Shmuel C. Shapira, MD and Joshua Shemer
Rami Sagi, MD, Eyal Robenshtok, MD, Lior H. Katz, MD, Shmuel Reznikovich, MMHF, Israel Hendler, MD, Lior Poles, MD, Ariel Hourvitz, MD, Boaz Tadmor, MD, Meir Oren, MD, Giora Martonovich, MD and Boaz Lev, MD
The threat of a disease outbreak resulting from biologic warfare has been of concern for the Israeli health system for many years. In order to be prepared for such an event the health system has formulated doctrines for various biologic agents and defined the logistic elements for the procurement of drugs. During the last 4 years, and especially after the West Nile fever epidemic in 2000, efforts to prepare the healthcare system and the relevant organizations were accelerated. The Director-General of the Ministry of Health nominated a Supreme Steering Committee to fill in the gaps and upgrade the preparedness of the health system for an unusual disease outbreak. This committee and its seven subcommittees established appropriate guidelines, communication routes among different organizations, and training programs for medical personnel. The anthrax outbreak in the United States found the healthcare system in the hub of the preparation process, and all modes of action were intensified. Further work by hospitals, primary care clinics and all other institutes should be initiated to maintain a state of proper preparedness.
Michael Huerta, MD, MPH and Alex Leventhal, MD, MPH
Recent events have drawn world attention to “mythological diseases” such as anthrax, plague and smallpox, which have been out of the spotlight for some decades. Much of our current knowledge of epidemic intervention and disease prevention was acquired over history through our experience with these very diseases, such that the sudden panic over the re-emergence of these historically well-known entities is perplexing. Over time, changes in the balance of the epidemiologic triangle have driven each of these disease systems towards a new equilibrium with which we are not familiar. While the pathogens may be similar, these are not the diseases of the past. These new disease systems are insufficiently described by the classic epidemiologic triangle, which lacks a dimension necessary for providing a valid model of the real-world effects of bioterror-related disease. Interactions within the classic epidemiologic triangle are now refracted through the prism of the global environment, where they are mediated, altered, and often amplified. Bioterror-associated diseases must be analyzed through the epidemiologic pyramid. The added dimension represents the global environment, which plays an integral part in the effects of the overall disease system. The classic triangle still exists, and continues to function at the base of the new model to describe actual agent transmission, but the overall disease picture should be viewed from the height of the fourth apex of the pyramid. The epidemiologic pyramid also serves as a practical model for guiding effective interventional measures.
Manfred S. Green, MD, PhD and Zalman Kaufman, MSc
The appearance of “new” infectious diseases, the reemergence of “old” infectious diseases, and the deliberate introduction of infectious diseases through bioterrorism has highlighted the need for improved and innovative infectious disease surveillance systems. A review of publications reveals that traditional current surveillance systems are generally based on the recognition of a clear increase in diagnosed cases before an outbreak can be identified. For early detection of bioterrorist-initiated outbreaks, the sensitivity and timeliness of the systems need to be improved. Systems based on syndromic surveillance are being developed using technologies such as electronic reporting and the internet. The reporting sources include community physicians, public health laboratories, emergency rooms, intensive care units, district health offices, and hospital admission and discharge systems. The acid test of any system will be the ability to provide analyses and interpretations of the data that will serve the goals of the system. Such analytical methods are still in the early stages of development.
Paul E. Slater, MD, MPH, Emilia Anis, MD, MPH and Alex Leventhal, MD, MPH, MPA
Because of its high case-fatality rate, its very high transmission potential, and the worldwide shortage of effective vaccine, smallpox tops international lists of over a dozen possible bioterror and biologic warfare agents. In a scenario involving aerosol variola virus release, tens to hundreds of first-generation cases would ensue, as would hundreds to thousands of subsequent cases resulting from person-to-person transmission. A smallpox outbreak in Israel must not be regarded as a doomsday event: the methods of smallpox outbreak control are known and will be implemented. The rapidity with which organized outbreak control measures are competently executed will determine how many generations of cases occur before the outbreak is brought under control. Planning, vaccine stockpiling, laboratory expansion, professional training and public education, all carried out well in advance of an epidemic, will minimize the number of casualties. The reinstitution of routine smallpox vaccination in Israel, as in other countries, must be given serious consideration, since it has the potential for eliminating the threat of smallpox as a bioterror agent.
Stephen A. Berger, MD and Itzhak Shapira, MD
Shmuel Kron, MD, MPA and Shlomo Mendlovic, PhD, MD
Yoav Yehezkelli, MD, Tsvika Dushnitsky, MD and Ariel Hourvitz, MD
Ionizing radiation can cause acute as well as chronic and late illnesses, and is a well-known health hazard. Its use by terrorists and nations in the form of a non-conventional weapon is no longer impossible. The release of radioactive materials with the accompanying contamination and radiation has the potential of causing serious medical problems. In analyzing the different radiologic terrorism scenarios, a scheme is proposed for the triage and evacuation of injured, contaminated and non-contaminated casualties from the scene itself as well as from the periphery. Knowledge, plans and drills will lessen the impact of those potential attacks and prepare us to respond to such events.
Eyal Robenshtok, MD, Shay Luria, MD, Zeev Tashma, PhD and Ariel Hourvitz, MD
Atropine is the drug of choice for treatment of organophosphate (OP) nerve agent and insecticide intoxication and has been used for this indication for several decades. Adverse reactions to atropine may occur, and are of two types: toxic and allergic. Toxic reaction, the most common form, results from the anti-muscarinic effects of the drug. Since it is most probably related to interpersonal variation in sensitivity to atropine, toxic effects may appear at the usual therapeutic doses. The second type, allergic reaction, includes local manifestations, usually after the administration of eyedrops, and systemic reaction in the form of anaphylaxis. Since most patients manifest only a mild reaction, allergy testing is not performed and the prevalence of allergy to atropine is therefore not known. Severe allergic reaction to atropine is rare, as evidenced by the small number of case reports in the literature despite the drug's extensive use. Alternative anti-muscarinic drugs recommended for OP poisoning include glycopyrrolate and scopolamine. Glycopyrrolate is a peripheral anti-muscarinic drug that has been studied in comparison to atropine for many clinical indications, while scopolamine is an anti-muscarinic drug with both peripheral and central effects. An acceptable alternative regimen for patients with proven allergy to atropine is a combination of glycopyrrolate with centrally active drugs such as benzodiazepines or scopolamine.
Ronen Rubinshtein, MD, Eyal Robenshtok, MD, Arik Eisenkraft, MD, Aviv Vidan, MD and Ariel Hourvitz, MD
Recent events have significantly increased concern about the use of biologic and chemical weapons by terrorists and other countries. Since weapons of mass destruction could result in a huge number of casualties, optimizing our diagnostic and therapeutic skills may help to minimize the morbidity and mortality. The national demands for training in medical aspects of nuclear, biologic and chemical warfare have increased dramatically. While Israeli medical preparedness for non-conventional warfare has improved substantially in recent years especially due to extensive training programs, a standardized course and course materials were not available until recently. We have developed a core curriculum and teaching materials for a 1 or 2 day modular course, including printed materials.
Jehuda Hiss, MD, Maya Freund, PhD, Uzi Motro, PhD and Tzipi Kahana
Background: The majority (n = 445) of the Israeli and Palestinian fatal victims of the El Aqsa Intifada was examined at the National Center of Forensic Medicine in Tel Aviv. Analysis of the trauma sustained and the anthropologic profile of both the victims and the perpetrators elucidates the trends and contrasts them with the phenomenon in the past.
Objectives: The purpose of the forensic investigation of mass casualty incidents is manifold: establishing the minimal number of individuals involved, identifying the victims and perpetrators, collecting material evidence, and determining the modus operandi.
Methods: The postmortem examination includes external description of the bodies and their injuries, photo-documentation, and sampling of tissues. Radiography, dental examination, and a ten-print card of each cadaver are also recorded.
Results: The modus operandi of the current Intifada is somewhat different from that of the previous wave of terrorism and includes more road shootings and vehicular terrorism. In addition, three suicide bombers using explosive devices detonated within crowded areas were young women, and the age of the perpetrators has increased from up to 35 years to individuals as old as 47, thus greatly enlarging the potential number of suicide terrorists. Virologic and biologic tests have been introduced to examine the tissues of the suicide bombers since they are possible sources of contagion to the wounded victims.
Conclusion: The results of the medico-legal investigation of victims and perpetrators of terrorism enable us to establish the modus operandi and the profile of potential perpetrators, which can help in the prevention of similar attacks. Documentation of the different types of injuries in fatal victims of explosion and shooting contributes to improving the awareness of the medical staff treating the wounded of similar attacks. Further investigation into the reliability of virologic and biologic tests conducted on postmortem tissue is recommended.
Yoav Mintz, MD, Shmuel C. Shapira, MD, MPH, Alon J. Pikarsky, MD, David Goitein, MD, Iryna Gertcenchtein, Eng, Shlomo Mor-Yosef, MD and Avraham I. Rivkind, MD
Background: During a period of 13 months - 1 October 2000 to 31 October 2001 – 586 terror assault casualties were treated in the trauma unit and emergency department of Hadassah University Hospital (Ein Kerem campus); 27% (n = 158) were hospitalized and the rest were discharged within 24 hours.
Objectives: To analyze the special requirements of a large number of victims who received treatment during a short period.
Methods: Data were attained from the main admitting office and the trauma registry records. Analysis was conducted of: age, gender, mechanism of injury, anatomic site of injury, Injury Severity Score (ISS), and length of stay.
Results: Males comprised 81% of the hospitalized patients. The majority of the injuries (70%) were due to gunshot wounds and 31% of the hospitalized patients were severely injured (ISS ≥ 16). Twelve patients died, yielding a mortality rate of 7.5%.
Conclusion: The nature of the injuries was more complex and severe than trauma of other etiologies, as noted by the mean length of stay (10.2 vs. 7.2 days), mean intensive care unit stay (2.8 vs. 0.9 days), and mean operations per patient (0.7 vs. 0.5). The mean insurance cost for each hospitalized terror casualty was also higher than for other trauma etiologies (US$ 3,200 vs. 2,500).
Jacob T. Cohen, MD, Gil Ziv, MD, PhD, Joseph Bloom, MD, Daniel Zikk, MD, Yoram Rapoport, MD and Mordechai Z. Himmelfarb, MD
Background: The ear is the most frequent organ affected during an explosion. Recognition of possible damage to its auditory and vestibular components, and particularly the recovery time of the incurred damage, may help in planning the optimal treatment strategies for the otologic manifestations of blast injury and preventing deleterious consequences.
Objective: To report the results of the oto-vestibular initial evaluation and follow-up of 17 survivors of a suicidal terrorist attack on a municipal bus.
Methods: These 17 patients underwent periodic ear inspections and pure tone audiometry for 6 months. Balance studies, consisting of electronystagmography (ENG) and computerized dynamic posturography (CDP) were performed at the first time possible.
Results: Complaints of earache, aural fullness and tinnitus resolved, whereas dizziness persisted in most of the patients. By the end of the follow-up, 15 (55.6%) of the eardrum perforations had healed spontaneously. Hearing impairment was detected in 33 of the 34 tested ears. Recovery of hearing was complete in 6 ears and partial in another 11. ENG and CDP were performed in 13 patients: 5 had abnormal results on CDP while the ENG was normal in all the patients. The vertigo in seven patients resolved in only one patient who was free of symptoms 1 month after the explosion.
Conclusion: Exposure to a high powered explosion in a confined space may result in severe auditory and vestibular damage. Awareness of these possible ear injuries may prevent many of the deleterious consequences of such injuries.
Gabi Zeilig, MD, Harold Weingarten, MD, Rachel Laufer, BSW, Amichai Brezner, MD and Michal Navon, BSW
Dorith Shaham, MD, Tamar Sella, MD, Arnon Makori, MD, Liat Appelbaum, MD, Avraham I. Rivkind, MD and Jacob Bar Ziv, MD