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IN THIS ARTICLE    
Dark patches of skin above the temples may be a sign of Giant Cell Arteritis, a serious, though treatable, condition. more...  OTHER TOPICS |
Public Health and Bioterrorism: Learning the Lessons of the Anthrax Attacks Richard E. Dixon, M.D., and David J. Sencer, M.D., M.P.H. Dr. Sencer is Director Emeritus 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. Disclaimer: Drs. Dixon and Sencer have not consulted with the Centers for Disease Control and Prevention in the preparation of this article and the opinions expressed and actions proposed are those of the authors. Before October 2001 there was a lively debate in the medical world about whether the U.S. public health system should put significant amounts of its limited resources into preparations for a possible bioterrorist attack. The issues are well summarized by two articles published on TheDoctorWillSeeYouNow. In the first, entitled "Bioterrorism -- Are we prepared?", Dr. Martin Carey argues that the U.S. faces "a real threat" of terrorist attack using smallpox, anthrax, or some other biological agent. In the second ("Scare Stories Can Be Dangerous to Your Health") Drs. Cohen, Seidel and Gould disagree, asking instead: "Is it hype?" All this has changed since the September 11 terrorism and the anthrax attacks that occurred shortly afterward. Now the debate is not whether or not but how -- how to prepare for and respond to the next attack. The anthrax attacks and their aftermath continue to rewrite what is known about the clinical and public health approaches to epidemics caused by anthrax and bioterrorism in general. Four points are already clear:
Infectious Agents To Watch There are hundreds, if not thousands, of microorganisms or their toxic products that could be used as agents for bioterrorism (BT) or biowarfare (BW). Many of these are already available from commercial or natural sources. For example, Bacillus anthracis, the microorganism causing anthrax, was relatively easy to obtain from commercial, academic and government laboratories until recently. And not only from labs -- naturally occurring anthrax is still present in many parts of the world. Viable anthrax spores contaminate sites in the United States and occasional outbreaks of anthrax may occur because of exposure to these 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 and more cheaply than, for example, nuclear or chemical agents. Microbiologic agents have the added advantage that they can affect very large populations, and in such small quantities that they can be easily hidden and transported. Only a few of the many potential agents are believed, however, to represent a real threat. This is because most potential agents cannot cause the kinds of diseases or disabilities that will incapacitate an enemy or terrorize a population. And many cannot be converted into a form that allows them to be delivered efficiently or to cause high infection rates (i.e., they are difficult to "weaponize"). Immunizations are available for other potential BT and BW agents, while preventive or early treatments can blunt the effects of others. As a result, at the present time, only about 25 types of biologic agents have been identified as likely threats. Of those, seven have been given the highest priority ("Category A" agents) by the Federal Centers for Disease Control and Prevention (CDC):
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 new agents -- agents that are transmitted differently, have unusual clinical effects or are not controlled by current vaccines or other treatments. This makes it even more important for medical professionals to recognize and properly manage every single case of potential infection. A New Approach To catch every possible case, doctors must change their routine. With an awareness of BT and BW and by adding a new screening routine, doctors will be better able to help victims of the next attack and, hopefully, prevent an epidemic. Your doctor or nurse do not need to become experts on bioterrorism or on all the Category A microorganisms. Instead, they need to consider the possibility that you may be suffering from a BT infection or attack. You, the patient, can help too. If you are worried that your illness is somehow unusual and perhaps caused by a BT agent, you should voice these concerns to your doctor. In Table 1, we present some of the basic features of the Class A agents. They are not meant to become the basis of self-diagnosis. Just keep them in the back of your mind in case you come down with an unusual illness and be sure to tell your doctor your suspicions. Note that the information in Table 1 was based on research on naturally occurring disease and that agents used today for BT or BW may behave differently than they did in natural settings. Table 1. Features of Possible Bioterrorism Agents.
There are several other, less common agents that are sometimes listed as potential BT and BW agents:
"When you hear hoof beats, it's probably a horse, not a zebra" is a maxim that is told to medical students. Things are what they appear to be and the straightforward, common sense explanation is usually the most likely. One problem with bioterrorism is that it is a zebra. Though rarely will a patient with vague or confusing symptoms be a BT victim, the consequences of failing to identify quickly such a case are serious. Because some BT and emerging infections can be highly contagious, screening needs to begin even before the patient is seen by a doctor -- as soon as the receptionist first answers the phone or the nurse welcomes a patient to the office. The challenge for the public health system is to remain on the lookout for the extremely rare and unusual without causing too many false alarms, ordering too many useless tests or unnecessarily frightening too many patients. Op-Ed Epilogue What are the lessons learned as a result of the anthrax attack? First, public health officials 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 confirmed. 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 was probably from a domestically based terrorist. Public health authorities were surprised that such a highly sophisticated, weaponized strain had been prepared under those circumstances and that the strain so effectively contaminated diverse locations. 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 clear 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 benefits that go beyond bioterrorism. Better communication, better planning and better infrastructure add up to better disease prevention. And everyone in the health profession and the public should value prevention.
References 1. Miller 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.) return 2. The Medical Letter on Drugs and Therapeutics: Prevention and treatment of injury from chemical warfare agents. 2002; 44 (Issue 1121): 1-4. return 3. CDC: Considerations for distinguishing influenza-like illness from inhalational anthrax. MMWR 2001. 50:984-986 (November 9, 2001. 4. EID 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. return 5. The Medical Letter on Drugs and Therapeutics. Drugs and vaccines against biological weapons. 2001; 43 (Issue 1115): 87-89. 6. The journal "Emerging Infectious Diseases" includes links to a large number of BT and BW articles, including the July-August, 1999, 7. A comprehensive resource on the clinical and epidemiologic presentation and management of many BT and BW agents. 8. An important source for up-to-date information from The Johns Hopkins Center for Civilian Biodefense Strategies. 9. The home for the most recent CDC information about bioterrorism and includes clinical information, excellent illustrations, and information about public health resources (such as the National Pharmaceutical Stockpile), training resources, and policies. 10. CDC. Biological and chemical terrorism: Strategic plan for preparedness and response. MMWR. 2000; 49 (No. RR-4). This special report provides an overview of the public health response to BT threats. 11. Christie AB. Infectious Diseases: Epidemiology and Clinical Practice. Churchill Livingstone, Edinburgh, London, and New York, second edition, 1974. (This book, now out of print but still available in many libraries, contains unparalleled clinical and epidemiologic descriptions of illnesses rarely seen by today's clinicians, based on personal experience and a command of the literature of the time.) 12. Plotkin SA, Brachman PS, Utel M, et al. An epidemic of inhalation anthrax, the first in the twentieth century: I. Clinical features. Amer J Med. 2002; 112: 4-12. The 2001 anthrax episode was not the first epidemic of inhalation disease in recent memory. This is a reprinting of a report originally published in the American Journal of Medicine in 1960 and describes an epidemic of inhalational and cutaneous anthrax that occurred in a New Hampshire plant that processed goat hair and offers valuable clinical observations. 13. Lane HC, Fauci AS. Bioterrorism on the home front: A new challenge for American medicine. JAMA. 2001; 286: 2595-2596. 14. Bush LM, Abrams BH, Beall A, Johnson CC. Index case of fatal inhalational anthrax due to bioterrorism in the United States. N Engl J Med. 2001; 345: 1607-1610. 15. Swartz MN. Recognition and management of anthrax - an update. N Engl J Med. 2001; 345: 1621-1634. (review article) 16. Hajjeh RA, Relman D, Cieslak PR, et al. Surveillance for unexplained deaths and critical illnesses due to possibly infectious causes, United States, 1995-1998. Emerg Infect Dis. 2002; 8: 145-153. This large surveillance study provides a background estimate of severe illnesses that likely to be caused by infections but which are not diagnosed by routine meghods. Neurologic, respiratory, and cardiac presentations were most common. 17. Cole LA. Bioterrorism threats: Learning from inappropriate responses. Public Health Mgmt Pract. 2000; 6: 8-18. This study of inappropriate -- and sometimes dangerous -- reactions to bioterrorism threats emphasizes that practitioners must not only know what to do but must also know what not to do. 18. Inglesby T, Grossman R, O'Toole T. A plague on your city: Observations from Topoff. Clin Infect Dis. 2001; 32: 436-445 and Hoffman RE, Norton JE. Lessons learned from a full-scale bioterrorism exercise. Emerg Infect Dis 2000; 6: 652-653. These two articles are cautionary tales that describe the problems encountered by public health and safety officials have in responding to BT or BW simulations, emphasizing problems with authority, communications, and deciding who is in charge. |
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