Responding to chemical, biological, or nuclear terrorism: the indirect and long-term health effects may present the greatest challenge

Understanding Mass Panic and Other Collective Responses to Threat and Disaster

While mass panic (and/or violence) and self-preservation are often assumed to be the natural response to physical danger and perceived entrapment, the literature indicates that expressions of mutual aid are common and often predominate, and collective flight may be so delayed that survival is threatened. In fact, the typical response to a variety of threats and disasters is not to flee but to seek the proximity of familiar persons and places; moreover, separation from attachment figures is a greater stressor than physical danger. Such observations can be explained by an alternative "social attachment" model that recognizes the fundamentally gregarious nature of human beings and the primacy of attachments. In the relatively rare instances where flight occurs, the latter can be understood as one aspect of a more general affiliative response that involves escaping from certain situations and moving toward other situations that are perceived as familiar but which may not necessarily be objectively safe. The occurrence of flight-and-affiliation depends mainly on the social context and especially the whereabouts of familiar persons (i.e., attachment figures); their physical presence has a calming effect and reduces the probability of flight-and-affiliation, while their absence has the opposite effect. Combining the factors of perceived physical danger and the location of attachment figures results in a four-fold typology that encompasses a wide spectrum of collective responses to threat and disaster. Implications of the model for predicting community responses to terrorist attacks and/or use of weapons of mass destruction are briefly discussed.

The Effect of Risk Communication on Public Behavior to Non-Conventional Terrorism-Randomized Control Trial

Non-conventional terrorism (NCT) incorporates an extended dimension of uncertainty that can lead to fear among the public. Health officials have an unsubstantiated assumption that thousands will seek treatment in hospitals following NCT. This study aims to examine public behavioral intentions in the case of NCT and the effect of risk communication on intents. An online randomized controlled trial was conducted among 1802 adult participants in Israel. Threat perception and behavioral intent before and after exposure to hypothetical NCT scenarios were assessed stratified to the type of media, exposure to rumors, and risk communication. The majority (~64%) of participants are aware of the NCT threat. Almost half (45%) of participants indicated a "high" or "very high" chance of seeking medical attention following an NCT incident. Regression analysis suggests that the odds of participants exposed to risk communication to report an elevated intent of seeking medical attention were 0.470 (95% CI: 0.359, 0.615) times that of participants not exposed to risk communication, χ² = 30.366, p < 0.001. The findings demonstrate the importance of effective risk communication in reducing undesired public behavior during NCT crises. Efforts must be invested to create a robust risk communication infrastructure to allow the proper management of possible NCT incidents.

The panic buying behavior of consumers during the COVID-19 pandemic: Examining the influences of uncertainty, perceptions of severity, perceptions of scarcity, and anxiety

The lack of a vaccine for COVID-19 and the limited amount of reliable data on the cessation of the disease have made people feel more vulnerable to the disease. As a result, people in many countries have been found to engage in panic purchasing, which has adversely affected the supply system for the retail market. Applying behavioral inhibition system theory, reactance theory, and expectancy theory, this research examines how psychological factors such as uncertainty, perceptions of severity, perceptions of scarcity, and anxiety affected the panic purchasing behavior of consumers. This study was conducted in Malaysia in light of the 2020 outbreak of the COVID-19 pandemic. The results from structural equation modeling indicate that uncertainty, and perceptions of scarcity are positively associated with anxiety but not with the panic purchasing behavior of consumers. In addition, anxiety fully mediates the relationship among these variables and the panic purchasing behavior of consumers. Taken together, these findings provide support for doing more empirical research in order to develop a more resilient retail strategy and to improve consumer service.

The variations in individual consumption change and the substitution effect under the shock of COVID-19: Evidence from payment system data in China

Over the last two decades, scholars have pointed to the significance of the impact of extreme events on consumption, a prominent part of national economies. How does the COVID-19 epidemic influence consumption? Using high-frequency payment system panel data, we explicitly consider the individual consumption changes and the substitution effect between online and offline markets of multiple categories by constructing autoregressive integrated moving average (ARIMA) models and conducting regression analyses. The p value and regression coefficients of the substitution elasticity are used to estimate the changes and the substitution effects from the offline to the online channels. The results show that consumption saw a remarkable decline after the surge of COVID-19 in 2020 compared to 2019. Overall, online markets were more resilient than the offline markets and the substitution effects after the epidemic's outbreak between the online and offline markets were significant for one-third of the consumption categories. However, the online market could not replace the offline market for some categories due to the product characteristics. The vulnerable industries in the face of the epidemic's intervention are determined as being traditional catering, transportation, tourism, and education, and the shortage of healthcare services in extreme events is also pointed out. The results provide suggestions for policies on targeted enterprises and public service.

COVID-19 Pandemic: A Compressive Review on Gender, Herd Immunity, and Physiological Mechanisms

BACKGROUND

Researchers and scientists experienced the spread and aid recovery of the COVID-19 pandemic with a condition of great uncertainty. With limited understanding of SARS-CoV-2, current attempts at controlling its spread are focused on the suppressing approach (to reduce a sustained endogenous transmission) and the mitigating approach (to reduce the growth rate of the epidemic). On the one hand, while there has been no firm explanation, many governments have considered immunity passport and herd immunity for paths out of restrictive physical distancing measures imposed to control the spread of SARS-CoV-2 but were not successful.

PURPOSE OF REVIEW

Herein, we attempted to systematize the lessons and shreds of evidence related to the spectrum of illness, the physiological mechanisms of host susceptibility, herd immunity, immunity passport, gender disparities, and severe challenges and uncertainties posed by the COVID-19 pandemic. We hope that the insights provided in this review will help raise the effectiveness of the treatment policies and preventive measures required to end the pandemic.

RECENT FINDINGS

The use of immunity passports is suggested to certify an individual at low risk of acquiring or transmitting SARS-CoV-2. But, an individual might nevertheless carry the virus at similar levels and for a similar duration to those previously uninfected, with an unchanged potential for transmission. Vaccine-induced herd immunity is a complex issue inherent to a vaccine and the population receiving the vaccine. The central epidemiological questions about are as follows: what proportion of the population should be vaccinated to meet elimination (in a local program), eradication (in a global program) or a defined level of control? How is this affected by demographic factors (such as gender)? What is the best age at which to immunize? Besides, although age-dependent mortality risk is estimated to be higher for men and older people, such interpretation across gender, age groups, and countries, however, must be accepted with caution at present.

SUMMARY

COVID-19 has taught us that health is the basis of global wealth and international solidarity is an essential response and a superior approach to isolationism. Hence, we must be clear about what the alternatives are when evaluating the merits of different ways of tackling this pandemic both in the short term as well as in the long term.

COVID-19 Pandemic: from Molecular Biology, Pathogenesis, Detection, and Treatment to Global Societal Impact

PURPOSE OF REVIEW

In December 2019, there was an outbreak of viral disease in Wuhan, China which raised the concern across the whole world. The viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or novel coronavirus or COVID-19 (CoV-19) is known as a pandemic. After SARS-CoV and Middle East respiratory syndrome (MERS)-related CoV, COVID-19 is the third most pathogenic virus, hazardous to humans which have raised worries concerning the capacity of current security measures and the human services framework to deal with such danger.

RECENT FINDINGS

According to WHO, the mortality rate of COVID-19 exceeded that of SARS and MERS in view of which COVID-19 was declared as public health emergency of international concern. Coronaviruses are positive-sense RNA viruses with single stranded RNA and non-segmented envelopes. Recently, genome sequencing confirmed that COVID-19 is similar to SARS-CoV and bat coronavirus, but the major source of this pandemic outbreak, its transmission, and mechanisms related to its pathogenicity to humans are not yet known.

SUMMARY

In order to prevent the further pandemic and loss to humanity, scientists are studying the development of therapeutic drugs, vaccines, and strategies to cure the infections. In this review, we present a brief introduction to emerging and re-emerging pathogens, i.e., coronavirus in humans and animals, its taxonomic classification, genome organization, its replication, pathogenicity, impact on socioeconomic growth, and drugs associated with COVID-19.

Innovations in Health Care Management: the Effect of the Pandemic on the Labour Market Change

The COVID-19 pandemic was identified in 17 days, and the related enormous economic and social impacts have mobilized the global scientific world in almost all areas of science. The leaders of individual countries have to face a challenge that has been unprecedented for many decades. The global pandemic could lead to profound changes in the balance of power, economic operations, and the labor market. In turn, the accompanying measures have brought a lot of changes to everyday life. Although the government of Romania had taken some measures to avoid the collapse of the economy. However, the experts did not regard these as efficient enough. At this time two-thirds of the Hungarian population do not feel that the media exaggerates the severity of the COVID-19 outbreak and the economic consequences of the pandemic are undisputable for the Hungarian people, just like for the Italian and French people who were severely affected by the virus. People have been deprived of the joy of social gatherings, free movement, travel and many of them have even lost their jobs. The primary question at the moment is whether countries could finance the sectors in hardship and whether their inter-dependence regarding the exchange of goods imposes any kind of danger to their citizens. In terms of macro-economy, however, the long-term consequences are much more interesting, and it raises questions like how the countries will be able to handle the situation resulted by the increased unemployment and the different trade relations. This study presents a primary research with the age group of 18-30. The target group is leaders of student unions and academics of four universities. This questionnaire survey aims to examine how the Hungarian and Transylvanian respondents see the prospective economic effects of the current situation on the different sectors of the economy. In addition to the descriptive statistical analysis, the perception of economic impacts was examined with variance analysis concerning different demographic characteristics, and the currently studied subject area. Is the negative attitude prevailing or do the different groups react differently to the state of affairs? The greatest differences in the opinion of respondents could be observed in the area of lifestyle and healthcare. The experts think that the pandemic will result in great changes in the offices, homes, schools, and places of work. Negative aftereffects are not predicted in higher education, sales, and trade. It can be concluded that negative labor market trends are expected, therefore probably the young generation currently studying in higher education will be one of the biggest losers of the virus in the long run. Keywords: COVID 19, pandemic, economic impact, changes in subject areas.

Tracking and Analyzing Individual Distress Following Terrorist Attacks Using Social Media Streams

Risk research has theorized a number of mechanisms that might trigger, prolong, or potentially alleviate individuals' distress following terrorist attacks. These mechanisms are difficult to examine in a single study, however, because the social conditions of terrorist attacks are difficult to simulate in laboratory experiments and appropriate preattack baselines are difficult to establish with surveys. To address this challenge, we propose the use of computational focus groups and a novel analysis framework to analyze a social media stream that archives user history and location. The approach uses time-stamped behavior to quantify an individual's preattack behavior after an attack has occurred, enabling the assessment of time-specific changes in the intensity and duration of an individual's distress, as well as the assessment of individual and social-level covariates. To exemplify the methodology, we collected over 18 million tweets from 15,509 users located in Paris on November 13, 2015, and measured the degree to which they expressed anxiety, anger, and sadness after the attacks. The analysis resulted in findings that would be difficult to observe through other methods, such as that news media exposure had competing, time-dependent effects on anxiety, and that gender dynamics are complicated by baseline behavior. Opportunities for integrating computational focus group analysis with traditional methods are discussed.

Mental health consequences of chemical and radiologic emergencies: a systematic review

This article reviews the literature pertaining to psychological impacts in the aftermath of technological disasters, focusing on the immediate psychological and mental health consequences emergency department physicians and first responders may encounter in the aftermath of such disasters. First receivers see a wide spectrum of psychological distress, including acute onset of psychiatric disorders, the exacerbation of existing psychological and psychiatric conditions, and widespread symptomatology even in the absence of a diagnosable disorder. The informal community support systems that exist after a natural disaster may not be available to communities affected by a technological disaster leading to a need for more formal mental health supportive services.

Understanding public responses to chemical, biological, radiological and nuclear incidents--driving factors, emerging themes and research gaps

This paper discusses the management of public responses to incidents involving chemical, biological, radiological and nuclear materials (CBRN). Given the extraordinary technical and operational challenges of a response to a CBRN release including, but not limited to, hazard detection and identification, casualty decontamination and multi-agency co-ordination, it is not surprising that public psychological and behavioural responses to such incidents have received limited attention by scholars and practitioners alike. As a result, a lack of understanding about the role of the public in effective emergency response constitutes a major gap in research and practice. This limitation must be addressed as a CBRN release has the potential to have wide-reaching psychological and behavioural impacts which, in turn, impact upon public morbidity and mortality rates. This paper addresses a number of key issues: why public responses matter; how responses have been conceptualised by practitioners; what factors have been identified as influencing public responses to a CBRN release and similar extreme events, and what further analysis is needed in order to generate a better understanding of public responses to inform the management of public responses to a CBRN release.

Psychosocial care to affected citizens and communities in case of CBRN incidents: a systematic review

Disasters are associated with a substantial psychosocial burden for affected individuals (including first responders) and communities. Knowledge about how to address these risks and problems is valuable for societies worldwide. Decades of research into post-disaster psychosocial care has resulted in various recommendations and general guidelines. However, as CBRN (chemical, biological, radiological, nuclear) events form a distinctive theme in emergency planning and disaster preparedness, it is important to systematically explore their implications for psychosocial care. The aim of this study is to answer two questions: 1). To what extent does psychosocial care in the case of CBRN events differ from other types of events? 2). How strong is the scientific evidence for the effectiveness of psychosocial care interventions in the context of a CBRN event? A systematic literature review was conducted. Searches were performed in Medline, PsychINFO, Embase and PILOTS. Studies since January 2000 were included and evaluated by independent reviewers. The 39 included studies contain recommendations, primarily based on unsystematic literature reviews, qualitative research and expert opinions. Recommendations address: 1) public risk- and crisis communication, 2) training, education and exercise of responders, 3) support, and 4) psychosocial counselling and care to citizens and responders. Although none of the studies meet the design criteria for effectiveness research, a substantial amount of consensus exists on aspects relevant to CBRN related psychosocial care. Recommendations are similar or complementary to general post-disaster psychosocial care guidelines. Notable differences are the emphasis on risk communication and specific preparation needs. Relevant recurring topics are uncertainty about contamination and health effects, how people will overwhelm health care systems, and the possibility that professionals are less likely to respond. However, the lack of evidence on effectiveness makes it necessary to be careful with recommendations. More evaluation research is absolutely needed.

The impact of communication materials on public responses to a radiological dispersal device (RDD) attack

It is a common assumption that, in the event of a chemical, biological, radiological, or nuclear (CBRN) attack, a well-prepared and informed public is more likely to follow official recommendations regarding the appropriate safety measures to take. We present findings from a UK study investigating the ability of crisis communication to influence perceptions of risk and behavioral intentions in the general public in response to CBRN terrorism. We conducted a focus group study involving a scenario presented in mock news broadcasts to explore levels of public knowledge, information needs, and intended behavioral reactions to an attack involving an overt radiological dispersal device (RDD), or dirty bomb. We used the findings from these focus groups to design messages for the public that could be presented in a short leaflet. We then tested the effects of the leaflet on reactions to the same scenario in 8 further focus groups. The impact of the new messages on levels of knowledge, information needs, and intended compliance with official recommendations was assessed. The provision of information increased the perceived credibility of official messages and increased reported levels of intended compliance with advice to return to normal/stop sheltering, attend a facility for assessment and treatment, and return to a previously contaminated area after decontamination of the environment has taken place. Should a real attack with an RDD occur, having pretested messages available to address common concerns and information needs should facilitate the public health response to the attack.

Development of a Decision Framework for Establishing a Health Register Following a Major Incident

Introduction

Health registers have been established in the United Kingdom (UK) and elsewhere following mass exposure to novel agents or known agents, but there is no consensus on the criteria for establishing such registers.

Objective

This study aimed to develop a decision framework to assess the need for establishing a health register for major chemical, biological, radiological, and nuclear (CBRN) incidents.

Methods

The study comprised three stages. In the first stage, the study team prepared a list of potential criteria that may be used to assess the need for setting up a health register based on literature review and personal experiences in previous incidents. In the second stage, the potential criteria were evaluated in two Delphi rounds involving experts and key decision makers from the UK Health Protection Agency (HPA) and academic organizations. In the final stage, the criteria were converted into a decision framework, and its utility was tested using four fictional scenarios.

Results

A total of 11 statements were proposed by the study group. These criteria were revised following feedback from 16 experts in the first Delphi round. All 11 statements achieved consensus at the end of the second Delphi round. Pilot testing of the agreed criteria on four fictional scenarios confirmed validity and reliability for use in the decision process.

Conclusions

A decision framework to assess the need for setting up a health register after a major incident was agreed upon and tested using fictional scenarios. Further areas of work for practical implementation of the criteria and related planning for systems and protocols have been identified.

ParanthamanK, CatchpoleM, SimpsonJ, MorrisJ, MuirheadCR, LeonardiGS. Development of a decision framework for establishing a health register following a major incident. Prehosp Disaster Med. 2012;27(6):1-7.

Driving deaths and injuries post-9/11

OBJECTIVES

In the days immediately following the terror attacks of 9/11, thousands of Americans chose to drive rather than to fly. We analyzed highway accident data to determine whether or not the number of fatalities and injuries following 9/11 differed from those in the same time period in 2000 and 2002.

METHODS

Motor crash data from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System were analyzed to determine the numbers and rates of fatalities and injuries nationally and in selected states for the 20 days after September 11, in each of 2000, 2001, and 2002.

RESULTS

While the fatality rate did not change appreciably, the number of less severe injuries was statistically higher in 2001 than in 2000, both nationally and in New York State.

CONCLUSIONS

The fear of terror attacks may have compelled Americans to drive instead of fly. They were thus exposed to the heightened risk of injury and death posed by driving. The need for public health to manage risk perception and communication is thus heightened in an era of global fear and terrorism.

Psychiatry and terrorism

Terrorism has dominated the domestic and international landscape since 9/11. Like other fields, psychiatry was not well prepared. With the 10th anniversary of the 9/11 attack approaching, it is timely to consider what can be done to prepare before the next event. Much has been learned to provide knowledge and resources. The roles of psychiatrists are challenged by what is known of the causes of, consequences of, and responses to terrorism. Reflecting on knowledge from before and since 9/11 introduces concepts, how individuals become terrorists, how to evaluate the psychiatric and behavioral effects of terrorism, and how to expand treatments, behavioral health interventions, public policy initiatives, and other responses for its victims. New research, clinical approaches, and policy perspectives inform strategies to reduce fear and cope with the aftermath. This article identifies the psychiatric training, skills and services, and ethical considerations necessary to prevent or reduce terrorism and its tragic consequences and to enhance resilience.

Impact of public health emergencies on modern disaster taxonomy, planning, and response

Current disaster taxonomy describes diversity, distinguishing characteristics, and common relations in disaster event classifications. The impact of compromised public health infrastructure and systems on health consequences defines and greatly influences the manner in which disasters are observed, planned for, and managed, especially those that are geographically widespread, population dense, and prolonged. What may first result in direct injuries and death may rapidly change to excess indirect illness and subsequent death as essential public health resources are destroyed, deteriorate, or are systematically denied to vulnerable populations. Public health and public health infrastructure and systems in developed and developing countries must be seen as strategic and security issues that deserve international public health resource monitoring attention from disaster managers, urban planners, the global humanitarian community, World Health Organization authorities, and participating parties to war and conflict. We posit here that disaster frameworks be reformed to emphasize and clarify the relation of public health emergencies and modern disasters.

Methodological challenges in assessing general population reactions in the immediate aftermath of a terrorist attack

Assessing mental health needs following a disaster is important, particularly within high-risk groups such as first responders or individuals who found themselves directly caught up in the incident. Particularly following events involving widespread destruction, ingenuity and hard work are required to successfully study these issues. When considering responses among the general population following less devastating events such as a conventional terrorist attack, or following an event involving a chemical, biological, radiological or nuclear agent, other variables may become more relevant for determining the population's overall psychosocial well-being. Trust, perceived risk, sense of safety, willingness to take prophylaxis and unnecessary attendance at medical facilities will all be important in determining the overall psychological, medical, economic and political impact of such attacks. Assessing these variables can help government agencies and non-governmental organizations to adjust their communication and outreach efforts. As there is often a need to provide these data quickly, telephone surveys using short time-windows for data collection or which use quota samples are often required. It is unclear whether slower, more conventional and more expensive survey methods with better response rates would produce results different enough to these quicker and cheaper methods to have a major impact on any resulting policy decisions. This empirical question would benefit from further study.

Mechanistic modeling of emergency events: assessing the impact of hypothetical releases of anthrax

A modular system for source-to-dose-to-effect modeling analysis has been developed based on the modeling environment for total risk studies (MENTOR),((1)) and applied to study the impacts of hypothetical atmospheric releases of anthrax spores. The system, MENTOR-2E (MENTOR for Emergency Events), provides mechanistically consistent analysis of inhalation exposures for various release scenarios, while allowing consideration of specific susceptible subpopulations (such as the elderly) at the resolution of individual census tracts. The MENTOR-2E application presented here includes atmospheric dispersion modeling, statistically representative samples of individuals along with corresponding activity patterns, and population-based dosimetry modeling that accounts for activity and physiological variability. Two hypothetical release scenarios were simulated: a 100 g release of weaponized B. anthracis over a period of (a) one hour and (b) 10 hours, and the impact of these releases on population in the State of New Jersey was studied. Results were compared with those from simplified modeling of population dynamics (location, activities, etc.), and atmospheric dispersion of anthrax spores. The comparisons showed that in the two release scenarios simulated, each major approximation resulted in an overestimation of the number of probable infections by a factor of 5 to 10; these overestimations can have significant public health implications when preparing for and responding effectively to an actual release. This is in addition to uncertainties in dose-response modeling, which result in an additional factor of 5 to 10 variation in estimated casualties. The MENTOR-2E system has been developed in a modular fashion so that improvements in individual modules can be readily made without impacting the other modules, and provides a first step toward the development of models that can be used in supporting real-time decision making.

Symptomatology attributable to psychological exposure to a chemical incident: a natural experiment

BACKGROUND

Exposure to a complex emergency has a substantial psychological component, which is rarely assessed. This study compares the health impact of physically and psychologically mediated exposure to a complex emergency.

SETTING

The Sea Empress oil tanker spill.

DESIGN

A cross-sectional analysis of self-report questionnaire responses collected from inhabitants of 6 different coastal towns-4 of them physically exposed to the oil spill, 2 unexposed-was undertaken. The towns were known to be psychologically homogeneous before the incident. Perceived risk was used as a measure of psychological exposure. Anxiety, depression and symptom reporting were used as measures of health impact.

PARTICIPANTS

1089 (69%) men and women aged 18-65 years responded.

MAIN RESULTS

Perceived risk was associated with raised anxiety and non-toxicologically related symptom reporting, whereas physical exposure to oil was only associated with toxicologically related symptom reporting. The impact of raised perceived risk on the population was greater than that of physical oil exposure, involving more persons over a wider area.

CONCLUSIONS

Psychological exposure was shown to be quantifiable, and to be a substantially more sensitive measure of health impact than physical exposure in relation to psychological outcomes. This type of analysis has important implications for emergency response planning, and for the interpretation of a complex emergency by the general public.

Bioterrorism--types of epidemics, new epidemiological paradigm and levels of prevention

Biological attacks can cause both an epidemic of infectious disease and of fear and panic. Epidemiological triangle chain models can be used to present both these types of epidemic. By merging these two triangles we suggest a new four-sided pyramidal model of bioterrorism attack and appropriate levels of prevention. Primordial prevention of biological attacks should comprise the impeding of access of both terrorists and biological agents to the territory. The primary prevention level should comprise internal surveillance of potential sources of agents and terrorists. Secondary prevention activities should be directed toward breaking both the epidemic of infectious disease and that of fear and panic. Tertiary prevention should include measures for repair following the attack. This is a task mainly for mental health professionals, curing and rehabilitating those affected by the epidemic of fear and panic. The suggested epidemiological model can be implemented into training programmes for detecting and responding to bioterrorist attacks around the world.

Bringing Order Out of Chaos: Effective Strategies for Medical Response to Mass Chemical Exposure

An accident or a deliberate terrorism attack releasing hazardous chemicals will create chaos, confusion, and seeming unpredictability that complicates the emergency response. Clinicians are challenged to urgently treat patients needing care, even before a chemical is confirmed. Emergency response planning that focuses on preparing for predictable challenges to the health care system and applies basic toxicologic principles to clinical decision-making can bring a sense of order to the chaos and provide medical care that will be best for the most victims of an incident.

Acute toxic effects of nerve agent VX on respiratory dynamics and functions following microinsillation inhalation exposure in guinea pigs

Exposure to a chemical warfare nerve agent (CWNA) leads to severe respiratory distress, respiratory failure, or death if not treated. We investigated the toxic effects of nerve agent VX on the respiratory dynamics of guinea pigs following exposure to 90.4 mug/m3 of VX or saline by microinstillation inhalation technology for 10 min. Respiratory parameters were monitored by whole-body barometric plethysmography at 4, 24, and 48 h, 7 d, 18 d, and 4 wk after VX exposure. VX-exposed animals showed a significant decrease in the respiratory frequency (RF) at 24 and 48 h of recovery (p value .0329 and .0142, respectively) compared to the saline control. The tidal volume (TV) slightly increased in VX exposed animals at 24 and significantly at 48 h (p = .02) postexposure. Minute ventilation (MV) increased slightly at 4 h but was reduced at 24 h and remained unchanged at 48 h. Animals exposed to VX also showed an increase in expiratory (Te) and relaxation time (RT) at 24 and 48 h and a small reduction in inspiratory time (Ti) at 24 h. A significant increase in end expiratory pause (EEP) was observed at 48 h after VX exposure (p = .049). The pseudo lung resistance (Penh) was significantly increased at 4 h after VX exposure and remained slightly high even at 48 h. Time-course studies reveal that most of the altered respiratory dynamics returned to normal at 7 d after VX exposure except for EEP, which was high at 7 d and returned to normal at 18 d postexposure. After 1 mo, all the monitored respiratory parameters were within normal ranges. Bronchoalveolar lavage (BAL) 1 mo after exposure showed virtually no difference in protein levels, cholinesterase levels, cell number, and cell death in the exposed and control animals. These results indicate that sublethal concentrations of VX induce changes in respiratory dynamics and functions that over time return to normal levels.

Illness by suggestion: expectancy, modeling, and gender in the production of psychosomatic symptoms

BACKGROUND

Expectancy and modeling have been cited as factors in mass psychogenic illness (MPI), which reportedly affects more women than men.

PURPOSE

The purpose of the study is to assess the effects of expectancy and modeling in a controlled laboratory analogue of MPI.

METHODS

Students were randomly assigned to inhale or not inhale an inert placebo described as a suspected environmental toxin that had been linked to four symptoms typical of reported instances of MPI. Half of the students observed a female confederate inhale the substance and subsequently display the specified symptoms.

RESULTS

Students who inhaled the placebo reported greater increases in symptoms, and the increase was significantly greater for the specified symptoms than for other symptoms. Observation of the confederate displaying symptoms increased specified symptoms significantly among women but not among men. Changes in reported symptoms were significantly associated with changes in unobtrusively observed behavior.

CONCLUSIONS

Symptoms typical of clinical reports of MPI can be induced by manipulating response expectancies, and the effects are specific rather than generalized. Among women, this effect is enhanced by observing another participant (who in this study is also female) display symptoms. This suggests that the preponderance of women showing symptoms in outbreaks of MPI may be due to gender-linked differences in the effects of modeling on psychogenic symptoms.

Trends in healthcare use in the New York City region following the Terrorist Attacks of 2001

BACKGROUND

In 2001, terrorism led to emotional stress, disruptions in adherence to treatments and access to services, and exposure to environmental contaminants in New York City (NYC).

METHODS

To describe healthcare use following the terrorist attacks of 2001, we examined insurance claims for January 2000 to March 2002 among more than 2 million residents of the NYC region who were enrolled in the health plans of a large insurer, including overall use by care setting and use for selected conditions that may be associated with stress or other disaster consequences. For all enrollees and for those residing at varying distances from the World Trade Center (WTC), we compared observed use to expected use, based on comparable intervals in prior years and adjusted for seasonal and secular trends.

RESULTS

Use declined across all care settings in the 3 weeks following September 11. From October 1 to December 31, 2001, outpatient visits rose beyond expected both overall and for specific cardiovascular, gastrointestinal, and dermatologic conditions. Declines in overall mental health service use began immediately after September 11 and were sustained through March 2002. Changes in healthcare use were more marked among those residing within 10 miles of the WTC than those residing at greater distances.

CONCLUSIONS

A transient decline in visits across all settings occurred immediately after September 11, followed by a sustained increase in demand for health care for conditions that may be associated with stress or other disaster consequences.

Nuclear terrorism: the role of hematology in coping with its health consequences

PURPOSE OF REVIEW

This review reports on a novel approach to use blood cell change patterns after accidental whole body radiation exposure (to be expected as a consequence of nuclear terrorism) as reliable indicators of effect and as an aid to plan therapeutic measures.

RECENT FINDINGS

There is growing concern about the potential of nuclear terrorism. Several scenarios are being discussed. In all of them one finds elements that mimic the experience gained in assessing and treating humans who were exposed to ionizing radiation in radiation accidents. This experience leads to diagnostic and therapeutic measures laid down in a recently published Manual on the Acute Radiation Syndrome. The European Bone Marrow Transplantation Group (EBMT) together with the Institut de Radioprotection et de Sûreté Nucléaire (IRSN) in Paris and the University of Ulm published a consensus paper to use 'response categories' based on organ-specific gradings of severity as indicators of the severity of health impairments.

SUMMARY

The implication of this review is obvious: the medical staff confronted suddenly with the challenge of clinically managing an irradiated person will find all scientifically based recommendations in order to cope with the evolving problems on a scientific-pathophysiology driven approach.

A psychosocial risk assessment and management framework to enhance response to CBRN terrorism threats and attacks

Evidence in the disaster mental health literature indicates that psychosocial consequences of terrorism are a critical component of chemical, biological, radiological, and nuclear (CBRN) events, both at the clinical level and the normal behavioral and emotional levels. Planning for such psychosocial aspects should be an integral part of emergency preparedness. As Canada and other countries build the capacity to prevent, mitigate, and manage CBRN threats and events, it is important to recognize the range of social, psychological, emotional, spiritual, behavioral, and cognitive factors that may affect victims and their families, communities, children, the elderly, responders, decision makers, and others at all phases of terrorism, from threat to post-impact recovery. A structured process to assist CBRN emergency planners, decision makers, and responders in identifying psychosocial risks, vulnerable populations, resources, and interventions at various phases of a CBRN event to limit negative psychosocial impacts and promote resilience and adaptive responses is the essence of our psychosocial risk assessment and management (P-RAM) framework. This article presents the evidence base and conceptual underpinnings of the framework, the principles underlying its design, its key elements, and its use in the development of decision tools for responders, planners, decision makers, and the general public to better assess and manage psychosocial aspects of CBRN threats or attacks.

Perceived poisons

Perceived poisoning may manifest in numerous ways; however, all cases share certain characteristics. All are fostered by the wide availability of unreliable information about chemical safety, poor understanding of scientific principles, and ineffective risk communication. Although this problem is still incompletely understood, some approaches have been demonstrated to be useful, such as education about risk, appropriate reassurance, and empathy on the part of the practitioner. Successful management may curtail the spread or exacerbation of symptoms, whereas unsuccessful treatment may cause the problems to escalate, with detrimental effects on both society and patient.

Assessing the Readiness and Training Needs of Non-urban Physicians in Public Health Emergency and Response

Emergency readiness has become a public health priority for United States communities after the 9/11 attacks. Communities that have a less developed public health infrastructure are challenged to organize preparedness and response efforts and to ensure that health care providers are capable of caring for victims of terrorist acts. A survey was used to assess non-urban physicians' prior experience with and self-confidence in treating, and preferred training needs for responding to chemical, biologic, radiologic, nuclear, and explosive (CBRNE) cases. Data were collected through a mailed and Web-based survey. Although the response rate was calculated at 30%, approximately one third of the surveys were not able to be delivered. Most respondents reported never having seen or treated CBRNE-inflicted cases and were not confident in their ability to diagnose or treat CBRNE cases, but many were willing to participate in a state-led response plan. Almost half of the individuals had not participated in any related training but expressed interest in receiving training in small group workshops or through CD-ROM. These results provide potential direction for strategic preparedness planning for non-urban health care providers.

Bioterrorism, stress, and pain: the importance of an anticipatory community preparedness intervention

This article reviews the accumulating scientific evidence demonstrating the negative impact caused by a cataclysmic event, such as bioterrorism, on the mental health of a community. Moreover, the potential mental health problems created by the continuing threat of possible future events are discussed. This close link among disaster events, stress, pain, and psychopathology is presented from a biopsychosocial perspective. Although there are now efforts being systematically developed to prepare for possible future biological or chemical terrorism events, there is currently also a critical need for early mental health intervention in response to future attacks to decrease psychiatric sequelae, especially workforce illness and morbidity. In this article, examples of such emergency bioterrorism preparedness, incorporating a major focus on mental health issues, are reviewed. Although these are now recognized needs, there is still not a concerted effort to prepare the population for the mental health sequelae that would be produced by such events.

Facing the possibility of bioterrorism

The possibility of bioterrorism has been met by significant financial outlays to map out public health responses. These have included comprehensive audits of potential agents, as well as exploring mechanisms for counteracting their impact. Psychological intervention and communication have been identified as key areas requiring further work, as fear of infection could pose a greater strain on social resources than the pathogens themselves. Bioterrorism provides a powerful metaphor for élite fears of social corrosion from within. Accordingly, a broader historical and cultural perspective is required to understand why individuals and societies feel so vulnerable to what remain largely speculative scenarios.

Understanding mass panic and other collective responses to threat and disaster

While mass panic (and/or violence) and self-preservation are often assumed to be the natural response to physical danger and perceived entrapment, the literature indicates that expressions of mutual aid are common and often predominate, and collective flight may be so delayed that survival is threatened. In fact, the typical response to a variety of threats and disasters is not to flee but to seek the proximity of familiar persons and places; moreover, separation from attachment figures is a greater stressor than physical danger. Such observations can be explained by an alternative "social attachment" model that recognizes the fundamentally gregarious nature of human beings and the primacy of attachments. In the relatively rare instances where flight occurs, the latter can be understood as one aspect of a more general affiliative response that involves escaping from certain situations and moving toward other situations that are perceived as familiar but which may not necessarily be objectively safe. The occurrence of flight-and-affiliation depends mainly on the social context and especially the whereabouts of familiar persons (i.e., attachment figures); their physical presence has a calming effect and reduces the probability of flight-and-affiliation, while their absence has the opposite effect. Combining the factors of perceived physical danger and the location of attachment figures results in a four-fold typology that encompasses a wide spectrum of collective responses to threat and disaster. Implications of the model for predicting community responses to terrorist attacks and/or use of weapons of mass destruction are briefly discussed.

Environmental health promotion: bridging traditional environmental health and health promotion

This article highlights the juncture between environmental health and health promotion and underscores the need for health promotion involvement in environmental health practice. It begins with a synopsis of current issues in environmental public health and deficiencies in environmental public health practice that could be partly ameliorated by an increased focus on environmental health promotion. Environmental health promotion lies at the intersection between the two disciplines and can be defined as any planned process employing comprehensive health promotion approaches to assess, correct, control, and prevent those factors in the environment that can potentially harm the health and quality of life of present and future generations. An introduction is also provided to the six articles contained in this special issue focused on environmental health promotion, and a brief discussion of crosscutting themes and issues is presented.

Emotional and behavioral consequences of bioterrorism: planning a public health response

Millions of dollars have been spent improving the public health system's bioterrorism response capabilities. Yet relatively little attention has been paid to precisely how the public will respond to bioterrorism and how emotional and behavioral responses might complicate an otherwise successful response. This article synthesizes the available evidence about the likely emotional and behavioral consequences of bioterrorism to suggest what decision makers can do now to improve that response. It examines the emotional and behavioral impact of previous "bioterrorism-like" events and summarizes interviews with experts who have responded to such events or conducted research on the effects of community-wide disasters. The article concludes by reflecting on the evidence and experts' perspectives to suggest actions to be taken now and future policy and research priorities.

Hospital preparedness for possible nonconventional casualties: an Israeli experience

Since 9/11, hospitals and health authorities have been preparing medical response in case of various mass terror attacks. The experience of Tel Aviv Sourasky Medical Center in treating suicide-bombing mass casualties served, in the time leading up to the war in Iraq, as a platform for launching a preparedness program for possible attacks with biological and chemical agents of mass destruction. Adapting Quarantelli's criteria on disaster mitigation to the "microinfrastructure" of the hospital, and including human behavior experts, we attempted to foster an interactive emergency management process that would deal with contingencies stemming from the potential hazards of chemical and biological (CB) weapons. The main objective of our work was to encourage an organization-wide communication network that could effectively address the contingent hazards unique to this unprecedented situation. A stratified assessment of needs, identification of unique dangers to first responders, and assignment of team-training sessions paved the way for program development. Empowerment through leadership and resilience training was introduced to emergency team leaders of all disciplines. Focal subject matters included proactive planning, problem-solving, informal horizontal and vertical communication, and coping through stress-management techniques. The outcome of this process was manifested in an "operation and people" orientation supporting a more effective and compatible emergency management. The aim of article is to describe this process and to point toward the need for a broad-spectrum view in such circumstances. Unlike military units, the civilian hospital staff at risk, expected to deal with CB casualties, requires adequate personal consideration to enable effective functioning. Issues remain to be addressed in the future. We believe that collaboration and sharing of knowledge, information, and expertise beyond the medical realm is imperative in assisting hospitals to expedite appropriate preparedness programs.

Investigation of an electronic emergency department information system as a data source for respiratory syndrome surveillance

Emergency department syndromic surveillance may provide early warning of disease outbreaks due to bioterrorism or natural phenomena. The purpose of this investigation was to explore how an electronic emergency department information system could be used as a data source for respiratory syndrome surveillance. The process of data collection, entry, and transmission is described, and then a subset of data elements with potential epidemiological value is selected. The quality of the data contained in the system was evaluated by conducting a retrospective analysis of emergency department visits recorded in the system during 2001 and by reviewing clinical charts of cases with respiratory diagnoses. Diagnosis codes, discharge disposition, and demographic data were relatively complete; additional clinical data were not. Diagnosis codes were rapidly and reliably recorded. Data available in the system allows a description of emergency department visits for respiratory syndrome in terms of age, gender, location, severity of illness, and distribution in time. Encrypted data were transmitted every four hours to the health department without added work for emergency department personnel. Although significant obstacles remain, electronic emergency department information systems such as this may provide rapid, reliable data for syndromic surveillance.