Ten commandments’ and a lot of prayer

Keep your head when others are losing theirs

Thinking the unthinkable is a difficult process, full of caveats and contingencies, but the one stark truism of a bioterrorism event is: Expect casualties. "You’ve got to start off with the assumption right off the bat you won’t manage all of the patients — a lot of patients will die," said Randy Culpepper, MD, MPH, a bioterrorism expert with the U.S. Army Medical Research Institute of Infectious Diseases at Fort Detrick in Frederick, MD. "That’s just going to be the bottom line. The number of casualties will be overwhelming in any city with any moderate-scale biological agent release."

But with that disturbing initial concession, what then can health care providers do to prepare for the worst and lessen any death and suffering that may occur? Culpepper provided some guidance in Seattle at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC), held in June. These are the 10 recommended maxims — or commandments, as Culpepper calls them — for how to handle a bioterrorism event:

1. Thou shalt maintain an index of suspicion. Recent emerging diseases such as West Nile Virus and foot-and-mouth disease in European livestock have triggered suspicions of possible bioterrorism events, Culpepper said. "We’ve never had West Nile virus in this country, ever," he said. "So all of a sudden now we have dying animals and dying people because of this new virus. Do you think we thought about bioterrorism? You bet we did. Five years ago, 10 years ago, we probably would not have thought about that."

Similarly, might a bioterrorist want to strike an economic blow by devastating livestock with an infectious disease? "That very well could have been a bioterrorist event, by releasing that agent into a herd somewhere, knowing that it would be propagated from herd to herd," he said. "[It would be] very easy to do. So at least, we’re thinking about it. At least, we have that raised index of suspicion now."

In trying to distinguish a possible bioterrorism event from a naturally emerging infection, look for a sharply rising epidemic curve that suggests a mass exposure, he said. In addition, consider the geographic aspects of the disease. "If I had a pneumonic plague in Arizona, am I too worried?" he said. "Am I suspicious? Not too much. We have plague in southwest United States quite a bit. If I have a plague case in Washington, DC, am I worried? Oh, yeah."

2. Thou shalt protect thyself and thy patients. Standard infection control precautions should be sufficient for most agents, though protective suits and filtered masks would be needed for chemical and airborne exposures, he said. There are only two vaccines licensed for any of the bioterrorism agents: anthrax and smallpox. Those vaccines are of limited availability, and vaccines for the other agents are still under research. "Suffice it to say that it’s going to take at least four to 10 more years before any other bioterrorism vaccine gets licensed by the FDA [Food and Drug Administration]," Culpepper said.

3. Thou shalt adequately assess the patient. "We’re going to need as many health care providers as we can get our hands on to help as a team to manage the consequences of this overwhelming event," he said. "So it’s important for everybody to understand how to adequately assess the patient."

Questions to consider include route of entry, effects, severity, and duration of illness. "Try to find out where the onset occurred, where the exposure occurred," he said. "Don’t forget there might be other illnesses in addition to the biological agent of exposure."

Get the history of the patients, he urged, including immunization records, where they have been, and whether anyone else they have been with is ill. Try to determine if they have been exposed to mosquitoes, fleas, or other possible vectors. The source of infection and time of exposure are critical factors. The physical exam, Culpepper recommended, should focus on four body systems: respiratory, neuromuscular, circulatory, and dermatological.

4. Thou shalt decontaminate as appropriate. Sterilization and disinfection protocols for surfaces and equipment must be followed, but basic infection control measures are just as important.

The importance of soap and water

"The bottom line for personnel [and] patients: If you’re going to decontaminate, soap and water are all you need," he said. "Because, after all, these are just bugs. They’re just bugs like we deal with all the time. What do we teach in the hospitals? Soap and water — wash your hands. Isn’t that adequate usually for most organisms? For material, though, if you wanted to use a bleach solution, you can do that. Five percent bleach kills most everything. [But] decontamination isn’t that big of an issue for bioterrorism."

5. Thou shalt establish a diagnosis. Following an exposure to a bioagent, there is such a small window of opportunity that it is critical to establish a diagnosis so therapy can begin, he said. "If the patient’s critically ill, I’m afraid we might be doing autopsy specimens. But at least if we can identify through an autopsy what the cause of death was, there still may be patients who haven’t even begun to be symptomatic yet."

Culpepper cited some typical manifestations of common bioterrorism agents. For example, anthrax gets in the lungs, starts to multiply, and creates toxins. "The organisms multiply in the mediastinum space in the lymph nodes; the lymph nodes start expanding; and once they start expanding, they start bleeding into the space between the lobes of the lungs," he said. "If you take an X-ray, [you will see] a very classic white large area in the center of the chest instead of the nice dark lung fields. Widened mediastinum is classic for anthrax."

On the other hand, plague patients will likely be coughing up blood. Smallpox patients may look like they have chickenpox, but there are key differences, he reminded. In chicken pox, lesions typically appear on the trunk of the body first and may present in various stages. With smallpox, lesions appear on the face and hands first and then work inward on the body. In addition, with smallpox, all of the lesions are at the same stage of development, he added. Botulism causes a flaccid paralysis that begins with the head (e.g., droopy eyelids) and works its way down the cranial nerves into the respiratory muscles. Viral hemorrhagic fevers like Ebola will present dramatically with patients bleeding out of the nose, eyes, ears, and gums.

"You need that high index of suspicion," he said. "You need to make this clinical diagnosis quickly because we have a small window of opportunity. You need to use your clinical skills, your epidemiological skills . . . and your laboratory skills. You need them all to really put the whole picture together. If I was a doctor in a hospital, and I’ve got a huge epidemic going on, I’m going to [the infection control practitioner]. You tell me what’s going on. You help me out. Identify what the source of this thing is."

6. Thou shalt render prompt treatment. Looking at the patient in terms of respiratory/ neurological status and rapid/delayed onset of symptoms can guide expedient therapy. "Notice that all the immediate symptoms occur as a result of chemical exposures, which you may not be so sure of right off the bat," Culpepper said. A cyanide kit and nerve agents can help treat the rapid onset cases. Botulism antitoxin is needed for botulism exposure, and the antibiotics doxycycline and ciprofloxacin are recommended for the bacterial organisms, he noted.

"If you don’t know what it is — if you’ve got a large epidemic and you’re learning that this is probably an unnatural event that’s caused by some terrorist — but you [see] delayed, primarily pulmonary symptoms, start dispensing doxy or ciprofloxacin right away," he said. "Just start doing it. Don’t even wait."

7. Thou shalt practice good infection control. "Standard precautions are adequate enough infection control for literally almost all the biological agents," Culpepper said. Exceptions include smallpox, which would require airborne precautions similar to those used for measles or pulmonary tuberculosis.

The only other bioterrorism agent that is contagious to secondary contacts is pneumonic plague, which would require droplet precautions like those used for pertussis. "There are only two — smallpox and pneumonic plague — [that] I’m concerned about easily being transferred person-to-person in our modern health care system," he said.

Contact precautions are recommended for viral hemorrhagic fevers, which are not airborne pathogens but can be associated with blood exposures. Poor infection control and too much contact with patients and victims have contributed to spread in African outbreaks, he noted.

Regardless of pathogen, a question that will arise at the local level is what to do with infected cadavers. Culpepper advised consulting the hospital pathologist and formulating a plan. "Are you going to cremate them?" he asked. "I don’t think so. [Not] before they even get returned to their families? [There are] lots of concerns here, but you’ve got to think about it."

8. Thou shalt alert the proper authorities. If a bioterrorism incident occurs, immediately notify all public health contacts, laboratory personnel, and the Federal Bureau of Investigation. Opening lines of communication in advance is advised, and many communities have done that, Culpepper said. "You’ve just got to notify everybody."

9. Thou shalt assist in the epidemiological assessment. While the basics of conducting an epidemiological investigation are well known, many health care providers are ill-prepared to do it. Health care epidemiologists will have to take the lead. "Who can do that better than you?" he asked APIC attendees. "Nobody. Not in your hospitals."

10. Thou shalt know and spread the gospel. Again, take the leadership role in developing a bioterrorism response plan and educating others. "Don’t plan in isolation," he said. "Plan with your whole community. It has to be a community effort. I’ve never met a biological agent that will stay within the confines of a base or military post. It’s a community problem. Educate your staff and exercise and train. I recommend making your [bioterrorism plan] part of your disaster preparedness plan."