Bioterrorism
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This issue of CHP/PCOR's quarterly newsletter covers news and developments from the winter 2004 quarter. It features articles about CHP/PCOR faculty member Mark McClellan's new position as administrator of the federal Centers for Medicare and Medicaid Services; a report by the Stanford-UCSF Evidence-based Practice Center evaluating the regionalization of bioterrorism preparedness and response; the development of a research protocol for a World Health Organization study on the effectiveness of public-private partnerships in health care; a new design for CHP/PCOR's Web site; and a roundup of last quarter's media coverage highlighting the centers' research work.

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Newsletters
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CHP/PCOR
Authors
Sara Selis
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OBJECTIVES: The authors sought to develop a conceptual framework for evaluating whether existing information technologies and decision support systems (IT/DSSs) would assist the key decisions faced by clinicians and public health officials preparing for and responding to bioterrorism.

METHODS: They reviewed reports of natural and bioterrorism related infectious outbreaks, bioterrorism preparedness exercises, and advice from experts to identify the key decisions, tasks, and information needs of clinicians and public health officials during a bioterrorism response. The authors used task decomposition to identify the subtasks and data requirements of IT/DSSs designed to facilitate a bioterrorism response. They used the results of the task decomposition to develop evaluation criteria for IT/DSSs for bioterrorism preparedness. They then applied these evaluation criteria to 341 reports of 217 existing IT/DSSs that could be used to support a bioterrorism response. Main Results: In response to bioterrorism, clinicians must make decisions in 4 critical domains (diagnosis, management, prevention, and reporting to public health), and public health officials must make decisions in 4 other domains (interpretation of bioterrorism surveillance data, outbreak investigation, outbreak control, and communication). The time horizons and utility functions for these decisions differ. From the task decomposition, the authors identified critical subtasks for each of the 8 decisions. For example, interpretation of diagnostic tests is an important subtask of diagnostic decision making that requires an understanding of the tests' sensitivity and specificity. Therefore, an evaluation criterion applied to reports of diagnostic IT/DSSs for bioterrorism asked whether the reports described the systems' sensitivity and specificity. Of the 217 existing IT/DSSs that could be used to respond to bioterrorism, 79 studies evaluated 58 systems for at least 1 performance metric.

CONCLUSIONS: The authors identified 8 key decisions that clinicians and public health officials must make in response to bioterrorism. When applying the evaluation system to 217 currently available IT/DSSs that could potentially support the decisions of clinicians and public health officials, the authors found that the literature provides little information about the accuracy of these systems.

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Medical Decision Making
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Dena M. Bravata
Kathryn M. McDonald
H Szeto
Wendy M Smith
C Rydzak
Douglas K. Owens
Douglas K. Owens
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We evaluated the usefulness of detection systems and diagnostic decision support systems for bioterrorism response. We performed a systematic review by searching relevant databases (e.g., MEDLINE) and Web sites for reports of detection systems and diagnostic decision support systems that could be used during bioterrorism responses. We reviewed over 24,000 citations and identified 55 detection systems and 23 diagnostic decision support systems. Only 35 systems have been evaluated: 4 reported both sensitivity and specificity, 13 were compared to a reference standard, and 31 were evaluated for their timeliness. Most evaluations of detection systems and some evaluations of diagnostic systems for bioterrorism responses are critically deficient. Because false-positive and false-negative rates are unknown for most systems, decision making on the basis of these systems is seriously compromised. We describe a framework for the design of future evaluations of such systems.

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Emerging Infectious Diseases
Authors
Dena M. Bravata
Vandana Sundaram
Kathryn M. McDonald
Wendy M Smith
H Szeto
MD Schleinitz
Douglas K. Owens
Douglas K. Owens
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This compendium of articles provides a clear view of the factors affecting the health of Americans and the role of public health, medical care, and the community in ensuring the nation's health. The Seventh Edition continues the emphasis of earlier editions on the health of the population, the determinants of health, women's health, long term care, and the precarious set of circumstances faced by the nation's public health and health care systems as we begin the 21st century.

New issues, particularly related to bioterrorism and community health are addressed in this edition. This volume also includes coverage of tobacco, immunizations, HIV/AIDS, environmental health, dietary guidelines, physical activity, and food safety. In addition, a major new feature is an article on community problem solving, emphasizing a multidisciplinary approach to collaborative practice and research to improve community health.

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Books
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Boston: Jones and Bartlett Publishers, Seventh Edition
Authors
Philip R. Lee
C Estes
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Drell Lecture Recording: NA

 

Drell Lecture Transcript: NA

 

Speaker's Biography: NA

Kresge Auditorium, Stanford University

Margaret Hamburg Vice President for Biological Programs Nuclear Threat Initiative
Conferences
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STANFORD, Calif.— More than 100 hostages are dead after Russian authorities used an unidentified gas to incapacitate terrorists holding 750 people in a Moscow theater. Nearly all of the deaths were due to the gas, which Russian authorities have so far refused to identify.

Press coverage has rightly emphasized grief and the question of why antidotes were not immediately available. It has then focused on whether the Russians' use of gas was a violation of the 1997 Chemical Weapons Convention. But this focus, while important, risks overlooking the big picture when it comes to Russian chemical weapons.

The Chemical Weapons Convention is a global treaty with more than 170 signatory nations. It bans the production, acquisition, stockpiling, transfer and use of chemical weapons -- the first arms-control treaty to outlaw an entire class of so-called weapons of mass destruction. It also requires its signatories to declare and destroy, by certain deadlines, the chemical weapons they possess.

Since the 1925 Geneva Protocol prohibiting the use of chemical and biological weapons in war -- a reaction to gas attacks in World War I -- the world has struggled to ban these weapons. In part, this is because of their indiscriminate nature.

After Sept. 11, 2001, it seems all the more important to eliminate stocks of such weapons because access to them could confer such power to terrorists. In a world with 70,000 metric tons of chemical weapons agents, some of which may be vulnerable to terrorist theft, the verified elimination of these weapons will be a step toward greater security for all. This is true despite the disturbing fact that Iraq, North Korea and certain other nations are not parties to the convention.

The weapons convention permits the production and use of riot-control agents for law enforcement purposes. Until the Russians inform us of the agent used, whether they were in violation of the convention will remain uncertain. But renewed attention to Russian chemical agents should focus on a more important issue. Russia retains some 40,000 tons of chemical warfare blister agents and nerve gas. It is required by the convention to destroy them, and the United States and European nations have agreed to help. But American efforts under the Nunn-Lugar Cooperative Threat Reduction program are stalled in Congress.

The Cooperative Threat Reduction program began in 1992. It provides expertise and funding to help the former Soviet Union secure and destroy nuclear, chemical and biological weapons and materials. Progress with chemical and biological weapons has been especially slow, and the Russians have too often been less than forthcoming.

Of particular concern has been the Russian stockpile at Shchuch'ye, a town near the southern border with Kazakhstan. The Shchuch'ye stockpile contains nearly two million artillery shells -- and hundreds of missile warheads -- filled with nerve gas or other chemical weapons. Although stockpile security has been upgraded with help from American financing, the threat of insider theft remains real. Many of the shells are in working condition, and they are small and easily transportable.

Cooperative Threat Reduction funds have paid to design a plant for construction at Shchuch'ye to destroy these weapons securely and safely. The Pentagon wants $130 million for construction in the new fiscal year. Russia, its economy still weak, won't do this without American assistance. But the program is currently stalled in a Congressional conference committee due to a disagreement over granting the president authority to proceed with the project.

The Bush administration's new national security strategy has emphasized the destruction of weapons of mass destruction by pre-emptive strikes if necessary. But at Shchuch'ye alone, the United States could destroy more than 5,000 tons of ready-to-use weapons of mass destruction through a different kind of pre-emptive strike -- action by a Congressional committee.  

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Commentary
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New York Times
Authors
Christopher F. Chyba

The Nation's capacity to respond to bioterrorism depends in part on the ability of clinicians and public health officials to detect, manage, and communicate during a bioterrorism event. Information technologies and decision support systems (IT/DSSs) have the potential to aid clinicians (e.g., physicians, nurses, nurse practitioners, and respiratory therapists) and public health officials to respond effectively to a bioterrorist attack.

Submitted by fsid9admin on
This unit contains lectures, originally given at Stanford University by leading scholars , and accompanying lessons strive to educate students about the past, present, and future implications of weapons of mass destruction by introducing them to the history, policies, ideologies, and strategies involved in decision making in this area.
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The anthrax attacks in fall 2001, and the fear and confusion that followed, made it all too clear that the United States lacks a comprehensive strategy for coping with bioterrorism. For too long, thinking about biological weapons has been held hostage to misplaced analogies to nuclear or chemical weapons. An effective strategy must begin by focusing on the special challenges posed by biological threats.

Reprinted in R.D. Howard and R.L. Sawyer, eds., Terrorism and Counterterrorism: Understanding the New Security Environment (Guilford, CT: McGraw-Hill/Dushkin, 2002), pp. 174-184.

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Foreign Affairs
Authors
Christopher F. Chyba
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