Special Feature
Biological Terrorism and the Emergency Department
By Robert Hoffman, MD
Formerly, terrorism only referred to events that happened in distant places on the globe, and always involved the use of conventional explosive weapons. The ease with which conventional weapons can be made and deployed, their ability to inflict mass casualties, and the low cost of raw materials made them the ideal instruments of terror. The bombing of the World Trade Center in New York brought terrorism to the forefront in the United States. The destruction of the federal building in Oklahoma City taught us that targets are not limited to big cities and national landmarks.
While these events have tremendous social and political ramifications, as emergency physicians we all feel able to respond to this form of terrorism. Victims of a bomb blast are not significantly different from those of an earthquake, a fire, or a massive transportation incident such as an airplane crash. We train for these disasters regularly. However, the break-up of the former Soviet Union, events in the Middle East, and enhanced domestic security have raised the specter of a new form of terrorism involving the use of chemical or biological weapons.
This is not a new concept: Lethal gases were used more than 1000 years ago, and the corpses of plague victims were used as catapult ammunition in the Middle Ages. Unfortunately, the sophistication that has resulted from state-sponsored weapons programs and public access to knowledge and resources has created an environment where chemical and biological weapons are likely to be used on United States soil. Government representatives repeatedly tell us it is no longer a matter of if these weapons will be used, but rather when they will be used. In fact, it has already happened! In 1984, a cult in Oregon attempted to influence a local election by adding Salmonella to a local salad bar. More than 700 victims were infected. Furthermore, many authorities have questioned whether the recent West Nile encephalitis outbreak in the New York area was of natural origin.
The authors of a recent article suggest that emergency physicians are not properly trained to recognize and respond to these events.1 A 14-question survey was distributed to 118 emergency medicine residency training programs. Only 53% of respondents claimed to have formal training in biological warfare as part of their program. This compared with formal hazardous materials training being provided in 84% of the programs. So, how do we prepare, and is it worth preparing for an event that may never happen?
Biological warfare and terrorism involve the weaponization of biological agents that already occur in nature. As such, the first step in preparedness is to understand the natural history of these diseases. Although the list of potential agents is extensive, it includes diseases such as viral hemorrhagic fever, tularemia, plague, Q fever, anthrax, botulism, and cholera. While many of these pathogens claim their natural victims outside the United States, the ease of international travel and the incubation periods for these disorders only guarantee that natural cases will occur on United States soil and most likely will be seen first in the emergency department. Thus, by preparing for terrorism, we in fact are preparing to recognize and treat rare and serious natural disease as well.
The next step in preparedness involves an understanding of the principles of infection control.2 Standard precautions of wearing gloves, hand washing, respiratory isolation, and proper disposal of contaminated material are essential when providing care for a patient exposed to a biological weapon. More importantly, they are equally important for routine cases of measles, chickenpox, and caring for patients with neutropenia or severe immune disorders. Universal precautions also apply to trauma patients and those with hepatitis or HIV. Hospitals need to assess their ability to handle serious outbreaks of measles or influenza. Once again, the lessons of preparedness for biological warfare or terrorism can be applied to daily practice.
Next, we must develop an understanding of the principles of diagnosis and notification. Many hospitals have the ability to diagnose common diseases that are associated with biological warfare or terrorism. The less common diseases require confirmation by specialized laboratories. All communities have lists of diseases that require mandatory reporting to public health officials. Emergency physicians should learn how to access these contacts for assistance with diagnoses of rare infectious diseases or unexpected outbreaks of more common diseases.
The final step involves initiation of treatment. While specific protocols are clearly beyond the scope of this work, many sources are available to guide therapy. Under most circumstances, drugs like doxycycline or ciprofloxacin have been shown to be effective against most bacterial pathogens that would be used in an attack. Specific vaccinations and antitoxin are available for some other agents. Contacts should be made with local health authorities and governmental representatives to develop stockpiles of these drugs.
Thus, it should be clear that we are all already somewhat prepared for biological warfare. Despite that fact, this is an excellent time to review principles mentioned above that will be useful in our everyday practice. Remember that the first and most important lesson is how to detect a potential bioterrorism event.3 The following events should raise your suspicion: simultaneous reports of sick people and animals, multiple patients with simultaneous illness, significant illness in young and healthy individuals, and emergence of unusual organisms.
Anyone who has read this far has successfully completed the first phase in training by recognizing that a potential problem exists. You are all encouraged to read and learn more about this threat.
References
1. Pesik N, et al. Do U.S. emergency medicine residency programs provide adequate training for bioterrorism? Ann Emerg Med 1999;34:173-176.
2. Keim M, Kaufmann AF. Principles for emergency response to bioterrorism. Ann Emerg Med 1999;34: 177-182.
3. Richards CF, et al. Emergency physicians and biological terrorism. Ann Emerg Med 1999;34:183-190.
Possible agents of bioterrorism include:
a. anthrax.
b. botulism.
c. tularemia.
d. all of the above.
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