First cases in a bioterrorism attack may go undiagnosed by physicians

First cases in a bioterrorism attack may go undiagnosed by physicians

A trip on the Metro and the cat’s out of the bag’

Though we live in the shadow of 9/11 and the anthrax attacks that followed, it appears likely that the first wave of bioterrorism attack in this country may go undetected. The most likely infectious agents to be used in a bioterrorism attack are so rarely seen that physicians simply may not make the initial diagnosis.

"One has to recognize the reality that physicians operating in a developed country like this one essentially see no naturally occurring anthrax and plague," says Joseph R. Masci, MD, author of a new book on bioterrorism preparedness and director of medicine at Elmhurst Hospital Center in New York City.¹ "There is no natural occurring smallpox in the world, and we see a thousand other diseases all the time. It is quite a challenge to keep them focused enough that they are going to pick the needle out of the haystack."

For example, more than one-half of 631 physicians tested were unable to correctly diagnose diseases caused by smallpox, anthrax, botulism, and plague, according to a recently published study.²

"Most American physicians in practice today have never seen any cases of these diseases in their practice," says Sara Cosgrove, MD, MS, lead author of the paper and an epidemiologist in the division of infectious diseases at Johns Hopkins University Hospital and Health System in Baltimore. "Education and training health care providers in disease recognition, treatment, and prevention strategies have the potential to significantly limit the effects of a bioterrorism attack."

What are the possible consequences of delayed or missed diagnosis? Obviously, the implications are the most serious for an agent that could spread from person to person like smallpox or pneumonic plague. "If [you miss those] all it takes is a trip on the Metro from the clinic and the cat’s out of the bag," says Stephen Sisson, MD, co-author of the study and assistant professor of medicine at Johns Hopkins. "The spread from person to person will be minimized the sooner you diagnose somebody and quarantine them."

While widening the ring of subsequent transmission is not an issue, missing an airborne anthrax diagnosis could spell death for the patient. "With anthrax the case fatality rate is quite high so delaying treatment may kill them," Sisson says. "But it is not going to spread disease."

Of course, prompt diagnosis would have implications for criminal investigations into the attack. "If you see a botulism case - again it is not spread from person to person - but there are going to be other people out there who were probably exposed in the same event," he adds. "Making the public aware and getting them into treatment sooner will be important."

Study: Diagnosis results poor’

In the Johns Hopkins study, an online educational intervention was completed by 631 physicians at 30 internal medicine residency programs in 16 states and Washington, DC, between July 1, 2003, and June 10, 2004. Participants completed a pretest, assessing ability to diagnose and manage potential cases of smallpox, anthrax, botulism, and plague. An online didactic module reviewing diagnosis and management of these diseases was then completed, followed by a posttest. Pretest performance measured baseline knowledge. Posttest performance compared with pretest performance measured effectiveness of the educational intervention. Results were compared based on year of training and geographic location of the residency program.

Correct diagnoses of diseases due to bioterrorism agents were as follows: smallpox, 50.7%; anthrax, 70.5%; botulism, 49.6%; and plague, 16.3% (average, 46.8%). Correct diagnosis averaged 79.0% after completing the didactic module. Correct management of smallpox was 14.6%; anthrax, 17.0%; botulism, 60.2%; and plague, 9.7% . Correct management averaged 79.1% after completing the didactic module. Performance did not differ based on year of training or geographic location. Attending physicians performed better than residents. The researchers concluded that physician diagnosis and management of diseases caused by bioterrorism agents is "poor," but the online training module increased scores dramatically.

"The Internet offers many resources on bioterrorism training, including the Centers for Disease Control and Prevention’s web site as well as the Hopkins’ curriculum, and physicians who want to be prepared should take the initiative to familiarize themselves with this information," Sisson emphasizes.

Though bioterrorism is very much a real world concern, it appears largely relegated to a fringe issue of emphasis in the nation’s medical schools and residency programs.

The study didn’t formally address that issue, but the findings are suggested in the fact that test scores did not improve regardless of post-graduate-year (PGY) of study. "In the programs that participated in this study, the PGY 1s and PGY 3s preformed no differently," Sisson says. "That suggests that there was no improvement in knowledge based on your years of training, which means your not learning during your residency how to handle this stuff. When we looked at similar scores on hypertension and diabetes management the score goes up from year to year."

Physicians trained before 9/11 may have received less information on bioterrorism. "Smallpox was mentioned to me once in medical school," Sisson says. "I finished residency 10 years ago. It wasn’t on the agenda. It had been eradicated so why would we need to learn about it? Since 2001 that certainly has changed. It seems like it should be included in the educational process, both for residency training and for continued certification."

Certainly, some educational efforts still resonated in the aftermath of the anthrax attacks. Many physicians tested in the study were quick to identify the tell-tale signs of airborne anthrax when shown a widened mediastinum on chest x-ray. "However, they did poorly with management issues," he notes. "They misunderstood the difference between prophylaxing with cipro for somebody who was exposed vs. treatment of somebody who actually has anthrax, which requires two antibiotics. That’s where people were not clear."

Smallpox recognition would presumably have been higher, as the study period overlapped the highly publicized vaccination campaigns for the military and health care workers. "It was surprising," he says. "The attending [physicians] did a little better than the residents, and we think that is because they are actually more familiar with chickenpox," he says. "My personal sense was there wasn’t as much discussion about what the rash of smallpox looks like and how to differentiate it from chickenpox. Whereas with anthrax, everyone was talking about the mediastinum widening that you see on chest x-ray. I think the national conversation about the two was a little bit different. With smallpox the whole issue of immunization was more of the national conversation than actual identification of somebody with smallpox."

Everyday demands trump bioterrorism

Still, given the demands placed on physicians, how much motivation are they really going to have to learn more about disease that they may never have to face? "That’s a very important question," he concedes. "In clinic everyday I see 20 people with hypertension, high cholesterol, diabetes, depression, and back pain. I owe it to them to be current on proper management [of those conditions] and new medicines that are coming out. So where does the time come to keep myself current and relearning about smallpox, anthrax, and botulism when it is very unlikely that I am going to see it?"

One method would be requiring some level of bioterrorism knowledge as part of board certification. "That would be the stick vs. the carrot," he says. "If you needed to know this stuff to get certified, you are going to know it.

In his book on bioterrorism preparedness, Masci includes key elements of a curriculum to keep hospital based health care workers educated about bioterrorism.

"There are many areas where hospital staff get annual reeducation, for example infection control, recognizing child abuse," he says. "I think emergency preparedness is something that every health care worker in a hospital should have at least a working familiarity with."

That said, it is no easy task to teach bioterrorism response job-specific duties and tasks in an education program, he concedes. "But I think that should be the goal, where everybody would know exactly what their role would be — or at least know who they could turn to for advice about what their role should be — in an attack."

Asked about the results of the Hopkins study, Masci notes, "It doesn’t surprise me. Prior to 9/11 there were similar studies. There was not only a very limited ability to recognize the symptoms of an attack, but a really shockingly low ability in response to questions, like What would you do next? Who would you contact?’"

With 9/11 and the anthrax attacks, awareness improved, but may again be fading as we move out from those landmark events. One solution is to hold tabletop exercises and drills to alert clinicians and responders about where their gaps in knowledge are, he adds.

"It’s difficult," Masci says. "We need to boil it down to some obvious features of these diseases for people. That’s been attempted. There was a long series of articles in JAMA going through the nuts and bolts of all the major agents. That’s a journal that most physicians read. But we’re going to have to constantly re-survey and reassess that."

The analogy of the hard-pressed physician extends to the hospitals they work in. There appears to be little extra time for anything in the modern climate of health care. "As far as the traditional agents of bioterrorism, the reality is that there will continue to be a relatively small group of public health professionals, physicians, and other health care workers who are involved in this area and are knowledgeable about it," Masci says. "But there will be a lot of on-the-spot training that will occur in the actual context of an attack. That’s inevitably the situation that we are in right now. We just can’t expect everybody to keep up to speed on all possible scenarios."

Moreover, the outlook becomes all the more complicated when one considers that the agents will not remain the same. The list of usual suspects may continue to shift as new diseases emerge or possible genetic modifications of old ones must be considered.

"I don’t want to sound discouraging because I think there is a lot that can be done and I am enthusiastic about this field," Masci says. "But when you talk about the indefinite future, the agents that are most likely to be of concern today may be very different from the ones that are of concern five years from now."

References

1. Masci JR, Bass E. "Bioterrorism: A Guide for Hospital Preparedness." Boca Raton, FL, CRC Press: 2005
2. Cosgrove SE, Perl TM, Song X, et al. Ability of Physicians to Diagnose and Manage Illness Due to Category A Bioterrorism Agents Arch Intern Med. 2005;165:2002-2006.