruptions in the National Capital region: an application of input-output analysis, Journal of Homeland Security and Emergency Management, 3 (2006), article 12. M. Casavant, Terrorism: biological, chemical, and nuclear: clinics in occupational and environmental medicine, Journal of Homeland Security and Emergency Management, 1 (2004), Article 309. WHO, Terrorist Threats to Food: Guidance for Establishing and Strengthening Prevention and Response Systems, World Health Organization, Geneva, 2002. See data provided by Memorial Institute for Prevention of Terrorism, www.mipt.org. W.R. Dombrowsky and F.G. Pajonk, Panic as mass phenomenon, Anaesthesist, 3 (2005), 245-253. R.R. Dynes, Panic and the vision of collective incompetence, Natural Hazards Observer, 31 (2006), 5-6. D.R. Franz and R. Zajtchuk, Biological terrorism: understanding the threat, preparation, and medical response, Disaster Monthly, 48 (2002), 493-564. K. Caruson and S.A. MacManus, Designing homeland security policy within a regional structure: a needs assessment of local security concerns, Journal of Homeland Security and Emergency Management, 4 (2007), article 7. www.bepress.com/jhsem/ A. Roberts (ed.), Governance and Public Security, Campbell Public Affairs Institute, Washington, DC, 2002. D.A. Ashford, R.M. Kaiser, M.E. Bales, K. Shutt, A. Patrawalla, A. McShan, J.W. Tappero, B.A. Perkins and A.L. Dannenberg, Planning against biological terrorism: lessons from outbreak investigations, Emerging Infectious Diseases, 9 (2003), 515-519. J.A. Pavlin, Bioterrorism and the importance of the public health laboratory, Military Medicine, 165, Supplement 2 (2000), 25-27. M. Schoch-Spana, Implications of pandemic influenza for bioterrorism response, Clinical Infectious Diseases, 31 (2000), 1409-1413.

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4. Multidisciplinary Approaches to Address Biological

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and Nonconventional Threats

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Nanosystems and CBRN Threats: A Resource Worth Exploiting, a Potential Worth Controlling Matteo GUIDOTTIa,b,1, Massimo RANGHIERIb and Alessandra ROSSODIVITAc a CNR-Istituto di Scienze e Tecnologie Molecolari, via Venezian 21, Milano, Italy b st 1 Field Unit, E.I.-S.M.O.M. Military Corps, Milano, Italy c Department of Cardiothoracic and Vascular Diseases, San Raffaele Hospital, Milan, Italy

Abstract. Nanosciences and nanotechnology can be considered as resources for the humankind, providing innovative tools and devices for the protection and decontamination from chemical, biological, radiological or nuclear (CBRN) warfare agents. At the same time, these disciplines may offer unprecedented and uncontrolled means of mass destruction, by the synthesis of novel and more effective aggressive agents or by improving the production capability of intentionally toxic systems. A multidisciplinary approach, with experts active in various fields, such as chemistry, physics, biology and materials science, is needed to have a strict control on potential illegal uses of nanosciences and nanosystems. Keywords. non-conventional threats, mass destruction weapons, nanosciences, nanotechnology, CBRN warfare agents, NBC defense

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Introduction When one talks about non-conventional threats, with regard to the use (or misuse) of chemical, biological, radiological or nuclear (CBRN) warfare agents, the feeling that a part of the scientists has worked so far (and is still working) deliberately in the bad direction is strong and it can lead to misleading points of view about Science and its role in improving people’s lifestyle. The concerns of the public opinion are even bigger in the case of new scientific domains, such as nanosciences and nanotechnologies, where the lack of knowledge generates wrong information and, consequently, wrong information leads to fear and unpreparedness, two elements that should be absolutely absent when professionals must cope with new risks and threats.

1. Nanosciences and Nanotechnologies Nanosciences and nanotechnologies had an exponential development in last decade, thanks to the remarkable and ever-increasing attention of fundamental sciences, such as

1

Corresponding Author: Fax: +39-02-50314405; Phone: +39-02-50314428; E-mail: [email protected]

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chemistry, physics, biology and materials engineering, towards the world at nanometric size (1 nm = 1·10-9 m) (Figure 1).

1 m ~ 1.27 ·109 cm

1 nm ~ 1.27 cm

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Figure 1. The Earth and a coin; a tennis-ball and an atom. A difference of nine orders of magnitude

The definition ‘nanosystems’ includes all those chemical objects whose dimensions are in the range from 1 nm to 100 nm and which show peculiar features thanks to quantum effects and to the presence of wide surfaces and interphasal domains [1–2]. When a particle is at nanometric level, the fraction of surface atoms increases considerably. Surface atoms often possess different properties from those located at the inner part of the particle. Nanometric systems therefore show noteworthy modification of their physical and chemical properties compared to the parent chemical species and they find (or can find) practical application in various domains. Metallic gold, for instance, is a noble and non-reactive metal in its bulk form, whereas it is able to act as a catalyst, promoting the oxidation of noxious chemicals, when it is dispersed as nanosized metal particles [3, 4]. Nanosciences represent the crossing-point of various disciplines, such as quantum physics, supramolecular chemistry, materials science or molecular biology and they are a reality in the field of pure and applied research. Conversely, nanotechnologies are still at an initial step of their potential development. Their main aim is exploiting and applying the goals of nanosciences to create materials, devices and systems at molecular level [5].

2. ‘Dual Use’ of Nanotechnology in CBRN Scenarios In the field of non-conventional CBRN threats, nanosystems (and the devices derived from these objects) present the risk of a ‘dual’ use. Nanotechnology and nano-based materials can be employed as a resource for humankind, providing new tools for the

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protection and decontamination from CBRN agents as well as powerful instruments for the detection of new threats. At the same time, however, nanosystems may offer unpredicted and uncontrolled means of mass destruction, by the design of novel and more effective aggressive agents or by enhancing the large-scale production of precursors for intentionally toxic systems [6]. It is worth highlighting that the know-how needed to develop ‘good’ or ‘bad’ nanoscience-based products is, in several cases, the same (Figure 2). The tools and the synthetic protocols leading to nanosystems employed in medical and pharmaceutical research for the development of innovative drugs can be easily switched towards the development of unprecedented aggressive agents created to damage a target organism at biochemical level.

Resource worth exploiting Industrial Production

Potential worth controlling Production of precursors Production of aggressives

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Nanosystems for medicine

More Effective CBRN Protection

Unintentionally Toxic Nanosystems

Intentionally Toxic Nanosystems

New, More Effective Agents

Figure 2. ‘Good’ or ‘bad’ use of nanotechnologies

Such potentially new synthetic pathways can be unknown to the international organizations that monitor the proliferation of CBRN warfare agents, such as the Organization for the Prohibition of Chemical Weapons [7]. Therefore, terrorist groups may find some ‘free zones’ that are uncovered by national and international legislation and can, in principle, develop novel hazardous compounds away from any control. Moreover, the exploitation of the current knowledge and technology for either positive or evil aims depends largely on the social, ethical and political environment where the scientist involved in nanotechnology research is located. Four different scenarios can be configured: 1) ‘Prohibition’; 2) ‘Control’; 3) ‘Defense’ and 4) ‘Proliferation’ The first scenario is the best case, where the complete ban of mass destruction weapons (MDW) is a reality and no risk of illegal use of aggressive compounds is present.

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In the second scenario the development of MDW is prohibited, but the use of nonconventional aggressive agents is possible, due to the presence of clandestine production sites (within terrorist groups or the so-called ‘rogue’ nations). According to the third scenario, the risk of the use of non-conventional weapons becomes probable, because of unstable international or domestic situations, and all the efforts are devoted to counteract the effects of a possible attack. Then, the fourth case is the worst-case scenario, where the development and production of CBRN warfare agents is concrete and no interdiction is effective. The four scenarios and the possible roles played by nanoscience and nanotechnologies are summarized in Figure 3.

Chemistry

Physics

Biology

Engineering

Materials Science

Nanotechnologies

Scenarios Prohibition

Control

Defense Production of Precursors

Detection Protection Decontamination

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Disposal

Proliferation

Medical Countermeasures

Unintentionally Toxic Nanosystems Production of Aggressives Intentionally Toxic Nanosystems Weapons

Figure 3. ‘Dual use’ of nanosciences and nanotechnologies in the four different scenarios

According to this simplified scheme (maybe simplicistic, but hopefully effective, for a synthetic discussion), some latest and relevant advances in several disciplines, such as chemistry, physics, biology, materials science, engineering, etc. in the field of nanoscience and nanotechnologies are here reported. The following cases show how the expertise at lab-scale level in the development of nanosystems may lead to the production of either useful tools (protection, decontamination, etc.) or unexpected threats (new aggressive agents, new clandestine production methods, etc.) at large-scale level. The ethical choice of the researchers is then the determining factor.

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3. Nanosystems Helping Humankind 3.1. Protection The current widely-used technology for the individual protection from CBR(N)2 aggressive agents is mainly based on the adsorption properties of activated charcoal. It is used in individual protection equipments, such as gas masks and anti-NBC suits. The noxious compounds are therefore removed from the air stream in direct contact with the body and irreversibly bound to the filtering charcoal layer, but they are not destroyed or abated. A promising alternative can be the use of reactive layers, based on nanosized metal oxides, where the aggressive compound is strongly adsorbed and decomposed into non-toxic by-products (Figure 4).

50 μm

2 nm

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Figure 4. Scanning electron microscope (SEM; left) and transmission electron microscope (TEM; right) image of zinc oxide nanoparticles active in the adsorption and abatement of aggressive agents. (courtesy of Dr. C. Bisio, University of Eastern Piedmont, Alessandria, Italy)

The nanostructured oxides (e.g. zinc titanate ceramic nanometric fibers or cyclodextrin-functionalized nanofibers) proved to be efficient compounds in the degradation of nerve or mustard agent simulants in few minutes under ambient conditions, giving rise to detoxified non-hazardous secondary products. Such nanosystems can be inserted in textile materials to produce active protective clothing that never reach saturation, as degradation occurs directly after the toxic compound is retained, and that, in principle, do not need a special disposal, because they do not contain toxic agents any more [8, 9]. Otherwise, the active detoxifying nanosystems can find application in formulations of active protective creams for direct skin applications [10]. In particular, nanoparticles of pyrogenic titanium dioxide (TiO2 nanospheres with particle size of ca. 30 nm) are able to decompose efficiently nerve agents vapors (mainly G agents), acting as photocatalysts in the presence of photons from sun light and of the oxidizing power of atmospheric oxygen. Such catalytic action can be synergistically coupled to the shielding effect of perfluorinated polymers, in order to have an in situ decontaminating skin cream. Nanostructured inorganic/organic composite materials can be also used to accommodate and immobilize enzymes that are active in the hydrolysis of P-O, P-S, PCN and P-F bonds and thus in the biodegradation of organophosphorous nerve agents 2

Nuclear (N) mass destruction weapons should not be considered in these examples.

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[11]. For instance, the broad-spectrum enzyme organophosphorous hydrolase (OPH) from Pseudomonas diminuta can be immobilized on polymeric supports, in order to have nanocomposite protein-silicone polymers [12]. The resulting composite materials are active even at room temperature and are, often, biocompatible and suitable for the production of protective wear. 3.2. Detection Current methodologies for the detection of CBR(N) agents rely on a huge variety of principles: from simple colorimetric drop tests, to complex spectrophotometric techniques for off-site detection. Nanotechnologies can provide some basic innovations in this field too. The so-called ‘smart dusts’, for instance, are sensors, in form of powder, based on nanostructured porous silicon which are effective for the remote detection of nerve agents (Figure 5) [13, 14]. The phosphorous-containing toxic compound, in fact, interacts specifically with the surface of the nanosized silicon and induces a change in its optical features. The variation in optical signal can then be detected, even at some distance (currently, up to 25 m), by spectroscopy. P-F bond cleavage on the surface of the sensor

Nerve agent (containing fluorine)

Evolved HF interacts with the surface of the sensor

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‘smart dust’

Change of the local optical characteristics

Optical (infrared) signal

Detection by remote spectroscopic devices

Figure 5. Simplified mechanism of nerve agent detection over Si-based nanosensors (‘smart dusts’)

Analogously, the ever-increasing miniaturization of devices for the chemical analysis and diagnostics leads to the development of microreactors (and soon nanoreactors) for the detection of MDW. Thanks to the innovative ‘lab-on-a-chip’ technology, where not only the electronic components are miniaturized, but also the parts in which the (bio)chemical reaction is carried out, some instruments are able to give a fast and precise response in the detection of toxic metabolites, pathogenic agents or toxins (such as ricin) in the environment [15]. Furthermore, the extended miniaturization reduces the risk of handling relatively large amounts of hazardous

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samples for analytical purposes and the potential further spreading of the contamination. 3.3. Decontamination

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The decontamination from CBR(N) agents is mainly based on physical removal, dissolution or chemical destruction of the contaminant. Huge amounts of water, solvents and/or aggressive reagents (sodium hydroxide, hypochlorites, peroxides, etc.) are necessarily employed and these methods have consequently a poor economic and environmental sustainability. Recent techniques based on nanosystems, on the other hand, can provide solid catalytically-active materials with acid, basic or redox functionalities which enhance the decomposition rate of the noxious contaminants even at room temperature and can represent an alternative process to conventional thermal destruction and incineration for the abatement of CBR(N) weapons [16]. Such nanomaterials are often inorganic oxides (magnesium oxide, transition metalcontaining nanoporous silica, nano-ordered alumina, etc.) with very high specific surface area (ca. 1000 m2g-1) as well as with remarkable adsorption capacities (Figure 6) and they are therefore particularly suitable for capturing noxious vapors and volatile species. In addition, they possess at nanoscopic level defective crystalline edges, corners and sites that are much more reactive in the chemical degradation of aggressive agents than their bulk counterparts.

Figure 6. Transmission electron microscope (TEM) image of a vanadium-containing nanoporous silica material for oxidative degradation of hazardous compounds

4. Nanosystems Against Humankind On the other hand, the study of nanosized materials may open the way to the development of a new class of toxic materials starting from non-hazardous precursors. In fact, common (and often non-toxic) compounds such as silica, alumina, carbon or metals, when they are put in form of nanoparticles, nanotubes or nanofibers, can be easily absorbed by the body via inhalation, skin absorption or ingestion, and can

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interact straightforwardly with internal vital organs. In several cases, such new nanosystems are not considered as toxic agents by law because they are chemically identical to non-nanosized parent materials. However, their peculiar surface and morphological features can affect dramatically their toxicological properties. In fact, since they have dimensions similar to biological materials (enzymes, nucleic acids, antibodies), nanosystems can spontaneously act as biopromoters or bioinhibitors in metabolic processes and thus induce a beneficial or harmful effect onto the host organism. A remarkable example is the debate about the toxicity of carbon nanotubes (CNT; Figure 7).

100 nm

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Figure 7. Chemical structure (left) and transmission electron microscope image (right) of carbon nanotubes

Until few years ago, North American and European legislations have considered CNT as a form of synthetic graphite. This evaluation arose from the principle that the toxic proprieties of a substance are only due to its chemical composition. Then, a new approach in the evaluation of the ‘chemical identity’ of a molecule, according to which not only the chemical formula, but also the spatial arrangement, the crystalline configuration or the allotropic form play altogether a key role in determining the toxicological characteristics, led to the idea that nano-shaped materials can be ‘new’ chemicals with respect to the parent chemicals they are obtained from. Thanks to this, U.S. EPA – TSCA Inventory [17] and European REACH [18] legislations now consider CNT as something substantially different from graphite or carbon black. There is also a global awareness that CNT, because of their high biocompatibility and penetration ability, might be used, in principle, as a component for novel drugs [19] as well as an unexpected toxic compound [20]. Similarly, the advances in miniaturization of chemical reactors, as described above, may lead to easy clandestine productions of hazardous and/or explosive substances. Thanks to small dimensions, dangerous manufactures are performed at relatively low rates, but with a constant production (in the range of 10–100 kg day-1). These technologies have already been applied in China to the synthesis of nitroglycerine for pacific purposes in a microreactor featuring internal structures on a micrometer scale (10 to 500 µm) and with a productivity of ca. 15 kg day-1 [21]. As a main source of concern, however, the intrinsic advantages of these microsystems, i.e. the limited handling of hazardous compounds or the careful control of highly exothermal reactions [15], can be analogously applied to the illegal production of MDW.

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5. Conclusions If a multidisciplinary approach is needed to study nanosciences and nanotechnologies, a multidisciplinary approach is needed to have a strict control on potential illegal uses of nanosystems too. Experts active in various fields, not only from the academia, but also from the industrial world, have to work cooperatively to follow constantly the state of the art, point out which kind of critical technologies may have a ‘dual use’, control and limit the diffusion of the hazardous nanosystems that may be potential precursors of MDW, and cooperate with CBRN emergency prevention organizations in order to plan suitable countermeasures against this kind of new threats. Then, the ethic implications linked to the legal or illegal use of the nanotechnologies show how education plays a major role in spreading the principles of ban of MDW and in leading the young researchers towards the ‘good’ side of the scientific research.

Acknowledgements The authors gratefully acknowledge the Italian Association of the Sovereign Military Order of Malta (ACISMOM) and Italian Army General Staff (Stato Maggiore Esercito) for the support given to BioHaza 2008.

References [1] [2]

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G.M. Whitesides. Nanoscience, Nanotechnology, and Chemistry. Small. 1 (2005) 175. R. Psaro, M. Guidotti, M. Sgobba, Nanosystems. In: Inorganic and Bio-inorganic Chemistry Vol. II. Bertini I, ed. Encyclopedia of Life Support Systems (EOLSS). Oxford (UK): EOLSS Publishers Co. Ltd; (2008) 256; S. Mann, Life as a nanoscale phenomenon. Angew. Chem. Int. Ed., 47 (2008) 5306. C. Della Pina, E. Falletta, L. Prati, M. Rossi, Selective oxidation using gold. Chem. Soc. Rev. 37 (2008) 2077. I. Okuda, J. Kawahara, M. Haruta, Advances in nano-particulate gold catalysts. Materia 46 (2007) 265. V. Balzani, Nanoscience and nanotechnology: the bottom-up construction of molecular devices and machines, Pure Appl. Chem., 80 (2008) 1631. J. C. Glenn, Nanotechnology: Future military environmental health considerations. Techn. Forecasting Social Change, 73 (2006) 128. http://www.opcw.org. Accessed September 4, 2009. M. Boopathi, B. Singh, R. Vijayaraghavan, A Review on NBC Body Protective Clothing. Open Textile J. 1 (2008) 1. S. Sundarrajan, S. Ramakrishna, Fabrication of nanocomposite membranes from nanofibers and nanoparticles for protection against chemical warfare simulants. J. Mater. Sci., 42 (2007) 8400. S. Hobson, E. H. Braue Jr., E.K. Lehnert, et al. Active topical skin protectants using reactive nanoparticles. US Patent 6403653; (2002); to US Army and Nanoscale Materials Inc. Z. Prokop, F. Oplustil, J. DeFrank, J. Damborsky, Enzymes fight chemical weapons. Biotech. J. 1 (2006) 1370. I. Gill, A. Ballesteros, Degradation of Organophosphorous Nerve Agents by Enzyme-Polymer Nanocomposites: Efficient Biocatalytic Materials for Personal Protection and Large-Scale Detoxification, Biotech. Bioengineer., 70(4) (2000) 400. T.A. Schmedake, F. Cunin, J. R. Link, et al. Standoff Detection of Chemicals Using Porous Silicon Smart Dust Particles. Adv. Mater., 14 (2002) 1270. Detecting Chemical Agents, Chem. Eng. News, June 12, (2000) 12. J. Thilmany, Think small: Lab-on-a-chip technology shrinks the biological laboratory to the micro scale and expands the potential for future applications. EMBO reports. (2005) 6913.

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[16] C. R. Ringenbach, S.R. Livingston, D. Kumar., C.C. Landry, Vanadium-Doped Acid-Prepared Mesoporous Silica: Synthesis, Characterization, and Catalytic Studies on the Oxidation of a Mustard Gas Analogue. Chem. Mater. 17 (2005) 5580. [17] US Environmental Protection Agency. TSCA Inventory Status of Nanoscale Substances - General Approach, January 23, 2008. http://www.epa.gov/oppt/nano/nmsp-inventorypaper2008.pdf. Accessed September 4, 2009. [18] Commission Regulation (EC) NO 987/2008 of 8 October 2008. Amending Regulation (EC) No 1907/2006 of the Council on the Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) as regards Annexes IV and V. Official Journal of the European Union. (2008), L268, 14. [19] E.S. Hwang, C. Cao, S. Hong, et al. The DNA hybridization assay using single-walled carbon nanotubes as ultrasensitive, long-term optical labels. Nanotech. 17 (2006) 3442. [20] C. H. Lin, D. Y. Liou, K. W. Wu Opportunities and challenges created by terrorism. Techn. Forecasting Social Change, 74 (2007) 148. [21] A.H. Thayer, Chem. Eng. News, May 30, 83 (22), (2005), 43.

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Pandemics and Bioterrorism A. Trufanov et al. (Eds.) IOS Press, 2010 © 2010 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-60750-086-5-127

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Modern Biooptical Instruments for the Express Control of Total Toxicity, Individual Chemicals, Viral and Bacterial Infections to Prevent Bio- and Medical Threats Nickolaj F. STARODUB1 National University of Life and Environmental Sciences of Ukraine, Kiev

Abstract. The main attention is paid to some chemicals related to the group named as endocrine disrupting factors. First of all, it is observed the proposed methods based on the biosensorics principles and intended for the express estimation of total toxicity at the screening analysis of environmental objects, revealing of individual toxins and for the diagnostics of diseases induced by viruses. At the beginning the efficiency of the developed biosensor is analyzed in case of the work with the standard solution. Then the obtained results are compared with that received at the application of biosensors in real conditions. The working prototypes of biosensors are created for the application in the area of human and veterinary medicine, ecology and biotechnology.

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Keywords. chemical substances, mycotoxins, total toxicity, viral infection control, optical biosensors, development and application

Introduction Today the problem of protection of environment from different types of chemical substances is very current [1, 2]. As a rule they are toxic, stable, and able to bioaccumulation, subjected to a long time transfer in atmosphere and may induce different non-desirable effects among people and environment in the places of their production and remote territories [3]. About global dispersion of such chemical substances and scale of their dangerous it is testified by data [4, 5]. According to the proposed classification [3] it is marked out: pesticides, industrial products (polychlorinated biphenyls, hexachlorbenzenes) and associated substances (dioxins, furans, polycyclic aromatic hydro carbonates). Special place belongs to surfactants production of which exceeds several billion tons and among them ionic, non-ionic and cationic forms are distinguished [3–6]. In spite of the recommendation of the controlling units to product biodegradable surfactants their mineralization could be complicate and they together with the half-disintegrated products accumulate in natural water sources. The chronic toxic dose of non-ionic surfactants for fishes and number of 1 Corresponding Author: Nickolaj F. Starodub, 15 Herojev Oboroni Str., Kiev, 03041, Ukraine, E-mail: [email protected].

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vertebrates ranges 0.1–20 mg/L. The presence of surfactants in water may arouse the changes in populations of living organisms [7]. The acute influences of chemical substances on the organism in many cases are well known [8, 9]. Intensive application of pesticides leaded to a number of ecological catastrophes [10, 11]. In USA the permissible concentration of pesticides in drinking water should be at the most of 3 µg/L [12]. In Europe this levels much less (0.1–0.5 µg/L) [13]. Other group of toxic substances is presented by mycotoxins which enumerate more than 400 low molecular non-immune nature chemicals produced by ca. 200 species of fungi [14, 15]. A special attention is paid to mycotoxines according to the several reasons: they are very wide dispersed, have high toxicity and, at last, there is a high probability for their application by bioterrorists. Some species may be obtained by very simple way and they have much more toxic effect than ypirite and lewisite [16–19]. Both circumstances form very serious problem at the prevention of their application by bioterrorists. According to the legislations of some countries and commissions of FAO/WHO the permissible concentration of T2 was stated on the level of 0.1 mg/kg of animal body [20]. People are under negative pressure of many infections too. Among of which there is necessary to pay especial attention that caused by big group of retroviruses, in particular, virus of the type C (retrovirus family from an oncovirus rod) and birds flu retroviruses (HPAI A(H5N1-virus)). First one is causative agent of enzootic bovine leucosis [21]. Bovine leucosis virus (BLV) contains revertase and six antigen proteins, of which are superficial (an envelope protein) glycoprotein (gp51) and inside protein (p21) [22, 23]. Ecological relationships between human leukaemia, livestock populations and bovine lymphosarcoma were investigated in Iowa. There is a high positive correlation between acute lymphoid leukaemia in males and cattle density. So, leukaemia is potential problem from both public health and economic perspectives [24]. HPAI A(H5N1-virus induces acute disease with damage of digestive and respiratory apparatus. In spite of decreasing of bids flu expansion temp in 2007 in comparison with 2006–2007 years [25] in 2009 it was registered simultaneous number of announcements about the appearance of this disease in China, Canada, Vietnam and Egypt [26]. There is very big dangerous if this virus would be adapted to organism of people. What is common for all these above mentioned situations which may have a very strong impact on people health? There is necessary to prevent non-desirable bio- and medical threats by accomplish of express and constant evaluation of organism status and monitoring of environmental objects. The providing of appropriate services by simple, very selective and sensitive methods for the express revealing of toxic components and infection sources in environment is very important approach among other ones directed to prevent serious consequences. Unfortunately the analytical methodologies for analysis are extremely high complicate, routine, expensive and time consumable. That is why, the development of the innovative approaches, such as chemo- and biosensors, is very urgent. This article is a review of our activity in field of the development of the instrumental analytical approaches for the sensitive and selective, very fast and simple determination of the above numerated toxins and at the diagnostic some viral diseases. Among of different types of biosensors the main attention will be paid optical ones only. Certainly, at the beginning we analyze efficiency of these devices at their work with the standard solution. Then the obtained results are compared with that received in

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real conditions. It is necessary to mention that the directions of our activity in field of biosensors reflect three aspects: fundamental research, creation of working prototypes and development of some elements of technology. Fundamental aspect includes: the selection of types of transducer and signals for the registration of the biospecific interaction, the choosing of the sensitive biological material and the effective methods for its oriented immobilization.

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1. Control of Total Toxicity The traditional methods for the determination of total toxicity are based on the application of living organisms: daphnia, luminescent bacteria (BLB), algae and fish. Since traditional methods are very time consumable, routine and complicate we have developed their biosensorics variants which should help to overcome these disadvantages. We have taken five person of Daphnia magna (24 h ages) and the main principle measurement concluded in the introducing of them for some time into 5 mL of the solution to be analyzed [27]. Then an aliquot (0.5 mL) of this solution was mixed with some optimal quantities of luminal and H2O2 to determine chemiluminescence (ChL) induced by daphnia exometabolites [28]. Quantity of last is proportional to the level of ChL and inversely proportional to toxicity of the analyzed sample. It was stated that the sensitivity of this approach to potassium biochromate (standard chemical substance used for the calibration of the traditional methods) was 0.005 mg/L. It was on two orders higher and overall time of analysis much less than in case of the application of the traditional method (30-120 min contrary to 1-2 days or more). Methomyl and tween-80 was registered at the concentration of 0.0013 and 0.1 mg/L, respectively [29]. During 2 h of daphnia incubation in T2 solution the intensity of ChL decreased proportionally to the concentration of toxin from 0.001 to 2 mg/L [30]. The standard method based on the daphnia immobilization shown much less sensitivity (on one order). Patulin in the concentration of 0.01–1.0 mg/L aroused the adaptive reaction of daphnia which connected with the gradual ChL increasing [31, 32]. Next its concentrations (>1 mg/L) caused sharply decrease of ChL signal. Maybe in the first case patulin stimulated stomach of daphnia system to excrete some substances which are able to stimulate ChL. In other one patulin aroused daphnia mortality. On the basis of BLB the special devices were developed and now are in the industrial production: Microtox test, LUMIStox, Mutatox [33]. In our investigations we used Photobacterium phosphoreum K3 (IMB B-7071), Vibrio fischeri F1 (IMB B7070) and Vibrio fischeri Sh1 purified from Black sea and Sea of Azov [34]. For the registration of bioluminescence (BL) it was developed a special stationary (on the basis of combination of photomultiplier with computer), semi-stationary (with the application of fiber optics for bacteria immobilization) and portable (with the BL registration by photodiodes) [35]. The samples contented 0.8 ml of the tested substance in 2.5% solution of NaCl, 0.1 ml of 0.5 M buffer (pH 7.0 or 5.5) and 0.2 ml of 5x105 BLB cells/ml. In other case BLB (105 cells) were immobilized in sepharose gel deposited on the end of fiber optics. In both case the BL intensity (I) was registered through 30–120 min. The level of toxicity was presented as the concentration, which caused 50% decrease of the intensity of BL (EC50). The value of EC50 oscillated in range of 7–19 mg/L in the dependence of the incubation time of BLB in the T2 mycotoxin solution (10–30 min). It is necessary to underline that the sensitivity of V. fischeri F1 to T2 micotoxin is much higher in

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comparison with the sensitivity of Ph. phosphoreum Sq3 [36]. Concentration patulin from 0.63 to 40 mg/L caused sufficient decreasing of the BL I at the influence on Ph. phosphoreum Sq3 during 12–60 min. The value of EC50 for patulin was in frame of 0.63–1.25 mg/L [37]. With the prolongation of time of influence (up to 90 min) the toxic effect of patulin increased and EC50 value was in frame of 0.15–0.63 mg/L. At the decreasing of medium pH to 5–5.5 the sensitivity increased up to one order. The EC50 value has analogy with semi lethal dose established for animal and it correlates with other indexes of toxicity [38]. It is necessary to mention that the intestinal barrier of animals is destroyed at the patulin concentration about 1 mg/L [39]. The cationic and anionic SAS had the similar kinetics of BL inhibition. Nonionic SAS, have additional stage on which the inhibition is absent or some activation of BL is observed. Therefore, for revealing toxicity of this group of SAS it is necessary to incubate these substances with bacteria a long time [37]. It is necessary to mentioned that both proposed optical biosensors are characterized by high sensitivity and they can fulfill all practice demands in the respect of the estimation of total toxicity of environmental objects before the solving of the question: is it necessary to check them on the presence of some groups of toxic elements or concrete toxins. This principle was realized by us at the feed back control of the process of the waste water purification from surfactants [29].

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2. Determination of Concrete Toxic Elements In this case optical immune biosensors based on surface plasmon resonance (SPR), grating diffraction, interferometry, directional couplers, reflection interferometry, fibrous optics with the fluorescent and electro-ChL detections are most dispersed [1, 2]. We have developed the immune biosensors based on the SPR, total internal reflection ellipsometry (TIRE) and nanocrystalline porous silicon (NCPS) for the control of patulin, T2-mycotoxin, nonylphenol (NP) and pesticides: 2.4dichlorophenoxyacetic acid (2,4-D), atrazine and simazine [40–42]. In case of SPR based immune biosensor it was realized a number of algorithms of analysis, including of “direct”, “competitive” and so called “to saturated” ways. There is necessary to mention that in case of the developed algorithm of method of “up to saturation” allows detecting NP with sensitivity about 2–5 ng/ml and working controlled concentrations – 5–1000 ng/ml. The sensitivity of “competitive” way was obtained on the level ca. 10 ng/ml and working range was up to 1000 ng/ml. The “direct” way of analysis allowed NP detection with the sensitivity ca. 100 ng/ml and working controlled concentrations was up to 2000 ng/ml. The time of analysis was ca. 10 min at the previously prepared transducer surface and immobilized sensitive structures) [40]. In case of “direct” of algorithm of analysis there is possibility to reveal T2 mycotoxin starting from 100 ng/ml. At the “competitive” analysis the sensitivity was ca. 10 ng/ml. The sensitivity of T2 determination by SPR immune biosensor was very similar if polyclonal and monoclonal antibodies (Ab) were used as specific recognizing structures. In case of the use of monoclonal antibodies and analysis fulfillment by “to saturation” way the sensitivity of T2 determination was on the level of 20 ng/ml [41, 42]. It was shown that in case of the immobilisation of specific Ab from antiserum on the gold surface covered by some polyelectrolytes (PESA) with lectins we obtained the sensitivity of 2.4-D determination on the level 1 ng/ml. If we have used procedure of

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the Ab immobilization through the application of surface covered by PESA with protein A and than we have fulfilled “competitive” analysis the sensitivity of the 2.4-D determination was increased approximately on one order. Maybe protein A is more effective intermediate agent for the directed orientation of Fab-fragments of Ab towards solution than lectins. Probably Ab may have carbohydrates not at the Fcfragment only and at the Fab-fragments also. In case of preservation of the similar immobilization procedure of the specific Ab on the gold surface but at the fulfillment of analysis by “to-saturation” way some smaller concentration of 2.4-D may be registered. In model experiments with the corn we can determine 2.4-D at the concentration ca. 0.1 ng/ml [41]. TIRE allows obtaining very sensitive direct analysis of low molecular weight toxic substances including NP and T2 mycotoxin. The sensitivity of analysis of last was on the level of 0.1 ng/ml. The linear plot of biosensor response was up to 100 µg/ml. The obtained results give possibility to calculate affinity constants of antibody-hapten interaction. It was stated that these coefficients were 1.7.106 mol–1 s and 1.9.107 mol–1 s for both poly- and monoclonal T2 antibodies, respectively [40–42].

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3. Diagnostics of Retroviral Infections by SPR Based Immune Biosensor The SPR based immune biosensor was used for the rapid determination of the specific Ab to BLV antigen (Ag) in blood and milk serum of cattle. Sensitivity of the analysis by immune biosensor is similar to the ELISA-method and much higher than immune diffusion test. Optimal dilutions of blood and milk serums were 1:500 and 1: 20 respectively. The turnaround time of the analysis was equal no more than 30 min including time for the Ag immobilization on the transducer surface, blocking free binding sites, Ag-Ab interaction and all washing procedures. The treatment of the gold surface by dodecanthiol allows achieving higher sensitivity of the analysis in comparison with that case when this surface was bare. Moreover, in contrast to the ELISA-method, application of the immune biosensor allowed performing analyses without any additional labelled molecules that confirms the advantages of the biosensor analysis before the traditional one [43–46]. To reveal of birds flu we together with the collaborators from the Institute of Cybernetics of National Academy of Sciences of Ukraine have developed the portable immune biosensor based on the SPR which is completed by GSM system and allowed not obtain very quickly result of analysis only and transferring it to the special medical controlling office [47–50]. This device has the same sensitivity as stationary one but gives possibility to recognize the place of infection revealing in real conditions.

4. Conclusion So, during our scientific researches we have developed various types of biosensors for reveling different substances in environment, for control of some technical processes and for biochemical diagnostics. In all cases these biosensors were able to fulfill practice demands. The obtained results give to us basis for conclusion that global express, selective, sensitive, simple and constant control of conditions of our life and state of our organism may be done the most effective with wide application of biosensors intensive development of which is urgent our task for today. A special

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attention should be given multi-parametrical and multi-functional biosensors, which are more suitable for global screening both aspects: organism and environmental objects.

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[28] I.A. Levkovetz, S.P. Ivashkevich, V.I. Nazarenko, N.F. Starodub, Application of chemiluminescent method for the determination of the Daphnia magna sensitivity to different types of toxic substances, Ukr. Biochem. J. 74 (2002), 120– 124. [29] I.A. Levkovetz, N.F. Starodub, V.I. Nazarenko, S.P. Ivashkevich, at al., Estimation of toxicity of water solutions of SAS during their oxidative treatment, Water Chemistry and Technology 25 (2003), 30–42. [30] O.S. Gojster, N.F. Starodub, G.A. Chmel’nitskij, Determination of Ɍ2 mycotoxin by chemiluminescent method with the use of Daphnia, Hydrobiol J, 5 (2003), 85–91. [31] L.N. Pylipenko, A.V. Egorova, Pylipenko I.V., N,F, Starodub et al., Investigation of toxic effect of patulin with the help of biosensorics systems, Food Sciences and Technology N1 (2007), 35–38. [32] N.F.Starodub, L.N. Pilipeko, I.V. Pilipenko, A.V. Egorova, Mycotoxins and other low weight toxins as instrument of bioterrorists: express instrumental control and some ways to decontaminate polluted environmental objects, Timisoara Medical J. 58 (2008), Issn 1583–5251. [33] I.E. Tothill, A.P.F. Turner, Developments in bioassay methods for toxicity testing in water treatment, Trends in Anal. Chem. 15, (1996), 178–188. [34] A.M. Katzev, N.F. Starodub, Investigation of effect of some surface–active substances on the intensity of bacterial bioluminescence, Ukr. Biochem. J. 75 (2003), 94–98. [35] N.F. Starodub Biosensor control of acute total toxicity of water and soil polluted by polycyclic aromatic hydrocarbons, In: NATO Proceedings “Mud Volcanoes, Geodynamics and Seismicity”, G. Martineli and B. Panahi (eds), Springer, 2005, 221–226. [36] Ⱥ.Ɇ. Katzev, O.S. Gojster, N.F. Starodub, Influence of T2 mycotoxin on the intensity of bacterial bioluminescence, Ukr Bioch J . 75 (2003), 99–103. [37] N.F. Starodub, M.I. Kanjuk, S.P. Ivashkevich, at al., Patulin toxicity and determination of this toxin in environmental objects by optical biosensor systems. Proc. of 3–th Inern. sci.–tech. conf. „Sensor electronics and Microsystems technologies” (SEMST–3), Ukraine, Odessa, June 2–6, 2008, 237–238. [38] M.T. Elnabarawy, R.R. Robideau, S.A. Beach, Comparison of three rapid toxicity test procedures: Microtox, Polytox and activated sludge respiration inhibition, Toxicity Assess 3 (1988), 361–370. [39] R. Manfoud, M. Maresca, N. Garmy, J. Fantini, The mycotoxin patulin alters the barrier function of the intestinal epithelium: mechanism of action of the toxin and protective effects of glutathione, Toxicol. Appl. Pharmacol. 181 (2002), 209–218. [40] N.F. Starodub, A.V. Demchenko, N.V. Piven at al., Development of new methods of immunochemical detection of non–ionic surfactants in water, Water Chemistry and Technology, 27, (2005), 591–599. [41] A.V. Nabok, A. Tsargorodskaya, A.K. Hassan, N.F. Starodub, Total internal reflection ellipsometry and SPR detection of low molecular weight environmental toxins, Appl. Surface Science 246 (2005), 381– 386. [42] A.V. Nabok, A.Tsargorodskaya, A. Holloway, at al., Registration of T2mycotoxin with total internal reflection ellipsometry and QCM impedance methods, Biosensors and Bioelectronics 22 (2007), 885– 890. [43] N.F. Starodub, V.P. Artjukh, L.V. Pirogova, at al., Express diagnostics of bovine leucosis on the basis of biosensor analysis, Veterinary medicine N11 (2001), 26–27. [44] N. Starodub, L Pirogova, Improvement of immune component immobilisation on the optical transducers by use of some lectins, International conference optoelectronics, optical sensors and measuring techniques. 14–16 May 2002. Germany, 2002, 175–180. [45] L.V. Pirogova, L.I. Nagajeva, N.F. Starodub, Application of lectins for the revealing of antibodies to the glycoproteins of leucosis virus in serum blood of bovines, Ukr. Biochem. J. 74 (2002), 97–101. [46] L.V. Pirogova, N.F. Starodub, V.P. Artjukh, at al., Express diagnostics of bovine leucosis by the immune sensors based on the surface plasmon resonance, Ukr. Biochem. J. 74 (2002), 88–92. [47] N.F. Starodub, V.O. Romanov, R. V. Kochan et al., Application of biosensors for the express diagnostics of acute viral infections and mycotoxicosis, Bull. Khmelnitski National Univ. 6 (2006) 223– 226. [48] M.F. Starodub, V.O. Romanov, R.V. Kochan, at al., Implementation of SPR–biosensors for express– diagnostics of acute viral infection and mycotoxicosis. In Proc. ɨf the IEEE Intern. Workshop on medical instruments and applications MeMeA, Poland, Warsaw, May 4–5 (2007). [49] V. Romanov, M. Starodub, I. Galelyuka, O. Skrypnyk, Smart portable tester for express–diagnostics of bird flue: principles of design. In: Information Science and Computing. Int. Book series, “Intelligent Technologies and Applications”, n 5. Suppl. to int. J. “Information Technologies and Knowledge”, Ithea, Sofia, 2 (2008), 80–84. [50] O.V. Palagin, V.O. Romanov, N.F. Starodub et al., Virtual laboratory for the biosensor designing, Med. Informatics and Enginering 2 (2008), 36–40.

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Behavior of Some Pathogenic and Genetically Modified Bacteria in Groundwater Samples Zdenek FILIP1 and Katerina DEMNEROVA2 Department of Biochemistry and Microbiology, Institute of Chemical Technology, Prague, Czech Republic

Abstract. Different pathogenic bacteria appeared capable of survival in groundwater longer than 100 days, and perhaps, they can be transported for distances from the site of contamination. Their elimination by a predator such as Bdellovibrio sp., seems to fail under an ambient temperature of about 10 °C. Also in model groundwater microcosms, bacteria bearing either natural or recombinant plasmids appeared detectable for up to 150 days, and the expression of plasmids remained stable. The survival of all bacteria under testing, however, was evidently handicapped in non-autoclaved groundwater samples, i.e., those containing natural microbial population. Keywords. pathogenic bacteria; genetically modified bacteria; bacterial survival; groundwater

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Introduction Groundwater stands for about 1% of all water on the Earth, but simultaneously it represents some 90% of the fresh water reserves [1, 2]. In Germany, up to 50% of drinking water originates from groundwater [3]. Similarly, in the former Czechoslovakia (now the Czech Republic and the Slovak Republic), some 45% of drinking water supplies were covered from groundwater resources, with a long-term tendency to enhance this percentage [4]. Also, over 100 million Americans rely on groundwater for drinking water, and in rural areas up to 95% of the water used is groundwater [5]. Given such extensive use of groundwater in Europe and in other parts of the world, a significant problem we face is the risk of groundwater pollution. There is a growing public concern over potential ramifications of accidental or intentional contamination of groundwater, for example, a health hazard caused by pathogenic bacteria. Recently, the American Academy of Microbiology strongly recommended that the field reconsider available knowledge and develop novel methods to identify and control pathogenic bacteria that might be used in a bio-attack [6]. More than twenty years ago several Czech scientists devoted considerable attention to different aspects of groundwater quality and its management. This topic was stressed extensively in a textbook, [7]. Various techniques for exploration and 1

Visiting Professor (Former: Federal Environmental Agency, Branch Langen, Germany). To whom correspondence should be addressed: Prof. Katerina Demnerova, Department of Biochemistry and Microbiol., ICT Prague, Technicka 3-5, CZ-166 28 Prague 6, Czech Republic. 2

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effective utilization of groundwater resources have also been described [8]. Additionally, methods used in the USA and other countries for the assessment and investigation of groundwater pollution have been discussed and evaluated [9, 10].

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1. Microorganisms in Groundwater Groundwater aquifers naturally harbor microbial communities, the specific composition of which co-defines the water quality and its suitability for human consumption and other uses. Several such communities have been distinguished, including: (i) stygobionta, i.e., autochthonous microbes obligatory inhabiting groundwater aquifer; (ii) stygophilic microbes that preferentially inhabit groundwater but are capable of living in a surface water as well, and (iii) stygoxenic species, i.e., allochthonous microorganisms that may enter groundwater aquifer accidentally, or could be released intentional [7]. The average microbial counts as determined in groundwater environments have been summarized in Table 1. Due to a low concentration of nutrient in the underground, a vast majority of groundwater-related bacteria remains undetected if fully concentrated nutrient media, i.e., commercial ones, are employed for analyses of water samples. If using a 20-fold diluted medium, e.g., the bacterial counts higher up to 104 can be obtained [11]. Also undoubtedly, a high percentage of bacteria might appear associated with different solids in a groundwater aquifer (see in Figure 1); thus, they can hardly be counted individually. In a pristine groundwater aquifer, microorganisms are capable of different activities. Depending on the aquifer depth, the microbial metabolism usually governs aerobic, facultative anaerobic or obligatory anaerobic processes. Within these frames, the microbial activities include (i) removal of organic carbon compounds that might impart odor and flavor to drinking water; (ii) solving of minerals, with an increase in dissolved solids and a subsequent alteration of aquifer permeability; and (iii) catalytic reactions that might lead to an elevated concentration of undesirable compounds, such as ferrous iron and hydrogen sulfide [2]. Table 1. Average counts of bacteria in groundwater and aquifer material samples. [From: Ref. [7]]

Sample

Counts of bacteria per ml-1 ( g–1)

Groundwater pumped Groundwater ladled Mud from a groundwater well Sediment from a groundwater aquifer

10 2 103 10 4 105

– 104 – 105 – 107 – 107

2. Health Relevant Bacteria in Groundwater An improper treatment, disposal and usage of manure, municipal wastewater, sewage sludge and solid wastes, can result in contamination of a groundwater aquifer with nonresident microorganisms, including pathogenic or facultative pathogenic bacteria. It is

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a b

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Figure 1. Bacteria suspended in water, and heavily inhabiting a clay particle (a), but less a quartz one (b). (Photo by Z. Filip)

reported that some bohemian scientists recognized this kind of risk to water resources as early as 1877, and consequently a regular bacteriological water testing was strongly recommended decades ago [7]. Nevertheless, the problem has remained rather unsolved. Much later, several surveys performed in the USA indicated that aquifer depth and even rainfall may have impact on the microbial quality of groundwater. In a rural region of Texas, a vast majority of the examined wells less than 15 m in depth was found to be contaminated by either fecal coliform bacteria or fecal streptococci [12]. In Egypt, a significant level of bacterial pollution has been reported in groundwater samples drawn from 15 wells, the depth of which ranged even between 45 m and 95 m. Total coliform or fecal coliform bacteria, were found in 92% and 55% of examined water samples, respectively; and spore-forming clostridia were detected in 45% of samples [13]. For the sake of drinking water security it is important to obtain data on the survival and transportation of potential pathogenic agents in groundwater. Coliform bacteria have been found capable of survival for a very broad range of durations between 40 and 1000 days, and their transportation from the contamination source has been estimated as distant as 1200 m [7]. In our laboratory, we also checked the survival of different health relevant bacteria in groundwater samples [14, 15]. The species used, their origin and sanitary importance are listed in Table 2. For the experiments, groundwater was obtained from a 140 m deep well, and samples were kept at 10 ± 1°C. In some of the experimental microcosms sand from a Pleistocene groundwater aquifer was added to simulate conditions likely to exist in a porous aquifer. The slopes of the curves in Figure 2 indicate that (i) no apparent multiplication of test bacteria occurred under experimental conditions, but (ii) several bacteria survived at rather high cell-concentrations for a period of 100 days. However, B. megaterium was completely eliminated after 12 days, and the counts of B. cereus, B. megaterium and S. aureus were reduced from 2 to 6 log, within only 10 days. After 30 days,

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S. aureus was no longer detected. The colony counts of B. cereus and C. perfringens were strongly reduced during the first 10 days, but later they remained rather unchanged, perhaps due to the formation of resistant spores. B. megaterium, might have failed to form spores in groundwater microcosms. Some other bacteria under testing, such as S. faecalis, P. aeruginosa, and Y. enterocolitica, survived up to 50 days upon a count reduction less than 90%. The survival of E. coli and S. typhimurium was reduced by four log, i.e., to 99.99%. If sand from a groundwater aquifer was added to the microcosms, a longer survival of the test bacteria has been observed (not shown). Table 2. The bacteria under testing in samples of groundwater, and their sanitary importance.

Bacteria

Sanitary importance

Escherichia coli Salmonella typhimurium Pseudomonas aeruginosa

Enteritis; Local infections Enteritis; Typhoid fever; Food poisoning Otitis; Urogenital inflammation; Skin gangrene Diarrhoea; Appendicitis; Septaemia Skin inflammation; Enterotoxin formation Non specific infections Non specific food poisoning; Infections in animals Food spoilage Gasoedema; Tissue necrosis; Enterotoxin formation; Food poisoning

Yersinia enterocolitica Staphyloccocus aureus Streptococcus faecalis Bacillus cereus

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Bacillus megaterium Clostridium perfringens

Figure 2. Survival of some pathogenic and facultative pathogenic bacteria in groundwater. (From: Ref. [15])

In summary, many of the test bacteria inoculated into groundwater microcosms remained viable and detectable in numbers between 102 and 106 ml-1 after 100 days. In view of these experimental results a “Fifty-Days Die-Off Limit” for pathogenic bacteria, which represents a presumption of the groundwater safety as advocated in Germany since 1951 [16], seems somewhat weakly founded.

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Several authors from Russia and Eastern European countries also studied the behavior of sanitary important microorganisms in groundwater. From a comprehensive review [4], the results can be summarized as follows: (i) In a sandy or shell-calcareous groundwater aquifer health important bacteria survive from 30 to 400 days; (ii) a simultaneous contamination of groundwater aquifer with phenols or mineral oil derivates does not effect the survival of the sanitary important bacteria but sometimes it stimulates the growth of autochthonous saprophytic microbes; (iii) in addition to their ability to survive, the transportation of pathogenic bacteria in groundwater represents an important factor in the sanitary safety of groundwater. The following average radii of bacterial spread should be taken into account: (i) 30–40 m in aquifer composed of a fine sand (grain size < 2mm); (ii) up to 200 m in aquifer composed of coarse sand (grain size 2–4 mm); (iii) up to 1000 m in a gravel and karstic aquifer.

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3. Bacterial Predators and Viruses in Groundwater In many natural and polluted aquatic environments, appearances of bdellovibrios have been documented and their role as predators in nutrient-impoverished sites investigated [17]. These organisms exist as small (ca. 0.3 ȝm X 1.5 ȝm), highly motile prokaryotic cells incapable of independent growth and reproduction. For reproduction to occur, a bdellovibrio collides with, and attaches to, a gram-negative bacterium. Then it penetrates through the cell membrane, and multiplies while the target bacterium dies (Figure 3). Since several pathogenic bacteria, possibly also groundwater contaminants, belong to the gram-negative group, we attempted to establish whether bdellovibrios should play a role as a factor to control their spread. In our laboratory experiments we used a Bdellovibrio sp. capable of attacking E. coli cells [18]. As shown in Figure 4, the multiplication of bdellovibrios was restricted to a temperature range between 25 and 30°C. Thus, in a groundwater aquifer that exhibits an ambient temperature of about 10°C, bdellovibrios would hardly play an important role to control the spread of pathogenic bacteria.

Figure 3. Bdellovibrio sp.: (a) A strongly magnified single cell,; (b) Individual bdellovibrios (very small cells) attacking a bacterium; (c) destroyed bacterial cell releasing novel bdellovibrios. (Foto: R. SmedHildmann / Z. Filip)

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Figure 4. Effect of temperature on predatory activity of Bdellovibrio sp. against E. coli grown on nutrient agar. (PFU = Plaque Forming Unit). (From: Ref. [18])

A number of outbreaks of water born diseases have been reported as evidently caused by viruses [19]. More than 100 types of enteric viruses can be considered as pathogenic to man, and the ingestion of only a single virus particle might lead to infection in a certain proportion of susceptible people. For example, in the USA between 1946 and 1980, enteric viruses were identified as the causative agent in 12% of the waterborne disease outbreaks [20]. According to World Health Organization [21], viruses can be transported and persist for months in a groundwater aquifer. By using a bacteriophage as a model, setback distances between 15 m and 150 m in a groundwater aquifer have been calculated in order to achieve a safe concentration decrease of about 7 log ml-1 [22]. In our field investigations on the spread of enteric viruses in a sandy soil which might resemble in some way a sandy aquifer, and which was long-term irrigated with wastewater, the presence of viruses could be detected only in a maximum soil depth of 2 m [23]. 4. Behavior of Plasmid-Bearing Bacteria in Groundwater Natural plasmids have been detected in bacteria isolated from pristine as well as chemically polluted subsurface aquifer [24], and some genetically engineered plasmids could gain importance in the bio-cleaning of chemically polluted aquifers [25]. For these reasons but also for the sake of ecological and health safety it is an imperative to investigate the behavior of genetically engineered bacteria in groundwater under laboratory conditions first. In our experiments we used Pseudomonas aeruginosa and Pseudomonas stutzeri strains bearing either a conjugative plasmid RP4, or non-conjugative recombinant plasmids pKT210 and pKT261, respectively [26]. The individual plasmids encoded resistance to different antibiotics, and thus the fate of the strains could be followed in cultural media with the respective antibiotics added. As shown in Figure 5, P. stutzeri strains exhibited different survival kinetics in sterile groundwater at 10°C. With the exception of the strain pKT261, the colony

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Figure 5. Survival of P. stutzeri (Ƒ), P. stutzeri RP4 (x), P. stutzeripKT210 (ż), P. stutzeri pKT (¸) in sterile groundwater at 10°C.cfu = colony forming units on a growth medium with rifampicin andnalidixic acid added. (From: Ref. [26])

counts of which declined slowly and gradually from the beginning to the end of the experiment, all other strains showed a rapid decline within the first 10 to 30 days. Later, the same count increased such that at the end of the experiments both the plasmid-less and the RP4-bearing strains reached almost the initial counts of colonies. As shown in Figure 6, there was a rapid decline of P. aeruginosa and P. aeruginosa RP4 in a non-sterile groundwater. After 120 days of incubation, only some 102 instead of 107 ml-1 colony forming units could be counted. At the same time the numbers of autochthonous bacteria increased from less than 1 x 102 up to 1 x 106 ml-1. This development indicated there is a capacity in indigenous bacteria to suppress the development of bacterial strains artificially introduced into natural groundwater samples. Of the different physical and chemical factors that bacteria respond to in order to survive in groundwater samples, the pH apparently plays an important role. Our experimental results showed that plasmid-bearing strains were more sensitive to acidic (pH 5.8) and alkaline (pH 9) conditions than their plasmid-les counterparts. But also at pH 7.3 most of the plasmid-bearing bacteria died off in groundwater faster than the plasmid-less strains (not shown in Fig.).

5. Conclusions The results of our experiments indicate that a safe delineation of water protective zones should not be based only on the assumption of a rapid dying of pathogenic bacteria introduced into groundwater. As concerns genetically modified bacteria, they appear rather lacking a fitness to compete for survival with bacteria naturally inhabiting groundwater aquifer.

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Figure 6. Survival of P. aeruginosa (Ƒ), P. aeruginosa RP4 (ż) and the development of autochthonous bacteria (*) in non-sterile groundwater at 10°C; cfu = colony forming units. (From: Ref. [26])

Acknowledgement

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The senior author (Z.F.) gratefully acknowledges a Visiting Professorship (Marie Curie Chair) granted by courtesy of the European Commission, Brussels, and tenable at the Institute of Chemical Technology, Prague, Czech Republic. He also wishes to acknowledge an excellent cooperation of his former co-workers at the Federal Environmental Agency, Branch Langen, Germany.

References [1] [2] [3] [4] [5] [6] [7] [8] [9]

Stetzenbach, L.D., Kelley, L.M. and Sinclair, N.A., 1986, Isolation, identification, and growth of wellbacteria. Ground Water 24: 6-10. Coates, J.D., and Achenbach, L.A., 2002, The biogeochemistry of aquifer system, in: Manual of Environmental Microbiology, 2nd ed., Ch. J. Hurst, ed., ASM Press, Washington, DC, pp. 719-727. Schleyer, R., and Kerndorff, H., 1992, Die Grundwasserqualität westdeutscher Trinkwasserressourcen, VCH Verlag Weinheim, 249 pp. Filip, J., 1989, Verunreinigungen und Schutz des Grundwassers in einigen Ländern Osteuropas. Res. Report Suppl., Grant 02-WT-8628 of the German Fed. Ministry of Res. & Technol.; Inst. of Water, Soil & Air Hygiene, Branch Langen, 60 pp. Bitton, G. and Gerba, C.P. (Eds.), 1984, Groundwater Pollution Microbiology, Willey & Sons, New York, pp. 1-7. Keim, P., 2003, Microbial Forensics: A Scientific Assessment. Amer. Acad. Microbiol., Washington, DC, 24 pp. Pelikan, V. 1983, Groundwater Protection, SNTL Praha, 323 pp. (in Czech). Melioris, L., Mucha, I. and Pospisil, P., 1986, Groundwater – Methods of Research and Investigation, ALFA Bratislava / SNTL Praha, 429 pp. (in Slovak). Canter, L.W., 1985, Methods for assessment of ground water pollution, in: Ground Water Quality, C.H. Ward, W. Giger and P.L. McCarty, eds. Wiley, New York, pp. 270-306.

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[10] Young, C.P., and Baxter, K.M., 1985, Overview of methods for ground water Investigation, in: Ground Water Quality, C.H. Ward, W. Giger and P.L. McCarty, eds., Wiley, New York, pp. 219-240. [11] Ghiorse, W.C., and Balkwill, D.L., 1985, Microbiological characterization of subsurface environments, in: Ground Water Quality, C.H. Ward, W. Giger, and P.L. McCarty, eds., Wiley & Sons, New York, pp. 387-401 [12] Gerba, Ch. P., 1985, Microbial contamination of the subsurface, in: Ground Water Quality, C.H. Ward, W. Giger, and P.L. McCarty, eds., Wiley & Sons, New York, pp. 53-67. [13] El-Zanfaly, H.T.,and Shabaan, A.M., 1988, Applying bacteriological parameters for evaluating the underground water quality, in: Proc. Int. Conf. on Water and Wastewater Microbiology, vol. 2, Newport Beach, CA, USA, pp. 75-1 – 75-4. [14] Filip, Z., 1988, Verhalten einiger pathogener und anderer Mikroorganismen im Grundwasser im Hinblick auf die Bemessung von Wasserschutzzonen, Öff. Gesundh.-Wes. 50: 427-430. [15] Filip, Z., Kaddu-Mulindwa, D., and Milde, G. 1988 Survival of some pathogenic and facultative pathogenic bacteria in groundwater, Water Sci. Technol. 20: 227-231. [16] Knorr, M., 1951, Zur hygienischen Beurteilung der Ergänzung und des Schutzes großer Grundwasservorkommen, gwf 92: 104-110. [17] Rittenberg, S.C., 1979, Bdellovibrio: A model of biological interactions in nutrient- impoverished environments? in: Strategies of Microbial Life in Extreme Environments, M. Shilo, ed., Life Sci. Res. Rep. 13, Verlag Chemie, Weinheim, pp. 305-322. [18] Filip, Z., Schmelz, P, and Smed-Hildmann, R. 1991, Bdellovibrio sp. – a predator under groundwater conditions? A short communication. Water Sci. Technol. 24: 321-324. [19] Filip, Z., 1983, Über die gesundheitliche Bedeutung von Viren im Wasser – ein Expertenstandpunkt, Forum Städte-Hyg. 34: 54-58. [20] Lippy, E.C., and Waltrip, S.C., 1984, Waterborne-diseases outbreaks 1946–1980: A thirty-five years perspective, J. Amer. Waterworks Assoc. 76: 60-67. [21] WHO Scientific Group, 1979, Human Viruses in Water, Wastewater and Soil, Technical Report Series 639, World Health Organization, Geneva, 50 pp. [22] Yates, M.V., and Yates, S.R., 1988, Virus survival and transport in ground water, in: Proc. Int. Conf. on Water and Wastewater Microbiology, vol. 2, 49-1 – 49-7. [23] Filip, Z., Seidel, K., and Dizer, H. 1983, Distribution of enteric viruses and microorganisms in longterm sewage treated soil. Water Sci. Technol. 15: 129-135. [24] Ogunseitan, O.A., Tedford, E.T., Pacia, D., Sirotkin, K.U., and Sayler, G.S., 1987, Distribution of plasmids in groundwater bacteria. J. Ind. Microbiol.1: 311-317. [25] Stotzky, G., Devanas, M.A., Zeph, L.R., 1988, Behavior of genetically engineered microbes in natural environments and their potential use in in-situ reclamation of contaminated sites, in: Biotechnologische In-situ-Sanierung kontaminierter Standorte,Z. Filip, ed., Fischer, Stuttgart, pp. 293-343. [26] Claus, H., Rötlich, H., and Filip, Z., 1992, Survival in groundwater of some bacteria with natural and recombinant plasmids. Microb. Releases 1: 103-110.

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Geological Environment as a Factor of Natural and Man-Made Disasters Evgeniy E. KONONOV Irkutsk State Technical University, Lermontova st. 83, 664074, Irkutsk, RF, [email protected]

Abstract. Interconnection between geological environment and urbanization is discussed in this lecture.

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Keywords. geological environment, faults of the lithosphere

Territory urbanization is a global process involving the entire ecosystem of Earth. By the beginning of the XXI century more than 60% of the world's populations live in cities. The emergence of huge urban mega-cities leads to a new way to assess the relationship between the city and its industrial complex, its social and communication infrastructure and the environment. Technical processes occurring in urban areas have long had sizes comparable to natural, but the intensity of development went around them. Unfortunately, the man-predator removes some of the resources in his obsession to conquer nature, destroys other resources and then man-«hero» tries to rebuild them. J. Milton, the English poet, says: “Do not condemn Nature, it has performed its duty. To care about the performance of their ...”. And the famous philosopher F. Bacon, says: “To control Nature, one must submit to her”. Unfortunately, the understanding that the role of geological environment in urban territories has to be considered the basis on which and through which the infrastructure of the city have to be created, is not taken into account, despite the fact that health problems and life are of great interest, concern and heated debate. Geological environment is a natural multicomponent dynamic system with all its internal relationships, structure, and autonomy. The geological environment is the basis for buildings, roads, rail and underground communications. The sustainability of the geological environment towards external intervention is not infinite. Very often the parameters balance of the geological environment is disrupted and we see the reaction of the geological environment. The reaction can be extremely diverse, and well known to the inhabitants of cities: holes, collapse of roads and pavements, slope landslides in places where they never occurred before. We see flooded basements, especially in the central urban areas, sunk houses, destruction of building foundations as a result of soil deformation. For example, the Irkutsk urban area has ample evidence of a disturbed geological environment. Which is the way to prevent this situation? We cannot return the geological environment in the original condition. But we can do much to restore its sustainability in the future and stop its destruction right now. For this, the requirements are: serious study of geological environment sustainability within the city, creation of special expert maps, continuous monitoring of the geological environment. There is a need organization for any decisions of urban

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sustainability assessment with the existing geological environment of specific urban area to determine the level and nature of security intervention in the geological environment. A relief is a simple, fast and effective method for studying the state of the geological environment. It is an indicator of changes in the geological environment, its response to intervention. On appearance one aspect of relief is applied on the lithology, that is the orientation of the geological processes that created the geological environment. It is important to study the relief in seismic areas, where the resistance of arrays of rocks with seismic vibrations depends not only on the strength of these shocks, but to a large extent determined by the morphology of slopes and, their relative position towards the approach of seismic waves. The faults of the lithosphere are triggers for many geological processes. Information about location, structure specificity, development history, process dynamics, can predict the location and nature of natural phenomena, as well as the location and nature of slowly but steadily developing geologic processes. High level of fragmentation in areas of active faults contributes to a free circulation of groundwater and a fragmented surface. And finally, it is well known that fractures are very often the cause of deformation of buildings and various surface and underground communications. The role of fractures in generating the formation of earthquakes foci is undoubtful. The recent earthquake in Irkutsk (August 2008) has shown again the need to strengthen research on the city’s geological environment. Establishment of area-specific maps, taking into account the sustainability of the geological environment’s seismic component, will allow a more rational, and economically justified (and safer for people) method to create new elements of the city infrastructure. Thus, today, the concept of human security and economic objects, taking into account the inevitable risks of natural and man-made disasters, should be based not only on creating reliable and efficient technology, but also an important component of a comprehensive natural system as a geological environment. There is need to change the thinking of our city managers, people who responsible for making decisions on development and the transformation of the city.

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Mass Destruction Weapons and their Contribution to Pandemic Effects Alberto BRECCIA FRATADOCCHI1 Accademia delle Scienze dell’Istituto di Bologna, Bologna, Italy

Abstract. The term ‘Mass Destruction Weapons’ encompasses any intentionally negative event caused by biological, chemical and nuclear agents. A more specific definition could be: all those harmful agents which cause death or injury to people in a non-conventional way and which damage, often irreversibly, the environment. There are similarities between non-conventional biological, chemical and nuclear agents and the spreading of pandemics. CBRN agents cause a psychological effect, such as fear and anxiety. The psychological impact gets a maximum after a terrorist attack or after the use the use of non-conventional weapons. For instance, the public opinion felt such sense of anxiety after the terrorist attack in the Japanese subway with the nerve agent, sarin, or in other occasions. Chemical toxic agents may have biological effects too and their dispersion in air could cause pandemic effects when they are in high concentration. The poor knowledge about Mass Destruction Weapons on population produces panic and a deep psychological impact. The defence actions against this kind of pandemics are prevention and education: prevention means informing population and organizing a national task force for rapid intervention and countermeasures; education means the organization of a proper information at School and in Academia about mass destruction weapons, their negative effects and the defence from them, with obligatory courses.

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Keywords. Mass Destruction Weapons, Pandemics, Psychological Effects, CBRN agents

Introduction The Weapons of Mass Destruction can be classified in three groups: A) Nuclear and Radiological Weapons, B) Biological Weapons, C) Chemical Weapons. The term “Weapons of Mass Destruction” makes most people think – first of all – of nuclear weapons, but chemical weapons have displayed their destructive effects on humans too, during the last century. In recent years, the public opinion worldwide has become aware about the importance of treaties banning chemical and biological weapons. The first defense against biological, nuclear and chemical threats is made thanks to international Conventions and Treaties [1].

1. Similarity between Mass Destruction Weapons and Pandemic Effects The similarities between the different types of Mass Destruction Weapons and the spreading of pandemics are more than people could consider. 1

Via Zamboni 31, 40126 Bologna, Italy, E-mail: [email protected].

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First of all, both of them imply psychological consequences: fear and anxiety. While a conventional bomb acts as a high explosive, the fear of the unknown (this is the case when radiation, radioactivity, chemical or biological agents are concerned) causes a large and unpredictable response. The fear factor comes out from the apparently complex physical, chemical and biological implications. Fear and anxiety are extremely pandemic. In addition, the chemical and biological weapons can produce physiopathologic effects which are directly pandemic. Also the weather conditions and other factors, which govern the diffusion of contaminants, such as movement of people, import/export of goods, mail exchange, etc., can affect largely the onset of a pandemic. 2. Types of Non-Conventional Weapons 2.1. Nuclear Weapons Nuclear weapons produce mechanical effects, such as heat, light and pressure, in a similar way as explosives, but they produce also huge amounts of radiations, which cause direct injury, cancer, birth defects, not only during the explosion, but also several years after the event. In this manner, their effects produce destruction and psychological pandemic effects during the diffusion of radioactive nuclides worldwide. On the basis of these relevant effects, only the nuclear weapon should be considered a mass destruction weapon. It is worth noting however that only nuclear weapons have not been completely banned yet by international treaties.

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2.2. Nuclear Weapons International Legislation The international legislation on the nuclear weapons starts with the Nuclear non Proliferation Treaty in 1968. Since that year several systems of Conventions have been active [2, 3]: • • • • •

Bilateral treaties called SALT 1 (1972), SALT 2 (1979), START I and II (1991–93), ABM (1972) Treaties on Nuclear tests USA/USSR (1974–76) Treaties on missiles (1987) and SORT (2002) Multilateral treaties 1963, 1996, 1980, 1994, 1997 Regional Ban of Nuclear Weapons, five treaties.

None of those treaties were signed by all the countries of the World, but only a part of them decided to ban or to stop the proliferation of nuclear weapons. 2.3. Biological Weapons Most of Biological Weapons are agents of common diseases. The main characteristic of biological agents, toxins and pathogens is that they can be often treated successfully. There are many different natural (anthrax, smallpox, plague, etc.) and man-made agents. In the 1950’s and 60’s, some studies have been carried out to introduce genetic modifications in order to obtain more potent or resistant pathogens and toxins [4].

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Biological agents are basically pandemic. This kind of weapons has been banned totally with the Biological Weapon Convention in 1973. 2.4. Pandemic Effects of Biological Warfare Agents Biological Weapons can be used for lethal or incapacitating purposes. They are essentially bacteria, viruses, fungi or toxins (neurotoxins, cytotoxins, batrachotoxin, microcystin, etc.). Many pathogens can also cause zoonoses. Such agents can produce pandemic effects [5]. Their effects are insidious because of the long persistency and incubation and of eventual contacts between infected patients and vectors. 2.5. Biological Weapons Convention The Biological Weapons Convention is the first multilateral disarmament treaty banning the production of an entire category of biological agents that could be used as Mass Destruction Weapons [6]. The entire title of this agreement is: Convention on the prohibition of the Development, Production and Stockpiling of bacteriological and toxin weapons and on their destruction. It was opened for signature on April 10, 1972 and entered into force on March 26, 1975. The basic difference with the Convention of Chemical Weapons ban is that no fine or other penalty will be charged to the Country which produce and/or use those agents.

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3. Chemical Weapons The so called Chemical Weapons are designed to kill or cause harm to an enemy. Their effects are thought to hit population, rather than to cause total destruction. The most common types of chemical agents do not show pandemic effects on their own, but they create fear and anxiety inside the population like an epidemic and this can be considered similar to a large pandemic effect. When a chemical agent is released (typically as an aerosol) it creates a primary cloud. Then the cloud settles to the ground giving rise to different concentrations and, so, to different toxicity. Afterwards, the weapons can be degraded by secondary chemical processes, by photochemical processes triggered by sunlight or by favourable weather conditions. These processes reduce gradually the toxicity. 3.1. Origin of Chemical Mass Destruction Weapons In ancient times, noxious agents were utilized during the war of Cirrha in Greece in 590 B.C. An aqueduct from Pleistus river was polluted by Athenians with hellebora roots, a purgative, to get enemies unable for the incoming battle [7, 8]. During the Peloponnesian war in 423 B.C., Spartan allies took an ancient fort of Athenian by directing smoke of sulphur-based gases. The most widely used non-conventional weapons in warfare, in antiquity, were the “flame weapons” (ancient documents report several names for those weapons: “Greek fire”, “Sea fire” or “Roman fire”). In old Chinese manuscripts (from 500 to 1400 A.D.), several weapons are mentioned containing charcoal, sulphur and saltpetre to produce rockets and explosive iron bombs.

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3.2. International Treaties about Chemical Weapons The modern term “Mass Destruction Weapons” was used for the first time in 1937 by the New York Times, describing the bombing of Guernica in Spain with chemical weapons [9]. Then that term has been referred to as the complete range of weapons from chemicals to nuclear, biological and radiological since the Nuclear Treaty of Non Proliferation, signed in 1968. A feeble attempt of a first treaty for the prohibition of the chemical weapons was made in 1900 with The Hague Convention. That treaty did not stop the use of toxic chemical for warfare purposes. In fact, since 22 April 1915, when chemical weapons were used at Ypern (Belgium), they caused casualties to more than 1,300,000 people during the first World War. Then, in 1925, the Protocol of Geneva was signed to ban partially chemical and biological harmful agents. 3.3. Chemical Weapon Effects Chemical Warfare Agents are poisonous aerosols (vapors, gases), liquids and solids that have toxic effects on humans, animals and plants. They are delivered by several means of dispersion: directly as gas o vapours or aerosols, by bombs, sprayed by aircrafts or boats, diffused as liquids to create hazard or harm to human beings and to the environment. Their effects can be immediate and/or delayed. The chemicals with the most lethal potential are listed ) in three tables of Annexes of the international Convention on Chemical Weapons (CWC) following a criterion of increasing toxicity level. The Convention entered into action in 1997. It operates through the Organisation for the Prohibition of Chemical Weapons.

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3.4. Chemical Weapons: Action and Effects The general effects of the chemicals weapons depends on the way of dispersion of toxic agents and on the biological effect on human beings and on the environment. The different types of Chemical Weapons consist in chemicals which: prevent the blood from carrying oxygen; irritate or destroy the respiratory system; cause the nervous system to malfunction; cause uncontrolled bleeding; cause lesions on the skin; act as toxins. The negative effects of dispersion can be attenuated by the strong variation of the concentration which reduces the lethal effect. In any case, such effects generate panic and anxiety which could be considered psychologically as a pandemic effect. 3.5. Infectious Substances Infectious substances (Figure 1) belong to Class 6.2 and are assigned to UN Nos. 2814 or 2900 on the basis of the risk group defined from the World Health Organization (WHO, Laboratory Biosafety Manual, second edition 1993) [10]. Infectious substances contain pathogens which are defined as microorganisms or recombinant microorganisms, hybrid or mutant, which cause infection disease in humans or animals.

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Figure 1. Label of toxic chemicals, class 6.1 (left) and of pathogens, class 6.2 (right)

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4. Final Remarks Mass Destruction Weapons are extremely dangerous, but not all of them show the same level of toxic action. They can be delivered in different ways and by different means. Most of them are difficult to use or some antidotes can be, in some cases, readily available. In detail, Nuclear Weapons need an organization that only a big and modern country can give. Biological Weapons often produce effect similar to conventional diseases and they can be rapidly controlled, even if a part of new unknown pathogens can pose important problems. Chemical Weapons could be, in principle, more dangerous, because all toxic chemicals can be used as weapons and there is a continuous production of new toxic compounds. For that reason, all the Conventions should have an Organisation that carries out and monitor the steps of control, protection, destruction and decontamination. The Convention for the prohibition of Biological Weapons (BTWC) has not its own Organisation to control the effects, the production and the proliferation of the weapons. Actually, the World Health Organisation monitors the development of diseases and the outbreak of new pandemics from any kind of source. The defense actions against this kind of pandemics are: 1) prevention and 2) education. 1) Prevention implies thorough information to population and the organization of a task force for a rapid intervention. 2) Education means the set up of an appropriate education at School and in the Academia about the meaning of the mass destruction weapons, their effects and a proper activity of defence from those weapons, with obligatory courses.

References [1] [2]

R. Everett Langford. Introduction to Weapons of Mass destruction, Wiley Interscience, John Wiley & Sons, Inc. Publ., Hoboken NJ, USA, (2004), p.1. L. Bacaini, C. Salvetti, Disarmo Nucleare, Occidente n.1 e 2, 1997; Internet, www.comitatoatlantico.it (Accessed August 2009)

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R. Everett Langford, Introduction to weapons of Mass Destruction, Wiley Interscience, John Wiley & Sons, Inc. Publ., Hoboken NJ, USA, (2004), p. 78. [4] D. Hank Ellison, Emergency action for Chemical and Biological Warfare Agents, CRC Press LLC, Boca Raton FL, USA (2000), p.1. [5] D. Hank Ellison, Emergency action for Chem., CRC Press LLC, Boca Raton FL, USA (2000), pp. 117132. [6] R. Everett Langford, Introduction to Weapons of Mass Destruction, Wiley Interscience, John Wiley & Sons, Inc. Publ., Hoboken NJ, USA, (2004), p.148. [7] Storia delle Armi Chimiche, http://doc.studenti.it (Accessed August 2009). [8] R. Everett Langfort: Introduction to Weapons of Mass Destruction, Wiley Interscience, John Wiley & Sons, Inc. Publ., Hoboken NJ, USA, (2004), p. 211. [9] L. Woollomes Tabassi: Organisation for the Prohibition of Chemical Weapons, The legal Test, T.M.C. Asser Press, (1999). [10] H. F. Bender, P. Eisenbarth, Hazardous Chemicals, Wiley-VCH Verlag GmbH & Co KGaA, Weinheim Germany, 2007, pp. 321-328.

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[3]

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Significance of Noninvasive Cardiology Care in Present-Day Peculiarities of Hazardous Regions M.G. SHURYGIN Scientific Center of Reconstruction and Restorative Surgery SB RAMS, Bortzov Revolutzii 1, 664003, Irkutsk, RF, [email protected]

Abstract. In this article diagnosis and treatment of traumatic cardiac injuries and cardiac pathology due to psychotic disturbance are discussed. It is necessary to stress that management of traumatic heart injury is very difficult. Programs for the management of stress-induced cardiac pathology, especially in vulnerable aged populations, are not yet formulated.

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Keywords. traumatic cardiac injury, stress-induced cardiac pathology, diagnostic, management

In present we see worldwide increasing tendencies of common traumas and chest traumas, as results of transportation accidents and emergency situations. The frequency of technical catastrophes increased more then 40% in Russia during the 5-year period 2002–2006 [1]. Closed (blunt) chest traumas registered are 42–44% of all cases of traumas in peaceful time and is increased to 50% of victims in modern wars. The frequency of cardiac injury is 17–25% of all these cases. Patients from this category have severe clinical symptoms; for example haemotamponade, arrhythmias and acute cardiac failure [2]. The importance of early diagnosis of cardiac traumatic injury is very high, because early hospitalization and adequate medical care decreases mortality more then twice. Diagnosis of closed cardiac trauma is difficult because severe cardiac trauma is frequently combined with other traumas. Absence of typical symptoms is observed in this situation. Late diagnosis of cardiac trauma occurs in 25–50% in trauma centers. Moreover, lack of time, absence of laboratory and diagnostic equipment, hard conditions on accident place lead very rarely to diagnosis of cardiac injury before hospital stage. Involving of heart in common injury may be suspected in chest pain, high heart rate frequency (more than compensatory tachycardia), breathlessness and arrhythmias. ECG diagnosis is very helpful and shows symptoms of cardiac injury in overload right chambers (right position of axis, growth of P-wave amplitude in II, III and aVF leads) and deviation (equal rate depression and elevation) ST. Transesophageal EchoCG may be used in hospital for control of liquid in pericardium, alerts about thrombus in heart chambers, damages of structure and local contractility. Early diagnostics of traumatic cardiac injury is very important for the choice of treatment strategy. Patients with chest trauma who died within the 24-h period after accident had macroscopic explicit heart injury in autopsy in 90 % of cases. Using blood substitutes with rapid compensation of decompensated hemorrhage and shock is a main

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strategy in patient with non-injured heart and severe trauma. Unfortunately, this is impossible in case of combined trauma with heart injury, because high volumes of transfusions and filling speed may cause acute cardiac failure. Small volume infusion (colloids, crystalloids and hyperosmosis solutions) and anti-arrhythmic therapy (antiarrhythmic agents and electroversion/defibrillation) use with commonly accepted practice (ensure of airway paths permeability, immobilization, increasing O2 saturation and analgesia) for prevention of unwanted scenarios. Chest trauma and possible cardiac injury is an outwardly visible problem. Despite that, cardiac pathology due to psychotic disturbances constitutes a concealed-delayed action challenge. This problem is well elucidated in M.A. Samuels’ article [3], where the modern concepts for different forms of sudden death from “Voodoo’s death” story were reviewed. H. Selye demonstrated that certain hormones created a predisposition for the development of cardiopathy with necroses [4], but psychic or nervous stimuli (e.g., restraint, fright) were required to develop it. Part of modern concepts of sudden death concerned neurogenic heart diseases. It is also accepted that acute myocardial infarction, sudden cardiac death and stroke can be triggered by stressors such as heavy physical exertion and severe emotional stress. Probable pathological processes, triggered/induced by psychological factors, are involved in the aetiology of cardiovascular system abnormalities:

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• • • • • • • • •

Catecholamine infusion; Stress increase or depletion of steroids; Nervous system stimulation through sympatic nerves; Microvascular changes; Increase of plasma fibrinogen; Platelets aggregation; Endothelial dysfunction; Ischemic and cardiomyopathy lesions; Reperfusion disorders.

Significance of stress-triggered cardiac lesion is more important now because the population’s mean age is increasing. With the projected increase in the elderly population, and the prevalence of age-related cardiovascular disabilities worldwide, in different hazardous situations the mechanisms for age-mediated cardiac vulnerability start, and the development of strategies to limit myocardial dysfunction in elderly have never been more urgent. A group of scientist from different scientific institutes worldwide provided specific recommendations in regard to the evaluation and intervention in each of the core components of cardiac rehabilitation [5]. These recommendations include such parts as initial evaluation (measuring of risk factors, obtain ECG at rest and during exercise, formulation of preventive plan), management of lipid levels, management of hypertension, cessation of smoking, weight reduction, management of diabetes, psychosocial management, physical activity counseling and exercise training. Of course, the same programs are not adequate for hazardous situations. Elaboration of such programs is particularly important because no pharmacological interventions have yet fully blocked mental stress-induced ischemia.

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Conclusion: it is necessary to stress that the management of heart injury is very difficult. Programs for management stress-induced cardiac pathology, especially in vulnerable aged populations, are not yet formulated.

References [1]

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[2] [3] [4] [5]

S.F. Goncharov, About some problems of medical provision of population in crisis situations, Voen. Med. J., 7 (2005), 15. Y. Miyoshi, K. Ohara, Traumatic cardiac injury, Kyobu Geka, 57 (2004) 742-750. M.A. Samuels, The Brain–Heart Connection, Circulation, 116 (2007) 77-84. H. Selye, The Chemical Prevention of Cardiac Necrosis. New York, NY: Ronald Press; 1958. P. Giannuzzi et al., Secondary Prevention Through Cardiac Rehabilitation, Eur. Heart J., 24 (2003) 1273-1278.

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5. Modeling Information-Sharing and Communication

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The Supercourse: Former Soviet Union Countries Practice

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Eugene SHUBNIKOVa,* , Faina LINKOVb, Andrey TRUFANOVc and Ronald LaPORTEd a Institute of Internal Medicine, Novosibirsk, Russia, b University of Pittsburgh Cancer Institute, Pitttsburgh, USA c Irkutsk State Technical University, Irkutsk, Russia d University of Pittsburgh, Pitttsburgh, USA

Abstract. Former Soviet Union (FSU) SuperCourse is created in the frame of Supercourse project – online library of lectures in public health, epidemiology and Internet – www.pitt.edu/~super1. Education and information sharing is paramount to preventing all forms of diseases and conditions. The Supercourse Team asserts that the Internet provides a powerful and inexpensive tool for the improvement of health as well protection from disasters. To date, more than 500 public health workers from all 15 FSU countries have participated to integrate Internet-based education into prevention of all form of diseases and terrorism/bioterrorism. FSU Supercourse is collaboration of FSU scientists involved in prevention and the Internet for creation of Russian language library of lectures. The main topics of presentations include global health, information security, non-communicable diseases, infectious diseases, disaster medicine, disaster preparedness and mitigation. The training in the area of prevention and Internet-Prevention (I-Prevention) is the primary goal of the collaboration. We started development of FSU Supercourse at the beginning of 2000 as a part of Drs.Shubnikov and Troufanov’s fellowship at the University of Pittsburgh. The number of Internet users in Russia reached 2 million people in 2000. By the end of year 2006 the number of Internet users in Russia reached 21% of total population (about 30 million people). The fast growing of Internet users is big advantages for Internet based programs, but the number of Internet users in Russia still lower compare with European countries (more than 50%). Recently, we introduced a Russian language Supercourse web site at http://www.supercourse.pochta.ru/. More than 250 lectures translated into Russian language already available, including lecture by Dr.Noji on Public Health Disaster Consequences of Disasters. Creation and development of country or language specific libraries of lectures and development of scientific networks as FSU Supercourse, is a tool for education and improving global health including prevention of biological threats and pandemics. Our FSU Supercourse may become a backbone for other health and science projects in FSU countries. Keywords. supercourse, FSU, Public Health Education, internet, prevention

Introduction Russia and other FSU countries became independent around 18 years ago (December 26, 1991), but most of adult population did not change much their lifestyle, habits as well their working places and even system of organization of medical care. It is useful to begin an account of health status developments with a consideration of the Soviet

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period, as the present health crisis of the Russian Federation and other FSU countries has its roots in events that long precede the collapse of the Soviet Union. The Russian Federation is the largest country in the world, stretching from Europe to the Pacific, with a highly urbanized (74%) and educated multiethnic population of 148 million persons (data for 1995), a strong industrial base, and abundant natural resources. The Soviet health system prided itself, and was recognized internationally as an important model, because of its successes since the 1930s in making health care available for all as a free public service. With universal access to preventive and curative care, control of infectious disease was achieved, and health indicators improved [4]. Since the 1960s, an “epidemiologic transition” has occurred in varying degrees in the different republics and ethnic populations of the Soviet Union. This transition has been characterized by declining mortality from infectious diseases and rising death rates from noninfectious diseases. Life expectancy remained static during the 1970s and 1980s but has declined dramatically since 1990, especially for men [4]. Up to the 1990s, the Soviet health system was largely successful in controlling the major infectious diseases. Infectious disease crude mortality rates declined from 87 per 100 000 in 1960 to 21 in 1980 and 12 in 1991 (a decrease of 86%). During the period 1960 through 1992, however, total mortality increased from 739 to 1216 per 100 000 (a gain of 65%). Circulatory disease mortality rose from 261 per 100 000 to 646 per 100 000 (an increase of 148%), trauma mortality rose from 86 to 173 per 100 000 (an increase of 101%), and cancer mortality rose from 138 to 202 per 100 000 (an increase of 46%) [4]. Statistical and epidemiologic data, regarded as state secrets, have been restricted for data sharing in the Soviet Union since the 1970s. Health services in the field lacked the data, the authority, and appropriate forums for meaningful professional debate. The centralized management system understood that an epidemiologic transition was occurring but responded to the increase in cardiovascular diseases by treating them as “social diseases” with a medical/curative approach. National health strategy focused almost exclusively on the medical care system. This helped to justify increasing hospital bed supplies and prophylactic checkups and case finding by health care providers. Checkups were promoted in the polyclinics, themselves heavily burdened with treatment services. The Ministry of Health and the government in general had no active programs to reduce risk factors for noninfectious disease and trauma. Prevention lacked a population based or health promotion approach. At the same time, the system was unable to provide adequate access for the general population to advanced medical technology and therapeutic interventions needed to improve outcomes in treatment of acute life-threatening conditions, such as acute cardiovascular diseases and trauma. Food supply and poor nutrition were, and continue to be, chronic problems in Russia. Healthy foods are not readily available; meats are very fatty; fruits and vegetables are limited in supply and variety. Fortification of foods with vitamins and minerals, such as iodine in salt, is practiced but not mandated or widely available [4]. We agree with T. H. Tulchinsky and E. A. Varavikova [4], that one of the objectives for Health reform in Russia and other FSU countries is raising standards of medical care to international levels, which will require a series of changes in medical undergraduate and graduate education. We also agree that publication of epidemiologic data on a weekly or monthly basis and wide circulation would contribute to increasing professional awareness and use of epidemiological information. Information should be provided to the media and interest groups to raise the general level of health consciousness [4].

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Nongovernmental professional organizations should be developed and strengthened by improving networking with the rest of the world through promotion of access to professional literature, modern standard textbooks, conferences, and postgraduate training in other countries.

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1. The Supercourse FSU Supercourse is created in the frame of Supercourse project – online library of lectures in public health, epidemiology and Internet – www.pitt.edu/~super1. Education is paramount to preventing all forms of diseases and conditions. Supercourse evolved in an unusual way. In 1985 a group of young assistant professors (including Ron LaPorte) decided to map out the global patterns of childhood diabetes. This group included Naoko Tajima from Tokyo, Ramachandran from Madras, Jaakko Tulimento from Helsinki, Yang Ze from Beijing, Franco from Brazil, Eugene Shubnikov from Russia, and a few others. Our approach is based in part our successes in training over 500 people worldwide in diabetes epidemiology as part of the WHO Multinational Project for Childhood diabetes (WHO Diabetes Mondiale, “DiaMond”). This is a very similar approach to that taken with CDC international training programs. The project built Type 1 diabetes registries worldwide to assess the geographic variability of the disease. The main finding was a 400-fold variation in incidence between Finland and certain areas in China. During the course of the program there were 155 centers from 70 countries with the Pittsburgh WHO Collaborating center as the hub, reference centers for registries, and molecular epidemiology. Template registry methods of operation were developed and provided to all centers. In order the join the network, any particular center needed to develop their own local protocol based on the template, and have it approved by experts. In addition, over 10 DiaMond training sessions were held with more than 300 students. This network developed because the members were enthusiastic, well networked, and everybody wanted to collaborate. The WHO DiaMond project was an enormous success. It helped build a cadre of global diabetes epidemiologists. Before 1985, there were no registries and very few, if any, Type 1 diabetes epidemiologists in developing countries. After 1990 there were 30 registries in 20-25 developing countries. There were approximately 100 investigators participating in the WHO DiaMond project from developing countries. Prior to 1990 there were no publications concerning the incidence of childhood diabetes in developing countries. After the beginning of the WHO Project, 47 centers from 30 developing countries reported incidence data. These epidemiologic publications from developing countries were the some of the largest number for any multinational NCD project. The WHO DiaMond Project ended in 2000; however many of the centers worldwide, which are supported by local sustainable interest, continue to this day, as Novosibirsk (Russia) Diabetes Registry. Another root of current Supercourse model is training course in diabetes epidemiology. The IDF, Cambridge University and the WHO have been running 10 day training course in diabetes epidemiology since 1981. Ron LaPorte has been faculty in most of the training course. He wanted to see what impact the Cambridge courses have had on creating diabetes epidemiologists. He had the list of names from the 3rd (1987) and 4th (2000) courses. He identified all the students who were from developing

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countries; there were 19. They then tracked through Google Scholar and Pub Med until now. The results were striking: These students from developing countries produced 349 publications during the 20 year period. The median number of publications was 9. These were virtually all in excellent journals. Many of the students from developing countries collaborated with the faculty and other students from outside their countries. Clearly, the Cambridge course had an enormous impact. The students have continued to stay in touch with their teachers and other students. In doing such projects we began to recognize that the most important cost-effective system for improving global health was open sharing of information. Our concept was very simple. We need to first develop a network of scientists in prevention world wide on the Internet. We have been amazed as to how rapidly this has happened as we currently have 64 000 primarily academic faculty from 174 countries. Secondly we felt that the best route to improve health is to educate the educators concerning prevention – give them all good lectures to use. We thus conceived of a simple concept of a lecture library where everyone would provide their lectures for free, and everyone would get full credit for their work. We thought that we in Supercourse would be sort of like the art gallery, and anybody would put your pieces of beautiful art (your lectures) on exhibition for the teachers of the world to use. New teacher would not be as good as expert, but he would be much better than present his own lecture. The third, and most important, that in developing countries researchers have not received the “Lancet”, “Science”, “Nature”, etc. in 15 years. How can one teach if do not have access to the literature? We can give educators in developing countries something better, access to our lectures, and access to our minds. This is a shared system, it is not a typical American system where the US or International Organization pours money in, and it dies once the money goes away. We are building it so that it can be sustainable in India, for virtually no costs, and will be valuable enough that governments will pick it up themselves. For example, the Cuban Ministry has created a mirrored copy of the Supercourse, they also are in the process of translating the whole course into Spanish, and making it available to the world. Cuba is also developing a national Supercourse for information specific to their country. We are also working on systems to cross the digital divide; we are distributing CDs and DVDs for free with 3600 lectures on.

2. FSU Supercourse The Supercourse Team asserts that the Internet provides a powerful and inexpensive tool for the improvement of health as well protection from disasters. We invented word I-prevention which is Internet Prevention. I-Prevention is Low band width information transfer reaching large numbers of well people to prevent. Information for noncommunicable diseases is what “vaccinations” are to infectious diseases. Information is the best means to improve health. Our program is different from Telemedicine, which use expensive telecommunication technologies to a small number of sick people. But as people will always get sick, we believe that I-Prevention together with Telemedicine will improve health in Russia and FSU countries. Steps in Developing of Russian/FSU Supercourse: •

Network of the scientists involved in prevention and the Internet in Russia and FSU

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Russian Language or Russia/FSU connected Public Health Library of lectures at the Internet I-prevention Program with relations between Russian, FSU, US and scientists from around of the world

First, our goal was to network the scientists involved in prevention and the Internet in Russia. Second, it was important to establish a large Russian Language Lecture Library on the Internet. This is created a backbone for a Russian I-PREVENTION program based upon the model established (Supercourse). Communications between members occurs via: • • • •

Mailing list Sharing of lectures Personal E-mail contacts Personal and group meetings

As of April 2009, we have monthly newsletter for all members from FSU countries together with scientists from other countries, representatives from different agencies, Medical Academies and private organizations. We use regular meetings as Moscow Summer Public Health School in 2004, Salzburg medical seminars, and previous NATO meetings in Lithuania (2005) and Macedonia (2006) as a venue for further interaction and personal contact. The training in the area of prevention and Internet-Prevention (I-Prevention) is the primary goal of the collaboration. Our Help to Russian/FSU Public Health Teachers •

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• •

Free access to the Supercourse web library of lectures www.pitt.edu/ ~super1 Cutting edge, interesting lectures available from Supercourse website and CD/DVDRoms. Share knowledge, education and training systems with other public health professionals in FSU and worldwide through personal contacts

The main topics of presentations include global health, information security, noncommunicable diseases, infectious diseases, disaster medicine, disaster preparedness and mitigation. We started development of FSU Supercourse at the beginning of 2000 as a part of Drs. Shubnikov and Troufanov’s fellowship at the University of Pittsburgh. The number of Internet users in Russia reached 2 million people at the moment (2000) [1]. By the end of year 2006 the number of Internet users in Russia reached 21% of total population [2] (about 30 million people). The fast growing of Internet users is big advantages for Internet based programs, but the number of Internet users in Russia still lower compare with European countries (more than 50%), for example [2]. Recently, we introduced a Russian language Supercourse web site at http://www. supercourse.pochta.ru/. More than 250 lectures translated into Russian language already available including lecture by Dr.Noji on Public Health Disaster Consequences of Disasters [3]. There is also bilingual page (Russian and English) of FSU Internet prevention Program at www.pitt.edu/~super1/national/index.htm/. FSU

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Supercourse page has now about 350 lectures from FSU authors or with topics related to FSU countries. 2/3 of these lectures are in Russian language and there are 15 Health Profiles with the health indicators for all FSU countries. We have lectures devoted to Internet Prevention in other languages too and we will be happy to have more materials at other languages. Recently first Ukrainian Lecture became available – www.pitt.edu/~super1. Supercourse team has created a Disaster web page where lectures on terrorism/ bioterrorism are available from experts in this area – www.pitt.edu/~super1/disasters/ disasters.htm. Internet prevention program as a part of Supercourse project is not designed as a program for prevention of threat from disasters, but in the frame of Disasters Supercourse page we have FSU Supercourse members who published their lectures on disasters.

3. Conclusions To date, more than 600 public health workers from all 15 FSU countries have participated to integrate Internet-based education into prevention of all form of diseases and terrorism/bioterrorism. FSU Supercourse is collaboration of FSU scientists involved in prevention and the Internet for creation of Russian language library of lectures. Which ways we may use for improve Health in Russia and FSU countries with Supercourse?

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• • •

Improve prevention Reach everybody Make it inexpensively

As Internet provides an inexpensive way to distribute information from person to person, and prevention is information transfer, we think that Supercourse model will improve prevention through trained Public Health specialists in Russia. Role of FSU Internet Prevention Network in improvement Health in Russia and FSU countries: • • •

Networking Russian and FSU Public Health specialists via Internet Improve prevention through the training of Russian and FSU Public Health specialists with Supercourse Library of lectures in Epidemiology, Public Health and Internet - www.pitt.edu/~super1/national/index.htm Provide Russian Language Lectures on prevention via FSU Internet Prevention web site - http://www.supercourse.pochta.ru/

Creation and development of country or language specific libraries of lectures and development of scientific networks as FSU Supercourse, is a great tool for education and improving global health including prevention of biological threats and pandemics. The FSU Supercourse project will help determine rational spending of limited resources for medicine in FSU countries and become a backbone for other health and science projects.

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References http://www.lexa.ru/ (accessed March 13, 2000) http://www.rambler.ru/news/it/statistics/9287460.html (accessed November 4, 2008) http://www.pitt.edu/~super1/lecture/lec20391/index.htm (accessed November 4, 2008) T H Tulchinsky and E A Varavikova, Addressing the epidemiologic transition in the former Soviet Union: strategies for health system and public health reform in Russia, Am J Public Health (1996), 86(3), 313–320.

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[1] [2] [3] [4]

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Globalization of Public Health Communication: Preparing Local Leaders using the Supercourse

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a

Faina LINKOVa, Eugene SHUBNIKOVc and Ronald LaPORTEb University of Pittsburgh Global health Institute, Pittsburgh, Pennsylvania, USA b Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA c Institute of Internal Medicine, Novosibirsk, Russia

Abstract. Public health communications is a serious concern worldwide. Improved information exchange is the most cost effective means to improve public health. There needs to be access to high quality epidemiological educational data and information as to how best to do research for public health professionals and instructors world wide. Existing Internet based materials on public health awareness, disaster communications, and environmental health are poorly organized, their scientific quality is questionable, and they are often difficult to obtain due to high cost. The Supercourse project (www.pitt.edu/~super1) is a collection of over 3600 lectures on public health, prevention, and Internet, targeting the teacher vs. the student. It is being developed by over 56000 faculty from 174 countries who are sharing for free their best lectures. Just in Time knowledge Supercourse network is currently being developed in order to foster the exchange of high quality prevention information and to create a trusted source of epidemiological information in the area of public health and preparedness. Supercourse project is aiming to close the digital divide through the development of low bandwidth lectures, opening mirrored servers in the developing countries, distribution of Supercourse CDs, and networking public health professionals from across the world. Quality control mechanisms for the lectures are developed based on our unique approach of multilayered quality control. Inadequate public health information exchange among health professionals may lead to poorly trained public health and medical students, inadequate prevention systems, and ultimately sicker population. Global, low cost, low bandwidth, high impact projects like Supercourse are needed to improve public health and preparedness world wide and foster communications between local and global scientists. Keywords. Public Health Education, supercourse, JIT knowledge

1. Supercourse: the On-line System for Obtaining PowerPoint Lectures in the Area of Global Health The Parent Supercourse comprises 3600 PowerPoint lectures on prevention that are housed in a lecture library on the Internet (www.pitt.edu/~super1/). It is an open source system where scientists across the world share their best lectures for free and every lecture is “copy left”, instead of copy right, and thus usable by anyone. In the past 10 years the Global Health Network Supercourse built a network of over 58000 scientists from 174 countries. The Supercourse developers are working on bringing the concept

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of a Supercourse model to global health prevention. The Global health Prevention Supercourse will be used to “Whisk Research into the classroom” as we described in the British Medical Journal [1]. Our goal is to research how best to translate global health prevention science into the classrooms of the world for better prevention of global health. Our research is national and international, with over 30% of the faculty from developing countries. We are one of the few epidemiology groups concerned about reaching the “unreached” populations around the world. Specifically, we closely collaborate with many institutions on the African continent and with many developing countries around the world. The problem of research to classroom translation is evident in almost all college classrooms where prevention is taught. Recently we have examined a sample of books used in global health courses in the Graduate School of Public Health and the Medical School at the University of Pittsburgh. The most recent references in these books for global health prevention research were 3-10 years old. Clearly, we are not translating the latest research into the classroom very well at our university. Similar situation can be observed in various institutions around the globe, in both developing and developed world. With the Supercourse, the aim is to change this situation and deliver much needed information to doctors, nurses, public health professionals, and other individuals with interest in global health and medicine around the world.

Figure 1. Supercourse front page, January 2009

2. Lectures The lectures in the Supercourse are like any PowerPoint lectures that would be used as building blocks of curricula in various educational institutions. They are designed to help teachers educate students about global health prevention. This does not necessarily mean that the lectures will produce immediate functional or behavioral changes now, but will in the future. We are thus researching how to advance knowledge and

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education by not excluding people from developing countries and the un-reached. Global health education is viewed as being vitally important in the war against global health. This is an innovative concept that can lead to a marked improvement in the translation of knowledge to the classroom in developing countries, in developed countries, and your classroom. If we marry global health prevention with the Internet and make this information accessible, we can have a profound effect on the world through improved communication of global health prevention information.

3. JIT Lecture Development in the Supercourse At the time of crisis, there is a pressing need for high quality lectures. Targeting the educator, the Supercourse aims to deliver top quality lectures to scientists and educators from around the globe. The open access Supercourse Library of Lectures consists of low-bandwidth lectures developed by academic prevention experts in the fields of epidemiology and public health. To address the problem of the “epidemiology of fear” associated with disasters, our group, in collaboration with Dr. Ali Ardalan from Teheran, Iran, developed several scientific lectures dealing with basic facts about hurricanes and other natural and man made disasters. Please visit www.pitt.edu/~super1/lecture/lec20371/index.htm for the lectures on hurricane. In addition to the lecture on hurricanes, Supercourse has lectures on earthquakes, commercial air flying, etc. All just in time lectures in the Supercourse library can be accessed at http://www.pitt.edu/~super1/JIT/jit.htm.

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4. Target Group: Educators of the World In contract to existing distance education technologies, our target is not a student, but the educator. The goal of the Supercourse is to empower the local teacher with high quality materials, not to replace the teachers. This system is designed to benefit faculty members, nurses, doctors, rehabilitation professionals, and all other types of educators. For example, if one needed to present a lecture on breast health, there are 15 lectures that have slides on breast health and breast cancer. Typically, it takes, an expert teacher 10–15 hours to prepare a lecture on a new topic. With the Supercourse, one can have an exciting lecture in 1–3 hours. Using this template model, we can prepare better lectures, at 1/5 the time. Much or preparation time is eliminated. There is no need to “reinvent” the wheel, all we need to do is to share template lectures. This is particularly important for the public health topics that already have large numbers of existing lectures.

5. Progress Report and Current Status Public health and environmental health in particular is becoming increasingly global. Destruction of the ozone layer might be related to melanomas in Auckland and California; global migrations bring new patterns of global health, and world trade of tobacco impacts global cancer risk. Chronic disease became a major cause of death in

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both developed and developing world. Despite the globalization of public health, there has been little research on the most optimal mechanisms for information delivery to remote parts of the world. We have established the technologies where global education is now possible, and educators can learn from each other. What will make our research more successful is the building of an International Library of Lectures for Global health on the Internet. As part of our parent Supercourse, we have already built a large and vibrant group of scientists, and have networked faculty from 174 countries. We already have hundreds of faculty specializing in environmental and global health issues. About 20-30% of our lectures are coming from developing countries, providing a good contrast to major biomedical journals that publish only a very small percentage of materials from the developing world. Supercourse is collaborating with the Library of Alexandria in Egypt to take the Supercourse model from the field of public health and medicine and use of for other disciplines, including chemistry, physics, biology, etc. Supercourse lectures, which provide great theoretical background on public health research methods in general, become even more valuable when used in conjunction with existing data resources like CancerMondiale, SEER, and Global health Atlas. By linking these sources of information, theory is supported by practical opportunities to explore the data, evaluate global health trends, and produce new publications. Collaborative efforts between public health faculty members around the world, supported by collaboration with existing data sources, promises to be a unique and low cost approach to better global health research locally and globally.

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6. Application of mHealth Technologies Mobile devices such as PDAs are increasingly used as a part of healthcare interventions [2]. Increasingly, health care professionals will need to retrieve, store, share, and send data using several types of wireless devices. These devices include personal digital assistants, laptops, Web tablets, cell phones, clothing that monitor heart rate and blood pressure, and many others [3]. Mobility brings a totally new dimension to the healthcare domain and to the whole interdisciplinary provision of regional healthcare. Healthcare services can be provided in virtually any location, where access to a mobile communications system is available [4]. Despite the fact that mobile technologies have been used extensively for the storage and exchange of medical data among physicians, the application of mHealth technologies for public health and prevention communications is still in infancy. Both, medical people and the general public have mixed feelings about the use of mHealth applications for public health information exchange. A 2007 national public opinion survey of 1404 Americans revealed variations in sentiments concerning the desirability of several mobile healthcare technologies based. The survey revealed high levels of interest in emergency intervention services, but much less so in public health and information and monitoring services [5]. Given the ease of access to mobile devises not only in the US, but also around the world, it is time to better utilize mobile technologies for public health and prevention information sharing. Public health communications is a serious concern worldwide. Public health information can be easily shared via computer, however only 10% of the world’s population has a PC at home. In contrast, over 50% of the world’s population owns a cell phone. Improved information exchange is the most cost effective means to

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improve local to global health, however we need to find effective means for information sharing. There needs to be access to high quality epidemiological educational data and information as to how best to do research for public health professionals and instructors world wide. We are in the process of making Supercourse lectures compatible for mHealth applications. Our preliminary results showed that Supercourse lectures can be easily viewed from a cell phone. Inadequate public health information exchange among health professionals may lead mHealth applications will be used as a backbone for improving health information sharing among public health experts, doctors, nurses, teachers, and educators around the world. One of the pressing priorities of the Supercourse development is the marriage of mHealth technologies and public health information repositories for information sharing in the area of bioterrorism, environmental health, and global health. This aim can be achieved with improved civilian-military collaboration, expert knowledge reachback, and other collaborative efforts.

7. Quality Control

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Supercourse developers pay very special attention to quality control procedures in the Supercourse. Several systems are utilized for quality control of the Supercourse lectures, including peer review form at the end of each lecture (Figure 2), traditional peer review by a panel of experts, editorial board, and many others. In the Supercourse, we been examining new approaches to QC by developing or adopting multiple quality assessment methods from other fields for PowerPoint on the web [6– 8]. We are utilizing both traditional and new systems for quality control. These systems include: a) Expert editorial board b) Screening to identify inappropriate lectures, as done in Nature and British Medical Journal c) Five star system (or priority score) similar to that used at Amazon.com d) Opinion of experts (professors) e) Personal characteristics of authors (rank, university, citations) f) Web statistics for utilization of lectures: hits, links, Page Rankings g) Key note speeches, benefiting from the choice of speakers by the relevant society h) Publications and citations from Google Scholar i) Model similar to NIH style review To our knowledge there have been few other efforts taking a multiform quality assessment approach. Moreover, very few articles have been published in the area of QC of online lectures, let alone Internet-based PowerPoint lectures. Our Supercourse group has published several articles on QC for PowerPoint lectures online [6–8]. One of our major quality control studies explored the applicability of traditional peer review systems for online lectures; we were surprised to find very poor agreement among peer reviewers [9]. The multilayered approach to QC that we would like to develop in the Supercourse is defined as the utilization and synthesis of several existing QC systems, including peer review, editorial board, consumer feedback, web based approaches, and any other methods relevant to QC of online materials.

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Figure 2. Lecture review form in the Supercourse

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8. Conclusion Networks of public health professionals, networks of interdisciplinary professionals, as well as networks of networks, are very powerful means to disseminate public health messages, especially in the area of environmental health and disasters. With the distribution of hurricane lectures, the Supercourse group demonstrated that JIT knowledge can be distributed rapidly and virtually free-of-charge throughout the trusted network of scientists, administrators, educators, and public health practitioners. As scientists and as public health educators, the Supercourse group will continue to deliver cost-effective public health knowledge about the science of natural and manmade disasters to prevent the “epidemiology of fear” from infecting our collective consciousness. What was done by the Supercourse group with JIT knowledge on hurricanes could potentially serve as a model for teaching the public about all natural and man-made disasters through “lectures on demand.” The hurricane lectures and other JIT lectures are available on the Supercourse Web site http://www.pitt.edu/ ~super1/JIT/jit.htm. All Supercourse content is available from www.pitt.edu/~super1.

References [1] [2] [3] [4]

R.E. Laporte, A. Sekikawa, E. Sa, F. Linkov, M. Lovalekar, Whisking research into the classroom. Brit. Med. J. 324(7329) (2002) 99. D.R. Kaufman, J.B. Starren, A methodological framework for evaluating mobile health devices. AMIA Annu Symp Proc (2006) 978. R.J. Campbell, L. Durigon, Wireless communication in health care: who will win the right to send data boldly where no data has gone before? Health Care Manag (Frederick) 22(3) (2003) 233-240. A. Prentza, S. Maglavera, L. Leondaridis. Delivery of healthcare services over mobile phones: e-Vital and CHS paradigms. Conf Proc IEEE Eng Med Biol Soc 1 (2006) 3250-3253.

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[5] [6] [7] [8]

J.E. Katz, R.E. Rice. Public views of mobile medical devices and services: A US national survey of consumer sentiments towards RFID healthcare technology. Int J Med Inform (2008). F. Linkov, R. LaPorte, M. Lovalekar, S. Dodani. Web quality control for lectures: Supercourse and Amazon.com. Croat Med J., 46(6) (2005) 875-878. F. Linkov, M. Lovalekar, R. Laporte, Scientific Journals are "faith based": is there science behind peer review? J R Soc Med 99(12) (2006) 596-598. F. Linkov, M. Lovalekar, R. LaPorte, Quality control of epidemiological lectures online: scientific evaluation of peer review. Croat Med J, 48(2) (2007) 249-255. M.Z. Al Kawi, History of medical records and peer review, Ann Saudi Med, 17(3) (1997) 277-278.

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Model of the Adaptive Hierarchical Information Security System A. L. ANTIPOV1 and A.I. TRUFANOV Irkutsk State Technical University

Abstract. The model of the adaptive hierarchical information security system is considered in this article. The interdisciplinary approach is based on an immune reaction concept of a biological organism on an entered antigen. Math description of this study represents a system of kinetic differential equations of second order with saturation. Some dynamic interaction of an information security system attacked by threats has been explored. Keywords. system, security, efficiency, level, hierarchy, immune reaction, threat, defense

Introduction

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The activity raise of any enterprise is directly connected with efficiency increasing for information resources using. In one’s turn efficiency of the information use directly interconnected with its defense problem. The most of systems are based on static models now. Static character leads eventually to infringement of the Ashby's Law of Requisite Variety [1]. Consequence of infringement of the Ashby's Law is: • • • •

Decrease in security of information system Decrease in the general speed of information systems of the enterprises; Restrictions on access to system of users; Increase of use of computing resources.

Thereof there is a refusal of construction of uniform information security system within the limits of the enterprises and the organization of the defense consisting of a set concerning simple independent subsystems, each of which operates in one or several, but not in everything, information channels. Working out of new approaches to construction and management of information security systems is the actual.

1. Formulation of Model The base of this model is the model of an adaptive hierarchical control system [2]. It is offered to use the immune reaction concept of a biological organism on an entered 1

For correspondence: [email protected].

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antigen [3] for construction of the mathematical model describing formation of the answer of an information security system on threats. The main functional property of model is possibility to dynamic expansion of an information security system. The system is constructed up to one level for lack of threat. The system is expanded to 3-levels hierarchical system in a case of appearance of threat. Let’s mark these levels: X, Y, and Z. Level X – is a base level of a system. Functions of regulation, functioning and the system control are realized on it. In case of appearance of external threat, elements of level X at interaction with an environment will carry out its evaluation. As level X operates expansion of subordinate level Y. Elements of level Y of a control system, repeatedly interacting with outside threat, develop the decision on expansion of level Z. Elements of level Y of a control system which repeatedly did not interact with threat are a source of information on the given threat. Working-out of counter-measures occurs at level Z. Let's construct a purposes tree of the control systems (Figure. 1) according to [4].

Level X

Level Y

Regulation of system

Interaction with threat

Control of system

Expansion of level Y

Level Z

Repeated interaction with threat

Working-out of counter-measures

Expansion of level X

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Figure 1. A purposes tree of the information security system.

Let’s designate through X – a saturation by elements at level X; Y – a saturation by elements at level Y; Z – a saturation by elements at level Z. Let’s designate a saturation by threat through G. Let's designate saturation by used counter-measures through F.

dX = v − α x XG − κ x X , dt dY = α x XG + μ (G )Y − α y YG − κ yY , dt dZ = α yYG − κ z Z , dt dG = −κ g G − α gf GF , dt dF = hz Z − α gf GF − κ f F . dt

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(1)

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where ν - appearance of new elements and κ i (i = x, y, z) - destruction time coefficient of out-of-date level's elements (X, Y, Z). Expansion of subordinate level of proportionally probability of interaction of level's elements (X, Y) with threats: for level X – α x XG, for level Y – α yYG, where α i (i = x, y ) – coefficient of interaction of level's elements (X, Y) with threats, α i (i = f , g ) – coefficient of interaction a countermeasure-threat. The increase of saturation of level's elements Y will go on with a speed μ (G ) . Function μ (G ) can be approximated a hyperbola:

μ (G ) = μ0G (κ g + G ) −1.

(2)

I.e. there is no growth of saturation of level's elements Y at G = 0, and growth rate of quantity of elements of level Y is increased at G > 0, but there can not be more some fixed value μ 0 . Coefficients κ g and κ f characterize time of threat's and counter-measure's obsolescence, hz – the rate of counter-measure's working-out on level Z. 2. Research of the Model

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2.1. Conditions of Research We will take advantage of the approaches developed in «The model of CommercialGrade immune system corporations “IBM” [5], in works [6, 7] at an estimation of model parameters. Variables are normalized and accept values from one range. We will exclude possible cooperation of attack's action for simplification of calculations, i.e. we will consider that threats influence independently. Then coefficients of interaction with threats will reflect speed of counteraction of defense system to attacking influences. Let’s accept that a range of ν = 0.1, a range of hz = 0.1, a range of μ 0 =0.1. As a zero threshold we will consider a condition that saturation level has fallen to 10-4. 2.2. Simulation Data Research of model of information security system in formalism of phase trajectories [8, 9] was spent to some stages. It was investigated particular two-dimensional models of the “Threat – Counter-measure” system at the first stage. It is presented examples of phase portraits of such model of a saturation of threats G = 10, 20 in Figure 2. The given particular model is characterized by small change of a phase portrait at essential change of entry conditions. Use two variables (threats and counter-measures) are not enough for effective work of information security system. The particular two-dimensional models of the “Threat – Counter-measure” system can be used only for the dynamic description of a choice of decisions at an antagonism with the attacking.

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Figure 2. Phase portraits of private two-dimensional model of system “Threat-counter-measure”

Following particular three-dimensional models of information security system (fixing two of five variables) were conducted at the second investigation phase: • • •

System “X-Y-Z” – constant level of a saturation of threats and countermeasures; Systems “Y-Z-G” – constant level of a saturation elements at level X and saturations of counter-measures; Systems “Y-Z-F” – constant level of a saturation elements at level X and saturations of threats.

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Examples of the most probable phase trajectories of particular three-dimensional systems are presented in Figures 3, 4.

Figure 3. Phase trajectory of particular systems “X-Y-Z”

Researches particular three-dimensional models have been spent for the purpose of studying of reaction's dynamics of three-level hierarchical defense system on critical conditions. The particular model of system “X-Y-Z” can be used for definition further sensitivity of information security system (the analysis of passive defense). Research of system “Y-Z-G” has shown that change of quantity and quality of elements of level X and developed counter-measures leads to heterogeneity of construction of information security system. I.e. the basic complexity in working out and maintenance of information security systems is necessary on 1st level.

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Figure 4. Phase trajectory of particular systems “Y-Z-G”

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Research of system “X-G-F” having one level of protection has been conducted at the third stage. Calculations on the given model have shown that the essential factor reducing efficiency of given system is maintenance at constant level of a saturation of counter-measures after the decision of a problem of threat's neutralization. Research of full five-measured model of information security system has been conducted at last stage. The existence of such information security systems is demonstrated during research of Lyapunov’s stability system model.

Figure 5. Change of a saturation by elements at level X.

Figure 6. Change of a saturation by elements at level Y.

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On Figures 5–9 are presented schedules of saturation’s change by elements at levels (X, Y, Z), changes of counter-measures’s and threats’s saturation at following entry conditions: speed of elements's occurrence at level X = 0.5; the saturation by elements at level X =1; coefficient of elements’s interaction (level X, Y) with threats = 0.5; coefficient of elements’s ageing of level (X, Y, Z) = 0.5; the saturation threats =5; the saturation counter-measures =0; the rate of counter-measure's working-out on level Z = 0.5; coefficient of interaction a counter-measure-threat =0.5; coefficient of threats’s /counter-measures’s obsolescence = 0.05.

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Figure 7. Change of a saturation by elements at level Z.

Figure 8. Change of the counter-measures's saturation.

Figure 9. Change of the threats's saturation.

The most probable phase trajectory on a cut of “Threat – counter-measure” of system's model is presented on Figure 10. Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

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Figure 10. Phase trajectory of full five-measured model

Neutralization of threats occurs less than for 20 conditional time intervals even at fivefold excess of a threats’s saturation G over saturation X system's elements during the initial moment of time. The offered model of information security system possesses essential firmness to high level of threats. 3. Conclusions

•

•

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• •

Primary advantage of the offered approach to working out, the control and estimation of information security systems is concluded in use of dynamism’s principle and, hence, strict conformity to the Ashby’s Law of Requisite Variety. The developed dynamic model of hierarchical system offers the chance of a optimization's problem of information streams defense. The methodology of nonlinear dynamics allows visually and with sufficient degree of reliability to estimate information security systems and it is sufficient for studying a time interval. Speed of reaction of system of protection depends first of all on speed of expansion of 2nd and 3rd levels of protection. Additional simple economic estimations specify that information security system constructed and the principles here shown have higher security's level of information resources at lower cumulative cost of possession.

References [1] [2] [3] [4] [5] [6] [7] [8] [9]

U.R. Ashby, Introduction in cybernetics, Komkniga, Moscow, 2006. A.L. Antipov, A.N. Malov, Model of an adaptive hierarchical control system, Fundamental Problems of Optoelectronics and Microelectronics II; Y.N. Kulchin, O.B. Vitrik, V.I. Stroganov; Eds, Proc. SPIE Vol. 5851 (2005), 209-212 U.M. Romanovskij, N.V. Stepanova, D.S. Chernavsky, The Mathematical biophysics, the Science, the Main edition of the physical and mathematical literature, Moscow, 1984. A.V. Shilejko, V. F. Kochnev, F.F. Himushin, Introduction in the information theory of systems, Radio and communication, Moscow, 1985. J.O. Kephart, A Biologically Inspired Immune System for Computers, High Integrity Computing Laboratory IBM Thomas J. Watson Research Center, http://www.ibm.com, (access August 2009). V. A. Gerasimenko, A.A. Maluk, Bases of information defense. News, Moscow, 1997. A.I. Trufanov, Balance model of manufacture of information resources in the conditions of competitive struggles, The collection of scientific labour “Problems of balance and stability in economic and social systems”(1999), 125-127. J.A. Danilov, Lectures on nonlinear dynamics. Elementary introduction, Postmarket, Moscow, 2001. N.V. Karlov, N.A. Kirichenko, Fluctuation, a wave, structure, PhysMathLit, Moscow, 2001.

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6. Case Studies and Regional Threats

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Cooperation between Civilian and Military Organizations during an Emergency: A Case Study Evaluation of the 2008 Reentry of an Uncontrolled U.S. Government Satellite Contaminated with Hydrazine

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Chuck TOMLJANOVICH1, Conrad VOLZ1, Sandra QUINN1, Andrey TRUFANOV2, and Alessandra ROSSODIVITA3 1 University of Pittsburgh, Graduate School of Public Health, Department of Environmental and Occupational Health, A712 Crabtree Hall (PUBHT), Pittsburgh, PA, 15261, U.S.A, [email protected] 2 Irkutsk State Technical University, Lermontova 83, 664074 Irkutsk, RF, [email protected] 3 “San Raffaele” Hospital Scientific Foundation, Milan, ITA, [email protected]

Abstract: Over a period of several weeks in February through March of 2008, a satellite operated and managed by the U.S. National Reconnaissance Office (NRO), became uncontrollable and began reentering Earth’s atmosphere. Normally, space debris reentering the atmosphere does not survive, or it is very likely to fall into either the world’s oceans or lightly populated regions of the Earth. In fact, no serious injuries or property damage has been confirmed as caused by debris reentering the Earth’s atmosphere. Under this emergency scenario however, specialists predicted that upon impact over 1,000 pounds of hydrazine could be released as a hazardous toxic gas, which could possibly endanger the public’s health and welfare wherever the satellite finally fell. In response to this potential crisis — even thought the likelihood of a significant adverse risk event was small — the Department of Defense (DoD), Office of the Assistant Secretary of Defense (Public Affairs) (OASD[PA]), developed a crisis and risk communication plan. The intent of the plan was to: engage multiple audiences (both domestic and international); inform the public with the appropriate information in order that they can respond to the risk; protect public health; demonstrate the U.S. Government’s commitment to responsible space operations; and, establish that the U.S. Government is very capable to respond to this crisis. The intent of this paper is to examine the satellite crisis communication event as a case study learning tool. Specifically, this paper is intended to identify: key messages, audiences and stakeholders, key communication channels, underlying theory, other pertinent factors (the role of trust, the importance of experienced professionals, the significance of leadership support, etc.,), and best practices in a manner that facilitates effective future emergency risk communication campaigns during biological threats and/or pandemics. Keywords: Risk Communication, Hydrazine, International, Biological, Pandemics, Military.

Satellite,

Crisis Planning,

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Background and Introduction

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Over a period of several weeks in February through March of 2008, a satellite operated and managed by the U.S. National Reconnaissance Office (NRO), became uncontrollable and began reentering Earth’s atmosphere. Normally, space debris reentering the atmosphere does not survive, or it is very likely to fall into either the world’s oceans or lightly populated regions of the Earth. In fact, no serious injuries or property damage has been confirmed as caused by debris reentering the Earth’s atmosphere (NASA, 2008). Under this emergency scenario however, specialists predicted that upon impact over 1,000 pounds of hydrazine1 (used as a rocket fuel) could be released as a hazardous toxic gas, which could possibly endanger the public’s health and welfare wherever the satellite finally fell (DoD, 2008a, b, c, d, e). In response to this potential crisis — even thought the likelihood of a significant adverse risk event was small — the Department of Defense (DoD), Office of the Assistant Secretary of Defense (Public Affairs) (OASD[PA]), developed a crisis and risk communication plan. The intent of the plan was to: engage multiple audiences (both domestic and international); inform the public with the appropriate information in order that they can respond to the risk; protect public health; demonstrate the U.S. Government’s commitment to responsible space operations; and, establish that the U.S. Government is very capable to respond to this crisis (OASD, 2008; Ryder, 2008). The intent of this paper is to examine the satellite crisis communication event as a case study learning tool. Specifically, this paper is intended to identify: key messages, audiences and stakeholders, key communication channels, underlying theory, other pertinent factors (the role of trust, the importance of experienced professionals, the significance of leadership support, etc.,), and best practices in a manner that facilitates effective future emergency risk communication campaigns during biological threats and/or pandemics.

Approach and Methods The approach and methods for conducting this case study included desktop research (i.e., literature review and internet research), as well as personal communication interviews with Department of Defense (DoD) subject matter experts. Literature review included primary references provided through the University of Pittsburgh, GSPH, Class BCHS 2572 (Risk Communication) (Quinn, 2008), and information compiled from the Internet. Interviews included contacting current DoD government officials from the U.S Army Center for Health Promotion and Preventive Medicine (USACHPPM) and OASD(PA), as well as subject matter experts from other federal agencies such as the Department of Homeland Security (DHS). These subject matter experts were directly involved as contributing specialists in DoD’s risk and crisis communication effort 1

Hydrazines (CAS No. 000302-01-2) are clear, colorless liquids that are generally manufactured for use as rocket fuels and propellants. They are highly reactive substances that easily catch fire. Human exposure to hydrazine causes irritation to the eyes and respiratory system. Severe short-term exposures can causes seizures, pulmonary edema, damage to the liver, kidneys, and central nervous system, and in extreme exposures even death. It is also classified by the U.S. EPA as a probable human carcinogen (U.S. EPA Group B2 Carcinogen) (ATSDR, 2008; CDC, 2008; and, U.S. EPA, 2008).

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during the satellite reentry emergency. Interview questions developed for this case study are presented in Appendix A. The focus of the desktop research and interviews was to identify government officials responsible for developing messages, determine the origin of final message content, identify success factors of messaging, and define message deficiencies (i.e., lessons learned) in a manner that describes what worked and what didn’t under this emergency crisis event. The intent is to motivate improvements in crisis and risk communication messaging in future emergency risk communication campaigns.

Results: Basic Messaging Objectives, the Spokesperson(s), and Audience Profile

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The space debris resulting from the reentry of the satellite had the potential to be dispersed over wide-spread areas, as well as over a wide time span possibly impacting multiple stakeholders. As such, communication objectives, key messages, audiences, and stakeholders identified were far-reaching and broad. Once the impending crisis was declassified, the Office of the Secretary of Defense (OSD) created a plan to assure an “active posture” in communicating the unfolding events of the satellite’s reentry, and those risks posed by potential public exposures to hydrazine fuel. The OASD[PA] Office was the lead agency for coordinating all emergency communication during the different phases of the crisis ranging from the initial public release when the unfolding event became unclassified, until the ultimate in-space destruction of the satellite occurred by the DoD (i.e., the U.S. Navy). Communication plans included having OASD(PA) transition communication lead to the Department of Homeland Security (DHS) should the debris and contamination land within the boundaries of the U.S., while retaining the U.S. Department of State as the lead for all diplomacy activities with foreign nations adversely impacted by the debris should the satellite fall outside of the borders of the U.S. (OASD, 2008). Specific objectives were outlined by the DoD in the OASD Satellite Engagement Communications Plan (2008). They included: • • • •

Reinforce that the U.S. Government is concerned about public safety, and that the government is committed to safe space operations. Maintain communications with allies of the U.S. and all foreign governments in a timely and technically accurate manner. Build confidence that the U.S. is well equipped and well-postured to respond globally. Be responsive, accurate, and truthful about the event as expediently as possible through the answering of all questions from the public and the media about the DoD’s efforts to respond to the reentry of the satellite.

Multiple themes and messages were created to respond to the event (OASD, 2008). Primarily, messages fell under the main categories of: (1) Engagement (the U.S. selected to destroy the satellite at a low altitude to reduce the risk of debris researching the earth); (2) Reentry (in the event that debris and hydrazine causes damage, the U.S. will be responsible); and, (3) Space Operations (all governments are responsible for their space operations, and that those operations are increasingly technically complex with not all activities equally successful). Each message developed under these broad

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categories focused on being open and honest with the public, explaining the facts associated with the reentry of the satellite, and taking full responsibility while solidly assuring preparedness for full response by the DoD. According to materials published by the OASD(PA), and personal discussions with the Public Affairs Officer responsible for providing support to the communications effort (OASD, 2008; Ryder, 2008), a number of audiences were identified by the DoD as critical to the success of the ongoing emergency communication plan. They included: interagency leadership (e.g., Department of State, Department of Homeland Security, etc.); Foreign Governments (e.g., potential impact sites and vulnerable populations); Congress (i.e., the Senate and House of Representatives); NASA; and, the Media (i.e., U.S. and international public). All audience stakeholders identified had specific targets for messaging, as well as specific messaging tactics that included developing and delivering written products, briefings and releases (e.g., press and congressional), and reentry prediction releases (OASD, 2008; Ryder, 2008; DoD, 2008a, b, c, d, e). Other federal agencies chartered for the protection of public health and environment also conducted related information releases concerning the hazards associated with hydrazine fuel exposures such as through the Center for Disease Control’s (CDC’s) Health Alert Network (ATSDR, 2008; CDC, 2008; and, U.S. EPA, 2008). All communications were geared toward meeting the goals and objectives of the OASD(PA) emergency risk and crisis communication plan.

Discussion: Attributes for Success & Areas of Development

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Research conducted for this case study suggests that the risk and crisis communication plan worked well for the DoD. According to Heath (2008), this particular crisis communication event was a “big success” and a good example of DoD working with other Federal Agencies for a level of focused coordination that was “historical”. A number of factors and attributes led to its success. Those included, but are not limited to, the following: •

•

•

Applying risk and crisis communication theory such as a modified communication persuasion matrix as described by Glik (2007) (i.e., OASD[PA] created a through risk communication plan outlining an overarching strategic and tactical planning matrix for crisis communications that included message sources, audiences, and expected outcomes); Holding true to key crisis communication success factors as outlined by Reynolds and Seeger (2005) (i.e., OASD[PA] created and delivered messages regarding the current state of the conditions during the reentry event that were principally informative, situation centered, and delivered by appropriate authority figures and technical experts); and, Anticipating the public’s level of risk perception as described by Slovic (1987) (i.e., OASD[PA] created an extensive anticipatory set of questions and answers to respond to the perceived risks related to the unknown and factors of dread associated with the satellite’s reentry to Earth and subsequent public exposures to hydrazine).

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Along with the basic principles of risk and crisis communication theory evident through the development and execution of the OASD[PA] plan, there were a number of factors and principles that were clearly distinguishable in the execution of the crisis plan that should be noted. Those basis principles as identified in personal communications with OASD[PA]’s contributing officer, Lt. Col., Ryder (2008) and DHS’s Public Affairs Officer Mr. Heath, included the following: •

•

• • •

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•

“Truth is the best strategy.” According to Lt. Col., Ryder, truthful and routine messages explaining what is known and what is not known was the single most important factor for OASD[PA]’s success in this crisis communication event. Clearly and immediately sharing “facts and projected happenings” about this complex event was also important in assuring that the receivers of the messages understood what was happening, and that they remained aware in a manner that would ultimately lead toward overall public health protection. Executing the plan with “very experienced professionals” and “collaborative cross-talk” with key agencies at the table was crucial in maintaining effective crisis communication with all stakeholders. “Contingency planning is a must.” Risk mitigation and worst-case scenario planning assured that all potential consequences considered and anticipated as part of the preparation activities. “Sr. Leadership Support was invaluable.” Having Sr. Leadership support from the OASD Public Affairs Office up to, and including, the President of the United States assured that all resources necessary for creating and delivering crisis communication messages were available, and that all authority figures and technical experts were consistent during the crisis communication event. “Use of the DHS National Incident Communications Conference Line (or NICCL calls) as a primary communication line helped channel the communication among several strategic stakeholder agencies including the DoD, FEMA, HHS, and the FFA.” The NICCL calls, combined with multiple agencies working together under one strategic plan was a principal factor in this event becoming one of the best examples of focused coordination during a crisis.

Overall, information dissemination from the OASD[PA] during this crisis event appeared more than adequate, clear, consistent, and credible. And although there were key lessons for success in this case study (i.e., rapid factual communication with the public, stakeholder collaboration, flattened communication channels where less executive oversight was required, etc.,), there were some features of the event that challenged the DoD and remained factors of “fog and friction” that required “heavy lifting” by the individuals creating the messages (Ryder, 2008). Those factors identified by Ryder (2008) and Heath (2008) included: • •

A short and compressing time-line; A technically complex event with significant uncertainty;

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• • •

An administratively complex event (i.e., dealing with classified information across multiple agencies and time zones); Resource limitations (albeit initially); and, Mixed Messages.2

According to Ryder (2008), this was “not a monolithic event”, but very dynamic undertaking that was comprised of multiple agencies, seams, and points of potential failure. It possessed multiple levels of complexity requiring relentless planning up to the delivery of final briefings originating from the DoD’s OASD[PA]. This short case study provides a clear example of the importance of relying on basic principles of risk and crisis communication and emergency communication planning during crisis communication events. One important element is developing appropriate strategic and tactical plans, as well as coordinated guidance and communication as events unfold. The concepts of being truthful and rapid in information dissemination during an emergency are invaluable. Additionally, health professionals must remember that there will be challenges that threaten successful crisis communication activities that are very common (e.g., short time frame, complex unfolding events, limited resources, multiple stakeholders, etc.,). Those challenges, however, can be overcome with focused communication and planning, and can become easier as events evolve (Ryder, 2008; Heath, 2008). Overcoming those challenges will require clear and purposeful upfront planning and coordination among all involved for a successful emergency risk and crisis communication effort during any biological threat or pandemic.

Acknowledgement

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A special acknowledgement to Lt. Col. Patrick Ryder, USAF, for sharing his insights from the event, as well as for his careful review of draft versions of this manuscript.

Appendix A: Interviews Interviews All Interviews were conducted by the author. Interviews were conducted by telephone, or via email. Handwritten notes (or electronic notes) were taken as appropriate. Interview respondents are quoted in the text if suitable. All respondents provided informed consent to participate. Questions are provided below. People contacted are also listed. People contacted were identified through the open Internet. Interviewees were believed to be associated with developing risk communication messages based on organizational title and DoD affiliation. For the purposes of this 2 According to Ryder, preceding almost immediately to this crisis event the U.S. Government officially disapproved of the People’s Republic of China taking action to engage and destroy one of their space satellites; However, their satellite was not uncontrollable, and was not posing danger to public health. The anti-satellite technology used was potentially tested to destroy satellites over 300 miles in space, and not descending into the Earth’s atmosphere.

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short case study, Interviewees were limited to organizations within the DoD. Secondary and/or tertiary contacts may have been identified from primary contacts and are noted as such. Respondents that have not yet replied to data requests are noted as such. Interview Introduction and Questions Q1. Hello, my name is Chuck Tomljanovic; I am a Sr. graduate student from the University of Pittsburgh, Graduate School of Public Health in Pittsburgh, PA. I am conducting a case-study evaluating of the risk communication messaging developed during a DoD crisis event. May I ask you a few questions regarding risk communication activities during a recent event in 2008? Q2. Did you have a role in formulating risk communication messages during the 2008 reentry of the uncontrolled U.S. government satellite and potential exposures to satellite debris contaminated with hydrazine? If so what was your role? If not, do you have a contact that did? To the extent of you knowledge, what was their role? Q3. What was a key element or number one attributes that helped in the development or shaping of your messages? What were you trying to do or say? Who were you trying to reach (i.e., who was the vulnerable population)? Q4. Do you feel that you succeeded and why/why not? Q5. Did your message(s) draw upon an underlying theory or best practices? What did you rely on and why/why not? Q6. From your perspective, what played a critical role in its success? What played a critical role in you or your team missing overall objectives or goals?

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People/Organizations Contacted Lt. Col, Patrick Ryder, USAF, OASD Public Affairs (Primary Reference) Mr. Mike White, Acting Program Manager, Health and Communication, U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM) (Secondary Reference) (Contacted: Reply Outstanding) Mr. Bruce Sprecher, U.S. Strategic Command Public Affairs (Secondary Reference) (Contacted: Reply Outstanding) Mr. Stan Heath, DHS Public Affairs (Secondary Reference) Mr. Richard Buenneke, DOS Space Policy (Secondary Reference) (Contacted: Reply Outstanding)

References ATSDR, 2008. What are Hydrazines? ATSDR Substance Profile for Hydrazine. Available online at: http://www.atsdr.cdc.gov/substances/hydrazines/ CDC, 2008. Potential Health Effects Associated with Hydrazine and Satellite Reentry. Official CDC Health Advisory. February 20, 2008. Distributed via Health Alert Network. Available online at: http://www.bt.cdc.gov/agent/hydrazine/HAN_02_2008.asp. DoD, 2008a. DoD To Engage Decaying Satellite. DoD Press Release, No. 0125-08. February, 14. Available online at:: http://www.defenselink.mil/releases/release.aspx?releaseid=11691. DoD, 2008b. Satellite Debris Analysis Indicates Hydrazine Tank Hit. DoD Press Release, No. 0146-08. February 25. Available online at:: http://www.defenselink.mil/releases/release.aspx?releaseid=11704.

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DoD, 2008c. Defense Department Background Briefing on the Satellite Intercept Attempt by Sr. Military Official. News Transcript. Presenter: Unnamed Sr. Military Official. February 20, 2008. Available online at: http://www.defenselink.mil/transcripts/transcript.aspx?transcriptid=4151. DoD, 2008d. Media Availability with Secretary Gates at the Pier for the USS Russell, Pearl Harbor, Hawaii. News Transcript. Presenter Secretary of Defense Robert M. Gates. February 21, 2008. Available online at: http://www.defenselink.mil/transcripts/transcript.aspx?transcriptid=4155. DoD, 2008e. DoD News Briefing with Deputy National Security Advisor Jeffery, Gen. Cartwright and NASA Administrator Griffin. News Transcript. Presenter: Deputy National Security Advisor James Jeffrey, Vice Chairman, joint Chiefs of Staff Gen. James Cartwright and NASA Administrator Michael Griffin. February 14, 2008. Available online at: http://www.defenselink.mil/transcripts/transcript.aspx?transcriptid=4145. Glik, D., 2007. Risk Communication for Public Health Emergencies. Annual Review of Public Health, 28, 33-54. Heath, S., 2008. Personal communications between Mr. C. Tomljanovic, University of Pittsburgh, GSPH, and Mr. Stan Heath, DHS Public Affairs. (DHS Public Affairs and Communications Coordinator for the Hydrazine Crisis.) Phone No. 202-282-8117. Telephone Interview Conducted October 20th, 2008. NASA, 2008. Orbital Debris Frequently Asked Questions. NASA’s Orbital Debris Program Office. Available online at: http://orbitaldebris.jsc.nasa.gov/faqs.html#13. OASD, 2008. “OASD Satellite Engagement Communications Plan, 14 Feb 08”. Office of the Assistant Secretary of Defense for Public Affairs. OASD(PA) Official Website: http://www.governmentattic.org/docs/(U)_OASD_Satellite_Engagement_Communications_Plan_(1400 _hrs_14_Feb_08).pdf. Quinn, S., 2008. BCHS 2572: Risk Communication. Graduate School of Public Health. Fall 2008. University of Pittsburgh, Graduate School of Public Health. Pittsburgh, PA. Reynolds, B. and M.W. Seeger, 2005. Crisis and Emergency Risk Communication as an Integrative Model. Journal of Health Communication, 10, 43-55. Ryder, P., 2008. Personal communications between Mr. C. Tomljanovic, University of Pittsburgh, GSPH, and Lt. Col. Patrick Ryder, USAF, OASD Public Affairs Office. (Public Affairs Officer for the Hydrazine Crisis.) Phone No. 703-697-8317. Telephone Interview Conducted October 16th, 2008. Slovic, P., 1987. Perception of Risk, Science, 236, 280-286. U.S. EPA, 2008. “Hydrazine.” Hazard Summary Created in April 1992; Revised in January 2000. Available online at: http://www.epa.gov/ttn/atw/hlthef/hydrazin.html. White, M., 2008, Personal communications between Mr. C. Tomljanovic, University of Pittsburgh, GSPH, and Mr. Mike White, U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM), Risk Communication Program Officer. Phone No. 410-436-7715. Telephone Interview Conducted October 17th, 2008.

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Counterterrorism: The First Italian Drill Alessandra ROSSODIVITAa,1, Marzia SPESSOTb and Gianna ZOPPEIc a Department of Cardio-thoracic and Vascular Diseases, b Emergency Department, Supervisor for Health Policy c San Raffaele Hospital Scientific Foundation, University of Medicine of San Raffaele “Life and Health”, Milan, Italy

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Abstract. Over the last decade conflicts and terrorism-related emergencies have represented a new concept of disaster and a new resurgence involving a complex pattern of global changes and imbalances. Throughout the globe, healthcare providers are increasingly challenged with the specter of terrorism and the fallout from weapons of mass destruction. The previous experiences of terrorism acts connected to the World Trade Center (09/11/2001), Madrid, London and Sharmel-Sheik attacks highlighted the problems related to a possible terrorist attack in Italy. The prediction of a possible future terrorist attack drives the efforts of public policy and government founding. A mass casualty situation (MCS) usually is short in duration and resolves itself. Planning is essential to minimize the risks to patients during MCS. The Italian government organized a counterterrorism program involving all forces engaged in security and emergency to test the real capacity of the security and emergency plans to protect civil population in term of civil defense, homeland security and public healthcare preparedness. On September 23 2005 in Milan, Italy, there was the first official counterterrorism Drill, organized with all forces engaged in emergency and security. The Drill was related to a government security program to prevent and prepare a counterterrorism response to a possible future terrorist attack in some Italian major towns like Rome, Milan, Naples and Turin. The authors show how the drill was organized and how their Hospital participates to this first National Italian Drill. Keywords. disasters, drills, exercises, pre-hospital and hospital preparedness, mass casualty events, terrorism

“But certain issue strokes must arbitrate; Towards which, advance the war” William Shakespeare, Macbeth Act V

Introduction One definition of Disaster is a situation or event which overwhelms local capacity, necessitating a request to a national or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering. Though often caused by nature, disasters can have human origins. Wars and civil disturbances that destroy homelands and displace people are included among the causes of disasters. Other causes can be: building collapse, blizzard, drought, epidemic, 1 San Raffaele Hospital. Department of Cardiothoracic and Vascular Diseases, via Olgettina 32 Milan, Italy. Fax no. +39.02.26437125; Phone no. +39.0226437118; E-mail : [email protected]

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earthquake, explosion, fire, flood, hazardous material or transportation incident (such as a spill of chemicals), hurricane, nuclear incident, tornado, or volcano. “A disaster is a calamitous event resulting in loss of life, great human suffering and distress, and large scale material damage” [1–3]. During the last decade conflicts and terrorism related emergencies have represented a new concept of disaster and a new resurgence involving complex pattern of global changes and imbalances. Throughout the globe, healthcare providers are increasingly challenged with the specter of terrorism and the fallout from weapons of mass destruction [4–7]. The previous experiences of terrorism acts connected to the World Trade Center (09/11/2001), Madrid, London and Sharm-el-Sheik attacks highlighted the problems related to a possible terrorist attack in Italy. Recent acts of terrorism have ranged from the dissemination of anthrax spores to intentional contamination of food to release of chemical weapons to suicide attacks using explosives. The primary goal of terrorism is to create fear and destabilize a myriad of political and economic structures. Terrorists using “conventional or non-conventional weapons of mass destruction” can decimate a large population, inflict enormous psychological and economic hardship, and incite political unrest by merely attacking small populations in multiple sites over a long period of time [8–10]. A mass casualty situation (MCS) is defined as a situation in which at certain moment, there are more casualties than the system is able to manage. The demand for medical care is greater than the supplies available. MCS usually is short in duration and generally resolves itself. MCS always happens suddenly, usually at the least convenient time, when the staff is most unprepared. Planning is essential to minimize the risk for casualties and people involved during an MCS. The goal of treatment in a MCS is to deliver an acceptable quality of care while preserving as many lives as is possible. Planning and drilling are the main ways to prevent and minimize the risks and avoid management mistakes [11–14]. The prediction of a possible future terrorist attack drives the efforts of public policy and government founding. The Italian government created and reinforced a strategy for dealing with MCS on the national level as well as on the individual hospital level. The objective was to organize a counterterrorism program with full scale exercises and drills, involving all forces engaged in security and emergency to test the real capacity of the security and emergency plans to protect civil population in term of civil defense, homeland security and public health care preparedness. On September 23, 2005 in Milan, Italy, there was the first official counterterrorism Drill, organized with all forces engaged in emergency and security. The Drill was related to a government program of security to prevent and prepare a counterterrorism response to a possible future terrorist attack in some of the main Italian cities like Rome, Milan, Naples and Turin. The authors show how the drill was organized and how the Hospital where they work participated in this first National Italian Drill.

1. Exercise Scenario The first city was Milan, on Friday September 23, 2005. Pandemics and Bioterrorism : Transdisciplinary Information Sharing for Decision-Making Against Biological Threats, IOS Press,

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Four different scenarios were chosen to realize the Drill at the same time. 1) The first was the Northern Milan Railways station Cadorna, in downtown Milan. 2) The second place was the Cadorna Underground station (MM), near the Northern Milan Railways station. 3) The third place was “Forlanini Airport”, in Linate. 4) The fourth place was the Town Hall (Figure no. 1). The people involved in the Maxi-Emergency, and in this Drill belonged to Prefecture, Police headquarters, Armed Forces, Fire Brigade, the Local Authority, EMS Service (118); 4 Hospitals, one of which was San Raffaele Hospital Scientific Foundation, the Italian Red Cross, Milan Town Council; Local Transport Service, Northern Milan Railways, Civil protection and Civil Protection volunteers. More than 2000 people were involved in Maxi-Emergency and in the carrying out of this Drill: 156 Civil Protection vehicles, 117 vehicles were made available from Fire brigades, Police, including NBC task forces, and the Red Cross vehicles, including 70 ambulances and 2 helicopters. 170 actors were chosen from civil protection volunteers to represent casualties. In addition, four of the main city hospitals were chosen to participate in and cooperate with to realize this drill to test the impact of pre-hospital interventions and the inside hospital preparedness to a Maxi-casualty event. San Raffaele Hospital scientific Foundation participated with its Maxi-Emergency Committee and members working actively to realize plans, respond and treat a Maxicasualties event inside the Hospital, and outside the Hospital to cooperate with all forces engaged in this Drill to coordinate and respond to the activity of the EMS service and other hospitals involved in this drill [18–21]. The casualties were 24 black codes, 37 red codes, 65 yellow codes and 100 green or white codes. The expected time for the drill was 1 h and 15 minutes. The alarm started at 12.03 pm. At 12.03 pm at the Northern Railways Station Milano-Cadorna, on platform no.1 the train called “Malpensa Express” is arriving from the International Airport of Malpensa – Milan, when a blast bomb explosion occurs in the train (there were some actors aboard who simulated the casualties) (Figure no. 2). At 12.20pm at the Underground Station Cadorna. Another bomb explosion was simulated inside the Underground Station (green line no. 2) in the third coach of the train directed to south Milan. At 12.30 The Townhall Evacuation. The Mayor and his working team were evacuated. At 12.30 Field Hospital-Medical Outpost Building (FH-MO). The first aid field hospital for casualties was set up in the square near Piazza Cadorna. The FH-MO was the first medical care station for casualties, where casualties were triaged and supported from a psychologist team too (Figure 3). At 12.48 pm A Terrorist attack at Linate Airoport of Milan “Forlanini” was simulated. The police and surveillance agents located a man with a “suspect “backpack near the check-in area of the British Airways, an area considered to high risk of a terrorist attack. The man run away the parking area of the airport and took control of a bus, its driver, and took some hostages. Then the police was engaged in a scenario of a battle against the terrorist. At 12.10 The Alarm to the San Raffaele Hospital Scientific Foundation started. The alarm started with a phone call by the EMS service (118) to the Emergency Department which declared red alert for a Maxi-casualty event. The Medical Disasters Manager or MDM called all people involved in Maxi-emergency to assume their role,

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according to their personal action card on maxi-emergency hospital plans, and to prepare the medical response to the casualties arrival inside the Hospital in the Emergency Department. The Operative Command Post was in the prefectural offices. All forces engaged in this Drill were coordinated by a Prefecture team; this phase is the fulcrum of all rescue operations, since it is from here that all the forces in the field are coordinated in their interventions by their respective coordinators. All the following field supervisors must be present at the Operative Command Post: Fire Brigade Medical Disaster Managers Police Forces and Army Volunteers And in contact with their respective headquarters.

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As soon as the alarm started at the first explosion, all forces taking part in the maxi-emergency and security were involved, and the professional rescue task team started to work. In Italy rescues are divide into a technical part (carried out by the Corpo Nazionale Vigili del Fuoco-Fire Brigade) and the medical part carried out by the Public Health Service (EMS service), which uses the “ Soccorso Sanitario 118”, which can nonetheless be supplemented by the aid of the hospital personnel. gravitating around them in daily emergencies and/or mass casualties emergencies, there might also be the Police Force (State Police, Carabinieri, the IRS, the State Forest Rangers, the Port Authorithies) and the Armed Forces (Army, Air Force, Navy). The professional staff consists of workers who perform daily rescues, and particularly the technical staff (Fire Brigade), the Emergency Medical System (118) and the Police Force. The tasks carried out in a disasters or in MCS situations, which were therefore performed by these workers during the drill are: Safety of the scene Survey, evaluation, and dimensioning of the scenario Search for and rescue of the casualties Medical rescue of casualties and their care and stabilization Transport of casualties to Medical Outpost (M.O.) and then to hospitals Guarding the safety perimeter The first rescue that arrived on the scene, examined it in order to evaluate the accessibility of the roads, the presence of the evolutive risk and the estimated number of victims. The Fire Brigade arrived first, to evaluate the type of accident reported, the features of the territory, the type of equipment needed, and all the problems related to safety; if they think a non-conventional weapon has been used, the NBC Task Force will be in charge of checking the entire area. Then the Police Force circumscribed and delineated the perimeters around the scene of the event in order to have the maximum control over the access to the site and, for the related investigations of the Judiciary Police. Then the medical staff arrived, with the aim of obtaining information on the type of accident which occurred in order to organize the rescue chain in all its phases, from the first triage up to the ambulance

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transporting casualties to the hospitals. The first team that intervened in the scenario of the disaster was the one with function of conducting the reconnaissance, providing the first estimate of the event and casualties to the EMS dispatch Center and performing the first triage of the victims according to the international procedures of disaster medicine. The ALS team (Advanced Life Support) supported the rescuers by helping, saving and transporting casualties who required long and complex medical maneuvers to be rescued. Then the rescuers started to transport the casualties subjected to triage from the rescue place to the Medical Outpost, placed nearby Piazza Cadorna. The victims were transported to the Medical Outpost in order of priority. The Medical Outpost-and the Field Hospital (FH-MO) locations were placed as close as possible to the scene of the disaster, then the medical support to casualties started, according to the triage procedures, with the purpose of stabilizing the vital function of the victims to allow their transportation to the hospital safety. Figure no. 3 shows the FH-MO; which was an inflatable pneumatic single tent. It was decided to use S.T.A.R.T. Triage, the simplest one to use, the S.T.A.R.T. protocol (START stands for Simple Triage And Rapid Treatment). This method makes it possible to very rapidly establish the priority of the casualties adopting simple evaluations that are easy to realize on the field. Table 1. describes the S.T.A.R.T. system. At the entrance of FH-MO a expert physicians evaluated all the casualties according to the Triage S.T.A.R.T. protocol in order to define the highest priority of treatment. The volunteers and the Psychologists team worked together and help medical triage team inside the FH-MO to assist casualties and support casualties those with mental disturbances from a disaster situation. The triage team worked according to standardized triage protocol procedures. “Triage is the process of sorting, selecting or prioritizing casualties when providing immediate and maximal care to each is impossible” The intent of triage can be defined as a medical process that determines the order of priorities of evacuations and treatment of victims in order to optimize the available resources for resuscitation, stabilization, dispatching, and transportation of casualties and this for the benefit of the largest possible number of casualties and to return as soon as possible to the routine level. After the stabilization procedures in the FH-MO area, all casualties were classified according to the START procedures and the final transportation to the Hospitals involved in these drill was organized. The second part of this drill was performed in San Raffaele Hospital- Scientific Foundation, which decided to continue the drill inside the Hospital to test the Hospital emergency plans and real capacity of a great hospital to react to a MCS in term of preparedness, assistance and treatment capacity. When the alarm started the 118 EMS Dispatch Center called the Hospitals, involved in this exercise, to realize and start the activations procedures for emergency plans of MCS and to prepare the Hospital staff mobilization. At 12.01 pm the Hospital Alarm was started by a phone call from the 118-EMS Dispatch Center. After twenty minutes all staff members in charge of responding in case of a Maxi-emergency situation were in the Emergency Department; two operating rooms were available in the meantime, the radiological and laboratory service were alerted too. It was activated the Operative Hospital Command Post. A special officer was assigned to deal with the media and relatives of the casualties.

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A plan to secure and maintain proper access to and from the hospital was arranged, along with internal and external assistance (e.g. police and security). The first step was to prepare the triage procedures inside the Emergency Department; the triage location was placed by the entrance of the Emergency Department; it was chosen for easy access to ambulances and rescue vehicles near the patient treatment area, to have sufficient space for allowing the stretchers transit. The Triage team leader was chosen from the most experienced anesthetist, he was trained according to the criteria of Hospital Disaster Management. The casualties are triaged into three separated groups (red, yellows and green); the patients were treated in separated locations in order to ensure that the majority of personnel was devoted to treating the most severely injured who would benefit most from the use of the committed resources. The Advanced Trauma Life Support (ATLS) guidelines were followed as closely as possible. Stay in the admitting area was limited to diagnosis and treatment of life-threatening injuries; diagnoses and treatments of additional injuries were done in the ward after MCS subsides. Medical documentation included medical records short, informative and transferable. At 13:18 pm the first patient of MCS arrived. A total of 12 patients arrived (4 red code; 2 yellow code; 6 green code). In the meantime 20 real patients were treated. No disturbance to the routine work of the hospital was generated. At 14:45 pm the end of Maxi-Emergency was declared. No problem with the ambulances arrival at the entrance of the Emergency Department was noted.

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2. Results The drill was performed in 2 hours and 45 minutes. The expected time was 1 hour and 15 minutes. All forces engaged in security and emergency worked together, to protect civil population in terms of civil defense, homeland security and public health care preparedness. The work was well-coordinated but the time to realize this exercise took longer then expected, probably due to the problems related to traffic and vehicles access to the disaster scenario The day was chosen without prior warning to the citizens, by the local authorities and EMS service to test the drill, like a real MCS situation on the field.

3. Discussion During last decade terrorism-related emergencies have impacted on every corner of the world [22]. Without warning, such events can suddenly become true disasters, overwhelming the capacity of the community to respond in terms of homeland security and medical health preparedness, focusing attention on new emerging problems related to clinical, health, security, political and ethical issues. Preparedness, planning, security, mobilizing resources, and conducting operations under austere and adverse conditions demand special considerations and management of all forces engaged in maxi-emergencies or mass-casualties situation related to a possible terrorist attack, in order to minimize harm to whole populations.

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A major lesson learned during the response operations to the September 11, 2001 attacks in the New York City and after the London attacks in 2005 drove the Italian government on reassessing their institutional capabilities and procedures to respond to a mass-casualty incident involving weapons of mass destruction or a terrorist attack. This Drill of September 2005 represents the first Italian government effort to realize this. The project was to constitute a national plan about the response to a mass- casualty event in terms of: (1) coordinating response and recovery actions, (2) conducting strategic decision-making, (3) managing resource allocation, and (4) testing medical and EMS preparedness. One of the basic functions of government is to protect the lives and property of its citizens. All forces engaged in emergency, including Prefecture, Police headquarters, Armed Forces, Civil Protection, Fire Brigade, Local authority, EMS Service (118); Italian Red Cross, and 4 Hospitals, were called and gathered to work together in a mass-casualty situations. The idea was to test these organizations in an emergency or catastrophic event, and how they share their resources and work together to mitigate the consequences of the event for the community, in order to establish a standardized system for providing coordinated assistance to local and state governments during disasters In the meantime the hospitals involved in this drill worked on building a common strategy for treating trauma victims and all casualties during a MCS. The occurrence of a disaster may involve an hospital facility and the goal of a mass casualty situation (MCS) treatment is to deliver an acceptable quality of care while preserving as many lives is possible and prevent complications. Such situations could occur anywhere and by different scenarios. It is crucial to explore and understand each hospital ability to manage a large number of casualties. Planning and drilling represent the key and strategy to minimize a MCS event. Building a National plan on MCS after a terrorist attack drives the efforts of our Nation. Public health and medical planning needs to occur on the local level, but the planning process evolves, therefore it is necessary to integrate planning activities with State and public institutions to create a future emergency network that can work on the local level and the national levels to facilitate this process. The goal of the emergency management system could be a inter-related system to reduce the loss of lives, property and damage through the close coordination and teamwork of individuals, organizations and resources. These associations should include law enforcement, public authorities, civil protection, fire brigades, red cross, emergency medical services, emergency management, environmental protection department, the medical community, and volunteers. Successful cooperation and coordination between these associations during any emergency situation is critical to respond in terms of reduction of morbility and mortality.

Acknowledgements The authors gratefully acknowledge the Maxi-Emergency Committee of the San Raffaele Hospital Scientific Foundation and University.

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References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19]

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[20] [21] [22]

D.E. Hogan, JL Burnstein., Disaster Medicine Lippincott Williams & Wilkins (2002). UN-Department of Humanitarian Affairs, IDNDR International Glossary of Basic Terms Related to Disaster Management 1992. S.W. Gunn. Multilingual dictionary of disaster medicine and international relief. Prehospital and Disaster Medicine Web site. Available at htpp :// pdm.medicine.wis.edu/vocab.htm. (Accessed March; 2002). J.L. Arnold, Disaster Medicine in the 21st Century: future hazards, Vulnerabilities, and Risk Prehosp Disast. Med. 17(1) (2002) 3. E.K. Noji, The public health consequences of disasters. New York: Oxford University Press; 1997. E.K. Noji, Public health issues in disasters Critical Care Med 33 (1) (2005) S29-33. E.K. Noji, Field investigations of natural disasters. In: Field Epidemiology. Gregg MB (Ed). New York, Oxford University Press, (2002) 365-383. D. Alexander. Terrorism, Disasters and Security Prehosp Disast Med 18 (3) (2003) 65. G. Ciottone, et al. Terrorism and other Man Made Disasters. United Nations Disaster Management Programme for Terrorist Events (2005). Canadian Security Intelligence Service, operational programs, updated Aug 2002, http://www.Csisscrs.gc.ca/eng/operat/ct_e.html L. Levi, M. Michaelson, H. Admi, D.Bregman R. Bar-Nahor. National Strategy for Mass Casualty and its Effects on the Hospital. Prehosp. Disast. Med. 17(1) (2002) 12. D. A. Bradt, C. Drummond. From Complex Emergencies to Terrorism – New Tools for Health-Sector Coordination In conflict –Associated Disasters. Prehosp Disast Med. 18 (3) (2003) 263. A. T. Mignone Jr, R. Davidson. Public Health Response Actions and the Use of Emergency Operations Centers. Prehosp. Disast Med 18(3) (2003) 217. C. Di Giovanni Jr., The Spectrum of Human Reactions to Terrorist Attacks with Weapons of Mass Destruction: Early Management considerations Prehosp Disast Med 18(3) (2003) 253. Esercitazione antiterrorismo- Counterterrorism Drill – more information at the Web Site of Local authorithies of Milan http // www.prefettura.micamcom.it/utg/comunicati/com20050923.html G. Santucci. Bombe a Milano, scatta l’operazione terrorismo. Corriere Della Sera 2005-09-23 (Cronaca di Milano) page 3. D. Ferrari. Terrorismo, promossa la fiction. Il Giorno 24 Settembre 2005. Il pool di psicologi combatte lo choc. Il Giorno 24 Settembre 2004, pp. 2-3 Cronaca della LombardiaMilano. E. Bonerandi. Attacco a Milano, ma è solo una prova. La Repubblica 24 settembre 2005, pp. 27 (Cronaca). M. Giannattasio, G. Cantucci. Bombe, kamikaze, ostaggi. Milano simula un attacco. Corriere Della Sera 24 Settembre 2005-09-25. R. Bonizzi. Attacco Terrorista, Milano passa l’esame. Il Giornale- Milano 24 Settembre 2005, pp. 45. G. L. Larkin, J. Arnold Ethical Considerations in Emergency . Planning , Preparedness and Response to Acts of Terrorism, Prehosp Disast Med. 18(3) (2003) 170.

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Crimean-Congo Hemorrhagic Fever in Turkey (2002–2008) Etem AKBAS1 Mersin University Faculty of Medicine, Department of Medical Biology and Geneticists, Mersin/Turkey

Abstract. To develop consensus-based recommendations for measures to be taken by medical and public health professionals if Crimean-Congo hemorrhagic fever (CCHF) viruses are used as biological weapons against a civilian population. The viruses are geographically restricted to the areas where their host species live. CCHF is a viral haemorrhagic fever of the Nairovirus genus of the family Bunyaviridae. CCHF virus is a tick-borne virus that causes a severe hemorrhagic disease in humans with a case fatality rate of approximately 30%. Although primarily a zoonosis, sporadic cases and outbreaks of CCHF affecting humans do occur. The disease is endemic in many countries in Africa, Europe and Asia. CCHF was first observed in the Crimea by Russian scientists in 1944 and 1945. Congo virus was first isolated in Africa from the blood of a febrile patient in Congo in 1956. It has been seem some of cities at TURKEY since 2002. According to the figures of Ministry Health, 3128 cases were notified from 2002 to 2008 and 155 cases resulted in death. The Ministry of Health, in close collaborations with the Ministry of Environment and the Ministry of Agriculture and Rural Affairs, is currently implementing control measures, and enhanced CCHF surveillance has been established nationwide. Public awareness campaigns are ongoing, stressing the adoption of personal protective measures to avoid tick bites, and targeting the rural population through television, radio, posters and leaflets.

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Keywords. Crimean-Congo hemorrhagic fever, cases, deaths, Turkey

Introduction Crimean-Congo Hemorrhagic fever (CCHF) is a zoonosis transmitted by ticks that cause severe outbreaks in humans. CCHF is a viral haemorrhagic fever of the Nairovirus group. Although primarily a zoonosis, sporadic cases and outbreaks of CCHF affecting humans do occur. The disease is endemic in many countries in Africa, Europe and Asia, and during 2001, cases or outbreaks have been recorded in Kosovo, Albania, Iran, Pakistan, and South Africa. The disease was first described in the Crimea in 1944 and given the name Crimean haemorrhagic fever. In 1969 it was recognized that the pathogen causing Crimean haemorrhagic fever was the same as that responsible for an illness identified in 1956 in the Congo and linkage of the 2 place names resulted in the current name for the disease and the virus. CCHF is a severe disease in humans, with a high mortality rate. Fortunately, human illness occurs infrequently, although animal infection may be more common. CCHF intensified 1 Corresponding Author: Etem Akbas, Mersin University, Faculty of Medicine. Department of Medical Biology and Geneticis, Mersin/Turkey; E-mail: [email protected].

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activity and outbreaks constitute a threat to public health services because of its high case fatality ratio (10–40%), its potential for nosocomial transmission, and the difficulties in case management and prevention requiring a sustained multi-sectoral approach [1, 2]. The geographical distribution of the virus, In the WHO European Region, CCHF is endemic in several areas of countries and territories south of the 50° parallel north. In these areas, the peak of CCHF activity observed during late spring and summer. Data available for 2008 indicate CCHF virus is circulating with particular intensity in Turkey, the Balkans, and southern districts of the Russian Federation [1]. Healthcare workers in endemic areas should be aware of the illness and the correct infection control procedures to protect themselves and their patients from the risk of nosocomial (hospital-acquired) infection [2].

1. Biology of CCHF Virus (CCHFV) The virus which causes CCHF is a Nairovirus, a group of related viruses forming one of the five genera in the Bunyaviridae family of viruses. All of the 32 members of the Nairovirus genus are transmitted by argasid or ixodid ticks, but only three have been implicated as causes of human disease: The Dugbe and Nairobi sheep viruses, and CCHF, which is the most important human pathogen amongst them [2]. Nairovirus include RNA as genetic material. It includes helical capsid and viral envelopes [3].

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1.1. Reservoirs and Vectors Numerous genera of ixodid ticks serve both as vector and reservoir for CCHF viruses; however, ticks in the genus Hyalomma are particularly important to the ecology of this virus. In fact, occurrence of CCHF closely approximates the known world distribution of Hyalomma spp. ticks. Therefore, exposure to these ticks represents a major risk factor for contracting disease [3]. Numerous wild and domestic animals, such as cattle, goats, sheep and hares, serve as amplifying hosts for the virus [4]. Many birds are resistant to infection, but ostriches are susceptible and may show a high prevalence of infection in endemic areas. Animals become infected with CCHF from the bite of infected ticks. A number of tick genera are capable of becoming infected with CCHF virus, but the most efficient and common vectors for CCHF appear to be members of the Hyalomma genus. Trans-ovarial (transmission of the virus from infected female ticks to offspring via eggs) and venereal transmissions have been demonstrated amongst some vector species, indicating one mechanism, which may contribute to maintaining the circulation of the virus in nature. However, the most important source for acquisition of the virus by ticks is believed to be infected small vertebrates on which immature Hyalomma ticks feed. Once infected, the tick remains infected through its developmental stages, and the mature tick may transmit the infection to large vertebrates, such as livestock. Domestic ruminant animals, such as cattle, sheep and goats, are viraemic (virus circulating in the bloodstream) for around one week after becoming infected. Humans who become infected with CCHF acquire the virus from direct contact with blood or other infected tissues from livestock during this time, or they may become infected from a tick bite. The majority of cases have occurred in those involved with the livestock industry, such as agricultural workers, slaughterhouse workers and veterinarians [1–5].

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C

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B

D

Figure 1. A. Nymph of Hyalomma, B. Male Hyalomma, C. Female Hyalomma, D. Female Hyalomma that is fully blood engorged [6]

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1.2. Clinical Features The length of the incubation period for the illness appears to depend on the mode of acquisition of the virus. Following infection via tick bite, the incubation period is usually one to three days, with a maximum of nine days. The incubation period following contact with infected blood or tissues is usually five to six days, with a documented maximum of 13 days [1–3]. Clinical presentation: In most cases, infection in humans causes few or no symptoms, although CCHF virus may cause a severe viral haemorrhagic fever. Person-toperson transmission to carers occurs, including in the health care setting [1]. Onset of symptoms is sudden, with fever, myalgia (aching muscles), dizziness, neck pain and stiffness, backache, headache, sore eyes and photophobia (sensitivity to light). There may be nausea, vomiting and sore throat early on, which may be accompanied by diarrhoea and generalised abdominal pain. Over the next few days, the patient may experience sharp mood swings, and may become confused and aggressive. After two to four days, the agitation may be replaced by sleepiness, depression and lassitude, and the abdominal pain may localize to the right upper quadrant, with detectable hepatomegaly [1, 2]. The mortality rate from CCHF is approximately 30%, with death occurring in the second week of illness. In those patients who recover, improvement generally begins on the ninth or tenth day after the onset of illness [2]. Global CFR in hospitalized patients (all grades of severity), however, is closer to 2–6% according to recent data collected in Turkey and the Russian Federation [2].

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1.3. Treatment, Prevention and Control General supportive therapy is the mainstay of patient management in CCHF. Intensive monitoring to guide volume and blood component replacement is required. The antiviral drug ribavirin has been used in treatment of established CCHFV infection with apparent benefit. Both oral and intravenous formulations seem to be effective. Although an inactivated, mouse brain-derived vaccine against CCHF has been developed and used on a small scale in Eastern Europe, there is no safe and effective vaccine widely available for human use. The tick vectors are numerous and widespread and tick control with acaricides is only a realistic option for wellmanaged livestock production facilities. Persons living in endemic areas should use personal protective measures that include avoidance of areas where tick vectors are abundant and when they are active (spring to fall); regular examination of clothing and skin for ticks, and their removal; and use of repellents. Persons who work with livestock or other animals in the endemic areas can take practical measures to protect themselves. These include the use of repellents on the skin (e.g. DEET) and clothing (e.g. permethrin) and wearing gloves or other protective clothing to prevent skin contact with infected tissue or blood. When patients with CCHF are admitted to hospital, there is a risk of nosocomial spread of infection. In the past, serious outbreaks have occurred in this way and it is imperative that adequate infection control measures be observed to prevent this disastrous outcome. Patients with suspected or confirmed CCHF should be isolated and cared for using barrier nursing techniques. Specimens of blood or tissues taken for diagnostic purposes should be collected and handled using universal precautions. Sharps (needles and other penetrating surgical instruments) and body wastes should be safely disposed of using appropriate decontamination procedures [2, 7].

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2. Crimean-Congo Hemorrhagic Fever in Turkey CCHF has been seemed some of cities in Turkey since the last 7 years. According to the data from Ministry of Health, 3128 cases were notified from 2002–2008 and 155 cases resulted in death (Table 1). In Turkey CCHF deaths were first seen in Gumushane and Erzurum in 2002 and 2003 [8]. It began to spread out to the near region cities such as Artvin, Bingol, Sivas, Erzincan, Tokat, Amasya, Corum, Ordu, Yozgat, Kayseri and Sanlıurfa In 2004 and 2005. In 2006 and 2007, CCHF deaths became more intense in Corum, Yozgat, Amasya and Tokat region. Moreover, they were seen in Ankara, Artvin, Aydın, Balıkesir, Bolu, Corum, Erzurum, Gumushane, Karabük, Kastamonu, Kırıkkale, Mardin, Sivas, Bursa and østanbul. As shown in Figure 2, In 1th January to 30th November 2008, CCHF deaths became more intense 10 deaths in Corum:, 8 deaths in Karabuk, 5 deaths in Tokat, 5 deaths in Sivas, 4 deaths in Yozgat, 4 deaths in Kastamonu, 3 deaths in Gumushane, 3 deaths in Samsun, 3 deaths in Amasya, 2 deaths in Bolu, 2 deaths in Ankara, 2 deaths in Ordu, 1 death in, 1 death in Konya, 1 death in Bingol, 1 death in Canakkale, 1 death in Giresun, 1 death in Isparta, 1 death in Bursa, 1 death in Cankırı, 1 death in Gaziantep, 1 death in Sakarya, 1 death in Burdur, 1 death in Malatya (Figure 2) [6, 9, 10].

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Table 1. The distribution of CCHF cases and mortal cases according to the years in Turkey. Years

Cases

Deaths

2002-2003

150

6

2004

249

13

2005

266

13

2006

438

27

717

33

until 30 November 2008

1308

63

Total

3128

155

2007

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th

Figure 2. Number of deaths due to CCHF in the cities of Turkey (1 th January to 30th November 2008)

3. Conclusions Turkish people have been suffered from CCHF since the last seven years in Turkey. According to the data from Ministry of Health, 3128 cases were notified from 2002 to 30th November 2008 and 155 cases resulted in death. The mortality rate seen from CCHF is approximately 5.3% in Turkey. This ratio is below the death ratio all over the world which is 30%. This can be attributed to two basic reasons: The first one is the use of early intervention, rapid diagnosis and developed treatment techniques. The second reason is that most of the tick bite cases are the ones caused by other species, which do not carry the Crimean-Congo Haemorrhagic fever viruses. It is observed that people bitten by ticks consult the hospitals after they snapped the tick off. When the tick is not available it is not possible to determine whether or not it carries CCHFV. In Turkey, as diagnosed CCHF cases and the condition of the cities with mortal cases by

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E. Akbas / Crimean-Congo Hemorrhagic Fever in Turkey (2002–2008)

CCHF are generally examined, an orderly geographical distribution is seen. Firstly, it was seen in the cities of Kelkit valley district of Erzurum, Gumushane Sivas and Tokat. Following years, the neighboring eastern and western cities were regularly added to the above-mentioned number of 24 cities. CCHF deaths seen specially May, June, July and August months (90%) [10] The mammalian animals (cattles, sheep, horses, donkeys and goats etc.) are disinfected by using certain chemicals to avoid ticks which carry CCHFV. On the other hand it is not possible to disinfect wild mammalian animals (wolves, foxes, rabbits, moles, mice, pigs, etc.) and their habitat. For this reason ticks have the chance to survive and contaminate these animals. In summary, it seems that it will be difficult to take CCHFV under control in the near future in Turkey.

References http://www.euro.who.int/surveillance/outbreaks/20080806_1 http://www.who.int/mediacentre/factsheets/fs208/en/index.html Nichol, S. T. 2001. Bunyaviruses, p. 1603-1633. In D. M. Knipe and P. M. Howley (ed.), Fields virology, 2nd ed. Lippincott Williams & Wilkins, Philadelphia, Pa (USA). [4] Ergönül Ö, Celikbas A, Dokuzoguz B, et al. (2004). "The chacteristics of Crimean-Congo hemorrhagic fever in a recent outbreak in Turkey and the impact of oral ribavirin therapy". Clin Infect Dis 39: 285– 89. [5] Yen, Y. C., L. X. Kong, L. Lee, Y. Q. Zhang, F. Li, B. J. Cai, and S. Y. Gao. 1985. Characteristics of Crimean-Congo hemorrhagic fever virus (Xinjiang strain) in China. Am. J. Trop. Med. Hyg. 34:11791182. [6] http://www.kirim-kongo.saglik.gov.tr/ [7] Chris A. Whitehouse. 2004 Crimean–Congo hemorrhagic fever. Antiviral Research 64:145–160 [8] Yalcın E. Hayvanlardan insanlara gecen hastalıklar: Kırım Kongo Kanamalı Atesi. Erzurum Veteriner Kontrol ve Arastırma Enstitusu Mudurlu÷u Yayını. Erzurum, 2003. [9] http://yenisafak.com.tr/Gundem/?t=23.11.2008&i=151958 [10] http://www.haberx.com/n/1120185/2002den-bu-yana-turkiyede-122.htm

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[1] [2] [3]

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The Anopheles Mosquitoes: Their Role in Malaria Transmission in Georgia George BABUADZE, Merab IOSAVA and Lela BAKANIDZE National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia

Abstract. One of the main priorities of Georgian health care system is control of malaria and its prophylaxes. The main goal of national strategy is decreasing malaria influence on population. In 2002 WHO adopted resolution about strengthening of anti malaria measures. The resolution concerns all anti malaria measures to decrease distress distribution of results of epidemics. During recent years the incidence of malaria in Georgia decreased (from 474 cases in 2002 to 25 in 2007). The progress in anti malaria measures and malaria elimination in the entire country is the main achievement of regional initiative, GF (Global Fund) and WHO joint effort. One of the main parts of mentioned program is malaria vector control

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1. Brief Information about Country Georgia is located on the border between Asia and Europe in central and east parts of south Caucasus. The territory of Georgia is spread on 69.7 square kilometers, the extreme east and west frontier crosses 40°05 and 46º44 latitude, and south and north frontier crosses 40°05 and 46º44 of eastern longitude. The majority of population lives on territories, where risk of malaria transmission is very high. The risk of malaria disease is high in west part of Georgia; in those parts of Guria that are 200 meter above sea level, in Achara – 250 m, in Samegrelo – 300 m, in Imereti- 400 m, in Racha-Lechkhumi – 550-600 and eastern Georgia - Kartli – 450-600 meter, Kaheti – 200–700 m. Less risk of morbidity than in western Georgia is in Javakheti region, east Georgia and in those populated areas of west Georgia, that are in Abkhazia – 500-1000 meter above sea level, Svaneti and Racha-Lechkhumi 800–1200, Achara – 1500. The data of country relief, temperature regimen, soil structure, typing of water reservoirs, that are favorable for Anopheles mosquito active life, the duration of transmission and basing on anthropological data analyses; the territory of Georgia is divided into four malariogenic zones: hyper, mezzo, hypo and non malariogenical.

2. Malaria, Introduction Malaria has been widespread in Georgia since ancient times, as the geographical location of the country and existing climatic conditions have been favorable for malaria transmission. At those times malaria often appeared as national disaster causing enormous economic and human loss. Ancient Greek, and later European investigators

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G. Babuadze et al. / Anopheles Mosquitoes’ Role in Malaria Transmission in Georgia

and travelers (Hypocrite, Homers, Termistios, Archangeli Lamberti, Chardin, etc.) regarded malaria as oldest illness of Georgian ethnicity. Malaria endemic territories of Kolkhida in Western Georgia were described in works of these authors. In 1920’s around 30% of the country population was affected by the disease, usually characterized by high case-fatality rate in lowlands (Kolkheti valley, West Georgia and Alazani valley in East Georgia). Territories with the highest malariogenic potential belonged to the valleys type of landscape, mostly in the western and eastern parts of the country. In 1924–1928 indices of malaria lethality were around 0.2%. Among causes of mortality of the population malaria had the highest position (6%) after pneumonia, tuberculosis and intestinal infections. As a response to this situation the Institute of Parasitology and Tropical Medicine was established in 1924 in Tbilisi. Due to complex measures against malaria undertaken by the Institute and specialized medical network a sharp decrease in morbidity by the year 1954 was achieved. By 1961 malaria was practically eliminated, and by 1970 – complete and sustained elimination were achieved. However, the receptivity of a great part of the territory remained high and potentially hazardous because of the existence of mosquito vectors and natural climatic and environmental conditions. In addition imported cases of malaria were registered in Georgia every year. In 1970–1995 years a total of 139 imported cases of malaria from 22 countries (9 Asian countries and 13 African) were revealed (Table 1). Table 1. Imported Cases of Malaria in Georgia by Plasmodium Species (1970–1995)

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Plasmodium P. vivax P. malariae P. falciparum P. ovale Total:

Number of cases 115 5 17 2 139

P. vivax accounted for 115 cases, P. malariae – for 5 cases, P. falciparum – 17 cases and P. ovale – 2 cases. After the eradication there was no indigenous transmission but at the middle of the 1990s the risk of its renovation increased because of the gradual rise of imported malaria cases following the occurrence of the large-scale malaria epidemics in the bordering countries and the social economical and political changes in the region including Georgia. Since 1991, after the collapse of the Soviet Union, the situation became critical in terms of maintaining malaria – free status. In 1996 the first autochtonous cases of P. vivax malaria in Georgia were registered in a settlement bordering Azerbaijan. In the following years the number of malaria cases detected gradually increased and reached 14 in 1998, 35 in 1999, 164 in 2000 with a peak in 2001 (437 cases) and 2002 (474 cases) according to the Ministry of Labor, Health and social Affair (MoLHSA) data. Taking into consideration the high malaria potential of the most of the territory of the country enabling further distribution of malaria and the existing risk of epidemics, the Ministry of Health started malaria control activities and in 2000 a National Malaria Control Programme following the strategy of the WHO RBM and with the assistance of WHO EURO was developed and introduced. The implementation of the programme by the Government with a support from the WHO

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and other organizations led to decrease of malaria incidence in the country. Most of the cases were located in the eastern part of the country but there were single cases and an outbreak (26 people engaged in 2001) registered in the former endemic territories of western Georgia. As a result of the large-scale activities carried out and the financial support of the Global Fund since 2004, a further gradual decrease of the malaria incidence of the population was achieved. In 2006 and 2007 the number of recorded cases dropped to 60 and 25 respectively. All local transmission appears to be Plasmodium vivax. At present indigenous P. vivax malaria exists in 18 districts of the country. In 2007 malaria transmission was mainly recorded in two southwestern regions – Kakheti and Kvemo Kartli, with an aggregation of cases in the districts (rayons) of Marneuli (6 cases), Signagi (3), Lagodexi (11) and Gardabani (3). Malaria is predominantly a rural disease affecting primarily the most impoverished groups of rural population (92% of the cases in 2000–2007). Groups at a higher risk are also the ones living in the areas bordering Azerbaijan, as well as western districts located at the Black Sea area. Among sedentary population, both genders are affected but among males the disease is detected more often that could be explained by their activities (private small illegal petrol producing minifactories are very common in the aria).

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Perennial dynamics of malaria cases in Georgia 1996–2007

500 450 400 350 300 250 200 150 100 50 0

433

472

306 235 169 154

19

96

19

97

19

98

58

36

13

0

3

25 19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

3. Dynamics of Malaria Cases in Georgia In 2007 in Georgia were registered 24 local cases of malaria P. vivax), incidence of malaria -0.54 and one imported (P. ovale) case from Nigeria (citizen of Nigeria, sportsman, who visited Tbilisi). In 2006 in Georgia were registered 58 local malaria (P. vivax) cases, incidence of malaria – 1.31, out of two imported cases one was (P. vivax) citizen of Georgia, who visited Moscow and another (P. falciparum – tropical malaria) – sailor citizen of Greece (the ship arrived from Guinea to Poti) In 2005 154 local cases (P. vivax) were registered, incidence of malaria was 3.56, one a case was imported who was citizen of France (arrived from Africa).

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G. Babuadze et al. / Anopheles Mosquitoes’ Role in Malaria Transmission in Georgia

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4. Anopheles Species and Geographical Distribution in Georgia In plain and mountainous zones of Georgia the anophelogenic area for favorable development of larval stages is 80.6%, but in foothill and low mountain areas is -11.5% and 7.9%. Area of water reservoirs, which is useful for development of blood-sucker insects water phases, is almost twice and half as much in west part of Georgia than in eastern part of the country. According to the data of 1990 physical area of water reservoirs is 199 626 hectare, among them anophelogenic are – 13 290 hectare. In west part of Georgia physical area is 13 784 hectare, anophelogenic – 9 660 hectare, in east part of Georgia – 5 842 he and anophelogenic -3 630 he. In plain and mountainous zone of central sea cost landscape favorable biotopes for development of larval phases of mosquitoes are mainly bogs, bogged up areas and pools, located in peat bog and silt wetlands. Anophelogenic water reservoirs are created as well by numerous grove water reservoirs, sand-pits, shores of rivers, lakes and water reservoirs, which are fed mainly by rivers. Stream speeds of big and medium rivers are reducing in the plain areas. In the period of spring-autumn floods wide gorges are over flooded and numerous permanent or provisional grove water reservoirs are created, in addition during droughts small rivers get dry in some places and turn into anophelogenic foci. Biotopes of larval stages of malaria vector mosquitoes in east part of Georgia is of the similar type as in west Georgia. High number of mosquitoes is detected in the gorges of big (Mtkvari, Alasani), as well as medium and small rivers, where multiple grove water reservoirs are created. As a result of wrong usage of irrigation system multiple anophelogenic foci is created. Eight species of Anopheles is spread in Georgia: An. maculipennis, An. saxarovi, An. melanoon, An. superpictus, An. plumbeus, An. hyrcanus, An. claviger, An. algeriensis From epidemiological view point, the main vectors of malaria transmission are all species of “maculopennis” (An. maculipennis, An saxarovi, An. melanoon). Minor vectors of malaria transmission are – An. plumbeus, An. hyrcanus, An. claviger, but An. algeriensis is not malaria vector. An. maculipennis is spread almost everywhere from 0–1700 sea level in west Georgia, but An. melanoon dominates in Kolheti plane seashore are 0-30 from sea level. In utmost east part of east Georgia in the adjustment area of salty water reservoirs numerous An. saxarovi is detected, but in rest places An. maculipennis is dominated. An. melanoon is detected locally everywhere 0-1000metre from sea level. An. claviger is spread in west Georgia, less An. plumbeus, An. melanoon is detected in Abkhasia forests. For adult sampling we use several methods: • • • •

Light traps with or without dry ice (CO2). Daytime resting station collections Protected human-bait landing counts. Sweep-nets and aspirators.

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5. Main Malaria Vectors Field and lab works (Morphology, cytogenetic and PCR), which were held during 1 year confirmed, that the main vectors of malaria in Georgia are Anopheles maculipennis, An. sacharovi, An. melanoon. An. maculipennis have a wide distribution in all investigated regions. An. sacharovi widespread in Eastern Georgia and in the south of Central Georgia (Marneuli, Gardabani). An. melanoon were collected only in regions near Black sea coast in Guria (Poti, Khobi). Also it is obvious, that An. maculipennis Meigen, 1818 species number is very high in whole malaria transmission period: 22–25 April–20–30 September. During the sampling we used the GPS system to make the exact checkpoints (First time in Georgia for vector control). All above mentioned really indicate that most primary malaria vectors in Georgia are An. maculipennis An. sacharovi, An. melanoon. Certainly, that in measures against malaria most important to decrease the population number of mentioned Anopheles species during the malaria transmission period. Relative Abundance of Anopheles maculipennis Complex Species in Georgia (2005-2006)

An. maculipennis

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An. sacharov

An. melanoon

References [1] [2] [3] [4] [5] [6] [7]

Sichinava, SH. G. 1973. Species and subspecies composition of blood sucking mosquitoes (Diptera: Culicidae) and their distribution on the Abkhazian-ASSR USSR. Meditsinskaya Parazitologiya I Parazitarnye Bolezni 42(3): 313-315. Sichinava et al. 1983. The prevalence and biology of Anopheles maculipennis Meig., 1818 in Western Georgia. Soobshcheniya Akademii Nauk Gruzinskoi, SSR 112(2): 417-420. N.I. Djaparidze, SH. G. 1960. Ixodes ticks of Georgia., Bull. Acad. Sciences of the Georgian SSR, 222 – 254. D. J. Lewis, A taxonomic review of the genus Phlebotomus (Diptera: Psychodidae), Bulletin of the British Museum (Natural History), Entomology series, 45(2), 24 June 1982 156-162. M.M. Artemiev, V.M. Neronov, Distribution and ecology of send flies of old world (Grnus Phlebotomus). Institute of Evolution, morphology and animals ecology, A.S. SSR., Moscow 1984. 45-75. O.B. Bezzhonova, G. Babuadze, M. I. Gordeev, I. I. Goriaacheva, A. B. Zvancov, G. Kurcikashvili, M.N.Ezhov, Malaria mosquitoes Anopheles maculipennis complex (Diptera, Culicidae) in Georgia, Meditsinskaia parazitologiia i parazitarnye bolezni 3, (2008) 32-6. I. Kalandadze, N. Beria, G. Babuadze, L. Qurcikashvili. 2006. The Malaria Epidemiological Surveillance Practical Application Book. Publication of the National Center for Disease Control and Public Health (NCDC), Tbilisi, Georgia.

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The Problem of Preventing Natural Foci Infections during the Development of New Territories Irina A. SHURYGINA Scientific Center of Reconstructive and Restorative Surgery SB RAMS, Bortzov Revolutzii 1, 664003, Irkutsk, RF, [email protected]

Abstract. This article deals about prophylaxis system for the prevention of natural foci infection. The main topics are related to prevention, tick-borne infections and helminthiasis. Keywords. natural foci infection, tick-borne encephalitis, tick-born borreliosis, helminthiasis, Diphillobothriasis, prophylaxis

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Only few territories are used for agricultural and industrial purposes in Siberia now. In many regions, the density of population is little more than 1 man per square kilometer. The development of new territories includes agricultural and industrial exploitation, building of railways and roads, creation tourist zones. The development of new territories is strictly connected with the risk of natural foci infection. The scenario includes: • • • •

Contacts with natural foci pathogen Contacts with new pathogens Transformation and expansion of a nosological area Increase in the number of anthropurgic focus, the detection of combined focus.

The transformation of natural focus is the result of a complex interrelation of several factors, such as social (e.g. socio-political changes, human leisure activities) or environmental (e.g. effects of climate changes on vectors). For example, factors, such as building of railways, roads, oil-pipe lines, exploitation of forests, etc. lead to an improvement of the conditions for vectors. The spectrum of the circulating pathogens, which can potentially cause human diseases, is rather wide. In particular: • • • •

Bacterial pathogens (pathogen of plague, tularemia, Tick-born borreliosis) Rickettsia (Tick-born rickettsiosis of North Asia, ehrlichiosis) Viral pathogens (Tick-borne encephalitis, the group of California encephalitis, hemorrhagic fevers) Helminthiasis (trichinosis, opisthorhosis, diphillobothriasis.

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209

Tick-borne encephalitis (TBE) is a flavivirus infection of the central nervous system. TBEV was discovered in 1937, when the construction of the “Baikal-Amur” railway started. In this period, many constructors fell ill because of an unknown neuroinfection and 30% of them died. During three expeditions the territory, the animals (ticks, mosquitoes, etc.) and the clinical cases were carefully examined. Heads of these expeditions were Zilber L.A. (1937), Pavlovsky E.N. (1938) and Rogozin I.I. (1939) During such expeditions, several goals were obtained: not only the etiologic agent, the vector and the hosts in the natural focus were discovered, but also a vaccine for prevention of TBE. Nevertheless, 8 investigators fell ill and 4 of them died. The etiologic agent is the tick-borne encephalitis virus (TBEV). It belongs to the family of Flaviviridae (genus Flaviviruses). The virion is 50 nm in diameter with an icosahedral capsid composed of capsid (C) protein and an RNA genome about 11 kb long. The capsid is surrounded by a lipid bilayer and contains the small viral membrane protein (M) and the larger viral envelope protein (E). The genomic positive-strand RNA is translated into a polyprotein from which three structural proteins (C, M, and E) and seven nonstructural proteins. Like many flaviviruses, it is an arbovirus. Tick-borne encephalitis virus circulates in wild animals and is transmitted by Ixodes ticks. In Siberia Ixodes persulcatus plays a major role in TBEV transmission, whereas in Europe it is I. ricinus. Ixodes ticks normally have a 3-year life cycle (range 2 to 6 years). They grow through four stages: egg, larva, nymph and adult. Larvae and nymphs feed principally on rodents, and adult ticks tend to feed on larger animals, include human. Ticks can therefore become infected at any stage, including infection through transovarial transmission, and they remain infected for life. Feeding process requires several days (from 2 h for male adult to 8 days for female adult). The saliva may contain and transmit TBEV. The virus concentration in saliva can increase from 10 to 100 times from the first to the third day of the blood meal. However, transmission typically occurs early in the feeding process. Vector tick density and infection rates in TBEV-endemic focus are highly variable. For example, TBEV infection rates in I. persulcatus in Russia vary from less than 0.1% to approximately 8%, depending on the geographic location and the period of the year. Tick activity starts in April/May and ends in September/October, usually with a maximum in the months of May/June. Now TBEV is endemic in temperate regions of Europe and Asia, from approximately 6 to 143 degrees of longitude (eastern France to northern Japan), from 40 to 65 degrees of latitude (northern Russia to Albania), and up to about 1,400 m in altitude. According to the International Committee for Taxonomy of Viruses, TBE Virus is classified as one species with three subtypes, namely the European, Siberian and Far Eastern subtypes. The severity and clinical characteristics are associated with the specific TBEV subtype. The Far Eastern subtype is mainly observed from far-eastern Russia, China and Japan. Human infection by the Far Eastern subtype results in the most severe form of central nervous system disorder, with a tendency for the patient to develop focal meningoencephalitis or polyencephalitis (64% of all cases). In the most severe forms, there is major damage to neurons in different parts of the brain and spinal cord. Case fatality rates of 25 to 30% have been recorded. The progressive form of TBE is rarely observed, and the disease is more severe in children than in adults. The morbidity is 1-3 cases on 100 000 people.

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The Siberian subtype circulates in Urals, Siberia and European part of Russia. It induces a less severe acute period and a high prevalence of the nonparalytic febrile form of encephalitis (86%). Case fatality rates rarely exceed 2 to 4%. Instead, there is a tendency for patients to develop chronic TBE (1–2%). Now, most cases of TBE occur in Siberian and Ural regions and here the incidence is 10 to 30 times higher than in the Russian Far East region, where TBEV was discovered in 1937. The European subtype comprises almost all known kinds isolates in Europe. Encephalitis produced by European-subtype viruses is biphasic, with fever during the first phase and neurological disorders, which occur in 19% of patients, during the second phase. In contrast with the severe Far Eastern-subtype infections, those following infection by European-subtype strains are usually milder, case fatality rates are often as low as 1%, and the disease is less severe in children than in adults. Chronic TBE has never been reported in Europe. The morbidity in this region is 1 case on 100,000 people. Infection caused by TBEV is one of the most widespread natural focus infections in Russia. Incidence varies from 5593 to 10298 cases annually and includes 150 deaths annually. The I. persulcatus that transmit TBEV can also transmit: Borrelia, the agent of borreliosis; Anaplasma phagocytophilum, the agent of human granulocytic anaplasmosis; Babesia, the agent of babesiosis; Ehrlichia, the agent of ehrlichiosis. Simultaneous infection with multiple organisms is also possible. Anaplasma phagocytophilum, Ehrlichia and Babesia were found in less than 1% of ticks. Symptoms of Ehrlichosis include fever, muscle pain, fatigue, headache, blood pathology (leukopenia, thrombocytopenia). Anaplasmosis causes severe anemia. Symptoms of Babesiosis are similar with malaria. In Siberia 15% of I. persulcatus contain a Borrelia. Two species of Borrelia have been identified as human pathogens in Siberia: B. garinii and B. afzelii. Clinical presentations of borreliosis are include acute and chronic phases. Acute phase include a characteristic expanding rash called erythema migrans at the site of tick attachment, fever and, rarely, meningitis. Many of these symptoms disappear even without treatment. After several months, approximately 60% of patients with untreated infection then begin the chronic phase of infections. Manifestations of this phase include chronic neurological complaints, arthritis, heart diseases and skin atrophy. Other problems are the natural foci helmintiasis. There are including diphillobothriasis, opisthorchiasis, etc. For example, Lake Baikal is widely known as a tourist resort. However, it is also the place of natural focus of diphillobothriasis. The Causal Agent is the cestode Diphyllobothrium dendriticum. The main of definitive host of D. dendriticum is the seagull Larus argentatus. Human is an additional definitive host. The adult D. dendriticum tapeworm resides in the small intestine of the definitive hosts. The fist intermediate host is freshwater crustaceans Epishura baikalensis. The second intermediate host is a famous Baikal fish omul. 70–90% of omul have plerocercoid larva. Human acquire the infection by eating raw or undercooked infected fish. 10% of men in countries around of Lake Baikal are ill. The strategy of human contagion prevention is based on the study of etiology, epidemiology and clinic of these diseases and on the set up of optimal methods for collective and individual prophylaxis. The comprehensive nature of a prophylactic system should envisage the use of tried-and-true specific and nonspecific measures against the entire group of infections.

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In theory, the best prophylactic method is the protection from all diseases simultaneously. Unfortunately, this is often impossible. For instance, for diphillobothriosis, only a nonspecific individual prophylaxis can be recommended, by modifying dietary habits and encouraging the cooking of fishes. Since the primary vectors of tick-borne diseases are ticks and they may transmit several pathogens, it is necessary to use methods of collective and individual prophylaxis. With regard to collective prophylaxis: • •

Creation a ‘tick-safe zone’. Use landscaping techniques to create a ticksafe zone around houses, parks, and recreational areas. Apply pesticides to control ticks. A pesticide designed to kill ticks is sometimes called acaricide. Acaricides can be very effective in reducing tick populations. If properly scheduled, a single application at the end of May or beginning of June can reduce tick populations by 70-90%. But 1 month after the pesticide application, ticks return back in the territories, where acaricides are used in 60% of cases. This is, on the contrary, impossible in all zones of forest.

The methods of individual prophylaxis are focused on the protection from tick bites: •

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• •

Wear long pants, long sleeves, and long socks to keep ticks away from the skin. Light-colored clothing will help spotting ticks more easily. Use insect repellent on exposed skin and clothing. Man in tick-infested areas should also inspect all parts of the body carefully including armpits, scalp, and groin every 2 h. And remove ticks immediately. Reducing exposure to ticks is the best defense against tickborne infections.

Then other methods are focused on preventing infections after tick biting. Specific immunoglobulins are used to prevent TBE and antibiotics are used to prevent Tickborn borreliosis. A vaccine exists only for TBE prophylaxis. Three equivalent, safe, and effective inactivated TBE vaccines are available now: ENCEVIR (Russia), FSME-IMMUN (Austria) and Encepur (Germany). For all vaccines, the recommended primary vaccination series consists of three doses (the second is taken 1–3 months after the first, and the third is taken 9–12 months after the second). Booster doses are recommended every 3 years. Their efficiency is higher than 95%. Immunity is induced against all TBEV variants, including the European, Siberian and Far Eastern subtypes. Vaccination is an effective method for the prophylaxis of Tick-Born Encephalitis. Austria is the only European country with a routine vaccination program. In Austria the reported annual incidence of this disease has declined approximately 10-fold since 1981, when a national vaccination program was implemented [1]. Unfortunately, in Russia, in endemic areas, only 3% of population has specific vaccinations. Cohort vaccination should be considered as a priority measure in high Tick-Born Encephalitis endemic areas [2].

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There are many prophylactic methods, but only a wide information to the population can help in the prevention from infectious diseases in endemic areas. A thorough information and education plan is needed to inform population about the methods of prevention from diseases.

References C. Kunz, TBE vaccination and the Austrian experience, Vaccine 21 (2003), 50–55. D.K. L’vov and V.I. Zlobin, Prevention of tick-borne encephalitis at the present stage: strategy and tactics, Vopr. Virusol .52 (2007), 26–30.

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[1] [2]

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Pseudotuberculosis – Epidemiology, Clinic and Prevention Measures Irina A. SHURYGINA Scientific Center of Reconstructive and Restorative Surgery SB RAMS, Bortzov Revolutzii 1, 664003, Irkutsk, Russian Federation, [email protected]

Abstract. Y. pseudotuberculosis possesses a high ecological adaptation. Y. pseudotuberculosis has many factors of pathogenicity (108 kDa chromosomeencoded peptide invasin, pili, adhesin, endotoxin, pYV plasmid encoded Yop protein systems (YopE, H, T, M, J, N, K, B, D, R, JpkA, LcrV), superantigen YPM, heat-stabile and heat-labile enterotoxins, cytotoxin). There are 21 serological variants of Y. pseudotuberculosis. In Irkutsk region only Ɉ:1b serological variant has been registered. 10 outbreaks of pseudotuberculosis were analyzed. Almost 75% of Y. pseudotuberculosis cases involve patients from 5 to 20 years old. Preventive measures includes control of the environment (general sanitation; identification of the common-source vehicles; water chlorination, in order to kill Yersinia spp.), education, sanitary preparation of food (especially, uncooked food), avoiding contamination of water supplies and food from animal feces.

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Keywords. Yersinia pseudotuberculosis, classification, epidemiology, clinic, prevention

The age of genus Yersinia is estimated to be ca. 42–187 million years. Y. pseudotuberculosis appeared 0.4–1.9 million years ago and the causative agent of plague, Y. pestis, appeared 1500–20000 yeas ago. Genus of Yersinia includes three pathogenic members: Y. enterocolitica, Y. pseudotuberculosis and Y. pestis. The high genetic homology between Y. pseudotuberculosis and Y. pestis (80% of chromosomal homology and 100% of virulence plasmid homology) is the reason of major interest on genetic and epidemiology of Y. pseudotuberculosis. Y. pseudotuberculosis is a gram-negative rod-shaped to ovoid bacillus. Y. pseudotuberculosis has many factors of pathogenicity. There are 108 kDa chromosome-encoded peptide invasin, pili, adhesin, endotoxin, pYV plasmid encoded Yop protein systems (YopE, H, T, M, J, N, K, B, D, R, JpkA, LcrV), superantigen YPM, acquisition of iron. Some strains produce a heat-stabile and heat-labile enterotoxins, cytotoxin. Y. pseudotuberculosis may have 11 types of plasmids (from 2 to 135 MDa). pYV plasmid (47 MDa) is a plasmid of virulence. Others plasmids functions are unknown. The classification of Y. pseudotuberculosis is based on the identification of somatic antigens (O-group). There are 21 serological variants of Y. pseudotuberculosis now: Ɉ:1a, Ɉ:1b, Ɉ:1ɫ, Ɉ:2ɚ, Ɉ:2b, Ɉ:2ɫ, Ɉ:3, Ɉ:4ɚ, Ɉ:4b, Ɉ:5ɚ, Ɉ:5b, Ɉ:6, Ɉ:7, Ɉ:8, Ɉ:9, Ɉ:10, Ɉ:11, Ɉ:12, Ɉ:13, Ɉ:14, Ɉ:15 [3]. Only Ɉ:1ɚ, Ɉ:1b, Ɉ:2b, Ɉ:2ɫ, Ɉ:3, Ɉ:4ɚ, Ɉ:4b, Ɉ:5ɚ, Ɉ:5b variants may lead to human pathology [1, 2]. In Irkutsk region only Ɉ:1b serological variant has been registered.

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I.A. Shurygina / Pseudotuberculosis – Epidemiology, Clinic and Prevention Measures

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Y. pseudotuberculosis has a high ecological adaptation. This microorganism has 2 optimal temperatures for growing: +4°C and +37°C. Y. pseudotuberculosis can grow in soil and in water. Yersinia spp. is able to multiply even at low temperatures (for example, under refrigeration). Y. pseudotuberculosis is ubiquitous in the environment. Y. pseudotuberculosis is primarily a zoonotic disease of wild and domesticated birds and mammals, with humans as incidental hosts. Fecal-oral transmission was registered by eating and drinking food and water contaminated by feces. Survival outside the host organism is: in water at +4°C – 225 days; in sterile water at +4 °- up to 3 years; in soil – up to 10 years. Almost 75% of Y. pseudotuberculosis cases involve patients from 5 to 20 years old. The highest incidence has been registered during cold seasons in temperate climates. Most of the epidemic outbreaks were recorded in play-schools, schools and army barracks, due to the presence of contaminated food, such as uncooked vegetables. The cases typically occurred between January and May (70% of all human cases) (Figure 1).

Figure 1. Seasonality of pseudotuberculosis

Pseudotuberculosis is a serious acute disease. Duration of incubation period is from 3 to 18 days, with an average of 10 days. The acute disease is manifested by fever, headache, pharyngitis, anorexia, vomiting, acute diarrhea, acute mesenteric lymphadenitis mimicking appendicitis, erythema nodosum, arthritis and hepatosplenic enlargement. Most of the infections are localized and self-limiting (contained by inflammatory response). The post-infectious arthritis is more severe in adolescents and older adults, especially those who are HLA-B27 positive. Y. pseudotuberculosis shows a

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I.A. Shurygina / Pseudotuberculosis – Epidemiology, Clinic and Prevention Measures

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predilection for male adolescents. Patients which show an iron overload (for example, haemochromatosis) or which are immunocompromised are predisposed to the septicaemic form of disease. We investigated 10 outbreaks of pseudotuberculosis in the period 1987–2001. The outbreaks were induced by Y. pseudotuberculosis of Ɉ:1b serotype. In 5 cases among them, Y. pseudotuberculosis had the plasmid 47 MD and in the other 5 cases the plasmids 47 MD and 82 MD. Overall, 416 patients were examined. We observed the inflammation of the pharynx and the crimson tongue with equal rate in both groups (65%). Rash was more often observed in those patients, from which Y. pseudotuberculosis (47 MD) was allocated (77.6% vs. 55.26%, Ȥ2 = 22.84, ɪ < 0.001). Affection of gastrointestinal tract, enlargement of liver and spleen, pain in the joints are more often observed in the diseases caused by Y. pseudotuberculosis (47 and 82 MD), than by Y. pseudotuberculosis (47 MD). In particular: nausea and vomiting were observed at 45.18 vs. 11.17% (Ȥ2 = 56.95, ɪ