American College of Physicians: Internal Medicine — Doctors for Adults ®

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Introduction: Strengthening the front line against bioterrorism

From the May ACP Observer, copyright 2004 by the American College of Physicians.

In 2001, anthrax-filled envelopes that were mailed to several sites along the East Coast made the threat of bioterrorism in this country a reality.

Along with killing five Americans, the attacks exposed serious vulnerabilities in the U.S. health care system. Some of the physicians who treated attack victims did not quickly recognize the symptoms of the rarely encountered anthrax bacteria. Subsequent delays in diagnosis and treatment increased the number of fatalities.

The tragic lesson learned during the 2001 attacks is that rapid recognition and reporting are key to containing the spread of bioweapons and reducing casualties. Because experts say that additional attacks are possible, they are calling on physicians to arm themselves with knowledge on likely bioterrorist agents.

Several factors, however, make physicians' front-line role in the battle against bioterrorism difficult. For one, internists rarely see most of the pathogens that are likely to be used in a bioterrorist attack. Patients may also present with atypical symptoms if unusual dissemination methods are used during an attack, or if pathogens have been changed at a molecular level.

This special supplement to ACP Observer is designed to re-acquaint physicians with the six pathogens the CDC has classified as category A pathogens. The agency has reserved this classification for agents that would be the easiest to transmit and would cause the greatest public health devastation. Several of these pathogens have already been developed or used as bioweapons, including anthrax, smallpox, plague and botulinum toxin.

Because the outbreak of disease in an attack is likely to differ from naturally-occurring disease from the same microbe, this supplement includes the "ACP Guide to Bioterrorism Identification," with a list of epidemiologic clues to help detect a potential event. (See the "ACP Guide to Bioterrorism Identification" and the "ACP Guide to Chemical Terrorism Identification.") The articles highlighting each pathogen include more specific epidemiologic indicators.

Any infection with a category A agent represents a potential public health emergency that must be contained by public health officials. Most of these pathogens require specialized sample collection, as well as testing procedures or reagents that only public health officials can provide.

Testing laboratories will also need to be warned to take the extra precautions required with a suspected category A pathogen. And physicians and other health professionals will have to follow guidelines for proper patient isolation and contact surveillance.

If physicians suspect that patients have been exposed to a category A pathogen, they should immediately report that information to local and state public health officials. CDC's message to physicians who suspect any form of bioterrorism is clear: Do not wait to confirm your suspicions with laboratory findings before reporting a suspected attack. As the events of 2001 made clear, fighting bioterrorism is not only a struggle against criminal intent, but also a race against the clock.

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Reporting suspected events

Internists are likely to be the first health care professionals to encounter victims of a bioterrorist attack. To ensure a prompt and effective response, public health officials urge physicians to do the following:

  • Immediately notify hospital infection control specialists and local and state public health officials whenever they suspect a bioterrorist attack has occurred. Any patients presenting with distinctive symptoms or signs of infection with a category A pathogen should prompt notification procedures.

  • Do not wait for confirmation.

  • Contact the laboratory conducting diagnostic testing on patients' specimens so personnel can take proper precautions and provide specific instructions on specimen collection, packaging and transport.

  • Notify the CDC when local laboratories and public health officials cannot be reached. The CDC's emergency response hotline, which operates 24 hours a day, is 770-488-7100. A list of state and local public health department contact information is online.

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Online resources

The Internet is a rich repository for information on bioterrorism, including facts, images and decision support tools. Here is a sampling of some of the resources available on the Web:

  • Decision support tools for anthrax and smallpox, detailed information on the pathogens likely to be used in a bioterrorist attack, and clinical images are on ACP's Bioterrorism Resource Center.

  • Palm pilot documents on bioterrorism identification, including quick facts on individual bioterrorism pathogens and clinical decision support tools, are online.

  • A list of bioterrorism agents and diseases, as well as detailed information on likely pathogens and clinical images, can be found on the CDC's Web site.

  • The College's MKSAP 13: Medical Aspects of Bioterrorism is online.

  • A clinician registry form to receive regular CDC updates on bioterrorism can be found online.

  • A bioterrorism self-assessment quiz is online. (Also see "Self-Assessment.")

  • ACP's public policy and advocacy recommendations on bioterrorism can be found at ACP Online.

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ACP Bioterrorism Resource Guide: Acknowledgements

Editor: Patrick Alguire, FACP

Special thanks to:

  • Tee L. Guidotti, FACP, director, division of occupational medicine and toxicology, George Washington University Medical Center.

  • Daniel Havlichek Jr., ACP Member, associate professor of medicine, Michigan State University College of Human Medicine.

Photos courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention.

This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of American Medical Colleges (AAMC), grant number U36/CCU319276-02-3.

Publication and report contents are solely the responsibility of the authors and do not necessarily represent the official views of the AAMC or the CDC.

The information included herein should never be used as a substitute for clinical judghment and does not represent an official position of ACP.

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