Airborne infection with Bacillus anthracis--from mills to mail

Mathematical models and analysis tools for risk assessment of unnatural epidemics: a scoping review

Predicting, issuing early warnings, and assessing risks associated with unnatural epidemics (UEs) present significant challenges. These tasks also represent key areas of focus within the field of prevention and control research for UEs. A scoping review was conducted using databases such as PubMed, Web of Science, Scopus, and Embase, from inception to 31 December 2023. Sixty-six studies met the inclusion criteria. Two types of models (data-driven and mechanistic-based models) and a class of analysis tools for risk assessment of UEs were identified. The validation part of models involved calibration, improvement, and comparison. Three surveillance systems (event-based, indicator-based, and hybrid) were reported for monitoring UEs. In the current study, mathematical models and analysis tools suggest a distinction between natural epidemics and UEs in selecting model parameters and warning thresholds. Future research should consider combining a mechanistic-based model with a data-driven model and learning to pursue time-varying, high-precision risk assessment capabilities.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Bacillus anthracis and Brucella melitensis

Introduction

Brucella melitensis and Bacillus anthracis are zoonoses transmitted from animals and animal products. Scientific information is provided in this article to support biosafety precautions necessary to protect laboratory workers and individuals who are potentially exposed to these pathogens in the workplace or other settings, and gaps in information are also reported. There is a lack of information on the appropriate effective concentration for many chemical disinfectants for this agent. Controversies related to B. anthracis include infectious dose for skin and gastrointestinal infections, proper use of personal protective equipment (PPE) during the slaughter of infected animals, and handling of contaminated materials. B. melitensis is reported to have the highest number of laboratory-acquired infections (LAIs) to date in laboratory workers.

Methods

A literature search was conducted to identify potential gaps in biosafety and focused on five main sections including the route of inoculation/modes of transmission, infectious dose, LAIs, containment releases, and disinfection and decontamination strategies.

Results

Scientific literature currently lacks information on the effective concentration of many chemical disinfectants for this agent and in the variety of matrices where it may be found. Controversies related to B. anthracis include infectious dose for skin and gastrointestinal infections, proper use of PPE during the slaughter of infected animals, and handling contaminated materials.

Discussion

Clarified vulnerabilities based on specific scientific evidence will contribute to the prevention of unwanted and unpredictable infections, improving the biosafety processes and procedures for laboratory staff and other professionals such as veterinarians, individuals associated with the agricultural industry, and those working with susceptible wildlife species.

Modeling on the Effects of Deliberate Release of Aerosolized Inhalational Bacillus anthracis (Anthrax) on an Australian Population

This study aimed to determine optimal mitigation strategies in the event of an aerosolized attack with Bacillus anthracis, a category A bioterrorism agent with a case fatality rate of nearly 100% if inhaled and untreated. To simulate the effect of an anthrax attack, we used a plume dispersion model for Sydney, Australia, accounting for weather conditions. We determined the radius of exposure in different sizes of attack scenarios by spore quantity released per second. Estimations of different spore concentrations were then used to calculate the exposed population to inform a Susceptible-Exposed-Infected-Recovered (SEIR) deterministic mathematical model. Results are shown as estimates of the total number of exposed and infected people, along with the burden of disease, to quantify the amount of vaccination and antibiotics doses needed for stockpiles. For the worst-case scenario, over 500,000 people could be exposed and over 300,000 infected. The number of deaths depends closely on timing to start postexposure prophylaxis. Vaccination used as a postexposure prophylaxis in conjunction with antibiotics is the most effective mitigation strategy to reduce deaths after an aerosolized attack and is more effective when the response starts early (2 days after release) and has high adherence, while it makes only a small difference when started late (after 10 days).

Airborne Transmission and Control of Influenza and Other Respiratory Pathogens

Despite uncertainty about the specific transmission risk posed by airborne, spray-borne, and contact modes for influenza, SARS-CoV-2, and other respiratory viruses, there is evidence that airborne transmission via inhalation is important and often predominates. An early study of influenza transmission via airborne challenge quantified infectious doses as low as one influenza virion leading to illness characterized by cough and sore throat. Other studies that challenged via intranasal mucosal exposure observed high doses required for similarly symptomatic respiratory illnesses. Analysis of the Evaluating Modes of Influenza Transmission (EMIT) influenza human-challenge transmission trial—of 52 H3N2 inoculated viral donors and 75 sero-susceptible exposed individuals—quantifies airborne transmission and provides context and insight into methodology related to airborne transmission. Advances in aerosol sampling and epidemiologic studies examining the role of masking, and engineering-based air hygiene strategies provide a foundation for understanding risk and directions for new work.

Water-Repellent TiO2-Organic Dye-Based Air Filters for Efficient Visible-Light-Activated Photochemical Inactivation against Bioaerosols

Recently, bioaerosols, including the 2019 novel coronavirus, pose a serious threat to global public health. Herein, we introduce a visible-light-activated (VLA) antimicrobial air filter functionalized with titanium dioxide (TiO₂)-crystal violet (CV) nanocomposites facilitating abandoned visible light from sunlight or indoor lights. The TiO₂-CV based VLA antimicrobial air filters exhibit a potent inactivation rate of ∼99.98% and filtration efficiency of ∼99.9% against various bioaerosols. Under visible-light, the CV is involved in overall inactivation by inducing reactive oxygen species production both directly (CV itself) and indirectly (in combination with TiO₂). Moreover, the susceptibility of the CV to humidity was significantly improved by forming a hydrophobic molecular layer on the TiO₂ surface, highlighting its potential applicability in real environments such as exhaled or humid air. We believe this work can open a new avenue for designing and realizing practical antimicrobial technology using ubiquitous visible-light energy against the threat of infectious bioaerosols.

Development and Inter-Laboratory Validation of Diagnostics Panel for Detection of Biothreat Bacteria Based on MOL-PCR Assay

Early detection of biohazardous bacteria that can be misused as biological weapons is one of the most important measures to prevent the spread and outbreak of biological warfare. For this reason, many instrument platforms need to be introduced into operation in the field of biological warfare detection. Therefore the purpose of this study is to establish a new detection panel for biothreat bacteria (Bacillus anthracis, Yersinia pestis, Francisella tularensis, and Brucella spp.) and confirm it by collaborative validation by using a multiplex oligonucleotide ligation followed by polymerase chain reaction and hybridization to microspheres by MagPix detection platform (MOL-PCR). Appropriate specific sequences in bacterial DNA were selected and tested to assemble the detection panel, and MOLigo probes (short specific oligonucleotides) were designed to show no cross-reactivity when tested between bacteria and to decrease the background signal measurement on the MagPix platform. During testing, sensitivity was assessed for all target bacteria using serially diluted DNA and was determined to be at least 0.5 ng/µL. For use as a diagnostic kit and easier handling, the storage stability of ligation premixes (MOLigo probe mixes) was tested. This highly multiplex method can be used for rapid screening to prevent outbreaks arising from the use of bacterial strains for bioterrorism, because time of analysis take under 4 h.

Estimating the nationwide transmission risk of measles in US schools and impacts of vaccination and supplemental infection control strategies

BACKGROUND

The spread of airborne infectious diseases such as measles is a critical public health concern. The U.S. was certified measles-free in 2000, but the number of measles cases has increased in recent years breaking the record of the nationwide annual number of cases since 1992. Although the characteristics of schools have made them one of the most vulnerable environments during infection outbreaks, the transmission risk of measles among students is not completely understood. We aimed to evaluate how three factors influence measles transmission in schools: personal (vaccination), social (compartmentalizing), and building systems (ventilation, purification, and filtration).

METHODS

We used a combination of a newly developed multi-zone transient Wells-Riley approach, a nationwide representative School Building Archetype (SBA) model, and a Monte-Carlo simulation to estimate measles risk among U.S. students. We compared our risk results with the range of reported transmission rates of measles in school outbreaks to validate the risk model. We also investigated the effectiveness of vaccination and ten supplemental infection control scenarios for reducing the risk of measles transmission among students.

RESULTS

Our best nationwide estimate of measles transmission risk in U.S. schools were 3.5 and 32% among all (both unvaccinated and immunized) and unvaccinated students, respectively. The results showed the transmission risk of measles among unvaccinated students is > 70 times higher than properly immunized ones. We also demonstrated that the transmission risk of measles in primary schools (assuming teacher self-contained classrooms) is less than secondary schools (assuming departmentalized systems). For building-level interventions, schools with ductless-with-air-filter and ductless-without-air-filter systems have the lowest and highest transmission risks of measles, respectively. Finally, our simulation showed that infection control strategies could cut the average number of infected cases among all students in half when a combination of advanced air filtration, ventilation, and purification was adopted in the modeled schools.

CONCLUSIONS

Our results highlight the primary importance of vaccination for reducing the risk of measles transmission among students. Yet, additional and significant risk reduction can be achieved through compartmentalizing students and enhancing building ventilation and filtration systems.

Modeling of the Transmission of Coronaviruses, Measles Virus, Influenza Virus, Mycobacterium tuberculosis, and Legionella pneumophila in Dental Clinics

Dental health care workers are in close contact to their patients and are therefore at higher risk for contracting airborne infectious diseases. The transmission rates of airborne pathogens from patient to dental health care workers are unknown. With the outbreaks of infectious diseases, such as seasonal influenza, occasional outbreaks of measles and tuberculosis, and the current pandemic of the coronavirus disease COVID-19, it is important to estimate the risks for dental health care workers. Therefore, the transmission probability of these airborne infectious diseases was estimated via mathematical modeling. The transmission probability was modeled for Mycobacterium tuberculosis, Legionella pneumophila, measles virus, influenza virus, and coronaviruses per a modified version of the Wells-Riley equation. This equation incorporated the indoor air quality by using carbon dioxide as a proxy and added the respiratory protection rate from medical face masks and N95 respirators. Scenario-specific analyses, uncertainty analyses, and sensitivity analyses were run to produce probability rates. A high transmission probability was characterized by high patient infectiousness, the absence of respiratory protection, and poor indoor air quality. The highest transmission probabilities were estimated for measles virus (100%), coronaviruses (99.4%), influenza virus (89.4%), and M. tuberculosis (84.0%). The low-risk scenario leads to transmission probabilities of 4.5% for measles virus and 0% for the other pathogens. From the sensitivity analysis, it shows that the transmission probability is strongly driven by indoor air quality, followed by patient infectiousness, and the least by respiratory protection from medical face mask use. Airborne infection transmission of pathogens such as measles virus and coronaviruses is likely to occur in the dental practice. The risk magnitude, however, is highly dependent on specific conditions in each dental clinic. Improved indoor air quality by ventilation, which reduces carbon dioxide, is the most important factor that will either strongly increase or decrease the probability of the transmission of a pathogen.

Ventilation control for airborne transmission of human exhaled bio-aerosols in buildings

The emergence of respiratory diseases, i.e., severe acute respiratory syndrome (SARS) epidemic in 2003, H1N1 influenza epidemic in 2011 and Middle East respiratory syndrome (MERS) outbreak, reiterated the significance of ventilation in buildings. The role of ventilation in removing exhaled airborne bio-aerosols and preventing cross infections has been multidisciplinary extensively studied after the SARS outbreak in 2003. The characteristics of droplet-borne, short-range airborne and long-range airborne transmission of infectious diseases were identified. Increasing ventilation rate can effectively reduce the risk of long-range airborne transmission, while it may be of little useful in preventing the droplet-borne transmission. To maintain the airflow direction from clean cubicles to dirty cubicles is an effective way to prevent the cross infection between cubicles, which is widely used in hospital isolation rooms. Field measurements showed that wrong air flow direction was due to poor construction quality or maintenance. The impacts of different airflow patterns on removing large droplets and fine droplet nuclei were discussed. Some new concepts in general ventilation systems and local personalized equipment were also introduced. This review updates current knowledge of the airborne transmission of pathogens and the improvement of ventilation efficiency concerning the infection prevention.

Comprehensive Laboratory Evaluation of a Highly Specific Lateral Flow Assay for the Presumptive Identification of Bacillus anthracis Spores in Suspicious White Powders and Environmental Samples

We conducted a comprehensive, multiphase laboratory evaluation of the Anthrax BioThreat Alert(®) test strip, a lateral flow immunoassay (LFA) for the rapid detection of Bacillus anthracis spores. The study, conducted at 2 sites, evaluated this assay for the detection of spores from the Ames and Sterne strains of B. anthracis, as well as those from an additional 22 strains. Phylogenetic near neighbors, environmental background organisms, white powders, and environmental samples were also tested. The Anthrax LFA demonstrated a limit of detection of about 10(6) spores/mL (ca. 1.5 × 10(5) spores/assay). In this study, overall sensitivity of the LFA was 99.3%, and the specificity was 98.6%. The results indicated that the specificity, sensitivity, limit of detection, dynamic range, and repeatability of the assay support its use in the field for the purpose of qualitatively evaluating suspicious white powders and environmental samples for the presumptive presence of B. anthracis spores.

Generic aspects of the airborne spread of human pathogens indoors and emerging air decontamination technologies

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Indoor air is an important vehicle for a variety of human pathogens.

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Review of airborne transmission of infectious agents from experimental and field studies, predisposing to establish air-surface-air nexus and possible ways of transmission to susceptible hosts.

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An overview of the methods for experimentally generating and recovering airborne human pathogens and environmental factors affecting their survival in air.

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Current and emerging technologies for decontamination of indoor air for human pathogens.

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Design, establishment, and validation of a room-size aerobiology chamber meeting the U.S. Environmental Protection Agency guidelines (2012) that can be used for assessment of air-decontamination technologies.

Indoor air can be an important vehicle for a variety of human pathogens. This review provides examples of airborne transmission of infectious agents from experimental and field studies and discusses how airborne pathogens can contaminate other parts of the environment to give rise to secondary vehicles leading air-surface-air nexus with possible transmission to susceptible hosts. The following groups of human pathogens are covered because of their known or potential airborne spread: vegetative bacteria (staphylococci and legionellae), fungi (Aspergillus, Penicillium, and Cladosporium spp and Stachybotrys chartarum), enteric viruses (noro- and rotaviruses), respiratory viruses (influenza and coronaviruses), mycobacteria (tuberculous and nontuberculous), and bacterial spore formers (Clostridium difficile and Bacillus anthracis). An overview of methods for experimentally generating and recovering airborne human pathogens is included, along with a discussion of factors that influence microbial survival in indoor air. Available guidelines from the U.S. Environmental Protection Agency and other global regulatory bodies for the study of airborne pathogens are critically reviewed with particular reference to microbial surrogates that are recommended. Recent developments in experimental facilities to contaminate indoor air with microbial aerosols are presented, along with emerging technologies to decontaminate indoor air under field-relevant conditions. Furthermore, the role that air decontamination may play in reducing the contamination of environmental surfaces and its combined impact on interrupting the risk of pathogen spread in both domestic and institutional settings is discussed.

Elimination of bioweapons agents from forensic samples during extraction of human DNA

Collection of DNA for genetic profiling is a powerful means for the identification of individuals responsible for crimes and terrorist acts. Biologic hazards, such as bacteria, endospores, toxins, and viruses, could contaminate sites of terrorist activities and thus could be present in samples collected for profiling. The fate of these hazards during DNA isolation has not been thoroughly examined. Our goals were to determine whether the DNA extraction process used by the Royal Canadian Mounted Police eliminates or neutralizes these agents and if not, to establish methods that render samples safe without compromising the human DNA. Our results show that bacteria, viruses, and toxins were reduced to undetectable levels during DNA extraction, but endospores remained viable. Filtration of samples after DNA isolation eliminated viable spores from the samples but left DNA intact. We also demonstrated that contamination of samples with some bacteria, endospores, and toxins for longer than 1 h compromised the ability to complete genetic profiling.

Quantitative models of the dose-response and time course of inhalational anthrax in humans

Anthrax poses a community health risk due to accidental or intentional aerosol release. Reliable quantitative dose-response analyses are required to estimate the magnitude and timeline of potential consequences and the effect of public health intervention strategies under specific scenarios. Analyses of available data from exposures and infections of humans and non-human primates are often contradictory. We review existing quantitative inhalational anthrax dose-response models in light of criteria we propose for a model to be useful and defensible. To satisfy these criteria, we extend an existing mechanistic competing-risks model to create a novel Exposure–Infection–Symptomatic illness–Death (EISD) model and use experimental non-human primate data and human epidemiological data to optimize parameter values. The best fit to these data leads to estimates of a dose leading to infection in 50% of susceptible humans (ID₅₀) of 11,000 spores (95% confidence interval 7,200–17,000), ID₁₀ of 1,700 (1,100–2,600), and ID₁ of 160 (100–250). These estimates suggest that use of a threshold to human infection of 600 spores (as suggested in the literature) underestimates the infectivity of low doses, while an existing estimate of a 1% infection rate for a single spore overestimates low dose infectivity. We estimate the median time from exposure to onset of symptoms (incubation period) among untreated cases to be 9.9 days (7.7–13.1) for exposure to ID₅₀, 11.8 days (9.5–15.0) for ID₁₀, and 12.1 days (9.9–15.3) for ID₁. Our model is the first to provide incubation period estimates that are independently consistent with data from the largest known human outbreak. This model refines previous estimates of the distribution of early onset cases after a release and provides support for the recommended 60-day course of prophylactic antibiotic treatment for individuals exposed to low doses.

Anthrax poses a potential community health risk due to accidental or intentional aerosol release. We address the need for a transparent and defensible quantitative dose-response model for inhalational anthrax that is useful for risk assessors in estimating the magnitude and timeline of potential public health consequences should a release occur. Our synthesis of relevant data and previous modeling efforts identifies areas of improvement among many commonly cited dose-response models and estimates. To address those deficiencies, we provide a new model that is based on clear, transparent assumptions and published data from human and non-human primate exposures. Our resulting estimates provide important insight into the infectivity to humans of low inhaled doses of anthrax spores and the timeline of infections after an exposure event. These insights are critical to assessment of the impacts of delays in responding to a large scale aerosol release, as well as the recommended course of antibiotic administration to those potentially exposed.

Evaluation of applicability of the Sartorius Airport MD8 sampler for detection of Bacillus endospores in indoor air

This study was designed to evaluate the measuring range and lowest limit of detection of Bacillus endospores in the ambient room air when the Sartorius MD8 sampler, and two different culture methods for bacterial enumeration were used. Different concentrations of bioaerosol were generated inside the test chamber filled with either the high-efficiency particulate air (HEPA)-filtered air or with the ambient room air. The detection of endospores in the HEPA-filtered air was achievable: (1) when they were aerosolized at a concentration above 7.56 × 10(3) CFU/m(3) and analyzed with spread plate method, and (2) when they were aerosolized at a concentration above 4.00 × 10(2) CFU/m(3) and analyzed with pour plate method. The detection of endospores in the ambient room air was possible: (1) when they were aerosolized at a concentration above 9.1 × 10(3) CFU/m(3) and analyzed with spread plate method, and (2) when they were aerosolized at a concentration above 5.6 × 10(2) CFU/m(3) and analyzed with pour plate method. The microorganisms present in the ambient room air interfere with precise quantification of Bacillus endospores when their concentration is relatively low. The results of this study may be helpful in critical assessment of the results obtained from monitoring the air for bacterial endospores.

A rapid and repeatable method to deposit bioaerosols on material surfaces

A simple method for repeatably inoculating surfaces with a precise quantity of aerosolized spores was developed. Laboratory studies were conducted to evaluate the variability of the method within and between experiments, the spatial distribution of spore deposition, the applicability of the method to complex surface types, and the relationship between material surface roughness and spore recoveries. Surface concentrations, as estimated by recoveries from wetted-wipe sampling, were between 5×10(3) and 1.5×10(4)CFUcm(-2) across the entire area (930cm(2)) inoculated. Between-test variability (Cv) in spore recoveries was 40%, 81%, 66%, and 20% for stainless steel, concrete, wood, and drywall, respectively. Within-test variability was lower, and did not exceed 33%, 47%, 52%, and 20% for these materials. The data demonstrate that this method is repeatable, is effective at depositing spores across a target surface area, and can be used to dose complex materials such as concrete, wood, and drywall. In addition, the data demonstrate that surface sampling recoveries vary by material type, and this variability can partially be explained by the material surface roughness index. This deposition method was developed for use in biological agent detection, sampling, and decontamination studies, however, is potentially beneficial to any scientific discipline that investigates surfaces containing aerosol-borne particles.

B. anthracis in a wool-processing factory: seroprevalence and occupational risk

In a Belgian wool-processing factory, living anthrax spores were found in raw goat hair and air dust, but confirmed anthrax cases had never been reported. Anthrax vaccines are not licensed nor recommended in Belgium. We conducted a B. anthracis seroprevalence study to investigate risk factors associated with positive serology and advise on protective measures. Overall 12·1% (8/66) employees were seropositive; 30% of persons processing raw goat hair and 20% of persons sorting raw goat hair were seropositive compared to 3% in less exposed jobs [adjusted prevalence ratio (aPR) 44·4, P=0·001; aPR 14·5, P=0·016, respectively). The number of masks used per day was protective (aPR 0·3, P=0·015). Results suggest a dose-response association for those processing raw goat hair. Host-related factors probably played a role as antibody response varied from person to person within an exposure group. Workers exposed to raw goat hair should be offered higher protection against anthrax and have access to anthrax vaccines.

Comparison of eight methods for the extraction of Bacillus atrophaeus spore DNA from eleven common interferents and a common swab

Eight DNA extraction products or methods (Applied Biosystems PrepFiler Forensic DNA Extraction Kit; Bio-Rad Instagene Only, Bio-Rad Instagene & Spin Column Purification; EpiCentre MasterPure DNA & RNA Kit; FujiFilm QuickGene Mini80; Idaho Technologies 1-2-3 Q-Flow Kit; MoBio UltraClean Microbial DNA Isolation Kit; Sigma Extract-N-Amp Plant and Seed Kit) were adapted to facilitate extraction of DNA under BSL3 containment conditions. DNA was extracted from 12 common interferents or sample types, spiked with spores of Bacillus atropheaus. Resulting extracts were tested by real-time PCR. No one method was the best, in terms of DNA extraction, across all sample types. Statistical analysis indicated that the PrepFiler method was the best method from six dry powders (baking, biological washing, milk, plain flour, filler and talcum) and one solid (Underarm deodorant), the UltraClean method was the best from four liquids (aftershave, cola, nutrient broth, vinegar), and the MasterPure method was the best from the swab sample type. The best overall method, in terms of DNA extraction, across all sample types evaluated was the UltraClean method.

Comparison of air sampling methods for aerosolized spores of B. anthracis Sterne

Bacillus anthracis Sterne spores were aerosolized within a chamber at concentrations ranging from 1 x 10³ to 1.7 x 10⁴ spores per cubic meter of air (particles (p)/m³) to compare three different sampling methods: Andersen samplers, gelatin filters, and polytetrafluoroethylene (PTFE) membrane filters. Three samples of each type were collected during each of 19 chamber runs. Chamber concentration was determined by an aerodynamic particle sizer (APS) for the size range of 1.114-1.596 μm. Runs were categorized (low, medium, and high) based on tertiles of the APS estimated air concentrations. Measured air concentrations and recovery efficiency [ratio of the measured (colony forming units (CFU)/m³) to the APS estimated (particles/m³) air concentrations] for the sampling methods were compared using mixed-effects regression models. Limits of detection for each method were estimated based on estimated recovery efficiencies. Mean APS estimated air concentrations were 1600 particles/m³, 4100 particles/m³, and 9100 particles/m³ at the low, medium, and high tertiles, respectively; coefficient of variation (CV) ranged from 25 to 40%. Statistically significant differences were not observed among the three sampling methods. At the high and medium tertiles, estimated correlations of measured air concentration (CFU/m³) among samples collected from the same run of the same type were high (0.73 to 0.93). Among samples collected from the same run but of different types, correlations were moderate to high (0.45 to 0.85); however, correlations were somewhat lower at the low tertile (-0.31 to 0.75). Estimated mean recovery efficiencies ranged from 0.22 to 0.25 CFU/particle with total CVs of approximately 84 to 97%. Estimated detection limits ranged from 35 to 39 particles/m³. These results will enable investigators to conduct environmental sampling, quantify contamination levels, and conduct risk assessments of B. anthracis.

Modeling the host response to inhalation anthrax

Inhalation anthrax, an often fatal infection, is initiated by endospores of the bacterium Bacillus anthracis, which are introduced into the lung. To better understand the pathogenesis of an inhalation anthrax infection, we propose a two-compartment mathematical model that takes into account the documented early events of such an infection. Anthrax spores, once inhaled, are readily taken up by alveolar phagocytes, which then migrate rather quickly out of the lung and into the thoracic/mediastinal lymph nodes. En route, these spores germinate to become vegetative bacteria. In the lymph nodes, the bacteria kill the host cells and are released into the extracellular environment where they can be disseminated into the blood stream and grow to a very high level, often resulting in the death of the infected person. Using this framework as the basis of our model, we explore the probability of survival of an infected individual. This is dependent on several factors, such as the rate of migration and germination events and treatment with antibiotics.

One-step conversion of to its using salts for GC-MSdetection of bacterial endospores

Methyl sulfate (MeSO4-) salts were explored as thermochemolysis-methylation (TCM) reagents for gas chromatographic (GC) analysis of dipicolinic acid (DPA) as its dimethyl ester (Me2DPA) from bacterial endospores. The reaction was carried out under non-pyrolytic conditions by inserting a small coiled wire filament coated with the sample and reagents directly inside a GC injection port at 290 °C. Above 10 : 1 methyl donor/DPA ratios, alkali metal salts of MeSO4- effected 80-90% conversion of DPA to Me2DPA, which was 10-20 times more active than the same amount of tetramethylammonium hydroxide (TMA-OH) at this temperature. A quaternary salt mixture consisting of 1 : 3 : 1 : 3 TMA+/Na+/OH-/MeSO4- methylated spore DPA with an average conversion of 86% (mean conversion by TMA-OH under the same conditions was 4%). Therefore, the sensitivity for detection of bacterial endospores was increased over 20-fold compared to that observed with the more commonly employed TMA-OH methylating reagent. The limit of detection by this method was 9 × 104 total spores. Mechanisms describing the observed behavior are proposed and discussed. This is the first use of MeSO4- as a TCM reagent for GC.

Potential for airborne transmission of infection in the waiting areas of healthcare premises: stochastic analysis using a Monte Carlo model

Background

Although many infections that are transmissible from person to person are acquired through direct contact between individuals, a minority, notably pulmonary tuberculosis (TB), measles and influenza are known to be spread by the airborne route. Airborne infections pose a particular threat to susceptible individuals whenever they are placed together with the index case in confined spaces. With this in mind, waiting areas of healthcare facilities present a particular challenge, since large numbers of people, some of whom may have underlying conditions which predispose them to infection, congregate in such spaces and can be exposed to an individual who may be shedding potentially pathogenic microorganisms. It is therefore important to understand the risks posed by infectious individuals in waiting areas, so that interventions can be developed to minimise the spread of airborne infections.

Method

A stochastic Monte Carlo model was constructed to analyse the transmission of airborne infection in a hypothetical 132 m³ hospital waiting area in which occupancy levels, waiting times and ventilation rate can all be varied. In the model the Gammaitoni-Nucci equation was utilized to predict probability of susceptible individuals becoming infected. The model was used to assess the risk of transmission of three infectious diseases, TB, influenza and measles. In order to allow for stochasticity a random number generator was applied to the variables in the model and a total of 10000 individual simulations were undertaken. The mean quanta production rates used in the study were 12.7, 100 and 570 per hour for TB, influenza and measles, respectively.

Results

The results of the study revealed the mean probability of acquiring a TB infection during a 30-minute stay in the waiting area to be negligible (i.e. 0.0034), while that for influenza was an order of magnitude higher at 0.0262. By comparison the mean probability of acquiring a measles infection during the same period was 0.1349. If the duration of the stay was increased to 60 minutes then these values increased to 0.0087, 0.0662 and 0.3094, respectively.

Conclusion

Under normal circumstances the risk of acquiring a TB infection during a visit to a hospital waiting area is minimal. Likewise the risks associated with the transmission of influenza, although an order of magnitude greater than those for TB, are relatively small. By comparison, the risks associated with measles are high. While the installation of air disinfection may be beneficial, when seeking to prevent the transmission of airborne viral infection it is important to first minimize waiting times and the number of susceptible individuals present before turning to expensive technological solutions.

Multigeneration cross contamination of mail with Bacillus species spores by tumbling

In 2001, envelopes loaded with Bacillus anthracis spores were mailed to Senators Daschle and Leahy as well as to the New York Post and NBC News buildings. Additional letters may have been mailed to other news agencies because there was confirmed anthrax infection of employees at these locations. These events heightened the awareness of the lack of understanding of the mechanism(s) by which objects contaminated with a biological agent might spread disease. This understanding is crucial for the estimation of the potential for exposure to ensure the appropriate response in the event of future attacks. In this study, equipment to simulate interactions between envelopes and procedures to analyze the spread of spores from a "payload" envelope (i.e., loaded internally with a powdered spore preparation) onto neighboring envelopes were developed. Another process to determine whether an aerosol could be generated by opening contaminated envelopes was developed. Subsequent generations of contaminated envelopes originating from a single payload envelope showed a consistent two-log decrease in the number of spores transferred from one generation to the next. Opening a tertiary contaminated envelope resulted in an aerosol containing 10(3) B. anthracis spores. We developed a procedure for sampling contaminated letters by a nondestructive method aimed at providing information useful for consequence management while preserving the integrity of objects contaminated during the incident and preserving evidence for law enforcement agencies.

Mathematical models for assessing the role of airflow on the risk of airborne infection in hospital wards

Understanding the risk of airborne transmission can provide important information for designing safe healthcare environments with an appropriate level of environmental control for mitigating risks. The most common approach for assessing risk is to use the Wells-Riley equation to relate infectious cases to human and environmental parameters. While it is a simple model that can yield valuable information, the model used as in its original presentation has a number of limitations. This paper reviews recent developments addressing some of the limitations including coupling with epidemic models to evaluate the wider impact of control measures on disease progression, linking with zonal ventilation or computational fluid dynamics simulations to deal with imperfect mixing in real environments and recent work on dose-response modelling to simulate the interaction between pathogens and the host. A stochastic version of the Wells-Riley model is presented that allows consideration of the effects of small populations relevant in healthcare settings and it is demonstrated how this can be linked to a simple zonal ventilation model to simulate the influence of proximity to an infector. The results show how neglecting the stochastic effects present in a real situation could underestimate the risk by 15 per cent or more and that the number and rate of new infections between connected spaces is strongly dependent on the airflow. Results also indicate the potential danger of using fully mixed models for future risk assessments, with quanta values derived from such cases less than half the actual source value.

Recovery efficiency and limit of detection of aerosolized Bacillus anthracis Sterne from environmental surface samples

After the 2001 anthrax incidents, surface sampling techniques for biological agents were found to be inadequately validated, especially at low surface loadings. We aerosolized Bacillus anthracis Sterne spores within a chamber to achieve very low surface loading (ca. 3, 30, and 200 CFU per 100 cm(2)). Steel and carpet coupons seeded in the chamber were sampled with swab (103 cm(2)) or wipe or vacuum (929 cm(2)) surface sampling methods and analyzed at three laboratories. Agar settle plates (60 cm(2)) were the reference for determining recovery efficiency (RE). The minimum estimated surface concentrations to achieve a 95% response rate based on probit regression were 190, 15, and 44 CFU/100 cm(2) for sampling steel surfaces and 40, 9.2, and 28 CFU/100 cm(2) for sampling carpet surfaces with swab, wipe, and vacuum methods, respectively; however, these results should be cautiously interpreted because of high observed variability. Mean REs at the highest surface loading were 5.0%, 18%, and 3.7% on steel and 12%, 23%, and 4.7% on carpet for the swab, wipe, and vacuum methods, respectively. Precision (coefficient of variation) was poor at the lower surface concentrations but improved with increasing surface concentration. The best precision was obtained with wipe samples on carpet, achieving 38% at the highest surface concentration. The wipe sampling method detected B. anthracis at lower estimated surface concentrations and had higher RE and better precision than the other methods. These results may guide investigators to more meaningfully conduct environmental sampling, quantify contamination levels, and conduct risk assessment for humans.

Framework for evaluating anthrax risk in buildings

If Bacillus anthracis (BA), the organism that causes anthrax, is known or suspected to have contaminated a building, a critical decision is what level of contamination is unacceptable. This decision has two components: (1) what is the relationship between the degree of contamination and the risk to occupants, (2) and what is an acceptable risk to occupants? These lead to a further decision: (3) how many samples must be taken to determine whether a building is unacceptably contaminated? We discuss existing data that bear on these questions, and introduce a nomogram that can be used to investigate the relationship between risk of contracting anthrax, the surface concentration of BA, the probability of detection, and the number of samples needed to ensure detection with a given degree of certainty. The same approach could be used for other agents that are dangerous due to resuspension of deposited particles.

Prophylaxis after exposure to Coxiella burnetii

Postexposure prophylaxis may avert Q fever illness and death when the probability of exposure is above the population-specific threshold point.

Coxiella burnetii is a category B bioterrorism agent. We numerically evaluated the risks and benefits from postexposure prophylaxis (PEP) after an intentional release of C. burnetii to the general population, pregnant women, and other high-risk populations. For each group, we constructed a decision tree to estimate illness and deaths averted by use of PEP/100,000 population. We calculated the threshold points at which the number of PEP-related adverse events was equal to the cases averted. PEP was defined as doxycycline (100 mg 2×/day for 5 days), except for pregnant women, where we assumed a PEP of trimethoprim-sulfamethoxazole (160 mg/800 mg 2×/day) for the duration of the pregnancy. PEP would begin 8–12 days postexposure. On the basis of upper-bound probability estimates of PEP-related adverse events for doxycycline, we concluded that the risk for Q fever illness outweighs the risk for antimicrobial drug–related adverse events when the probability of C. burnetii exposure is >7% (pregnant women using trimethoprim-sulfamethoxazole = 16%).

Inactivation of influenza A viruses in the environment and modes of transmission: a critical review

OBJECTIVES

The relative importance of airborne, droplet and contact transmission of influenza A virus and the efficiency of control measures depends among other factors on the inactivation of viruses in different environmental media.

METHODS

We systematically review available information on the environmental inactivation of influenza A viruses and employ information on infectious dose and results from mathematical models to assess transmission modes.

RESULTS

Daily inactivation rate constants differ by several orders of magnitude: on inanimate surfaces and in aerosols daily inactivation rates are in the order of 1-10(2), on hands in the order of 10(3). Influenza virus can survive in aerosols for several hours, on hands for a few minutes. Nasal infectious dose of influenza A is several orders of magnitude larger than airborne infectious dose.

CONCLUSIONS

The airborne route is a potentially important transmission pathway for influenza in indoor environments. The importance of droplet transmission has to be reassessed. Contact transmission can be limited by fast inactivation of influenza virus on hands and is more so than airborne transmission dependent on behavioral parameters. However, the potentially large inocula deposited in the environment through sneezing and the protective effect of nasal mucus on virus survival could make contact transmission a key transmission mode.

Modelling control measures to reduce the impact of pandemic influenza among schoolchildren

We coupled the Wells-Riley equation and the susceptible-exposed-infected-recovery (SEIR) model to quantify the impact of the combination of indoor air-based control measures of enhanced ventilation and respiratory masking in containing pandemic influenza within an elementary school. We integrated indoor environmental factors of a real elementary school and aetiological characteristics of influenza to estimate the age-specific risk of infection (P) and basic reproduction number (R(0)). We combined the enhanced ventilation rates of 0.5, 1, 1.5, and 2/h and respiratory masking with 60%, 70%, 80%, and 95% efficacies, respectively, to predict the reducing level of R0. We also took into account the critical vaccination coverage rate among schoolchildren. Age-specific P and R(0) were estimated respectively to be 0.29 and 16.90; 0.56 and 16.11; 0.59 and 12.88; 0.64 and 16.09; and 0.07 and 2.80 for five age groups 4-6, 7-8, 9-10, 11-12, and 25-45 years, indicating pre-schoolchildren have the highest transmission potential. We conclude that our integrated approach, employing the mechanism of transmission of indoor respiratory infection, population-dynamic transmission model, and the impact of infectious control programmes, is a powerful tool for risk profiling prediction of pandemic influenza among schoolchildren.

Modelling respiratory infection control measure effects

One of the most pressing issues in facing emerging and re-emerging respiratory infections is how to bring them under control with current public health measures. Approaches such as the Wells-Riley equation, competing-risks model, and Von Foerster equation are used to prioritize control-measure efforts. Here we formulate how to integrate those three different types of functional relationship to construct easy-to-use and easy-to-interpret critical-control lines that help determine optimally the intervention strategies for containing airborne infections. We show that a combination of assigned effective public health interventions and enhanced engineering control measures would have a high probability for containing airborne infection. We suggest that integrated analysis to enhance modelling the impact of potential control measures against airborne infections presents an opportunity to assess risks and benefits. We demonstrate the approach with examples of optimal control measures to prioritize respiratory infections of severe acute respiratory syndrome (SARS), influenza, measles, and chickenpox.

Role of ventilation in airborne transmission of infectious agents in the built environment - a multidisciplinary systematic review

There have been few recent studies demonstrating a definitive association between the transmission of airborne infections and the ventilation of buildings. The severe acute respiratory syndrome (SARS) epidemic in 2003 and current concerns about the risk of an avian influenza (H5N1) pandemic, have made a review of this area timely. We searched the major literature databases between 1960 and 2005, and then screened titles and abstracts, and finally selected 40 original studies based on a set of criteria. We established a review panel comprising medical and engineering experts in the fields of microbiology, medicine, epidemiology, indoor air quality, building ventilation, etc. Most panel members had experience with research into the 2003 SARS epidemic. The panel systematically assessed 40 original studies through both individual assessment and a 2-day face-to-face consensus meeting. Ten of 40 studies reviewed were considered to be conclusive with regard to the association between building ventilation and the transmission of airborne infection. There is strong and sufficient evidence to demonstrate the association between ventilation, air movements in buildings and the transmission/spread of infectious diseases such as measles, tuberculosis, chickenpox, influenza, smallpox and SARS. There is insufficient data to specify and quantify the minimum ventilation requirements in hospitals, schools, offices, homes and isolation rooms in relation to spread of infectious diseases via the airborne route. PRACTICAL IMPLICATION: The strong and sufficient evidence of the association between ventilation, the control of airflow direction in buildings, and the transmission and spread of infectious diseases supports the use of negatively pressurized isolation rooms for patients with these diseases in hospitals, in addition to the use of other engineering control methods. However, the lack of sufficient data on the specification and quantification of the minimum ventilation requirements in hospitals, schools and offices in relation to the spread of airborne infectious diseases, suggest the existence of a knowledge gap. Our study reveals a strong need for a multidisciplinary study in investigating disease outbreaks, and the impact of indoor air environments on the spread of airborne infectious diseases.

Predictive models of control strategies involved in containing indoor airborne infections

Recently developed control measure modeling approaches for containing airborne infections, including engineering controls with respiratory protection and public health interventions, are readily amenable to an integrated-scale analysis. Here we show that such models can be derived from an integrated-scale analysis generated from three different types of functional relationship: Wells-Riley mathematical model, competing-risks model, and Von Foerster equation, both of the key epidemiological determinants involved and of the functional connections between them. We examine mathematically the impact of engineering control measures such as enhanced air exchange and air filtration rates with personal masking combined with public health interventions such as vaccination, isolation, and contact tracing in containing the spread of indoor airborne infections including influenza, chickenpox, measles, and severe acute respiratory syndrome (SARS). If enhanced engineering controls could reduce the basic reproductive number (R0) below 1.60 for chickenpox and 3 for measles, our simulations show that in such a prepared response with public health interventions would have a high probability of containing the indoor airborne infections. Combinations of engineering control measures and public health interventions could moderately contain influenza strains with an R0 as high as 4. Our analysis indicates that effective isolation of symptomatic patients with low-efficacy contact tracing is sufficient to control a SARS outbreak. We suggest that a valuable added dimension to public health inventions could be provided by systematically quantifying transmissibility and proportion of asymptomatic infection of indoor airborne infection. Practical Implications We have developed a flexible mathematical model that can help determine the best intervention strategies for containing indoor airborne infections. The approach presented here is scalable and can be extended to include additional control efficacies. If a newly emergent airborne infection should appear, the model could be quickly calibrated to data and intervention options at the early stage of the outbreak. Data could be provided from the field to estimate value of R0, the serial interval between cases, the distributions of the latent, incubation, and infectious periods, case fatality rates, and secondary spread within important mixing groups. The combination of enhanced engineering control measures and assigned effective public health interventions would have a high probability for containing airborne infection.

Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises

The epidemics of severe acute respiratory syndrome (SARS) in 2003 highlighted both short- and long-range transmission routes, i.e. between infected patients and healthcare workers, and between distant locations. With other infections such as tuberculosis, measles and chickenpox, the concept of aerosol transmission is so well accepted that isolation of such patients is the norm. With current concerns about a possible approaching influenza pandemic, the control of transmission via infectious air has become more important. Therefore, the aim of this review is to describe the factors involved in: (1) the generation of an infectious aerosol, (2) the transmission of infectious droplets or droplet nuclei from this aerosol, and (3) the potential for inhalation of such droplets or droplet nuclei by a susceptible host. On this basis, recommendations are made to improve the control of aerosol-transmitted infections in hospitals as well as in the design and construction of future isolation facilities.

Modelling the transmission of airborne infections in enclosed spaces

The Wells-Riley equation for modelling airborne infection in indoor environments is incorporated into an SEIR epidemic model with a short incubation period to simulate the transmission dynamics of airborne infectious diseases in ventilated rooms. The model enables the effect of environmental factors such as the ventilation rate and the room occupancy to be examined, and allows the long-term impact of infection control measures to be assessed. A theoretical parametric study is carried out to demonstrate how changes to both the physical environment and infection control procedures may potentially limit the spread of short-incubation-period airborne infections in indoor environments such as hospitals.

Real-time monitoring of the membrane-binding and insertion properties of the cholesterol-dependent cytolysin anthrolysin O fromBacillus anthracis

Bacillus anthracis has recently been shown to secrete a potently hemolytic/cytolytic protein that has been designated anthrolysin O (ALO). In this work, we initiated a study of this potential anthrax virulence factor in an effort to understand the membrane-binding properties of this protein. Recombinant anthrolysin O (rALO35-512) and two N-terminally truncated versions of ALO (rALO390-512 and rALO403-512) from B. anthracis were overproduced in Escherichia coli and purified to homogeneity. The role of cholesterol in the cytolytic activity of ALO was probed in cellular cholesterol depletion assays using mouse and human macrophage-like lines, and also Drosophila Schneider 2 cells. Challenging the macrophage cells with rALO35-512, but not rALO390-512 or rALO403-512, resulted in cell death by lysis, with this cytolysis being abolished by depletion of the membrane cholesterol. Drosophila cells, which contain ergosterol as their major membrane sterol, were resistant to rALO-mediated cytolysis. In order to determine the molecular mechanism of this resistance, the interaction of rALO with model membranes comprised of POPC alone, or with a variety of structurally similar sterols including ergosterol, was probed using Biacore. Both rALO35-512 and rALO403-512 demonstrated robust binding to model membranes composed of POPC and cholesterol, with amount of protein bound proportional to the cholesterol content. Ergosterol supported greatly reduced binding of both rALO35-512 and rALO403-512, whereas other sterols tested did not support binding. The rALO403-512--membrane interaction demonstrated an equilibrium dissociation constant (KD) in the low nanomolar range, whereas rALO35-512 exhibited complex kinetics likely due to the multiple events involved in pore formation. These results establish the pivotal role of cholesterol in the action of rALO. The biosensor method developed to measure ALO recognition of cholesterol in a membrane environment could be extended to provide a platform for the screening of inhibitors of other membrane-binding proteins and peptides.

A probabilistic transmission dynamic model to assess indoor airborne infection risks

The purpose of this article is to quantify the public health risk associated with inhalation of indoor airborne infection based on a probabilistic transmission dynamic modeling approach. We used the Wells-Riley mathematical model to estimate (1) the CO2 exposure concentrations in indoor environments where cases of inhalation airborne infection occurred based on reported epidemiological data and epidemic curves for influenza and severe acute respiratory syndrome (SARS), (2) the basic reproductive number, R0 (i.e., expected number of secondary cases on the introduction of a single infected individual in a completely susceptible population) and its variability in a shared indoor airspace, and (3) the risk for infection in various scenarios of exposure in a susceptible population for a range of R0. We also employ a standard susceptible-infectious-recovered (SIR) structure to relate Wells-Riley model derived R0 to a transmission parameter to implicate the relationships between indoor carbon dioxide concentration and contact rate. We estimate that a single case of SARS will infect 2.6 secondary cases on average in a population from nosocomial transmission, whereas less than 1 secondary infection was generated per case among school children. We also obtained an estimate of the basic reproductive number for influenza in a commercial airliner: the median value is 10.4. We suggest that improving the building air cleaning rate to lower the critical rebreathed fraction of indoor air can decrease transmission rate. Here, we show that virulence of the organism factors, infectious quantum generation rates (quanta/s by an infected person), and host factors determine the risk for inhalation of indoor airborne infection.