October 6, 2001
Family physicians will be central in bioterrorism response
BY CINDY MCCANSE
The next time you're feeding pigeons in the park, think "disease vector." Granted, pigeons may not be the most efficient means of spreading infectious disease, but the possibility does exist.
Jonathan Temte, M.D., Ph.D.Just as the possibility of a biological attack on citizens of the United States exists, said Jonathan Temte, M.D., Ph.D., in a Friday special lecture on bioterrorism and primary care.
"My children and your children, and you and I, and our families and our communities have all become potential targets for terrorists," warned Temte, assistant professor in the family medicine department at the University of Wisconsin, Madison, and infectious disease researcher.
Since the events of Sept. 11, he noted, "What used to be in the imagination of authors is now front-page news." Unfortunately, he added, the general population has been left with mixed messages: One day's headline declares the United States virtually impervious to bioterroristic attack; the next day's decries the woeful inadequacy of current U.S. bioterrorism preparedness.
That preparedness largely hinges on knowing what to look for, said Temte. He listed the top six bioterrorism candidates identified by the CDC:
- anthrax (Bacillus anthracis);
- smallpox (variola major);
- plague (Yersinia pestis);
- tularemia (Francisella tularemia);
- botulism (Clostridium botulinum toxin); and
- viral hemorrhagic fevers (Ebola, Lassa, Marburg, yellow fever viruses, etc.).
But even when you know what you're looking for, that doesn't guarantee you'll know when you're looking at it, Temte said, as he read off the symptoms that characterize the initial clinical presentation of inhalational anthrax.
"Fever, cough, myalgia and malaise. Now, how many patients do you have in your practice who present with those symptoms?" he asked an audience numbering over a thousand. The same holds for the first signs and symptoms of smallpox, Temte went on. "In my practice, this looks like any number of rash illnesses."
From that point, though, patients with these illnesses take a rapid and drastic downturn. For patients with some of these diseases, little is available in the way of treatment.
Currently, only a single investigational drug -- cidofovir -- exists to treat smallpox, said Temte. A combination of anthrax vaccine and antibiotic therapy may be of benefit in patients exposed to the Bacillus bacterium, but only if they are administered immediately after exposure -- preferably within 24 to 36 hours. After that, only supportive measures are available to manage the disease.
Witness the 63-year-old Florida man recently reported as having contracted anthrax, most likely from spores long buried in the soil. His disease, although identified at a relatively early stage, proved fatal; he died yesterday.
So, how to avoid these diseases in the first place? What preventive measures are available? Again, the answers aren't always reassuring.
Given that the World Health Organization declared smallpox to be eradicated in 1980, production of the vaccinia vaccine against it was curtailed long ago and has only recently begun again in earnest. Clinical trials on the new vaccine won't begin until next year, and the initial shipment ordered by the U.S. government is not expected before 2004. However, the manufacturer recently announced efforts to step up its production schedule. At present, only 14 million frozen doses of the older vaccine remain in storage.
Look for things out of season influenza, for example, in July. Look, too, for things out of context, out of sequence, out of range. Anthrax vaccine availability is also deemed inadequate to deal with a significant bioterroristic event, although release of additional doses could come as soon as next year.
The real answer, said Temte, is to encourage vigilance among physicians in the community. "Look for things out of season," he said, "influenza, for example, in July." Look, too, he said, for things out of context, out of sequence, out of range.
Another key role for FPs will be establishing and maintaining contact with public health officials. "We need to know what their perspective is, and they need to know what ours is," Temte noted. He advised family physicians to form interactive partnerships with public health agencies to enable development and easy dissemination of treatment protocols.
But perhaps most critical for family physicians is to realize that there are significant psychosocial consequences that would accompany any biological attack: "Bioterrorism response isn't entirely limited to an infectious threat," Temte said. "This is where we need to be out there giving education, reassurance and presence."
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
FP Report | October 6 Headlines |AAFP Home | Search
