By Chris Schneidmiller
Global Security Newswire
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.
By David Francis
Global Security Newswire
WASHINGTON — The United States Postal Service is nearing completion of a four-year project to install systems that can detect anthrax in the mail (see GSN, Sept. 29). By the beginning of December, the Postal Service expects to have installed Biohazard Detection Systems at 282 mail-processing facilities around the country, said Don Crone, USPS manager of mail-processing protection systems. These detection systems are the Postal Service’s front-line defense against an anthrax attack through the mail system. Planning for the anthrax detectors started immediately after the Sept. 11, 2001, terrorist attacks, predating the anthrax attacks that killed five people later that year, Crone said. “From the engineering side, we immediately went out and started looking at technologies, what was available, talking to the experts, and of course we had a lot of people knocking on our doors with all sorts of ideas and things,” Crone said. The result of the push was the Biohazard Detection System. Developed by Postal Service engineers, the U.S. Army Soldier and Biological Chemical Command and Northrop Grumman, a prototype system was installed in Baltimore in June 2002. The Baltimore system “wasn’t a completely automated system like the final version, but had at least assembled most of the technologies and put it into a cabinet,” Crone said. “I’ll call it semiautomatic at the time. But we were trying to prove out the system.” The completed system combined existing technologies in a new way that allowed individual pieces of mail to be tested for anthrax. A hood positioned over the processing system collects air samples from each piece of mail that are taken into an aerosol collector. In the collector is a cartridge that holds the samples. This cartridge is then inserted into a polymerase chain reaction unit that conducts a DNA test to determine if anthrax is present. Crone said, however, that the lag time between collection and testing is not a concern. The Postal Service has developed protocols to keep mail from leaving a facility under anthrax testing is complete. Procedures are also in place to track individual parcels that have left the site. “The idea is to detect it early and contain it in that originating facility so we don’t contaminate other places,” Crone said. Each system costs about $175,000, but installation and site preparation push the cost to $250,000. Once installation of the systems is complete, 282 facilities will be equipped with 1,373 machines at a cost of $375 million, Crone said. The systems have been installed at all large mail-processing facilities around the country. Crone said smaller rural facilities are getting the system as installations come to an end. As of October, 218 facilities have received the system. Once installed, Northrop Grumman is responsible for maintaining the systems, Crone said. The only interaction postal workers have with the system is to replace cartridges that collect samples. The systems are designed so that Northrop employees are notified immediately if there is a problem. “The systems actually put out their own alert, so if something goes wrong with the BDS, the diagnostics will send out a message through our network automatically,” he said. “A field service rep will get a message right on their Blackberry, directly from a machine.” Crone said the system has so far proven to be perfectly reliable. He said 27 billion pieces of mail have been screened without a single false positive. If a system were to detect anthrax, the facility would be evacuated and the Homeland Security Department and the Centers for Disease Control and Prevention would be notified immediately. The sample that tested positive for the pathogen would be retested. If the result were positive, all employees present at the facility or who had contact with the infected batch of mail would be put on a five-day regimen of the anti-anthrax drug Cipro. Crone claimed the Biohazard Detection System is the most advanced system for detecting anthrax transported through the mail in the world. “This is the front line. And it’s pretty much cutting edge. To our knowledge there’s nothing else in the world that matches this,” he said. “The technology all existed, but this is really the only system that we’ve really taken and completely automated, which is what’s unique about this system.” Local postal officials and postal union officials share Crone’s enthusiasm for the system. Workers have been happy with the system, said Sally Davidow, a spokeswoman for the 330,000-member American Postal Workers Union. She said when the machines first arrive at processing facilities, workers generally need time to integrate them into their workplace. After a short time, however, workers become comfortable with the technology, she said. “I think the reaction is generally positive,” she said. “It’s been operating flawlessly,” added Baltimore post office spokesman Bob Novak. He said the system had not slowed down operations and has presented no difficulties to workers. “The good news is that it’s never gone off,” he said.
By Joe Fiorill
Global Security Newswire
WASHINGTON — Hospitals should continue to provide ventilators and intravenous fluids to victims of a biological attack but should suspend many other intensive-care interventions in order to help a larger number of patients, an expert working group on the subject says (see GSN, Oct. 21). In response to what the group calls a lack of guidelines for managing a bioterrorism-related surge in critically ill patients, the researchers say in a new paper that critical care should be initially limited to a small number of broadly useful interventions and may ultimately have to be refused to patients deemed least likely to survive. “There are going to be some very difficult ethical decisions that hospitals, regionally, need to be articulating,” working-group member Jennifer Nuzzo, a public-health analyst at the University of Pittsburgh Medical Center’s Center for Biosecurity, said this week. The Center for Biosecurity and the Society of Critical Care Medicine convened the 33-member working group, which included ex officio members such as smallpox-eradication pioneer D.A. Henderson and representatives of the Centers for Disease Control and Prevention and other federal agencies. The group calls on hospitals and regions to lay out clear emergency plans and criteria for the decisions in consultation with the public and the federal government, in order to facilitate work during an attack and to limit liability repercussions. “More lives could be saved if a circumscribed set of key critical-care interventions were offered to a larger number of patients rather than if maximal critical-care interventions, with all their incumbent human and material resource requirements (i.e., usual U.S. standards of critical care), could only be provided to a smaller number,” the group writes. “Usual critical care-triage processes,” the experts add, “are not intended to prioritize or arbitrate ICU admission decisions for a group of patients who all clearly will require critical-care interventions, as would be the case of large bioterror attacks or in the midst of a serious epidemic.” The group says its recommendations “might double, triple or perhaps even further augment” the critical-care capacity of hospitals that implement them during bioterrorism. “The feedback that we’ve gotten is that this has been a fairly novel paper,” Nuzzo said. “It certainly represents sort of a shift in the way of thinking.” Expert Questions Bioterrorism-Response Planners’ AssumptionsLead author Lewis Rubinson, an intensive-care specialist with the biosecurity center, said practitioners in his field have not had enough input into government and hospital disaster plans. Many planners, Rubinson said yesterday, assume that critical care would be discontinued entirely during bioterrorism or would be provided as normal but only until the usual intensive care beds are filled. “A lot of folks are going to get sick, and this idea of writing all of those people off or of first-come, first-served, in my mind, makes me a little queasy,” Rubinson said. “For the most part,” he said, “it’s still off of most people’s radar screens, as either too difficult or, ‘Why would we want to take care of critically ill patients in the face of a disaster?’” Rubinson said there is a “multitude” of reasons, including an inability to face up to large-scale bioterrorism as a potential reality, behind the planning problem. “Part is clearly the psychology. It’s hard to wrap your hands around it,” he said. At the same time, Rubinson said, “A lot of the people who are responsible for making these decisions do not understand what critical care or what definitive inpatient care is.” While emergency-care specialists have had frequent input into government-organized disaster planning, he said, intensive-care doctors have not — a situation that has led to a failure to address intensive care in many terrorism-response plans. “We all generally feel that we have had very little voice in structuring and controlling this aspect of the response to disasters,” Rubinson said. “We really have not been able to break into the very, very high-level planning on these kinds of things.” Experts Urge Keeping Intensive Care, Offer Decision-Making CriteriaCountering some of the planning assumptions deplored by Rubinson, the working group says in the paper that intensive care “will play an essential role in decreasing morbidity and mortality rates” during bioterrorism and that, as a result, clear, advance plans are needed. Federal assistance — whether in the form of dispatched disaster-response teams or of supplies from the Strategic National Stockpile of countermeasures — should not be counted on for the first few days of an outbreak, so hospitals and regions should begin developing their own plans for managing that early period, the group says. Primarily, say the experts, that means scaling back normal operations in order to help more people. Intensive-care units need clear “criteria to trigger a shift” to the emergency mode, which should be developed with government input to better anticipate the “substantial ethical, political, legal, regulatory and logistic ramifications” that could arise, the group says. New laws may be needed to address liability in such situations, the experts add. Critical-care interventions in hospitals are typically available to all patients who might benefit from them, but staff and supply shortages during bioterrorism could quickly make many disease-specific interventions untenable, the group writes. “At a minimum,” the group says, hospitals should plan to maintain basic ventilators, intravenous fluids, antibiotics and certain measures to prevent health problems that can be contracted in intensive-care units. Even while offering a limited set of interventions, the group continues, intensive-care units may find themselves with “insufficient resources to treat all seriously ill patients,” necessitating tough life-and-death decisions. “The most ethical way to help the greatest number of critically ill people survive in such dire conditions,” the group says, “is to give such interventions first to the people deemed most likely to survive.” “Triage decision-makers … could be forced to withhold essential elements of critical care from the patients categorized as most likely to die,” the experts say, or could “choose to give all patients a trial of essential elements of critical care and to withdraw critical care from those who do not clinically improve after a set period of time.” Nuzzo expressed hope that the recommendations would aid hospitals in saving more patients in the days immediately during a bioterrorist attack. “We felt as though that could make or break a hospital, at least while they’re waiting for outside help,” she said. One reason such plans are not already in place, she added, could be exaggerated expectations on the part of hospitals about the speed and content of federal aid. “I think that’s highly possible,” she said. “There may be a disconnect between local and federal perceptions of just who’s doing what.”
| 
Back to top
