May 2000 • Volume 6 • Number 5
On the front line
Bioterrorism: FPs may be first to sound the alarmBY CINDY McCANSE
Arlington, Va.It's the first nice day of spring, and you're beginning to regret having agreed to fill in at the local free health clinic for one of your partners.
Walking into one of the exam rooms, you're greeted by dry, wracking coughs. The patient, a 43-year-old male loading dock worker, complains of two days of fatigue accompanied by joint pain (flu), muscle aches (flu) and mild chest discomfort (and more flu). Several co-workers, he reports, have missed work this week with "some kind of bug."
His body temp is 101.8 degrees and nothing remarkable turns up on a routine physical exam.
So, if it walks like a duck and quacks like a duck -- it's a duck, right?
Transmission electron micrograph of Ebola virus
Histopathology of human large intestine in fatal anthrax caseThe answer is: not always.
According to some experts, primary care physicians may well be the vanguard of defense in a battle many of them are ill prepared to recognize, let alone fight. The possibility of a nuclear, chemical or biological terrorist attack on U.S. soil cannot be discounted, and practicing physicians must be equipped to respond appropriately.
Assistant Secretary of Defense for Health Affairs Sue Bailey, D.O., recently addressed differences in responses to nuclear, chemical and biological events. She spoke to medical military personnel, public health officials, emergency response personnel and practicing physicians at the Department of Defense Medical Initiatives Conference and Exhibition, "Weapons of Mass Destruction 2000," April 2-6.
The U.S. response to a nuclear attack -- decades in the making and fine-tuned during the Cold War -- would, of course, rely heavily on U.S. armed forces working with national and regional emergency response agencies. First responders to such an event would come from these entities.
In a chemical attack, Bailey noted, police and fire department personnel would be first on the scene. "But if it's a biological event," she told physicians, "the first responders aren't going to be people in uniform or those with the red lights on -- they're going to be you."
Scott Deitchman, M.D., M.P.H., from the National Institute for Occupational Safety and Health of the CDC in Atlanta, agreed.
In a plenary address to more than 600 attendees, Deitchman said community physicians are the key to recognizing a biological emergency. That recognition, he added, is going to require an astute physician with a high index of suspicion.
"I know that I for one wasn't taught about smallpox in medical school, other than that it was extinct, and I certainly wasn't told how to differentiate it from chickenpox," he said. "We need to bring physicians up to speed in how to make those diagnoses."
Look for zebras
The CDC has compiled a list of potential bioterrorism agents that reads like it's straight out of a B movie. Bacillus anthracis (anthrax), Yersinia pestis (plague), botulinum toxin, variola major virus (smallpox) and the Ebola virus strains are among those that top the list.
The initial clinical picture for many of these conditions mimics that of flu. No specific symptoms in the patient described above indicate he should be tested for d'Espine's sign or undergo chest radiography to look for a widened mediastinum -- a feature associated with inhalation anthrax. Yet, given his constellation of symptoms, this highly lethal disease is within the realm of possibility. Should anthrax be included in the differential diagnosis?
The answer is: maybe.
The Association for Professionals in Infection Control and Epidemi-ology Bioterrorism Task Force has identified several features that should increase physicians' suspicion of a bioterrorist attack:
- a rapidly increasing disease incidence in a normally healthy population,
- an epidemic curve that rises and falls during a short time,
- an unusual increase in the number of people seeking care, especially those with fever or respiratory or gastrointestinal complaints,
- an endemic disease that rapidly emerges at an uncharacteristic time or in an unusual pattern,
- an increased incidence of illness among people who frequently go outdoors compared with those who typically remain indoors,
- clusters of patients arriving from a single locale and
- large numbers of rapidly fatal cases.
The devil's in the details
For physicians, the problem only begins with making the diagnosis.
Sue Baily, D.O., assistant secretary of defense for health affairs
"The first responders aren't going to be people in uniform or those with the red lights on -- they're going to be you."In conference breakout sessions sponsored by the AMA, physicians discussed other critical issues, starting with treatment and prophylaxis.
The CDC is charged with storing and issuing pharmaceutical agents needed during biological incidents through its National Pharmaceutical Stockpile Program, but these supplies must be distributed at the community level. Collaboration among physicians and public health officials will be needed to ensure efficient dispersal of these assets and accurate patient tracking.
Other treatment challenges include prescribing drugs for off-label indications and managing the needs of special patient populations. Adequate communication and cooperation among health care facilities and responsible public information dissemination will also be imperative.
But none of these issues will be addressed if physicians don't first believe there's a threat.
As Jeffrey Thomasson, M.D., a St. Louis radiologist, observed at a breakout session, "There's a sense of, if not apathy, at least disbelief. It's like believing in the tooth fairy to think that this could happen."
Unfortunately -- to hear Bailey and others tell it -- it's not a matter of if, only when.
Want to learn more?
A mini-course on bioterrorism will be offered Sept. 22 at the AAFP Scientific Assembly in Dallas. "The Family Physician -- On the Front Line Against Bioterrorism" will be facilitated by Col. Dale Carroll, M.D., M.P.H., of Fort Sam Houston, Texas. This course has been reviewed and is acceptable for 1.5 Prescribed credit hours by the AAFP.
You can also tune in to a live, interactive satellite broadcast Sept. 26-28. "Biological Warfare and Terrorism: Medical Issues and Response," sponsored by the U.S. Army Medical Research Institute of Infectious Diseases, will air 12:30-4:30 p.m. EDT each day. To register, visit http://www.biomedtraining.org or contact Rick Stevens at (301) 619-4880.
Bibliographic resources include:
Institute of Medicine and National Research Council. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. Washington, D.C.: National Academy Press, 1999.
Franz, D.R.; Jahrling, P.B.; Friedlander, A.M.; et al. "Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents." Journal of the American Medical Association 1997; 278: 399-411.
Henderson, D.A. "Bioterrorism as a Public Health Threat." Emerging Infectious Diseases 1998; 4: 488-92.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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