TERRORISM

Guarding against biological agents

Vigilance is the key. Here are steps you can take right now.

By Dorothy L. Pennachio
Senior Editor

Are you prepared to treat patients in case of a bioterror incident?

Bernd A. Wollschlaeger learned firsthand about bioterrorism preparedness as a physician with the Israel Defense Forces during the Gulf War. Part of his duty was to see that civilians, including doctors, were prepared to cope with the worst possible scenarios.

"We made sure everyone had gas masks and decontamination kits, and that they knew how to use them," he says. "Because people knew how to protect themselves, there was surprisingly little panic during Scud missile attacks."

Wollschlaeger is now a family physician in North Miami Beach, FL, the state where the first anthrax death due to terrorism occurred a year ago. "The anthrax attack triggered a surge of physician interest in bioterrorism," he says. "But we live in an event-driven society." Interest in the medical aspects of weaponizing disease dropped off over the months following the anthrax attacks. Then, the Centers for Disease Control and Prevention last month presented new guidelines for smallpox preparedness.

Patients are concerned, too. Many ask what they should be doing to prepare for the unthinkable. What advice can you give unexposed patients who ask to be vaccinated against smallpox? What if they ask for Cipro or other prophylactic therapy? What about testing? What vaccines are available?

The one thing we've learned for sure since the first case of inhalational anthrax was diagnosed in the offices of a supermarket tabloid in Florida is that we're not adequately prepared, says James Hughes, director of the CDC's National Center for Infectious Diseases. Wollschlaeger, too, says he's concerned that massive panic would occur here if we were to experience anything akin to the 1995 sarin nerve-gas attacks in Japanese subways.

Primary care physicians would be on the front lines in the event of an attack—the first to see patients with vague symptoms that could signal a disease caused by intentional dissemination. Now's the time to ready yourself.

Look for zebras, not horses

"The first step in preparedness is breaking through the denial that we have nothing to worry about," says Rex Archer, director of the Kansas City, MO, Health Department. Take very seriously the anthrax letters of a year ago, even though few victims died.

"Maintain a high degree of suspicion," says Archer. "We can no longer presume everyday conditions. And if something seems amiss, we have to act rapidly." Terrorists can use fast-acting agents as weapons, so that by the time symptomatic patients are diagnosed, it's probably too late to treat them. The time from onset of symptoms to death can be as short as three days for inhalational anthrax, for example.

"Look for things out of season, out of context, out of sequence, out of range—influenza in July, for instance," says Jonathan L. Temte, a family physician and chairman of the Executive Committee for the Wisconsin Influenza Pandemic Plan.

Since knowledge is your best defense, familiarize yourself with symptoms that differentiate bioterror-related disease from common illnesses. If a disease that mimics pneumonia occurs in a previously healthy patient when there's no epidemic, that should make you suspicious. So should unusual clusters of disease or unusual levels of disease-associated morbidity and mortality.

You'll need to be aware of classic symptoms and early warning signs of the six diseases that the CDC has identified as Category A: anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fever. The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) Web site contains information about each of these diseases, as well as some decision support tools—interactive question-and-answer modules to aid in diagnosis. Also learn the clinical aspects of each agent and available diagnostic tests. You'll find links to articles on all the agents at www.hopkins-biodefense.org .

Arm your office staff with knowledge and gear

Every primary care office should develop a detailed disaster plan to deal with the possibility that an infected patient will come into the office. Infection control in the office is the first step. "Patients as well as staff should receive masks," says Rex Archer.

"Every office should have decontamination kits and protective gear," says Bernd Wollschlaeger. "Nothing fancy; just plastic covers, sealable plastic bags, masks, gloves, shoe covers, and bleach. Make sure enough potable water is available. Buy those things now—don't wait until everyone else needs supplies. When things start happening, you have to act—fast."

"An informed office staff is key to a good disaster plan," Archer adds. "Your staff can be among the first to sound the warning." Your appointment scheduler may be first to notice a swell in patient complaints of a particular nature. She should let you know when the phone's ringing off the hook. Give your scheduler a list of the symptoms of the Class A diseases and tell her to alert you to an increased number of patients with those symptoms, especially strange rashes, severe cough, and difficulty breathing.

Post names and phone numbers of local, county, and state public health departments; hospital infection control and pathology agencies; and other preparedness sources in your area, so they'll be handy if they're needed.

For sample disaster plans from several clinics and health systems around the country, you might want to read Bioterrorism Response Protocols for Medical Groups, published by the American Medical Group Association.

Helping to calm the worried well

You must also be prepared to contend with anxiety, panic, paranoia, and other psychological trauma associated with bioterrorism. Even false alarms about it can trigger such reactions. You'll need to help your worried well overcome fears without resorting to unnecessary testing and antibiotic use. Educate them about the risks associated with antibiotic use and development of resistant strains of organisms with inappropriate use.

Stockpiling Cipro "just in case" was a common scenario in the wake of last year's anthrax attack, but even now patients occasionally ask for it or for a smallpox antidote. If you won't provide it, they may turn to the Internet.

"Discourage patients from buying any such agents over the Internet," advises Jonathan Temte, "if for no other reason than that there's no guarantee they'll actually get what they're paying for."

As Wollschlaeger's experience during the Scud missile attacks in Israel showed, the best way to ease patients' anxiety is to arm them with information. Reassure them that you're in regular contact with public health authorities and know what actions to take in the event of an attack.

"Leave patient information materials and handouts about anthrax, smallpox, and general preparedness in the reception room," says Wollschlaeger. "Ask anxious patients if they have enough water on reserve, and tell those who take medication regularly to put aside a week's worth in case they aren't able to reach the pharmacy easily. Tell them to write down pertinent information about their medical history, so that if you're not available another doctor can step in and know what's going on."

It's important for patients to be alert and track their symptoms, says David Perlin, scientific director of the Public Health Research Institute in Newark, NJ. "If, for example, they have a severe respiratory illness, tell them not to wait as they normally might—they should go to the doctor." Now's not the time for self-treatment. If an outbreak occurs, doctors need to see suspected cases and report them to the CDC and public health authorities so a trail can be analyzed.

Historically, physicians and public health authorities haven't had the best rapport. It's time to build good relations. Public health authorities should be able to work through a diagnosis and, if necessary, bring in consultants from the CDC. In many communities, physicians can get on fax and e-mail notification lists for times of crisis. Make sure your public health department has your current contact information.

Smallpox may be the next threat

A suspected case of smallpox should be immediately reported to state and local health officials. Given that smallpox has been virtually eradicated, a single case would constitute an attack and prompt a nationwide program of voluntary vaccinations.

"With anthrax infection, attention was devoted to care of the infected individuals. The treatment plan for smallpox is different," says John Tooker, ACP-ASIM's chief executive officer. The first response after documentation of smallpox is quarantine—not hospitalization—because of the risk of infecting others.

If given within four days of infection, smallpox vaccine can prevent or lessen the severity of the disease. CDC officials announced in late September that up to 75 million doses could be shipped in a single day, and 280 million doses—enough to serve every American—in five to seven days.

In addition, a three-hour smallpox detection test has just been developed for use even on asymptomatic patients.

Some patients may ask to be vaccinated against smallpox or other probable bioterror agents. Most infectious disease experts don't recommend vaccination of the general population before an attack. "Health care workers, Yes," says Perlin, "but not for the general public. Dealing with side effects of vaccination, especially smallpox, could be substantial and costly." If vaccination of the general public is warranted, the CDC will release the vaccine.

Noting the real risks associated with such a massive endeavor, Tennessee Republican Sen. Bill Frist, the only physician in the Senate, recently wrote, "We should allow every American to make an informed choice as to whether to be vaccinated. . . . (but) of every million people who receive the vaccine, two to four people will die from its complications. Five times that number will become seriously ill. And the vaccination cannot be given to the millions of people with suppressed immune systems. . . . "

Still, the CDC's vaccination response plans have changed over several months. As we go to press, the CDC still recommends quarantine of people with smallpox and ring vaccination of people who've had contact with them. Mass vaccination would follow only if the outbreak couldn't be contained. In addition, this summer a government advisory panel recommended giving prophylactic smallpox vaccine to 500,000 health care and law enforcement workers.

Military personnel continue to be vaccinated, but federal health authorities are now storing a third of the available vaccine for use by police, firefighters, and others at high risk of exposure after an attack.

Besides the Category A diseases, what else should you be on the outlook for? Perlin sees staph as a possible biological weapon. "Staph is all over hospitals and easily spread," he says. "Due to antibiotic resistance, we can look only to vancomycin as a treatment. If a terrorist produced a totally resistant strain, staph could easily colonize a large portion of the population." Multidrug-resistant tuberculosis, also a highly contagious airborne infection, is another probable weapon.

The 1918 influenza pandemic killed 20 to 40 million people worldwide. "A pandemic could happen again," says Perlin. "Viruses are good vectors. Any virus against which we're unable to produce a vaccine could wreak havoc on the population."

To learn how health officials in Oklahoma handled a bioterrorism drill, see "A jellybean drill in Oklahoma."

Be on the lookout for . . .

• Rapidly increasing disease incidence in a normally healthy population.

• An epidemic curve that rises and falls over a short time.

• An unusual increase in the number of people seeking care, especially for fever or respiratory, dermatologic, or GI complaints.

• Disease that rapidly emerges at an uncharacteristic time or in an unusual pattern.

• Increased incidence of illness among people who frequently go outdoors compared with those who typically remain indoors.

• Clusters of patients arriving from a single locale.

• Large numbers of rapid fatalities.

Six diseases to learn about

Here are the diseases the CDC has identified as Category A— most likely to be used in a terrorist attack.

anthrax
botulism
plague
smallpox
tularemia
viral hemorrhagic fever

 

Dorothy Pennachio. Terrorism: Guarding against biological agents. Medical Economics 2002;20:47.