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The hair-splitting difficulties of crafting new health care infection control guidelines in an age of bioterrorism were underscored at a recent meeting of the Centers for Disease Control and Prevention’s (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC).
In conversations that would have not likely occurred prior to Sept. 11 and its aftermath, the CDC and its advisors wrestled with the clinical and psychological implications of bioterror infection control. HICPAC is revising patient isolation guidelines and, in doing so, must consider anew the agents of bioterror.
For example, the traditional wisdom is that anthrax cannot spread from person to person. However, there are rare reports of cutaneous anthrax being spread, particularly under Third World conditions when antibiotics may not have been administered, the committee discussions revealed. Given that, the committee debated whether those infected with cutaneous anthrax should be treated with standard precautions or the more rigorous contact precautions.
But the issue was left unresolved at the meeting, in part, because the purely medical concerns were clouded by the psychological implications.
"My main concern here is not so much whether standard or contact precautions would work," said William Scheckler, MD, HICPAC member and epidemiologist at St. Mary’s Hospital in Madison, WI. "But [it’s] the notion that the public might get, that anthrax can spread willy-nilly from cutaneous lesions. I am more concerned about the fear epidemic than anthrax exposures if we start saying that it requires contact precautions."
In addition, there is the issue of dealing with the incoming patient who reports exposure to a possible anthrax powder. Though, again, the traditional view is that anthrax is not communicable, there is the issue of a health care worker inhaling spores off the person’s clothing. Thus, the committee discussed wearing respiratory protection while getting such patients to an area where they can remove their clothes and shower. The committee may add a "decontamination section" to the document to address such issues, which must be addressed in the new age of bioterrorism.
"One of the [lessons] that we learned is that you can’t tell if a powder is aerosolized or not," said Julie Gerberding, MD, director of the CDC division of healthcare quality promotion.
Similar discussions based on threadbare data occurred regarding Ebola. The natural outbreaks in Africa have included cases that suggest the disease can be spread by the airborne route in its latter stages. There are accounts of family members of victims being infected without coming into contact with them. The committee discussed whether to stay with its current recommendations for contact and droplet precautions or recommend airborne precautions (e.g., tuberculosis).
"It seems like this is going to be so rare in the United States that being extreme in terms of the isolation would be reasonable," said Robert Weinstein, MD, HICPAC chairman and epidemiologist at Cook County Hospital in Chicago. "If this is a U.S. document [only], I have no problem being more extreme."
While such an approach appears reasonable given the rare natural occurrence of the pathogen, the specter of bioterrorism complicates making such a recommendation. "You may actually have a situation where it may not be possible to implement airborne precautions on a broad scale," Gerberding reminded.
Thus, despite a strong body of data suggesting that droplet precautions are sufficient, the more rigorous — and difficult to implement — airborne precautions may work their way into bioterrorism documents if the CDC made such a recommendation.