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.
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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
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CDC public health emergency
preparedness and response page (http://www.bt.cdc.gov/)
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Copyright 2002 American Medical Association. All
rights reserved.
