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On the heels of the vicious terrorist attacks of Sept. 11, 2001, and a harrowing succession of bioterrorism events involving anthrax, infection control professionals find themselves front and center in America’s new war. In particular, the unfolding anthrax investigations and mailings underscore that bioterrorism is no longer a theoretical concern. (See Bioterrorism Watch articles in this issue.)
While many ICPs have been warning about the threat of bioterrorism long before recent events, they are now less likely to have their voices ignored or their efforts unfunded. "I have heard the frustrations that [bioterrorism planning] has not been given as high a priority as other things," says Ellen Gursky, ScD, senior fellow and bioterrorism expert at the Center for Civilian Biodefense Studies at Johns Hopkins University in Baltimore. "That has all changed. I think there will be a lot more [federal] money, and we need to determine the best ways of using those dollars. Very definitely some of that money has to be used to help hospitals with their capacity to handle a large-scale disaster event," she says.
Indeed, groups such as the American Hospital Association in Chicago have argued that overly regulated and fiscally strapped hospitals have no money to prepare for such an event. (See Hospital Infection Control, March 2000; Feb. 2001, under "Archives" at www.HIConline.com.) In the wake of the attacks, the Joint Commission on Accreditation of Healthcare Organizations is asking Congress to earmark federal assistance for the nation’s hospitals if it expects them to handle a bioterrorism event. (See "JCAHO chief appeals for bioterror funding," in this issue.)
Scholars from the biodefense center have been testifying regularly before Congress on bioterrorism issues, warning repeatedly that most hospitals are ill prepared to deal with an attack in their communities. "We know that there are people who have these bioweapons," Gursky says. "They have the capability to manufacture and probably successfully use them. We have all had a wakeup call. It is likely that they are considering other opportunities to inflict mass harm."
But by the same token, bioterrorism preparedness will no doubt substantially increase nationwide, making a successful large-scale attack less likely than it was before Sept. 11. "A lot of people now in the government are taking this [threat] very, very seriously," Gursky says. "They have significantly ramped up surveillance, oversight, prevention procedures, and awareness. So while there may be a greater believability’ that [bioterrorists] might try something, I think we are better prepared and more rigorous in our oversight to prevent it from happening," she adds.
"What all this has done is to create an environment where all of a sudden there is a very receptive audience in hospital administration and among other local medical entities for discussing bioterrorism and for concrete planning," says Allan J. Morrison Jr., MD, MSc, FACP, a bioterrorism expert and health care epidemiologist for the Inova Health System in Washington, DC. "Previously, it may have been pushed off as a lesser priority given the constraints of health care in the current economy."
To guide in such preparations, the Association for Professionals in Infection Control and Epidemiology (APIC) in Washington, DC, is urging ICPs to review its disaster readiness checklist and its overall bioterrorism preparedness plan. (See "Answers to these questions will reveal facility’s readiness," in this issue.) "Everybody ought to go through it and seriously deal with all of the issues on that list," says APIC President Judith F. English, RN, MSN, CIC. "Now. The sooner the better. The list will help [ICPs] integrate what they do into the big picture. Communication will be everything."
In addition to bioterrorism preparedness, the checklist can help facilities prepare for chemical attacks and natural disasters, she says. The lead author of many of APIC’s bioterrorism plans, English is an ICP at the National Naval Medical Center in Bethesda, MD. The new emphasis on bioterrorism preparedness must include the critical component of protecting health care workers and their families, she says. Health care workers trying to treat hundreds of incoming infected patients would face a risk akin to firefighters and policemen who lost their lives trying to aid victims at the World Trade Center in New York City, she adds.
"They were just as victimized as the people in the buildings at that point," she says. "Health care providers need to be given assurances that they and their loved ones will be given appropriate antibiotics and preventive prophylaxis and therapy so they will show up for work. That is a very serious concern." Asked about the anthrax cases, English somberly reminded that one man already has died, calling the situation "a tragedy."
For those who witnessed the recent carnage, bioterror threats can scarcely approach the horror they already have experienced. Peggy Fracaro, RN, MA, CIC, infection control director at Columbia Presbyterian Hospital in New York City, saw the second of the Twin Towers collapse while standing outside her facility with stunned co-workers. (See "ICP eyewitness to day of infamy," in this issue.) "I’m on 168th Street and Broadway, with a full view of downtown," she tells Hospital Infection Control. "What you see on television does not reflect the true devastation. You don’t get that dimension of destruction."
If a wide-scale bioterrorism attack occurs, major metropolitan areas will be the likely targets, Morrison says. And as bad as the recent attacks on their cities were, both Morrison and Fracaro note that the toll of devastation could have been much worse. For example, emerging evidence suggests that the Washington, DC-bound plane that was brought down in Pennsylvania by heroic passengers likely was headed for another major target such as the Capitol or the White House.
"This breed of terrorists has no regard for human life," Morrison says. "But also they are very geared toward the symbolic aspects of the attack."
Likewise, had the Trade Center buildings fallen over rather than imploding, even New York could have seen a worse result, Fracaro adds. "You could have had a domino effect. Imagine what that would have done. You could have had miles of collapsed buildings. As awful as it was, the reality is it could have been worse. That’s hard to imagine from what you see down there."
The end result is that as gruesome as the Sept. 11 attacks were, they did not really test the health care system in the same way as a large-scale biological event. By the same token, the scattershot anthrax mailing campaign that has followed is not likely to generate any great number of victims because the disease is not communicable.
The prime concern regarding hospital preparedness for bioterrorism is the ability to handle a mass surge of casualties and/or infected patients, Gursky says.
That scenario did not play out in the recent attacks because there were so many immediate deaths. A rapid assessment conducted by city health officials during the first 24 hours after the incident indicated that most emergency department visits were for minor injuries. Approximately 10% to 15% of emergency patients were admitted, but few deaths occurred in the hospitals. Hospital bed and staff capacity was adequate, the department reported. "What we learned from the 11th in terms of surge capacity was limited because of the high mortality rate," Gursky says.
Indeed, in the shocking aftermath of the attack, New York City hospitals rolled out their disaster plans, discharged noncritical patients and waited for an onslaught of injured. At most facilities, they never came.
"It became pretty clear early on that there were going to be many more deaths than patients to try and save," Fracaro says. "Even in [hospitals] that were much closer to the disaster, the wave of injuries was in those first hours, that first day, then it stopped. Just body parts, pulverized concrete and steel. Devastating."
In the immediate aftermath, New York health officials alerted hospital ICPs to begin looking for signs of a secondary bioterrorism attack as evidenced by clusters of patients with the classic symptoms. (To see "Treatment of Biological Agent Exposure," click here.)
"People in the emergency departments [EDs] were looking for any cluster of fever, sepsis, or respiratory illness," Fracaro says. "[State health] was telling us to be alert and get back to them if they had any kind of suspicion that patients were being admitted with those kinds of symptoms."
At the same time, Centers for Disease Control and Prevention epidemiologists began staking out EDs to look for signs or symptoms of bioterror infections. CDC Epidemic Intelligence Service officers were stationed at EDs in 15 sentinel hospitals distributed throughout the city’s five boroughs. The efforts complemented an existing syndromic surveillance system that monitors 911 emergency calls.
"I think this was a prudent concern on the part of the city and the CDC," says Mike Bell, MD, medical epidemiologist in the CDC division of healthcare quality promotion. "We find it very unlikely, but it is not an impossibility. Rather then being caught flat-footed, it makes much more sense to be on the lookout."
In addition, the CDC mobilized to the site to get as much firsthand experience as possible with such a disaster. "Our main role was to gather information about what the impact was on individuals and on health care facilities following the attack," Bell says. "There is also a lot of work to look at the impact of the rescue efforts on the emergency workers and field working staff. You can imagine there is dust inhalation, trauma, and so on that occurs while you are trying to dig people out," he adds.
While nothing was found to indicate any biological agents were released in the immediate aftermath of Sept. 11, Bell says there will likely be a secondary wave of suffering of a different sort. "I think the thing that we might well find is that the psychological impact will likely be prolonged and fairly extensive," he says. "I imagine that people are going to be seeking counseling and care for post-traumatic stress syndrome for some time to come."
As far as the likelihood of more bioterrorism events in the days and months ahead, it remains an unpredictable problem, he adds. "The very nature of the problem is what makes it impossible to predict," Bell says. "What this does tell us is that there is a will to do damage. Whether it will be further incendiary attacks or whether it will be biological, I don’t think there is any way to predict. The problem with terrorism is that it is a sporadic thing. Denominators and baseline rates don’t mean anything. Then, if it happens, it’s 100%."