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Doctors Consider Their Place in Bioterror Response By Chris Schneidmiller WASHINGTON — Simply by doing their jobs, doctors could be the first to detect a covert act of biological terrorism and could be crucial in the medical response to such an attack (see GSN, Jan. 4). It’s a straightforward idea, but the topic of physicians’ roles following a biological incident and their ability to fill them remains an open question within the medical community. Recent studies have called into question doctors’ ability to correctly recognize diseases identified as major bioterror threats. Meanwhile, an article published in September encourages them to go beyond diagnosing and reporting cases in supporting the investigation of a biological event. Several doctors themselves in interviews questioned whether the threat of bioterrorism is a pressing concern today in the profession. It has been four years since the anthrax mailings that killed five people in the United States. The intervening years have seen few similar acts — notably a ricin-tainted letter sent to U.S. Senate Majority Leader Bill Frist (R-Tenn.) and the poisoning of then-Ukrainian presidential candidate Viktor Yushchenko — and no fatalities. Physicians today are far more worried by diseases such as influenza and measles that constitute an immediate threat rather than attending to a potential danger, said bioterrorism researcher Jonathan Temte. “The amount of interest in bioterrorism has totally waned,” said Temte, an associate professor at the University of Wisconsin Medical School’s Family Medicine Department. “It’s of no interest to anybody.” Temte said he gave a speech on bioterrorism that drew up to 3,000 people on Oct. 6, 2001, just as news was breaking of the first anthrax infection in the attacks. “I’m guessing if you gave a similar talk on bioterrorism today you would have significantly less people in attendance.” There was no bioterror curriculum at this year’s American Academy of Family Physicians Scientific Assembly in San Francisco, Temte said. Johns Hopkins University medical professor Stephen Sisson said he agrees there is a lack of urgency in the medical community — a reflection of disinterest in society on bioterror. However, the inadequate response immediately following Hurricane Katrina illustrated the need for readiness for a disaster, Sisson said. “You’ve got to keep your eyes on the ball. Even if it never happens we should be ready,” he said. Sensors being placed in transit systems, buildings and public areas around the nation cannot be completely counted on to detect a biological incident. A person infected with smallpox would not set off any alarms and could be infectious without showing physical signs of contagion, Sisson said. Another act of biological terror is certain to occur, said John Mitas, chief operating officer and deputy executive vice president of the American College of Physicians. Victims of an attack that initially goes unnoticed or is masked by another event — such as a bombing — might not connect their illness to a biological agent. That means they could visit their family practitioner rather than seeking more specialized help upon becoming ill, Mitas said. “The idea that everybody is going to go to large hospitals may not be true,” he said. It could be up to practicing physicians to detect an intentional outbreak as patients begin arriving at their offices, and then to alert public health authorities and begin treating victims, Sisson said. Sisson led a Johns Hopkins research team that surveyed the ability of 631 U.S. medical residents and faculty to correctly diagnose a disease that could be caused by an act of bioterrorism (see GSN, Sept. 27). The initial results of the online tests were not comforting. On average, 46.8 percent of the doctors in online testing correctly diagnosed smallpox, anthrax, botulism and plague. Given the proper diagnosis, 25.4 percent of the physicians identified the correct disease management strategy. However, after all participants studied information offered on the indicators and initial treatment strategies for each pathogen, correct assessment of the diseases in a second round of testing rose to an average of 79 percent and proper management was at 79.1 percent. A separate study published in the journal Academic Emergency Medicine found that 52 emergency physicians in Washington, D.C., averaged 59 percent correct on a 20-question test on the diagnosis and management of smallpox (see GSN, Oct. 14). Making an absolute diagnosis of a bioterror-related disease is not possible in most clinical settings, said James James, director of the American Medical Association Center for Public Health Preparedness and Disaster Response. That degree of finality must come from a laboratory. However, various diseases allow for varying levels of certainty based on clinical findings and the appearance of the patient, James said. Educational programs and training materials that have become prevalent in recent years have improved the ability of medical professionals to make the correct diagnosis for diseases related to bioterror, James said. “I think we’ve come a long way. We’ve got a long way to go,” he said. The American Medical Association and partnering organizations since 2003 have conducted National Disaster Life Support courses for more than 14,000 physicians and health care workers on supporting the response to terrorist attacks, infectious disease outbreaks and other emergencies. The American College of Physicians covers biological agent topics in its regular e-mail updates and newsletters for members, and at meetings that include discussions and tabletop exercises of a possible incident, Mitas said. The Internet is the best option for delivering information to physicians who are both professionally busy and perhaps disinclined to take time from their practice, doctors said. Web sites for the American Medical Association, American College of Physicians and Centers for Disease Control and Prevention offer extensive reference information on biological agents and preparedness. That way the information is easily accessible for physicians faced with what they believe could be a bioterror-related disease. The Johns Hopkins study showed the benefits of interactive online education, Sisson said. Physicians can study as their schedule allows, and requiring testing increases the comprehension and retention of information beyond what would be expected by just reading the material. The online program used in the study remains in use, Sisson said. He argued, though, that simply having the information available is not sufficient to bring the necessary focus to bioterror. Instead, a “carrot and stick” approach is needed. The carrot would be “a sense of personal satisfaction that you’re doing your part,” Sisson said, while the stick would involve physicians’ professional requirements. The American Board of Internal Medicine could require that doctors seeking their 10-year recertification display knowledge of the signs of exposure to a biological agent, he said. States could also offer courses on bioterror among the further learning physicians must accrue to be licensed every two years, he said. A Doctor’s Job?Doctors’ work when faced with a biological incident is not necessarily limited to a strictly medical response, according to three expert authors of a recent medical article. They can also aid a law enforcement investigation by preserving microbial samples and keeping thorough patient records that could later be used by authorities, says the PLoS Medicine article, by physician-scientist Steven Schutzer of the University of Medicine and Dentistry of New Jersey, FBI scientist Bruce Budowle and Ronald Atlas, co-director of the University of Louisville’s Center for the Deterrence of Biowarfare and Bioterrorism. A biocrime encompasses terrorism, but also attacks of a less ideological nature, such as a Dallas hospital laboratory worker who was charged in 1996 with using dysentery to poison a boyfriend and co-workers. The first order of business when faced with a possible biocrime is to report the finding to public health authorities and law enforcement. States often require that health agencies be notified when certain microbes are found; some call for reporting of specific diseases or “unusual clinical manifestations” — abnormal symptoms or infections that would not normally be seen at a particular time or place — to health or law enforcement authorities, according to the article. Physicians need not wait until the diagnosis is confirmed to begin making calls, Schutzer said. Waiting could delay the response and give a contagion additional time to spread, he said. “Don’t be afraid to call or be wrong,” Schutzer said. Temte said the doctor’s role following a biological attack should be focused on three components — caring for patients, reporting to public health authorities and ensuring that the infection does not spread to additional patients or medical personnel working in the same clinical area. “First and foremost their duty and their charge is to provide the best medical care to the people and families they care for,” he said. Schutzer and his colleagues argue that the additional effort promoted in their article would help patients along with authorities. They liken it to the medical collection of physical evidence from victims of sexual assault. “Physicians can ultimately serve their patients by acting, in the traditional role, as a healer,” the article states, “and by working with public health and law enforcement entities to help prevent further attacks and to bring justice. As with sexual assaults, identification and conviction of the attacker can bring closure and provide a degree of security to the patient.” The article encourages doctors who suspect a biocrime to “obtain samples that may serve as evidence early, frequently, and under a defined chain-of-custody process.” Human tissue or secretion samples and cultures taken from the throat, blood, sputum or skin lesions of a patient could be preserved for microbiological examination, Schutzer said. Bacteria and viruses could be preserved for collection by health officials. Such evidence could aid authorities as they seek the origin of the pathogen and those who put it into use. Preservation of samples from victims of the anthrax attacks allowed investigators to identify the strain being used and to theorize that it came from a laboratory rather than from nature, according to the PloS article. The case, however, remains unsolved. Maintaining thorough medical records on the patient is also important, as they could help determine the timeline for the incubation of the infection. Even a victim’s personal belongings may carry useful forensic evidence, the article states. Medical examiners and coroners should also be considered potential sentinels for an act of bioterrorism. They have authority to investigate “sudden, suspicious, violent and unattended” deaths, and might be the first medical professional to examine a biocrime victim, the article states. Schutzer said that the question of preserving evidence for a biocrime investigation has not been previously addressed in the medical community. While there are instructional courses, kits and well-trained medical personnel to aid collection of evidence in sexual assault cases, such support systems are largely absent relative to biological agents, the article states. The article’s authors hope their work can begin the discussion. There is hope for such an effort, according to doctors interviewed for this article. “I don’t think physicians’ compliance is ever going to be a problem in this arena. I think that they’re going to want to be a part of the positive response and not an obstruction to it,” said the American Medical Association’s James.
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