CNN: https://www.cnn.com/2019/11/26/europe/albania-earthquake-tirana-intl-hnk/index.html

https://www.youtube.com/watch?v=xE1V6-e1oAE

Citation: Bailey HM, Zuo Y, Li F, Min J, Vaddiparti K, Prosperi M, et al. (2019) Changes in patterns of mortality rates and years of life lost due to firearms in the United States, 1999 to 2016: A joinpoint analysis. PLoS ONE 14(11): e0225223. https://doi.org/10.1371/journal.pone.0225223

Data Availability: The data can be downloaded from https://www.cdc.gov/injury/wisqars/fatal.html.

“……Conclusion:

Between 1999 and 2016, the national rates of firearm mortality and YPLL indicating a shift in the burden of mortality towards younger individuals. While an increase in mortality was noted starting in 2014, the change towards an increase was set much earlier in different subgroups and states. Additional studies to examine county-specific patterns and the factors that explain the differences in trajectories is needed. Future interventions, programs, and policies should be created to address this shifting burden locally and should bear in mind the populations that are being most affected by shifts in firearm death……”

NYT

“A ship carrying almost 15,000 sheep overturned on Sunday in the Black Sea near Romania, according to news reports, setting off a desperate effort to rescue the animals and renewing a focus on the livestock shipping industry, which has been previously criticized for its treatment of animals.

It was not immediately clear what caused the ship, the Queen Hind, to overturn near the port city of Constanta shortly after it departed for Saudi Arabia.

The ship’s crew — 20 people from Syria and one from Lebanon — were all rescued…….

The fate of the sheep was less certain……..”

https://www.youtube.com/watch?v=bLHRKS3xOBE

https://chemm.nlm.nih.gov/nerveagents/FGAMMGPrehospital.htm

Pre-Hospital Treatment Recommendations (Autoinjector-Based) Nerve Agent Poisoning

Autoinjector Products:

DuoDote = ATNAA = Mark 1 kit = Atropine 2 mg + 2-PAM 600 mg AI

Atropine AI = various doses, two different manufacturers*

2-PAM AI = 2-PAM 600 mg AI

CANA = Diazepam 10 mg AI

* Please see the following webpage for more information on FDA approved atropine AI products and current nerve agent emergency use authorization information: https://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm063809.htm

https://chemm.nlm.nih.gov/nerveagents/FGAMMGHospital.htm

Hospital Treatment Recommendations (Weight-Based) Nerve Agent Poisoning

Product Definitions:

DuoDote = ATNAA = Mark 1 kit = Atropine 2 mg + 2-PAM 600 mg AI

AtroPen = Atropine AI, various doses

2-PAM AI = 600 mg 2-PAM

Fourth Generation Agents: https://chemm.nlm.nih.gov/nerveagents/FGA.htm

(Information as of January 18, 2019)

After the incidents in the United Kingdom (U.K.) in 2018 involving a fourth generation agent, the White House National Security Council convened a federal interagency working group to identify and develop resources to help the emergency response community prepare for and respond to a fourth generation agent incident if one ever occurs in the U.S., as well as support the development of specific guidance and training to enhance overall preparedness efforts. These resources meet the needs of U.S. emergency response professionals who sought to learn more about the agent used in the U.K. and how to protect themselves and respond if such incidents ever occur in their communities.

Fourth generation agents, also known as Novichoks or A-series nerve agents, belong to a category of chemical warfare agents that are unique organophosphorus compounds. They are more persistent than other nerve agents and are at least as toxic as VX. While fourth generation agents share similar characteristics with other nerve agents, fourth generation agents also pose several unique challenges in terms of toxicity, detection, persistence, and potential for delayed onset of symptoms. The following resources were developed to address these characteristics and challenges and provide tailored guidance to various segments of the emergency response community.

• Safety Awareness for First On-Scene Responders Bulletin – Designed to educate and prepare first responders for situations when law enforcement, fire, and emergency medical services (EMS) personnel are first to arrive on scene and initially may be unaware that a fourth generation agent is present. This bulletin will assist departments and agencies develop specific guidance and training to enhance overall preparedness efforts. (PDF – 791 KB)

• Reference Guide – Designed to educate and prepare hazardous materials (HAZMAT) response teams, the guide includes chemical and physical properties of fourth generation agents, as well as detection, firefighting, personal protective equipment, and decontamination recommendations for situations when responding to a known or suspected fourth generation agent incident. This guide will assist HAZMAT response teams develop specific guidance and training to enhance overall preparedness efforts. (PDF – 789 KB)

• Medical Management Guidelines – Designed to educate and prepare fire, EMS, and hospital staff and guide the medical management of patients exposed or potentially exposed to a fourth generation agent. (PDF – 858 KB) (Note: This is one PDF document that is divided into two Web pages, one for pre-hospital care and one for in-hospital care.)
  • Pre-hospital Medical Management Guidelines
  • Hospital Medical Management Guidelines

These resources were developed by a federal interagency working group comprising experts in medicine, science, public health, law enforcement, fire, EMS, HAZMAT, and occupational safety and health from the Department of Defense, Department of Health and Human Services (Office of the Assistant Secretary for Preparedness and Response, Centers for Disease Control and Prevention, and National Institute for Occupational Safety and Health), Department of Transportation (Pipeline and Hazardous Materials Safety Administration and National Highway Traffic Safety Administration’s Office of Emergency Medical Services), Department of Homeland Security, Federal Bureau of Investigation, Occupational Safety and Health Administration, and Environmental Protection Agency.

These resources are based on the interpretation of available data on fourth generation agents by U.S. government experts and previously developed federal guidance related to nerve agents. Moreover, the guidance was developed through a collaborative process which included extensive stakeholder review in the form of listening sessions and consultations with representatives from the various disciplines across the emergency response community.

Information as of January 18, 2019, was used to inform the development of these resources. They will be updated as new data becomes available that can further support any response to a potential fourth generation agent incident and help protect responders if such an incident ever occurs in the U.S.

Please refer comments and questions on these fourth generation agent resources to askasprtracie@hhs.gov.

Secret Service

“……Some of the key findings from this study, and their implications for informing school violence prevention efforts, include:
• There is no profile of a student attacker, nor is there a profile for the type of school that has been targeted:   Attackers varied in age, gender, race, grade level, academic performance, and social characteristics. Similarly,   there was no identified profile of the type of school impacted by targeted violence, as schools varied in size,   location, and student-teacher ratios. Rather than focusing on a set of traits or characteristics, a threat assessment     process should focus on gathering relevant information about a student’s behaviors, situational factors, and   circumstances to assess the risk of violence or other harmful outcomes.
•  Attackers usually had multiple motives, the most common involving a grievance with classmates: In addition to   grievances with classmates, attackers were also motivated by grievances involving school staff, romantic       relationships, or other personal issues. Other motives included a desire to kill, suicide, and seeking fame or   notoriety. Discovering a student’s motive for engaging in concerning behavior is critical to assessing the   student’s risk of engaging in violence and identifying appropriate interventions to change behavior and   manage risk.
•  Most attackers used firearms, and firearms were most often acquired from the home: Many of the attackers      were able to access firearms from the home of their parents or another close relative. While many of the firearms      were unsecured, in several cases the attackers were able to gain access to firearms that were secured in a locked   gun safe or case. It should be further noted, however, that some attackers used knives instead of firearms to      perpetrate their attacks. Therefore, a threat assessment should explore if a student has access to any weapons,      with a particular focus on weapons access at home. Schools, parents, and law enforcement must work together      rapidly to restrict access to weapons in those cases when students pose a risk of harm to themselves or others.
•  Most attackers had experienced psychological, behavioral, or developmental symptoms: The observable mental      health symptoms displayed by attackers prior to their attacks were divided into three main categories:   psychological (e.g., depressive symptoms or suicidal ideation), behavioral (e.g., defiance/misconduct or symptoms      of ADHD/ADD), and neurological/developmental (e.g., developmental delays or cognitive deficits). The fact that half of the attackers had received one or more mental health services prior to their attack indicates that mental health   evaluations and treatments should be considered a component of a multidisciplinary threat assessment, but not   a replacement. Mental health professionals should be included in a collaborative threat assessment process that      also involves teachers, administrators, and law enforcement.
•  Half of the attackers had interests in violent topics: Violent interests, without an appropriate explanation, are   concerning, which means schools should not hesitate to initiate further information gathering, assessment, and      management of the student’s behavior. For example, a student who is preoccupied or fixated on topics like the      Columbine shooting or Hitler, as was noted in the backgrounds of several of the attackers in this study, may be the      focus of a school threat assessment to determine how such an interest originated and if the interest is negatively      impacting the student’s thinking and behavior.

•   All attackers experienced social stressors involving their relationships with peers and/or romantic partners:      Attackers experienced stressors in various areas of their lives, with nearly all experiencing at least one in the six   months prior to their attack, and half within two days of the attack. In addition to social stressors, other stressors      experienced by many of the attackers were related to families and conflicts in the home, academic or disciplinary      actions, or other personal issues. All school personnel should be trained to recognize signs of a student in crisis.   Additional training should focus on crisis intervention, teaching students skills to manage emotions and resolve      conflicts, and suicide prevention.
•  Nearly every attacker experienced negative home life factors: The negative home life factors experienced by      the attackers included parental divorce or separation, drug use or criminal charges among family members, or      domestic abuse. While none of the factors included here should be viewed as predictors that a student will be   violent, past research has identified an association between many of these types of factors and a range of negative     outcomes for children.
•  Most attackers were victims of bullying, which was often observed by others: Most of the attackers were   bullied by their classmates, and for over half of the attackers the bullying appeared to be of a persistent pattern   which lasted for weeks, months, or years. It is critical that schools implement comprehensive programs designed to     promote safe and positive school climates, where students feel empowered to report bullying when they witness it      or are victims of it, and where school officials and other authorities act to intervene.
• Most attackers had a history of school disciplinary actions, and many had prior contact with law enforcement:     Most attackers had a history of receiving school disciplinary actions resulting from a broad range of   inappropriate behavior. The most serious of those actions included the attacker being suspended, expelled, or      having law enforcement interactions as a result of their behavior at school. An important point for school staff      to consider is that punitive measures are not preventative. If a student elicits concern or poses a risk of harm      to self or others, removing the student from the school may not always be the safest option. To help in making      the determination regarding appropriate discipline, schools should employ disciplinary practices that ensure      fairness, transparency with the student and family, and appropriate follow-up.
• All attackers exhibited concerning behaviors. Most elicited concern from others, and most communicated their      intent to attack: The behaviors that elicited concern ranged from a constellation of lower-level concerns to   objectively concerning or prohibited behaviors. Most of the attackers communicated a prior threat to their target or      communicated their intentions to carry out an attack. In many cases, someone observed a threatening   communication or behavior but did not act, either out of fear, not believing the attacker, misjudging the immediacy or     location, or believing they had dissuaded the attacker. Students, school personnel, and family members should be      encouraged to report troubling or concerning behaviors to ensure that those in positions of authority can intervene.….”

Pan American Health Organization / World Health Organization. Epidemiological Update:
Malaria in the Americas. 18 November 2019, Washington, D.C.: PAHO/WHO; 2019

“Between 2005 and 2014, there was an overall decreasing trend in the number of cases of malaria in the Region of the Americas; however, since 2015, there has been an increase in the number of malaria cases reported in the Region. This overall increase is due to the increase in cases over the last three years in the Bolivarian Republic of Venezuela along with increased transmission in endemic areas of countries such as Brazil, Colombia, Guyana, Nicaragua, and Panama, as well as outbreaks in countries that were moving towards elimination (Costa Rica, the Dominican Republic, and Ecuador)…..”