Edbert B. Hsu, Michael G. Millin. A Hospital-Based Strategy for Setting Priorities for Antiviral Prophylaxis during an Influenza Pandemic.  Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. June 1, 2008, 6(2): 171-178. doi:10.1089/bsp.2007.0057.  

In the event of an influenza pandemic, it is likely that there will be a shortage of antiviral medications to treat flu patients. How will hospitals decide who will receive the available medications? Based on the recommendations of an expert panel, the authors suggest some ways for hospitals to set priorities.

An influenza pandemic would place an unprecedented strain on the nation’s healthcare system—a compelling reason to carefully plan how priorities would be set for distributing antiviral medications. While antiviral medications have been added to the Strategic National Stockpile (SNS), these supplies are not designated as frontline resources and remain far from sufficient to provide mass prophylaxis for the entire population of the country. In the healthcare setting, providing general chemoprophylaxis may not be feasible because of high costs or inadequate supply. We propose a hospital-based strategy for setting priorities for antiviral prophylaxis that may offer a rational starting point for discussion and guide allocation decisions in the event of a shortage during a pandemic influenza outbreak.

Richard Lemay, Abla Mawudeku, Yuanli Shi, Martha Ruben, Camille Achonu.  Syndromic Surveillance for Influenzalike Illness Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. June 1, 2008, 6(2): 161-170. doi:10.1089/bsp.2007.0056.  

The authors looked at data over 5 influenza seasons in Ottawa, Canada, and compared the number and timing of emergency room visits for flu symptoms with confirmed cases of flu in the community. They suggest that pediatric hospitals could be sentinels of influenza and other infectious diseases.

Emergency department data are currently being used by several syndromic surveillance systems to identify outbreaks of natural or man-made illnesses, and preliminary results suggest that regular outbreaks might be detected earlier with such data than with traditional reporting. This article summarizes a retrospective study of 5 influenza seasons in Ottawa, Canada; time-series analysis was used to look for an association between consultation to the emergency department for influenzalike illness and the isolation of influenza virus in the community. The population studied included both children and adults consulting to 3 local hospitals. In 4 seasons, visits to the emergency department involving children younger than 5 years consulting mainly for fever and for respiratory symptoms peaked 1 to 4 weeks before the isolation of influenza virus in the community. If monitored regularly for the presence of key symptoms, pediatric hospitals might be efficient and cost-effective sentinels of influenza and of other infectious diseases.

Margaret E. Coleman, Brandolyn Thran, Stephen S. Morse, Martin Hugh-Jones, Stacey Massulik. Inhalation Anthrax: Dose Response and Risk Analysis.  Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. June 1, 2008, 6(2): 147-160. doi:10.1089/bsp.2007.0066.  

Based on scientific data, can we identify a threshold below which deleterious effects of Bacillus anthracis are unlikely? The authors present evidence about inhalation anthrax dose-response relationships and discuss how it should inform preparedness planning and risk management.

The notion that inhalation of a single Bacillus anthracis spore is fatal has become entrenched nearly to the point of urban legend, in part because of incomplete articulation of the scientific basis for microbial risk assessment, particularly dose-response assessment. Risk analysis (ie, risk assessment, risk communication, risk management) necessitates transparency: distinguishing scientific facts, hypotheses, judgments, biases in interpretations, and potential misinformation. The difficulty in achieving transparency for biothreat risk is magnified by misinformation and poor characterization of both dose-response relationships and the driving mechanisms that cause susceptibility or resistance to disease progression. Regrettably, this entrenchment unnecessarily restricts preparedness planning to a single response scenario: decontaminate until no spores are detectable in air, water, or on surfaces—essentially forcing a zero-tolerance policy inconsistent with the biology of anthrax. We present evidence about inhalation anthrax dose-response relationships, including reports from multiple studies documenting exposures insufficient to cause inhalation anthrax in laboratory animals and humans. The emphasis of the article is clarification about what is known from objective scientific evidence for doses of anthrax spores associated with survival and mortality. From this knowledge base, we discuss the need for future applications of more formal risk analysis processes to guide development of alternative non-zero criteria or standards based on science to inform preparedness planning and other risk management activities.