Course Authors
Martin Carey, M.D.
Dr. Carey reports no conflict of interest.
Estimated course time: 1 hour(s).
Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Upon completion of this Cyberounds®, you should be able to:
List the processes needed to adequately start to address a potential bioterroristic threat
Determine whom to contact in an emergency involving biological weapons
Discuss the importance of regular review of your institution's disaster plan and your role within it.
In this second Cyberounds® on bioterrorism, the discussion will center on process issues. What would YOU do if you were confronted by a potential bioterrorism incident? To paraphrase a famous movie quote: 'Who Ya going to call?'
Although questions will be asked, there are, unlike our previous Cyberounds® Emergency Medicine conferences, few 'correct' answers! Questions will be used more to trigger ideas and introduce areas which individual health care providers, whether in the United States or elsewhere, may find useful in developing a plan to address the issue of biological terrorism.
Q. What might tip off an emergency medicine physician that a biological weapon attack had occurred?
A. A number of events might alert an emergency physician or other health care worker that an attack had occurred. The sudden appearance of an unexplained illness in a number of persons, especially if these persons are young and otherwise usually healthy, should be considered a 'red flag'. If these people were all recently at a single event or had been to a single place in common should also be a warning. The presence of clusters of cases of an unusual organism or of an unexpected pattern of drug resistance should also be a warning. It is likely that a biological weapon will be administered as an aerosol; thus, a number of unexplained respiratory complaints should also raise concern.
Sometimes, information may come even before the appearance of the first victim, with tips from law enforcement or other government or state organizations. The presence of large numbers of sick or dying animals or plants may also raise concern about either a chemical or biological attack. As has been noted many times, vigilance and thinking about the possibility are very important.
Q. In general terms, what is the state of preparedness in America for an incident of biological terrorism?
A. Forty different government agencies are at work on preparation and planning for a biological weapons attack in the United States. Congress has promised to allocate many millions of dollars to the effort to develop adequate and workable plans to counter the threat. President Clinton stated, in January 1999, that he would ask Congress for $2.85 Billion to address the issue.
Recently, however, it has been noted that the lack of integration of health care providers and institutions into the planning process represents a potential major flaw. Traditionally, in the United States, federal funds in cases of disasters and disaster planning are targeted towards the 'first responders' - firefighters and law enforcement. Although this is entirely appropriate for the more common disaster scenarios (airplane crashes or major weather related events, for example), this model may not be wholly appropriate in cases of biological weapons attack, where there is not a recognized 'ground zero'.
Dr. J.F. Waeckerle, in a recent article in the Journal of the American Medical Association(1) stressed the importance of medical personnel becoming involved in planning and implementation of emergency procedures for biological weapons attacks. The reasoning is that, as was noted in the previous Cyberounds® on bioterrorism, primary care providers and emergency medical personnel are the most likely to first come in contact with victims of an attack. They are the persons most able to recognize that a surreptitious attack has occurred, provided they are trained in identification of the relevant signs and symptoms.
The American College of Emergency Physicians has recently been awarded a contract by the Office of Emergency Preparedness, United States Department of Health and Human Services, to develop a program to train health professionals for a terrorist attack. Information about this program should be available in the near future, and Cyberounds® will provide information about this program when it is finalized.
Hospitals have been reluctant to become involved in planning for biological weapons attack for a variety of reasons. It is useful to be aware of these concerns, so those physicians within institutions who wish to become involved in the planning process can address them. Lack of funding has been a major issue. The program could prove to be quite expensive, as specialized equipment and supplies are needed. Personnel would need to be trained to a sophisticated level, and this training would need to be updated and reviewed regularly. Additionally, there is the concern that a hospital that does participate in a biological weapons incident would suffer financially if it had to close for significant periods of time for decontamination after an event.
Q. What is the 'model' that serves as a framework, currently, for community planning against biological terrorism and what are the flaws in this model?
A. The current model that is used to design community response to biological terrorism is the hazardous materials or 'HAZMAT' model. This model is widely used in cases of toxic chemical exposures and is appropriate in most of these cases. However, HAZMAT does not consider biological agents used as weapons. Thus, this model is probably not appropriate in planning a community response to a biological weapons attack.
A further major problem with the current system of responses is the lack of a coordinated surveillance system. With the increased mobility of the population, and the ease and availability of rapid travel over long distances, it is not unreasonable to consider that 'pockets' of cases could occur in a number of places throughout the country, virtually simultaneously. One could, for example, imagine a scenario where a terrorist releases a vial of smallpox into the air at a busy railroad or airline terminal. Although there are local, regional and statewide surveillance systems in place, they are probably not, at present, sophisticated enough to be able to rapidly identify a possible biological attack. The development of integrated systems, able to readily detect unusual events, should be a high priority.
Other problems with the current system include a lack of physician knowledge about agents involved in biological weapons attacks. However, knowledge of the disease is only a part of the information needed. The health care provider needs also to be familiar with management of disasters at the local and regional level. This process should be a part of the training of emergency medicine residents and other health care providers.
The final problem involves the large number of government agencies involved in coordinating a response to biological weapons attack. There is a need for the various agencies to be centralized under the auspices of a single coordinating body.
In an attempt to address some of these concerns, the U.S. government has developed the Metropolitan Medical Response Systems (MMRS). So far, nearly 50 urban areas have been funded to develop these systems. More are expected to follow.
Q. What would be some of the priorities one should consider when evaluating a hospital disaster plan for its applicability to biological weapons attack?
A. Physicians and other health care providers need to be familiar with their own institution's disaster management plan. It is often too late to start reading when the first casualties start to arrive! Disaster plans should be tested regularly.
The best plans are straightforward and allocate participants to roles that would not be significantly different from those that they would normally have in everyday practice. For example, the precautions already taken to manage infectious patients should be followed. These precautions are clearly stated in the CDC Guideline for Isolation Precaution in Hospitals. Emergency health care workers should have an understanding of these guidelines. An added benefit of biological terrorism awareness, planning and training is that they could produce changes and improvements to routine daily care within emergency departments.
Most disaster plans exist to address scenarios that one could imagine happening within a given community - an airplane crash for communities near an airport or evacuation protocols in communities prone to hurricanes, for example. However, a biological weapon attack could occur anywhere, either because of release of organism within the individual community or because persons exposed elsewhere traveled into the community. Although anthrax is not transmitted from person to person, smallpox is. Thus, an 'epidemic' could occur anywhere.
If you review an existing disaster plan for applicability to biological terrorism, it is important to ensure that the program explicitly addresses:
- Protection from contamination of current patients and staff
- Best possible medical care for persons presenting to the institution
- Protection of the community within which the facility is situated by correct handling of contaminated materials, including patients dying from the biological agent.
It could be envisioned that once word got out of the possibility of a biological weapon attack, widespread panic would occur, both within the target community and elsewhere in the country. Members of the public may present en masse to health care facilities seeking 'protection' from the agent or a check to ensure they have not been exposed. In the sarin gas attack in Tokyo, for example, about 5000 persons presented acutely to health care facilities. Although there were 11 deaths, nearly 75% of persons presenting had no discernible signs or symptoms of exposure.>
A disaster plan must assess the available resources. A biological weapons attack will, likely, rapidly deplete resources such as antibiotics or vaccines. Cooperation between institutions in a single community, allowing pooling of supplies and sharing of equipment and even personnel, might be very important in saving lives. Techniques to facilitate this cooperation should be in place. It is unlikely that re-supply of institutions could occur in an expeditious manner in the setting of a widespread biological weapons attack.
It is necessary, finally, to consider the impact of a biological weapons attack on the health care workers themselves. The workers will witness death and severe illness in a large number of persons, including even loved ones, colleagues and children. Death or injury to children and to colleagues have consistently been shown to be events that health care workers find most stressful. A good disaster plan must include resources to provide psychological counseling and support for health care workers.
The exact means to implement these ideals are peculiar to the individual community. It is important for health care workers in emergency departments and in primary care facilities to be involved in efforts to design adequate plans to deal with the possible threat from biological weapons. We all hope that these plans will never be put to the test, but it is probably best, at least, to be prepared. Full preparation will involve health care providers, hospital administration and community based resources working in concert with state and federal agencies.
If we, as health care providers, make an extra effort to address this potential threat, it could be a win-win situation for us all. Health care workers would be educated on biological weapons and mechanisms would be in place to deal with disease outbreaks, whatever the cause. This could result in improved surveillance and, thus, improvement in public health and epidemiological monitoring.
Q. OK, the day has arrived and you think you have a biological terrorism incident on your patch. Who ARE Ya gonna call?
A. First off, you need to alert your own hospital of the possibility. In the specific case of a biological incident, this communication should clearly include pathology services, particularly infectious disease and infection control, as well as the usual disaster management teams. In the specific case of a biological weapons attack, the Federal Bureau of Investigation would coordinate the response. State and local public health organizations would be alerted. Other governmental organizations directly involved at the scene would include the Federal Emergency Management Agency (FEMA), and the Office of Emergency Preparedness. The Center for Disease Control in Atlanta should also be notified as a priority. Involvement of the National Guard or other defense forces may also be required. Although the emergency medicine physician may not be responsible for calling directly any or all of these agencies, the organizations involved should be known, so that an effective plan can be developed.
In countries other than the United States, the actual agencies called would be different, but the importance of activating the hospital plan and, then, involving law enforcement agencies rapidly must be stressed.
Some phone numbers and web pages that may help in information or planning include:
- CDC Emergency Preparedness and Response Branch
(770)488-7100 (available 24/7) - Domestic Preparedness National Response Hotline
(800) 424-8802 - US Army Medical Research Institute of Infectious Diseases
(888) 872-7443 OR (301) 619-2833 - Domestic Preparedness Helpline
(800) 368-6498 - SBCCOM: Program Director for Domestic Preparedness
- APIC - Bioterrorism Resources
This site offers a downloadable plan that can be tailored to individual hospitals.