Anthrax a year later: Biothreat wariness now an exam room reality

Physicians are keeping their eyes open to the possibility of bioterrorism while continuing to treat routine cases.

By Susan J. Landers, AMNews staff. Oct. 7, 2002. Additional information

Washington -- Just over a year ago, a Centers for Disease Control and Prevention public health message confirmed the diagnosis of anthrax in a 63-year-old Florida man.

With this, the reality of bioterrorism began to emerge. Until then, the use of biological weapons to cause illness and death among civilian populations was more the subject of novels than the practice of medicine. But suddenly, physicians found themselves playing a key role in public safety, as well as public health.

"The learning curve a few weeks after the anthrax outbreak was straight up, not only for the profession but also for the public," said AMA Trustee Timothy Flaherty, MD, who is a member of Health and Human Services Secretary Tommy Thompson's Council on Public Health Preparedness.

Twelve months later, the response is evident. National smallpox vaccination guidelines have been developed. Communication between physicians and public health departments has been improved. And doctors across the country have stepped up their knowledge of biological weapons and report an awareness that things are not always as simple as they seem.

"When we see rashes, we look a little more closely to make sure they are not consistent with smallpox," said internist Frances Durocher, MD, of Fairfax, Va., a Washington, D.C. suburb.

But they also maintain their perspective. "If someone comes in with a fever, cough and chest pain, you're not going to think first of anthrax," said Alan Pocinki, MD, a Washington internist whose office is six blocks from the White House. A number of other more plausible diagnoses would be appropriate, he noted.

On the other hand, there aren't many diseases that cause fever and rash. "It's a fairly short list," said Dr. Pocinki. "Nowadays you may think about some less common things, maybe not smallpox, but West Nile virus can do it."

Physicians have long been accustomed to reporting certain infectious diseases to their health departments, and recent educational efforts have increased their watchfulness.

"We're always on the lookout for some unusual flurry of something," Dr. Pocinki said. "If a whole bunch of people come in with some peculiar thing, we're going to say, 'Hey, what's going on here?' "

But Dr. Pocinki and Dr. Durocher practice in an area that was targeted by terrorists and where letters containing anthrax were processed in local mail facilities. What about a physician far removed from a target zone?

Before the events of last fall, bioterrorism was something that Todd Williams, MD, a family physician in Georgetown, Ohio, never considered. "Now it's taken a place in the back of my mind, and I'm afraid it's there to stay," he said.

"I assumed I'd spend my whole career never even suspecting, let alone diagnosing, smallpox, anthrax, botulism or mustard gas," Dr. Williams said. He has now learned a good deal about all of them.

Dr. Williams consulted his medical school texts for information on diseases cited as possible weapons of bioterror but found very little information. Those diseases were thought to have been removed from medical concern many years ago and did not even rate much space in textbooks of the 1990s when Dr. Williams was a student. "We had to get older texts."

Bioterror 101

Physicians also took advantage of the rapidly available information on Web sites or via briefings to learn the basics, according to the many medical specialty groups that monitored Web site hits and presented sessions at annual conferences. The necessary information to diagnose a smallpox rash was quickly posted on the Internet, as were tips on diagnosing such rarely seen illnesses as cutaneous anthrax.

For some experts, the sea change in interest was striking. An hour-long seminar on bioterrorism presented last November by Jonathan Temte, MD, PhD, a family physician and associate professor at the University of Wisconsin in Madison, was packed, he said. In contrast, he was told, "That's interesting but not very useful," following a similar seminar held the year before.

Physicians' awareness of the possibility of a bioterrorist attack has certainly been raised, said Scott Lillibridge, MD, director of the University of Texas School of Public Health's Center for Biosecurity in Houston. "I think physicians are a little more suspicious when patients present with unusual illnesses or atypical presentations of a common illness," he said.

"Many physicians have availed themselves of educational clinical awareness programs," said Dr. Lillibridge, who led the CDC's bioterrorism preparedness and response program for three years.

Physicians are also participating in local preparedness efforts, Dr. Lillibridge said, and are being called upon by the media as experts on bioterrorism concerns. Dr. Lillibridge has been on television, radio and in the newspapers, he noted, and recently he wrote an article for the Houston Chronicle on health preparedness since Sept. 11, 2001.

The pipeline

Not only do physicians have the information they need to recognize a possible threat, but the majority know what to do if they see a possible threat, said CDC Director Julie Gerberding, MD, MPH. Doctors are now much more likely to report their suspicions to local or state public health agencies, which are then forwarding those concerns to the CDC, she explained during a Sept. 19 briefing.

"We have received lots of false alarms involving fevers and sore throats," she said. "We love these false alarms; they help us exercise the system."

The alarms have been sounded from all parts of the country and from large urban health departments and small rural departments. "If there is a first case of smallpox, we are likely to know it in short order," she added.

The surveillance system is working in real time, agreed AMA Trustee Nancy Neilsen, MD, PhD. Dr. Neilsen, an internist from Buffalo, N.Y., said she had received an e-mail alert the night before from her local public health department warning physicians about an outbreak of salmonella in her practice area.

There has been a tremendous investment in the nation's public health system that began in 1999 but increased significantly after the 2001 attacks, Dr. Gerberding said.

"But there are still gaps," she said. "We must encompass every American, and we must be sure that the system can reach all first responders." She noted that, while an astute physician detected the first case of inhalation anthrax in Florida, the New York cutaneous anthrax cases were initially missed.

John Brennan, MD, an emergency physician at Saint Barnabas Medical Center in Livingston, N.J., agrees that there are gaps in the system. "The whole surveillance process is nowhere near where it needs to be," he said.

"If a couple of [potentially dangerous] episodes show up in this hospital or the hospital down the road, there is no good way to take that information and make cumulative data that are useful to us," he said.

ADDITIONAL INFORMATION:

The hit list

There is a wide array of illnesses that could be used as bioterrorist agents. The AMA Office of Disaster Preparedness and Physician Response has compiled a quick reference guide available online (http://www.ama-assn.org/go/disasterpreparedness) or by calling (312) 464-4026. The guide focuses on the following diseases:

Bacterial agents

Anthrax (cutaneous, gastrointestinal and inhalational)
Brucellosis
Inhalational (pneumonic) tularemia
Pneumonic plague
Q fever

Viral agents

Smallpox
Viral encephalitis
Viral hemorrhagic fevers

Biological toxins

Botulinum toxin
Staphylococcal enterotoxin B
Ricin
T-2 mycotoxins

Weblink

CDC public health emergency preparedness and response page (http://www.bt.cdc.gov/)

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