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What Everyone Should Know About Bioterrorism

Course Authors

Richard E. Dixon, M.D., and David J. Sencer, M.D., M.P.H.

Dr. Sencer is a former Director of the Federal Centers for Disease Control and Prevention (CDC) and Dr. Dixon is the former head of CDC's Hospital Infections Branch. Neither is currently affiliated with CDC.

Drs. Sencer and Dixon report no commercial conflicts of interest.

Disclaimer: Drs. Dixon and Sencer have not consulted with the Centers for Disease Control and Prevention in the preparation of this Cyberounds® and the opinions expressed and actions proposed are those of the authors.

This activity is made possible by an unrestricted educational grant from GlaxoSmithKline.

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.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • Identify and triage patients who may have been exposed to dangerous microbiologic agents, especially agents likely to be used by terrorists

  • Guide the collection of critically important information about such patients such as their histories, epidemiologic findings, clinical signs and diagnostic tests

  • Find expert sources for assistance in managing the clinical, public health and legal concerns that such patients raise

  • Assist in choosing the most appropriate empirical treatments for the patient and his or her contacts.

 

Preparations to respond to bioterrorism attacks took on a new urgency in October 2001 after cases of anthrax, which were clearly the result of a criminal attack, were recognized in Florida, Connecticut, New Jersey, New York City and Washington DC. While the anthrax incidents focused intense attention on the adequacy of current clinical and public health approaches to bioterrorist attacks, these attacks also highlighted the need to be prepared to deal with any dangerous and highly communicable threat, no matter whether it arises naturally or is the consequence of an intentional act of bioterror or biowarfare.

The investigation into the anthrax attacks continues to rewrite what is known about the clinical and public health approaches to epidemics caused by anthrax and bioterrorism in general. But four facts are already certain:

  • Practitioners who have first contact with patients must now routinely include the intentional use of biological agents in their differential diagnoses.
  • Primary care and emergency practitioners will generally be the first to see victims of bioterrorism attacks. But specialists who are not traditionally thought to be on the front line may also encounter such patients early, as occurred when dermatologists and surgeons treated cutaneous anthrax lesions early in the anthrax epidemic. Therefore, all clinicians need to be able to recognize patients who have dangerous communicable diseases.
  • The initial cases may be hard to recognize. Many bioterrorism agents -- as well as other naturally occurring and dangerous infections -- often produce non-specific initial symptoms and signs that are similar to those of more common conditions. Always remember that bioterrorism agents will not necessarily have tell-tale signs that will reliably raise an alarm.
  • Illnesses caused by other serious, naturally occurring, emerging infections are likely to present the same kinds of clinical and management problems as those caused by bioterrorism. Clinical and public health protocols effective for one group of infections will also be generally effective against the other.

Fortunately, the medical professional does not need to become an expert on bioterrorism or the microorganisms that may be used in criminal attacks. Instead, practitioners only need to incorporate a simple screening protocol, which should be used with every patient, in order to increase the likelihood that the critically important first cases will be recognized and properly managed. The protocol should help the practitioner:

  1. identify patients who may have been exposed to dangerous pathogens,
  2. order infection control precautions that will prevent spread to others,
  3. collect the needed clinical information and laboratory specimens,
  4. immediately notify public health authorities, and
  5. arrange currently recommended treatment and follow-up care.

These five actions are the critical first elements needed to protect against bioterrorism and other dangerous infections. Once they have been taken, appropriate investigations and actions can proceed. Without these five actions, important epidemics may not be recognized promptly and hundreds or even thousands of other people could be put at risk, including the patient's family, other close contacts and the clinician's own office staff.

This Cyberounds® is designed to help the practitioner recognize potentially affected patients and take the critical first steps to assure they are worked-up and managed properly.

Infectious Agents of Concern

Hundreds if not thousands of microorganisms or their toxic products could be used as agents for bioterrorism (BT) or biowarfare (BW). Many of these potential agents have been readily available from commercial or natural sources. For example, Bacillus anthracis, the microorganism causing anthrax, has been relatively easy to obtain from commercial, academic and government laboratories until recently. Furthermore, naturally occurring anthrax is still endemic in many parts of the world. Viable anthrax spores still contaminate sites in the United States, and sporadic domestic cases of anthrax may occur because of exposure to contaminated domestic sites or imported animal products.

Many of the agents that can be used in BT and BW attacks can also be produced in large quantities more cheaply than, for example, nuclear or chemical agents. Microbiologic agents have an added advantage in that small quantities can theoretically affect very large populations, and such small quantities can be easily hidden and transported.

Only a few of the many potential agents are believed to represent practical threats, however, because most of the potential agents are not efficient in causing the kinds of diseases or disabilities that will incapacitate an enemy or terrorize a population. Many of the agents cannot be produced in a form that allows them to be delivered efficiently or to cause predictably high infection rates (i.e., they are difficult to "weaponize"). Immunizations are available for other potential BT and BW agents, while prophylactic or early treatments can blunt the effects of still others.

As a result, only about 25 classes of biologic agents have been identified as likely threats at the present time. Of those, seven have been given highest priority by CDC and other experts (designated as "Category A" agents):

  • Variola major (smallpox)
  • Bacillus anthracis (anthrax)
  • Yersinia pestis(plague)
  • Clostridium botulinum toxin (botulism)
  • Francisella tularensis (tularemia)
  • Viral hemorrhagic fever agents, which include the
    • Filoviruses, which produce illnesses such as
      • Ebola and
      • Marburg hemorrhagic fevers
    • Arenaviruses, causing illnesses such as
      • Lassa (Lassa fever),
      • Junin (Argentine hemorrhagic fever) and related illnesses

Lower priority (Class B) agents also pose risk. Several have either been used in bioterrorism attacks (Salmonella was employed in 1984 to contaminate foods in salad bars in an Oregon community) or developed or used in warfare (e.g., Burkhnolderia mallei, which causes glanders in animals).(1)

More detailed descriptions of these agents and the diseases they cause are available from CDC, USAMRIID, and the Johns Hopkins Center for Biodefense Studies.

Most of the practical steps taken to reduce the risk of infection from likely BT and BW agents have focused on naturally occurring microorganisms and toxins. But bioengineering might produce microorganisms that are, in essence, new agents -- agents that are transmitted differently, have unusual clinical effects, or are not susceptible to either current vaccines or treatments. Since their characteristics cannot be easily predicted, it is difficult to prepare for them. This makes it even more important for practitioners to recognize and properly manage every case of potential infection.

It is also important to emphasize that BT and BW agents are not the only threats that practitioners must consider. The typical practitioner is much more likely to encounter a case of illness caused by a naturally occurring infection than one caused by BT. These naturally occurring infections can be just as difficult to manage and cause just as great a public health threat as a BT infection. So a practitioner needs to have some reliable way to identify every high-risk infection or toxic exposure, no matter what its source may be.

The First BT Victims May Be Difficult to Diagnose

Unless a practitioner's routine protocol assures that BT or other dangerous emerging infections are considered in differential diagnoses, affected patients are likely to be misdiagnosed and mistreated. We can predict that:

  • Early in their clinical course, most BT agents produce nonspecific symptoms and signs that will be mistaken for more common conditions.
  • Unlike physical terrorist attacks, BT attacks are unlikely to produce a dramatic event that signals their occurrence.
  • Days or even weeks lapse between exposure and onset of symptoms.
  • Victims of attacks with infectious organisms will be seen one-at-a-time by widely scattered primary care and emergency practitioners.
  • A single practitioner may see no more than one or two affected patients.
  • Public health surveillance systems will need individual reports from those scattered practitioners to recognize the epidemic patterns that set off alarms.
  • Few practitioners have clinical experience with diseases caused by important bioterrorism agents.
  • Patients are unlikely to volunteer a history that pinpoints the diagnosis since they may not have even been aware of their exposures. Information from a probing history may, however, suggest the diagnosis and source.
  • Practicing practitioners cannot wait for alerts from public health agencies before beginning to look for patients with BT or emerging infections.

Does this mean that every practitioner must become an expert on all diseases caused by potential bioterrorism agents? Fortunately, it is not necessary. Instead, every practitioner's office and emergency department needs to use a protocol that will improve the chances that BT will be thought of -- that it will be included in the differential diagnosis. Thinking about BT is the critical first step. It prompts the clinician to ask for appropriate consultation, order the proper empirical treatments, institute precautions to prevent spread of infection and obtain essential diagnostic tests.

Typical Features of Bioterrorism Agents Considered Most Likely

Estimates of mortality rates and incubation periods come from experiences with naturally occurring disease -- sometimes disease occurring many years ago. Agents used today for BT or BW may behave differently than they previously did in their natural settings. For example, newer treatments may dramatically improve outcomes. The mortality rates from the inhalational anthrax cases in the recent epidemic were substantially lower than anticipated. On the other hand, modifications to the agent may make them more virulent or easily spread than they are in their natural state.

Several other agents are sometimes listed as potential BT and BW agents but are not detailed in this Cyberounds® in detail because they are generally considered to be less important than the agents listed above or because their clinical presentations are not confused with other common infectious diseases. They include:

  • Ricin, a cytotoxin derived from the beans of the castor plant, which produces rapid pulmonary toxicity
  • T-2 Mycotoxins, a group of compounds produced by a common grain mold, which can cause severe dermal and mucous membrane toxicity beginning almost immediately after exposure
  • Staphylococcal enterotoxin B, an exotoxin that produces fever, chills, headache, myalgia and cough several hours after exposure
  • Glanders and melioidosis, bacterial infections that occur naturally and affect horses (glanders) and humans (melioidosis)
  • Q Fever, caused by the rickettsia Coxiella burnetti, a naturally occurring zoonotic disease that has occasionally caused human disease

Finding Zebras

"When you hear hoofbeats, don't first think of zebras" is a cherished clinical maxim. Bioterrorism is still a zebra. Only very rarely will a patient with vague or confusing symptoms be a BT victim. Nonetheless, because the consequences of failing to identify such a case when it does occur are so grave, individual cases must be identified. Unless bioterrorism is at least considered in the differential diagnosis -- unless "zebras" flash through the clinician's mind -- these rare but critically important cases will not be recognized. The challenge is to recognize these extremely rare, unusual cases without causing too many false alarms, ordering too many useless tests, or unnecessarily frightening too many patients.

The challenge can be met if practitioners institute a simple protocol in their offices that is used with all patients. After a while, such a protocol becomes a ritual, which, like other medical rituals, helps practitioners avoid missing important findings. Examples of such ingrained habits include the use of systematic interview questions, review of systems and comprehensive physical examinations. Since some BT and emerging infections can be highly contagious, the screening needs to begin when the receptionist first answers the phone or the nurse welcomes a patient to the office, in other words, before they are seen by the clinician.

Practice-Site Protocol to Recognize and Manage Biothreats and Other Serious and Contagious Infectious Diseases

The protocol should be applied from the point of first contact with a possibly-infected patient and continue until the likelihood of a serious or highly contagious infection is ruled-out or until all steps necessary to protect the patient and contacts have been taken.

It should include:

  • A procedure to triage patients with probable infections who seek appointments or arrive unannounced for care;
  • Rapid assessment to determine whether practice-site isolation precautions are needed; and
  • A process to determine whether a patient's clinical course is consistent with BT agents or other serious infections.

If the presentation is consistent with a BT infection or another serious infection, the protocol should include steps for:

  • Notifying and seeking advice from public health and other experts regarding clinical and public health management, as needed;
  • Collecting appropriate clinical information and tests to confirm or rule-out the suspected infection;
  • Implementing empirical therapy; and
  • Arranging follow-up and management of contacts who may be at risk of secondary spread.

If it is to be used, the protocol cannot be burdensome or disruptive to the normal rhythms of a busy office. The protocol described in this Cyberounds® is simple, does not add significantly to an office's or emergency department's workload and is intended to provide a starting point that can be adapted to a practice's unique needs and patient populations. It can also be adapted as more is learned about clinical and public health approaches to BT agents and other emerging infections.

Step 1: Receptionist's Infectious Disease Screening Questions

The office receptionist should routinely determine whether every patient who seeks an appointment or who arrives unannounced has:

  • Fever
  • Cough or difficulty breathing, or
  • Skin or mucous membrane rash

If a patient has any of those findings, go to Step 2.

Step 2: Receptionist's Infection Control Actions

If a patient has any of the conditions listed in Step 1:

  • Attempt to schedule when few or no other patients are in the office, but do not delay seeing the patient.
  • If the patient is actively coughing, bleeding, or has visible skin or mucous membrane lesions upon arrival, place the patient in an appropriate examining room or in an area where contact with others is minimized. Immediately obtain the practitioner's advice about what additional infection control precautions, if any, to employ.

Step 3: Use Infection Control Precautions to Prevent Spread of Infection When Necessary

Reception or nursing staff should immediately notify the practitioner whenever a patient meets triage criteria suggesting the need for isolation precautions, and the practitioner should order precautions appropriate for the case.

Immediately implement precautions directed by the practitioner, which may include keeping the patient in an examining room, closing the examining room door, and placing a sign on the examining room door indicating what kinds of infection control precautions should be used. The isolation precautions are based on the ways that a particular infective agent is spread from person to person.

Spread of Infections: Some infections may be inapparent but nonetheless capable of spreading to others. Examples include infections such as HIV and chronic hepatitis B or C. It has therefore become a routine for healthcare workers everywhere to use Standard Precautions, techniques used with every patient that are designed to prevent spread from exposures to blood and bodily fluids that occur during routine care. Standard Precautions do not necessarily block the spread of infections by droplets, airborne contamination, or physical contact with sources of contamination. Therefore, additional precautions are sometimes needed.

Droplets (secretions or other materials that harbor microorganisms) are sufficiently heavy to be affected by gravity. They typically settle to the ground or nearby surfaces within a several-foot radius. If inhaled, they are generally trapped in nasal, throat or other upper airway sites, which may become portals for infection. Droplets that have fallen to surfaces can be picked-up by touch and then inoculated by contact into eyes, the nose, mouth or other sites. Examples of infections spread by droplets are influenza, mumps, rubella and bacterial infections such as meningococcal and invasive Type B Haemophilus influenzae disease. Biothreat diseases spread by droplets include pneumonic plague.

Airborne particles are very small (less than 5-microns in diameter). They are more affected by ambient air currents than by gravity and therefore do not settle to surfaces. They remain suspended in the air and may be propelled long distances by gentle currents. Such particles are so small that they bypass upper airway defense mechanisms, and some are the right size to lodge in alveoli, which become pulmonary portals for infections. Only a few infections are spread by airborne particles. Among the more common are varicella, measles and tuberculosis from patients with cavitary pulmonary disease. Anthrax, especially if prepared in a weapons-grade form, and smallpox, on occasion, can be spread by this mechanism.

Contact spread occurs when an object contaminated with pathogenic microorganisms -- animate (for example, a person's wound) or inanimate surface (e.g., bedside table, endotracheal tube, foley catheter) -- serves as the source for spread. Hands contaminated at the source commonly carry infectious agents from patient to patient. Skin and wound infections, secretions and excretions provide a source for contact transmission. Patients harboring multiple antimicrobial resistant strains should also be treated with Contact Precautions. Viral hemorrhagic fevers are examples of biothreat diseases spread by direct contact.

Implementing Infection Control Procedures in Ambulatory Care Offices

Scrupulous handwashing between patient contacts and use of Standard Precautions for all patients are the most important infection control precautions that can be used to prevent the spread of infections and should be used with all patients.

Standard Precautions require all office personnel to:

  • Wash hands after contact with a patient, bodily fluids, secretions, excretia or other potentially contaminated items such as instruments, even if gloves are also used;
  • Wear fresh gloves for contact with any body fluids, secretions, excretia or other potentially contaminated items such as instruments if possible;
  • Wear a fresh gown, mask, eye protection or face shield during procedures that may produce splashes, sprays or aerosols of blood or body fluids;
  • Take precautions to prevent injury from needle sticks or other sharp instruments
  • Decontaminate surfaces, instruments and soiled linen.

Standard Precautions should be used with every patient, even if the patient has no symptoms or signs of infection.

Standard precautions as well as the other isolation techniques are described in more detail at the CDC Guidelines and should be reviewed by those who are not already familiar with them.

For the small number of infections where person-to-person spread occurs by contact, airborne or droplet spread, simple infection control precautions, such as those used in hospitals, are highly effective in preventing transmission from one person to another.

The typical office already has most of the supplies needed to implement infection control precautions: non-sterile gloves, surgical masks and disposable gowns. Face masks (or protective goggles) are needed in some settings, but offices that perform invasive procedures should already be equipped with those devices.

Hospital isolation rooms designed to prevent airborne spread can be placed at negative pressure in relation to surrounding rooms and corridors. Most offices do not have such facilities. When necessary, airflow can be improved by closing supply (incoming) air vents, opening return (outgoing) vents in the room and maintaining forced air ventilation in other areas.

Droplet Precautions should be identified by warning signs on exam room doors and elsewhere as needed:

  • Use Standard Precautions plus
  • Place patient in private examining room; a closed door is not necessary to prevent infection spread.
  • Wear a mask when working within 3 feet of the patient.
  • Have patient wear a surgical mask when leaving the room.

Contact Precautions should be identified by warning signs on exam room doors and elsewhere as needed:

  • Use Standard Precautions plus:
  • Place patient in examining room; a closed door is not necessary to prevent infection spread.
  • Wear gloves when in the room and change them after touching contaminated material.
  • Wear a gown when entering room if contact with patient is anticipated or if patient has diarrhea or an uncovered wound.
  • Disinfect patient care items, including equipment that directly contacts the patient or contaminated surfaces.

Airborne Precautions should be used for the small number of infections that can be spread by the airborne route. Masks should be placed outside door, and the room should have a sign describing the precautions that are in place.

  • Use Standard Precautions plus:
  • Place patient in private examining room and keep the door closed. The room for airborne precautions should ideally be at negative air pressure with respect to surrounding hallways and rooms. This is impractical in most ambulatory care offices and many emergency departments. As noted above, in the rare situations when airflow control is urgently needed, air pressures in rooms with forced air ventilation can usually be improved by blocking incoming air flow at the vent, maintaining exhaust flow and maintaining forced air ventilation elsewhere in the suite. An open window with an exhaust fan can also be useful. A patient requiring airborne precautions should be transferred as quickly as medically appropriate to a hospital with isolation facilities.
  • Respiratory protection for all who enter the room. Tightly fitting surgical masks are acceptable for use in these circumstances.
  • Have patient wear a surgical mask when leaving the room.

Step 4: Determine If Patient Is Potential BT Victim or Has Other Serious or Contagious Infectious Disease

No questions or physical findings will necessarily identify patients who have serious infections, of course, but responses to several screening questions and other clinical findings may strongly indicate that further investigations should be undertaken:

  • Where have you been and how have you traveled? Travel to locations known to be endemic for unusual infections or to potentially hazardous events or sites may provide useful clues. Risks often differ significantly between urban and rural areas, so it is important to obtain a precise history of places visited if travel exposure is suspected. Modes of travel may suggest exposures, and public health investigators will also seek this information if a contagious and dangerous disease is suspected. It is not necessary for a clinician to obtain thorough epidemiologic data, but it is important to discover as early as possible if others may be exposed because of travel on common carriers such as airplanes or buses, for example.
  • What do you do? The identity of patient's employer as well as the specific kind of work done is often very helpful in assessing risk. Employment by the U.S. Postal Service was a risk factor for anthrax during the 2001 bioattack in some regions of the country, but a job requiring the handling of mail, no matter who the employer, was an equally important history to seek.
  • Have you been around -- or exposed to -- others who have a similar problem? Finding several cases of disease with common exposures is one of the most important historical findings suggesting an outbreak of disease.
  • What are your hobbies? Hobbies may lead to exposures that, if known, are most useful in arriving at a diagnosis.
  • Have you had any unusual exposures or other recent experiences that you think may account for this illness? Because of unusual experiences or events, patients often have ideas about the causes of their illnesses, but they may be reluctant to volunteer the information unless asked. The associations may be faulty, of course, but this can be one of the more useful questions to ask in any unexplained illness.

Clinical Findings

The anthrax attacks illustrated the difficulty of differentiating serious BT agent from more routine respiratory infections such as influenza. CDC published a useful discussion of the clinical and epidemiologic considerations helpful to the clinician.(3)

Table 2 describes some of the typical syndromes associated with BT agents. Although many of the agents produce illness similar to that caused by other diseases, the syndromes themselves may be sufficiently characteristic to prompt specific diagnostic testing for a BT agent or other unusual infection or to call for consultation with infectious disease or public health experts.

Perhaps the most important finding suggesting the need to continue to consider a BT or emerging infection is the intuitive sense that there is something strange or unusual about the patient's course -- that it behaves or looks different from what is typical. An unusual clinical presentation does not, of course, indicate that the patient is a victim of a BT attack. However, it does indicate that a more extensive diagnostic work-up is needed which will probably include broader testing and consultation with clinical and public health specialists.

Step 5: Contact Public Health Authorities and, If Necessary, Expert Clinical Consultants

Public health authorities (and, if bioterrorism is suspected, law enforcement authorities) must be notified immediately if a patient is suspected of having a BT-related infection. They should also be called if another serious emerging infection is included in the differential diagnosis. Reports of notifiable diseases should also be made according to existing requirements. Public health officials can offer clinical advice, assistance in implementing precautions, help obtaining critical diagnostic tests, and they can also arrange appropriate follow-up for patients and their families and other contacts. Moreover, the public health officials may have heard of similar reports from other clinicians that may be useful guiding clinical management. Finally, by calling the local health department, the clinician may provide the critical first notice signaling an incipient epidemic. A current list of state and national resources are listed in the appendix to this course.

Infectious disease consultants can also provide useful advice about precautions, testing and management.

Step 6: Order Critical Diagnostic Tests

Table 2 lists some of the diagnostic tests that may be initially useful. Public health and clinical infectious disease consultants should be consulted about additional tests whenever a patient is suspected of having a serious BT or emerging infection.

Step 7: Institute Appropriate Treatment

Practitioners should not rely on published recommendations for prophylaxis or treatment of BT and other emerging infections unless they are certain that the recommendations are up-to-date. Recent experiences may render even recently published guidelines obsolete. Table 1 only indicates whether a vaccine or treatment was said to be available in March 2002. It should not be used to provide specific advice about an individual patient. Clinicians who suspect one of these rare conditions should seek the most current management recommendations from authoritative contemporary sources. Public health officials and infectious disease experts are appropriate sources of assistance, and other reference sources are also helpful.(2)

Step 8: Follow-up of Contacts

Local public health authorities normally have responsibility to identify others who may have been exposed to hazardous infections. The practitioner can assist in this effort by detailing the travels, activities and major contacts of patients suspected to have BT or other serious infections. That information should be shared with the public health authorities, and they may ask the treating practitioner to evaluate and manage some of those exposures.

Op-Ed Epilogue

What are the lessons learned as a result of the anthrax attack?

First, we need to communicate better, both to professionals and to the public.

Our audiences want to hear technical information from persons versed in the subject matter. Health information should come from health authorities; law enforcement information from the enforcers; political information from the politicians.

Nontraditional methods of communicating to the professions must be improved. The journal, Emerging Infectious Diseases, an online journal, had an authoritative report on cases of inhalation anthrax in November, 2001.(4) The article was peer reviewed but had limited readership. The delay in publication in traditional journals would have lessened its timeliness. The Internet is a magnificent source of timely information but it is difficult for the physician suddenly thrust into a role in bioterrorism to sift the grain from the chaff. It is a legitimate role of government to provide authoritative information, and the CDC and many state and local health departments rose to the occasion. The New York City Department of Health, in particular, conducted an aggressive information dissemination policy.

We must recognize that it is all right to say, "I don't know." Early attempts to explain away the first anthrax case as waterborne led the public and the professions to distrust information emanating from the U.S. Department of Health and Human Services. One new truth is that we don't know all we need to know about biological agents when they are introduced in a nontraditional manner.

As noted above, the anthrax attack that occurred in late 2001 has forced a reconsideration of both the clinical features of that condition as well as the method of transmission. Although relatively few serious inhalational anthrax cases occurred, it seems that exposures to the epidemic strain caused lower death rates than expected among patients diagnosed and treated promptly. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported. The importance of early diagnosis and treatment was ratified.

The attack had even more lessons for the public health community. Most experts agreed, after the first few cases, that the attack was not an assault from a nation with the capability of mass destruction but rather emanated from a domestically based terrorist. Public health authorities were surprised that such a highly sophisticated, weaponized strain had been prepared under those circumstances and how effectively that strain seems to have contaminated diverse locations. They also learned that mere isolation of an organism by screening culture surveys did not help to identify those at risk of disease.

A model for an outbreak of anthrax would have been wrong. Who would have put the porousness of paper into the equation? Yet it was the ability of the spores to escape from sealed envelopes that contributed to the loss of credibility of the scientists by the postal workers.

What went right?

The system worked. Cases were diagnosed, reported, investigated and the information made available. State and local health departments, while stressed by inadequate resources, coped with the cases and rumors and devoted endless laboratory hours processing materials suspected of being anthrax. The few false positives were environmental samples tested by kits that have not had adequate evaluation.

What needs to be done?

There needs to be a recognized health spokesperson. The role of the Surgeon General has been marginalized by the political nature of the position. The Surgeon General has little staff. Unless these deficiencies can be corrected, the Director of CDC should be the designated spokesperson.

There needs to be clearly articulated plans for combating bioterrorism. These plans should not be carved in stone but subject to continuous revision.

The infrastructure of the public health system needs to be continuously strengthened. Modern communication systems and upgraded laboratories are important but trained personnel are essential.

The state and local health departments need to continue their efforts to communicate with the health professions on a regular basis, while the health professions need to recognize the value and role of their official health agencies. Efforts to improve the public health infrastructure must include efforts to strengthen ties between public health departments and their communities, especially practicing physicians. State and local health officials can be very helpful to practicing physicians -- and vice versa -- but few on either side of the chasm separating the two realms seem to realize it.

Traditional surveillance techniques need to be augmented by syndromic surveillance methods such as monitoring emergency room visits, EMS calls and drug sales.

Some will argue that the necessary expenditures will reduce the amount of funds for needed health services. This is a short-sighted approach, since all of the stated needs have values that transcend bioterrorism. Better communication, better planning and better infrastructure equate to better disease prevention. And everyone in the health profession should value prevention.

Appendices


Footnotes

1Miller J, Engelberg S, Broad W. Germs: Biological Weapons and America\'s Secret War. Simon & Schuster, New York, 2001. (This carefully researched book by three New York Times writers constructs a fascinating history of bioterrorism and its scientific and political ramifications.)
2The Medical Letter on Drugs and Therapeutics: Prevention and treatment of injury from chemical warfare agents. 2002; 44 (Issue 1121): 1-4.
3CDC: Considerations for distinguishing influenza-like illness from inhalational anthrax. MMWR 2001. 50:984-986 (November 9, 2001.
4EID Vol. 7, No. 6 Nov-Dec 2001. Emerging Infectious Diseases, is also available electronically. The e-version is, of course, most useful in situations such as those described.