Our continued conversation with Dr. Sid Baccam addresses his basis for determining incubation periods for anthrax and the benefits and challenges of prepositioning antibiotics versus the benefits and challenges of Points of Dispensing (POD) access. If you missed the first part of the interview, click here.

Since there has never been a widespread anthrax attack, what did you use as a basis for determining incubation periods for anthrax? Besides the 2001 attacks, the only other real widespread anthrax event took place in Sverdlovsk, Russia in 1979. At that time, the Russians weren’t forthcoming with information about the event. Later, a team of American researchers went into Russia to investigate. They found out that it was an aerosol release of anthrax spores from a bio-weapons facility. It took a couple of years to get the data on incubation period and mortality rates. But there are many caveats that come with that because it was 12-13 years after the event and it is unclear whether we got all the data. No one is walking into this with blinders on thinking this is perfect data that has been compiled on incubation periods for anthrax.

IEM has used a couple of different sources for determining incubation and casualty estimates. One model was developed by Rickmeier et al. and has been used by the North Atlantic Treaty Organization (NATO) to estimate casualties caused by chemical, biological, radiological, or nuclear (CBRN) weapons. Another model we have used is one being developed and currently under consideration to replace Rickmeier et al. for use by NATO. Finally, we use an incubation model based on what happens inside a person who inhales anthrax spores.

IEM uses all three to model the incubation period. We are not at the point of saying any one of the three is better than the others. We would love to work with the best scientists out there–folks at the CDC and NIH–to dissect the data. We’d like to look at aspects of each of the three competing models to figure out if there’s one of three that is better. Or are there parts from each of the three models that we could use to make our own model?

In the years since the 2001 anthrax attacks there has been much talk about pre-positioning antibiotics for rapid dispensing to the public in the event of an attack. What are the benefits of prepositioning? What are the weaknesses?

One of the projects we’ve done for HHS was to look exactly at that—how do we dispense antibiotics more quickly? We’ve got three competing modalities— postal delivery, prepositioning, and Points of Dispensing (PODs).  One of our studies was to compare all three of them.

There have been three Postal delivery drills to test whether using USPS to deliver antibiotics directly to homes is feasible; we were fortunate enough to observe two of those drills in Philadelphia and Boston.  The thinking is that very few agencies or companies actually interact with the entire public on a daily basis – but Postal carriers do.  I saw first-hand that the Postal carriers could deliver antibiotics to houses and apartment buildings in a very timely manner – typically in less than 8 hours.  One of the large drawbacks to using Postal delivery of antibiotics is the fact that, currently, the plan is to deliver only one 10-day bottle of antibiotics to each household.  A major lesson that I learned was that if you let people do tasks that they are very familiar with, such as Postal carriers delivering mail, they are usually very successful.  Alternatively, if you ask people to do something they have never done before or very rarely do, such as working in PODs, you’re chances of success are not as good.

Prepositioning antibiotics in people’s homes has a lot of advantages because it cuts out all the logistics of distributing and dispensing the antibiotics. If the antibiotics are in homes, all you have to do is get on TV and tell people that they need to take the antibiotics in their kits. We can get people to start taking the antibiotics within hours. Conversely if they didn’t have the antibiotics at home, the Strategic National Stockpile (SNS) would physically have to ship the antibiotics to state and locals; the state and locals would have to activate all their workers, get the PODS set up, etc. You’re looking at probably a minimum of 24 hours before they could open PODs and hand out pills.

However, there are some weaknesses to pre-positioning. If the antibiotics are in people’s houses there’s always the potential for them to be misused. This is the biggest fear that people have, especially physicians. If people start misusing the antibiotics it can have a trickle-down effect and potentially increase the prevalence of antibiotic-resistant bacteria.

The other weakness that we found in our study is cost. If we are going to have medical kits for the public, who’s going to pay for them? Should the public buy them with their money? Would people spend money on something they may not perceive as necessary? And there is always a question of equity. Are we setting up a strategy that puts pressure on those that can’t afford the med kits, putting them at a disadvantage? This sets up the question of whether the government should pay for it, ship it, and cover all the costs. One of the legal issues with the government providing the med kits is that if the government were to provide them, the antibiotics would be considered a prescribed medication. Prescribed medications legally expire in one year, even though we know that the shelf life on these antibiotics is 8-10 years. You can imagine the cost of the federal government replacing antibiotics every one to two years for the entire American public.

The other concern is that terrorists could engineer anthrax so that it’s resistant to the prescribed treatment for anthrax. If you prepositioned antibiotics to the original strain in the homes, it will not be effective against the re-engineered strain and we’d have to depend on another mechanism to get people the antibiotics that might work. And the money spent on prepositioning is now wasted.

You have been studying the efforts related to POD access and have created a modeling and simulation tool for such purposes. When you are considering planning for PODs, how detailed do the simulations analyze the situation?

At the beginning we try to keep it simple and then add layers of complexity. For example, we ask the questions “when can you open PODs and how long does it take to get the antibiotic dispensed?” It starts getting very complex when we get into the logistics of distributing to state and locals. We want to know the logistics and that’s why we model not only the inside of the POD but the outside of the POD. What does it look like when people try to drive there—what is traffic congestion like; what about parking issues? Once you open the PODs, the stream of people coming into them is not uniform. It will come in fits and spurts, creating quite a mess. That’s one of the reasons we decided to look at the inside and outside of the POD to see what challenges people might be overlooking.

Your biomodeling work for HHS was cited in the recent NAS/IOM report entitled “Prepositioning Antiobiotics for Anthrax.” How did you become involved in the IOM report, and what did you do?

The IOM (Institute of Medicine) held a two-day workshop to hear presentations about the potential benefits or disadvantages of prepositioning antimicrobials at home. IOM has been aware of the medical consequence modeling and simulation work that we have done for HHS. In 2008, I was invited to participate in an IOM workshop to discuss different strategies for dispensing medical countermeasures for public health emergencies (Download full Dispensing Medical Countermeasures Workshop summary). Since that workshop, we have modeled the potential benefits of prepositioning medical countermeasures for HHS. So, IOM invited me to participate in their workshop on prepositioning antibiotics for anthrax. I was present on two panels for both days with several other modelers. They asked us about how our modeling was performed and what important aspects of modeling were included or not. We were able to provide them with our published studies as well.

Download full Prepositioning Antibiotics for Anthrax study.

Thank you, Dr. Baccam for your knowledge and insights. We appreciate the thorough work you’ve done to help improve preparedness for events involving Anthrax and Category A bioterrorism agents.

IEM Computational Epidemiologist Dr. Sid Baccam has been working with the Department of Health and Human Services for the past 9 years developing models to analyze response to bioterrorism attacks involving anthrax or other bioterrorism agents. Dr. Baccam has been specifically focused on post-exposure prophylaxis (PEP) dispensing logistics and its impact on medical consequences. The results of his work were recently cited in a National Academy of Sciences (NAS)/Institute of Medicine (IOM) report that analyzed strategies for prepositioning antibiotics to improve response to a terrorist attack involving anthrax.

We sat down with Dr. Baccam to gain a deeper understanding of his work with anthrax and bioterrorism response planning.

What is the nature of the modeling and simulation work that you are doing for HHS?

We’ve been working with HHS since 2003, helping them and answer two basic questions—how many people could possibly become sick or die from different biological attacks and what types of medical intervention strategies can we employ to help mitigate the impacts of biological attacks. We build models and simulations to help senior decision makers better understand how a biological attack may play out depending on different response policies. We combine a lot of information in our models, from infectious doses required to cause infection in people, to how the diseases may progress in the presence or absence of medical interventions, and the speed of the public health response, so we can show decision makers the potential consequences.

It’s very hard for people to conceptualize all the moving parts and to know how different factors affect the outcome – that’s where our models are the most beneficial. We can show decision makers how many people can become infected following an intentional attack with a biological agent. Based on different response strategies and the response speed, we can show them how many of these infected people could be saved by post-exposure prophylaxis (PEP) and how many people may still get sick and require hospitalization. Our modeling results help HHS answer their two main questions by showing how many people could become sick and whether some strategies they are considering may be better than others at preventing disease and saving lives.

Does your modeling focus solely on Anthrax?

CDC has a list of agents called Category A agents. These are the bioterrorism agents of most concern; anthrax is included in the list.  We’ve modeled all of the Category A agents. However the primary focus for HHS is anthrax because we’ve already experienced an attack with that agent being used.

How does your work address response to a bioterrorism attack in a new way?

Part of what we’ve been trying to do is look into the logistics, the concepts of operations for response to a bioterrorism event. It’s easy enough for someone to say an anthrax attack happened and we want to respond in 2 days. (This is an actual objective of the Cities Readiness Initiative (CRI) – having all CRI cities able to complete mass prophylaxis to their entire population within 48 hours.

Some of the modeling we do for HHS is breaking down what happens in the 48 hours after you push that red button and say go—the time when the antibiotics are being dispensed to citizens. We look directly at what things have to happen to reach the 48-hour goal. This involves looking at what the federal government has to do in terms of taking national stockpile assets and shipping them out to the state and local governments. Once the state and locals receive them, the onus is on them to start dispensing that to their population. We try to get into the logistics of this. We look at all the possibilities of “how long might this take?” and “how long might that take?

This is how we got into looking at the Points of Dispensing (POD) question. PODs are centralized locations such as schools or convention centers where the general public is directed to go to in order to pick up medication that can help protect them from becoming ill following a biological attack. When we talk about different modalities that can be used for post-exposure prophylaxis (PEP) dispensing, PODs will always be there. There are pros and cons to this. In 2008, the analogy “Every solution is Swiss cheese” was coined. Every solution covers some of the problem, but the problem is going to have holes. How do we cover those holes with other strategies? If you tried to cobble together multiple solutions, with all the Swiss cheese layers you’ve hopefully covered all the holes and have a complete solution that is effective

We are not aware of any other efforts besides ours that capture this kind of end-to end study. Some of the published papers that talk about dispensing use a start time of the actual opening of the POD and then see how long it takes to dispense the antibiotics. They disregard everything that led up to getting the antibiotic and POD set up. They make simplified assumptions that we don’t. You don’t just open the POD once and then you’re done. There is more that happens. For instance, not everyone will need to continue taking antibiotics. If we can narrow down the attack, we can identify the people that really need to continue taking antibiotics and those that can stop taking the antibiotics. The POD will need to reopen for a second dispensing of antibiotics, also known as follow-on dispensing.

More to come on our continued conversation with Dr. Baccam. Our next interview covers anthrax incubation periods and an analysis of prepositioning and Points of Dispensing (POD) access. Read Part 2 of Anthrax Bioterrorism Modeling interview.

In 1999, only 29 percent of U.S. residents used cell phones. Today, more than 91 percent of the U.S. population use cell phones — a 237% increase! Many people, “cord cutters,” as they’re known in the industry, have kicked their landlines to the curb and have only a cell phone number.  The number of cord cutters will probably increase, given the growing popularity and sales of smart phones that integrate many functions previously available only on computers.

It makes you wonder if landline phones are in the category with dinosaurs – something that roamed (pun intended) the earth eons ago.

What does this mean for telephone surveys, a major component of market research and a big part of IEM’s work in conducting public outreach surveys that help evaluate the public’s awareness and knowledge of emergency warning methods, sources of information during an emergency, and willingness and ability to follow recommended protective actions?

For sure, this phenomenon has impacted phone surveys.  However, a national study of surveys conducted using cell phones found that although conducting surveys with sampled cell phone numbers was feasible, there were lower response rates than in landline surveys, higher refusal rates, and lower refusal conversion rates (convincing respondents who have declined to take the survey to actually take it).

Because cord cutters tend to be younger populations, telephone surveys have experienced a sharp decline in the percentage of younger respondents interviewed.

This has not gone unnoticed by our customers, and, as a result, they have requested that we identify options to landline surveys. While including cell phones in the survey was a requested option, we recommended an internet survey in addition to the landline survey as an alternative to try to capture this younger demographic for the following reasons.

• Currently, telephone surveys use a process called random digit dialing to access telephone numbers where the prefix is attached to a specific geographic location. Cell phone number prefixes may be tied to a geographic location, but there is no guarantee that the person actually lives or works in that area.  To account for that, more cell phone numbers would have to be called to get a similar response rate to the landline telephone survey.  In addition, Federal law prohibits the use of automated dialing devices when calling cell phones; thus each number in the cell phone sample would have to be dialed manually, increasing costs.

• Most surveys are conducted to gather information from and document the experiences of adult respondents.  Since many adolescents and teenagers under the age of 18 have personal cell phones, they would be ineligible to participate in a cell phone survey.

• Research shows that adding a cell phone only portion to a telephone survey only changes the results of the overall survey by +/- 1 percentage point.

In 2012, IEM will conduct a pilot internet public outreach survey, along with the landline telephone survey, for one of our customers. We anticipate this will provide a wider range of respondents and do a better job of reaching younger age demographics. The survey questions will be comparable with previous surveys so we should be able to measure the effect of adding the internet survey to the previous landline phone only survey.

Stay tuned for the results.

Author: Disaster Social Network, IEM

As the rescue operations continue in Turkey and the death toll surpasses 500, a teenage boy used a rock to dig himself out of a collapsed building and was pulled from the rubble 100 hours after the Turkish quake. See dramatic video below, along with additional social media resources filtered from content about the 7.2 Turkey Earthquake that occurred on Sunday, October 23^rd.

News Articles

Turkey Rescuers Look for Survivors at 4 Buildings (10/31/11)
Boy, 13, pulled alive from rubble 100 hours after Turkish quake used a ROCK to dig himself out (10/28/11)
Earthquake Adds Even More Pressure to Relations Between Turks, Kurds (10/27/11)
Turkey earthquake death toll passes 500 (10/27/11)

Video

Social Media Saves Lives in Turkey
Turkey earthquake: Boy rescued after 108 hours under rubble
Turkey quake: Toll rises to 523

As all emergency managers have heard time and time again, communication is the number one issue discussed during after action reports following an exercise or disaster. By utilizing social media technology day to day, survivors are more prone to use this technology to verify a family member location and safety post disaster. In a blog posted by FEMA Administrator, Craig Fugate on September 21, 2011, FCC & FEMA: How to Communicate Before, During & After a Major Disaster, , it was recommended to use text messaging, e-mail, or social media during and after a disaster to make contact with your family and friends so to not tie up voice networks. This is due to the fact that data based services are less likely to experience network congestion allowing your messages to reach the intended party faster.

Social media communications is becoming more popular as more devices are capable of interacting with the various social networks. The questions to be answered are whether social media is capable of being a medium for reliable communications during disasters, whether social media is appropriate for disaster communication information and personal notes from individuals, and can social media communications replace human to human voice contact that provide real-time feedback?

As we’ve seen in the devastating earthquake in Turkey, the answer can be “yes”. Approximately five hours after the earth quake struck Turkey, Erhan Celik, a journalist for Turkey’s Kanal 7 TV station, decided to tweet his followers. He understood that thousands of survivors would be homeless due to the earthquake so he tweeted his followers to see how many would be willing to offer accommodations to quake survivors. Within seven hours, after his initial post, there were 17,000 emails in his inbox offering assistance of some sort. The accommodation emails were sent to the Istanbul governorate. These emails lead to the Istanbul governorate activating a 24 hour hotline to take over Celik’s initiative.

As information gets distributed faster and without vetting, it may be hard to verify that information being posted to social media sites is in fact true or from the true source. IEM’s Disaster Social Network has been filtering social media chatter during the recent Turkey earthquake to provide a useful resources guide geared toward the emergency management community. Future endeavors must determine how social media and emergency management can become partners or work together in disaster management.

Author: IEM’s Disaster Social Network (DSN), IEM

The links below include video of rescue operation of woman pulled from the rubble 3 days after the Turkey earthquake, aerial video of the destruction, and a large photo gallery showing the destruction, rescue efforts, and survivors and continuing coverage of challenges facing survivors.

Video:

Turkey earthquake: Teacher pulled out alive after 3 days
Aerial Video: Turkey earthquake devastation 
Turkey’s Quake Homeless Struggle for Shelter
Turkey earthquake rescue efforts intensify

Photo Gallery: 

Large gallery showing the destruction, rescue efforts, and survivors. http://www.boston.com/bigpicture/2011/10/the_turkey_earthquake.html

News Articles:

“Turkey earthquake death toll rises to 534; thousands remain homeless”

Author: IEM’s Disaster Social Network (DSN), IEM

IEM’s continuing social media resources coverage of the Turkey earthquake for October 25^th includes  new videos of dramatic rescues including a 2 week old baby and a toddler pulled from the rubble.

Twitter:

#deprem (Turkish word for “earthquake”)

Video:

“Dramatic Rescue for Baby After Turkish Quake”
“Toddler rescued from collapsed building after Turkey’s earthquake”
“Aerial Video: Turkey Earthquake Devastation”
“Turkey Quake CCTV”
“Turkey quake raises housing quality questions”
“Anger erupts over Turkey’s quake response”
“Aerial of earthquake-hit Turkey shows full extent of damage”
“Earthquake Van Turkey Turkiye deprem” (video of wedding party at time of earthquake)
“Chaos as Turkey quake aid arrives”

Photo galleries:

http://www.bbc.co.uk/news/world-europe-15442199
http://news.nationalgeographic.com/news/2011/10/pictures/111024-turkey-earthquake-today-world-van/
http://www.monstersandcritics.com/news/europe/features/article_1671063.php/Turkey-Earthquake-Pictures-October-25th

Author: IEM’s Disaster Social Network (DSN), IEM

IEM has continued to monitor the social media traffic around Sunday’s earthquake in southeastern Turkey. We’ve identified additional relevant first-hand accounts of the disaster.

A sweeping social movement is happening right now through Twitter to connect earthquake victims with safe shelter in private homes that were undamaged. Over 17,000 people have responded offering their homes to victims of the quake.  The movement was initially started by a reporter, but is now being facilitated through the government.  (#ÊvimEvindirVan)

Twitter:

#ÊvimEvindirVan (translation: “My home is your home, Van”)

http://twitter.com/#!/search?q=%23%C3%8AvimEvindirVan

This hashtag is being used by individuals to offer their housing to those left homeless after the quake.

An article on the movement: http://www.guardian.co.uk/world/2011/oct/24/turkey-earthquake-twitter-plea-help

Pictures:

http://www.bbc.co.uk/news/world-europe-15429748
http://www.bbc.co.uk/newsround/15429306

http://www.chicagotribune.com/news/sns-photos-earthquake-in-turkey-20111023,0,5769578.photogallery

Video:

http://www.youtube.com/watch?v=9qWUTwerIfY
Rescue footage: http://www.guardian.co.uk/world/2011/oct/24/turkey-earthquake-rescuers-search-survivors?intcmp=239

A 7.2 magnitude earthquake struck at 1:41 p.m. (1041 GMT; 6:41 a.m. EDT), near the city of Van and town of Ercis, Turkey. At least 138 people were killed and 350 injured in Sunday’s quake as buildings pancaked and collapsed into rubble. The area has experienced at least 20 aftershocks that threaten further damage and collapse of buildings.

First-hand accounts of disaster and recovery are provided through the links below. IEM is monitoring social media sites for the most current and relevant information available. These links provide the most up-to-date information.

Twitter Accounts:

http://twitter.com/#!/turkey
http://twitter.com/#!/trtenglishcom (state-run media)
http://twitter.com/#!/huffingtonpost/turkey-earthquake
http://twitter.com/#!/turkishnewsblog

http://twitter.com/#!/TheTurkishLife/turkey-news-events

Trends:

#Turkey #Earthquake
#Turkey
#Ankara
#Van (Van Province, location of earthquake)
#Turkey #Aftershock

Video

RAW first person shot of Eastern Turkey Earthquake- (USGS 7.2M) 6.6 magnitude (first-person video)
Raw: Aftermath of Turkey earthquake (first-person video)
Hundreds feared dead in Turkey quake
Turkey earthquake causes damage, casualties
Earthquake Van Turkey Turkiye deprem 23 10 2011
Earthquake in Turkey 23.11.2011

Photos:

http://uk.reuters.com/article/slideshow?articleId=UKTRE79M11620111023&slide=1#a=1
http://www.greenprophet.com/wp-content/uploads/2011/10/USGS-Eastern-Turkey-Earthquake-510×600.jpg
http://www.examiner.com/images/blog/EXID2858/images/0308-turkey-earthquake-600_full_380.jpg

http://www.topix.com/bigpic/mini-14de82f80a9e6b09b2ec8006fac05689

News Articles:

“Turkey earthquake leaves 138 dead and fears for hundreds more”
“Hundreds dead as quake shakes eastern Turkey”
“Report: Death toll rises to 217 after massive earthquake in Turkey” (includes CNN video)
“Strong earthquake hits Turkey, up to 1,000 feared killed”
“We can hear the screams – 1000 feared dead in Turkey earthquake”
“Up to 1,000 feared dead in Turkey earthquake” (includes two pictures and one video not found elsewhere)
“Turkey Earthquake 2011: 7.2 Quake Near Ercis Causes Death, Damage” (photos at the end of the article)
“Turkey declines Israeli aid offer”

Misc

USGS Turkey Earthquake Aftershock Info (5.1 Aftershock info)

The Disaster Social Network is continuing to monitor social media traffic pertaining to the September18th earthquake centered near Sikkim, India. We’ve identified some additional relevant resources of firsthand accounts, current satellite imagery of resulting landslides, and explanations of seismic activity in the area.

Twitter

http://twitter.com/#!/Kuldipnar – Kuldip Nar is working on recovery efforts in Sikkim
http://twitter.com/#!/search?q=%23sikkim - continuing updates
http://twitter.com/#!/Geoblogfeed – global geological information

A first look at NASA satellite imagery of landslides from the Sikkim earthquake:

http://blogs.agu.org/landslideblog/2011/10/06/a-first-look-at-nasa-satellite-imagery-of-the-landslides-from-the-sikkim-earthquake/?utm_source=twitterfeed&utm_medium=twitter

Few more photos:

http://earthquake-report.com/2011/09/27/the-most-impressive-image-series-of-the-nepal-sikkim-himalaya-earthquake-so-far/

Related Articles:

Himalayan /Sikkim Earthquake Blog: http://cdrn.org.in/blog/index.php/himalayan-earthquake-sikkim-earthquake-north-east-india/
Himalayan / Sikkim Earthquake Situation Report: http://cdrn.org.in/blog/wp-content/uploads/2011/09/Himalayan-Sikkim-Earthquake-Situation-Report-2011CDRN.pdf
“Understanding the 6.9 Sikkim earthquake” http://thewatchers.adorraeli.com/2011/09/20/understanding-the-6-9-sikkim-earthquake/
“Why do India, Himalayan region get so many earthquakes?“ http://www.alaskadispatch.com/article/why-do-india-himalayan-region-get-so-many-earthquakes