This article describes the plan for a coherent community response to terrorism developed with leadership from public health authorities in a large urban community located on the Mexican border with numerous military installations, an active seaport, and international airport. The actions expected of primary care physicians, with particular emphasis on expectations of pediatric health professionals, are explained in the context of the federal, state, and local infrastructure in place for early identification and effective response to acts of terrorism.
THE ROLE OF THE PHYSICIAN
In June 2002, two of the terrorists who would pilot flights on September 1 1, 2001, were in an emergency department in Florida. The reason the patient was brought to the emergency department by his friend was determined subsequently to be cutaneous anthrax.1 Although the skin condition undoubtedly responded to the prescribed antibiotic without the causative organism having been identified, it is difficult not to speculate how this scenario might have played out differently. A frontline physician has good reason to fear missing a diagnosis that has dire consequences for the patient, let alone consequences for the larger population or the nation.
Acquire Reliable Resources
The problem faced by physicians is not the lack of information, but rather how to determine which sources of information are valid, science-based, and up-to-date. Information has proliferated and been disseminated extensively since 9/11 to assist physicians with expanding differential diagnoses, using appropriate diagnostic procedures, treating conditions that may be the result of terrorìsm, as well as protecting themselves and others. Providing information is a crucial role for public health agencies at the national (Centers for Disease Control and Prevention [CDC], National Disaster Medical System, and the Food and Drug Administration), state (state departments of public health), and local county and/or city levels. A list of valuable resources available for pediatric health professionals is provided on page 92. These governmental agencies can help physicians identify information that is science-based and valid. In San Diego County, the Health and Human Services Agency conveys pertinent information to area physicians using written communication, the Internet, fax messages, telephone consultation, and educational programs.
Figure. The role of primary care providers reporting suspected signs of bioterrorism. Adapted from County of San Diego, Office of Public Health, October 2002.
Actions Expected of Physicians in Terrorism Events
Despite the plethora of data readily available for physicians, the question that begs an answer is: What exactly is a physician expected to do in the event of suspected or confirmed bioterrorism? In order to answer that question, some actions were formulated, with review and input elicited from area physicians in a variety of specialties and also from public health authorities. The resulting list of expected actions is shown in Table 1.
Expand Differential Diagnoses. Many physicians practicing in the United States have heard tins aphorism when learning about differential diagnoses: If you hear hoof beats, don't look out the window and expect to see zebras. The basis of the aphorism is Occam's Razor and refers to the principle introduced by the 14th century scholar that suggested trimming away unnecessarily complicated assumptions in thinking.2 Ironically, this principle may have to be shelved as not applicable in our current situation, since the etiology of rather ordinary signs and symptoms could be zebras instead of horses. In other words, physicians are now challenged to expand their differential diagnoses to include heretofore rare or presumed eradicated diseases such as smallpox, anthrax, plague, tularemia, viral hemorrhagic fevers, or botulism. Further, the modalities that can be used as weapons are even more diverse than germ warfare, and also include chemical and radiological agents.
Promptly Report. If one suspects an unusual clinical presentation that could be caused by a biological, chemical, or radiological agent, what exactly is the physician expected to do? Does the physician's responsibility include calling the local police, the Federal Bureau of Investigation (FBI), or the CDC? In San Diego County, the reporting responsibility of the primary care physician has been delineated and clearly described. Reporting suspected or confirmed signs of terrorism consists of one phone call to the Community Epidemiology Division of the county public health agency. This number is staffed 24 hours a day/7 days a week/365 days a year with an alternate number that uses an emergency communication system in case of telephone failure. Figure 1 illustrates the manner in which a single communication from the physician, when appropriate, results in the local public health authorities taking responsibility for initiating actions by local, state, and federal teams.
The most time-sensitive action is reporting suspected terrorism to local public health authorities. For example, if the suspected condition is smallpox, vaccination of close contacts should occur as soon as possible after exposure (ideally within 3 to 4 days) and certainly before 7 days have elapsed.3·4 Delaying the call until the laboratory results are available wastes valuable time needed to prevent spread of infection. Prompt reporting is encouraged by also offering 24 hours a day/7 days a week/365 days a year availability of consultation for physicians about diagnostic testing, patient treatment, and protecting the patient, one's self, family and co-workers. Further, an electronic communication system is in place with a Web site operated by the Division of Epidemiology: the emergency medical alert network This electronic system features two-way communication with the local medical community to alert providers of suspected and confirmed disease outbreaks.
In order to address the threat of terrorism, a new reporting system did not have to be created. The system only required expansion of focus, as it was already in place for reporting and preventing the spread of infections and addressing a variety of health problems of the diverse multicultural urban population in San Diego County. Indeed, it was this local, state, and federal reporting system in United States that led in 1981 to identifying acquired immunodeficiency syndrome and human immunodeficiency virus infection in an otherwise healthy group of males in Los Angeles County.5
Actions Expected of Physicians
What could happen if the countylevel public health authorities determine the situation is such that it is appropriate to notify other agencies and authorities of suspected terrorism? In San Diego, the local public health agency is poised to report and activate the local response team, the metropolitan medical strike team, local law enforcement, the FBI, the California Department of Health Services, and the CDC.
The CDC has the capacity to deliver emergency supplies that include prophylactic medications for a large population. If needed, the supplies from the National Pharmaceutical Stockpile Program can be delivered by air and distributed at locations accessible throughout this large county.
Protect Themselves and Others. In order to function as clinicians in stressful emergencies that may require many hours of being on duty, it is critical to plan carefully for the safety of families and close associates in situations that may occur because of terrorism or other disasters.
In order to prepare your family and those with whom you share a home, a plan to respond to catastrophic events should be developed. Table 2 lists components that might considered in a catastrophic event.6,7
THE CRITICAL ROLE OF THE PEDIATRIC HEALTH PROFESSIONAL
Pediatric health professionals are crucial in the surveillance, identification, and prompt reporting of possible terrorist events. Moreover, pediatric health professionals are in a position to provide resources to children and families to respond to threats of terrorism. Many recent graduates from medical training have cared for patients with chicken pox and other vaccine-preventable diseases only rarely.
Consideration for Home Preparedness
In consultation with public health officials, the pediatrician can construct a plan for diagnostic testing, appropriate antibiotic prophylaxis, and communication to reassure families that symptoms such as fever, headache, and body aches are common to many infections. Availability of antibiotics and vaccines will be critical at the actual site where biological terrorism may occur. While pharmaceuticals could be distributed through the National Pharmaceutical Stockpile Program, it is possible that agents used in bioterrorist events may be resistant to usual therapies. Early detection, appropriate isolation of infected individuals, and targeted chemoprophylaxis and vaccination, along with a plan for communication with key agencies, comprise the best available response.8
Modify Protocols in Practice Setting
Pediatric health professionals should review protocols used in their own practice settings that address precautions for respiratory isolation, contact isolation, droplet isolation, and use of universal precautions. The United States Army Medical Research Institute of Infectious Diseases publishes guidelines for patient isolation precautions with specific guidelines for selected diseases that may be caused by terrorism (see Resource List on page 000). Standard precautions should be used for all patients. Airborne precautions, in addition to standard precautions, should be used for suspected smallpox cases. Standard precautions plus droplet precautions should be used for suspected cases of pneumonic plague. Contact precautions added to standard precautions should be used for suspected cases of viral hemorrhagic fevers.9 These protocols should be reviewed regularly with staff.
A protocol to respond to a potential bioterrorism event should be either developed separately or integrated into existing protocols. These protocols should include contact information for the appropriate public health agency, isolation precaution procedures, appropriate treatment guidelines, and a practice-wide plan for responding to bioterrorism in local or distant locations. Even in San Diego, many pediatric offices were flooded with phone calls after the anthrax mailings on the East Coast in the fall of 2001. Resources should be readily accessible for patients and families. A system can be developed to direct patients and families to these resources, either through an additional branch of the existing phone menu, establishment of a patient education phone line with recorded material, or posting of relevant information and links on the practice Web site to allow for continued functioning of the remainder of daily practice activities. This system should provide reassurance for the worried well, while providing appropriate referral information for patients and families with symptoms related to a possible bioterrorism-related disease.
For a patient with a suspected bioterrorism-related condition, the appropriate protocols for treatment, isolation, and reporting of the condition should be followed. Full documentation, with appropriate referral to the local public health agency, should occur for all of these patients.
All of the above-mentioned protocols must be communicated with staff regularly through orientations and ongoing in-service training as well as with accessible policy and procedure manuals. Ongoing staff training and implementation of appropriate patient isolation techniques when a patient presents with symptoms caused by a potential bioterrorism event helps protect patients as well as coworkers and yourself.
Because pediatricians examine children in office, clinic, and emergency department settings, they may be the first to spot peculiar rashes, lung abnormalities, or blistering syndromes that result from a biologic or chemical agent.10 Children may be more difficult to assess because they may have difficulty reporting how they feel or what has happened to them. Emergency preparedness and response among pediatric practices is critical. As we have seen in natural disasters, pediatricians have a unique opportunity to help children and families in facilitating diagnosis, treatment, and psychological recovery from traumatic events.
SAN DIEGO PUBLIC HEALTH PREPAREDNESS AND RESPONSE
A real threat of bioterrorism exists for military and civilian populations in San Diego County because of its close proximity to the Mexican border, high level of military assets, international airport, active port, nuclear plant, and highprofile tourist events and destinations such as the Super Bowl and the San Diego Zoo. The County of San Diego has a population of nearly 2.9 million and encompasses approximately 4200 square miles.
San Diego County is home to the largest military complex in the nation, consisting of numerous military installations and a large civilian population either employed by the military or dependent on military personnel. It is also the busiest international border crossing in the world, with an average of 4.2 million crossings a month at San Ysidro and Otay Mesa.11 A strong biotechnology industry presence magnifies the potential impact of bioterrorism.
The Community's Plan
When developing a framework to plan a response to bioterrorism, it is clear that the threat is multidimensional and therefore requires a multifaceted response. Local public health entities are responsible for disease prevention and control, as well as disease surveillance activities. The County of San Diego Health and Human Services Agency, Public Health Services, includes epidemiologists, physicians, biostatisticians, laboratorians, and emergency medical services (EMS) planners with a long history of collaboration with hospitals, clinics, and private providers, as well as state and federal health agencies and local universities. Public Health Services has a history of effective disease surveillance and response. California law mandates that all health care providers report confirmed or suspected cases of more than 80 communicable diseases and conditions to the local health officer for the jurisdiction where the patient resides. The California Department of Health Services recently amended the California Code of Regulations of reportable diseases and conditions to include the intensive surveillance and immediate reporting of seven potential biological terrorism agents (anthrax, plague, botulism, brucellosis, smallpox, tularemia, and viral hemorrhagic fever agents).12
Emergency Medical Services. The EMS acts as the lead agency for terrorism planning and response. This includes coordination of the activities associated with early detection and response, mass patient care, mass prophylaxis and immunization, mass fatality management, environmental safety, and centralized command and control. In September 1997, the United States Public Health Service awarded a grant for the development of a San Diego metropolitan medical response system. They assigned the associated responsibilities to the EMS, and this began counterterrorism planning, and response and mitigation programs. In 1999, the EMS began development of a comprehensive terrorism preparedness plan. The EMS acts as the lead agency for the San Diego metropolitan medical strike team, a 153-member nuclear, chemical, and overt biological counterterrorism team responsible for responding to and mitigating terrorism events. The team consists of personnel from 13 agencies, including hazardous materials specialists, firefighters, police officers, FBI agents, physicians, and nurses. As part of this process, EMS partnered with the staff of the Community Epidemiology Division to develop the cornerstone bioterrorism plan, the biological weapons of mass destruction response plan.
Local Public Health Epidemiology. The Community Epidemiology Division usually receives morbidity reports via faxable report forms or direct telephone contact. The Health Insurance Portability and Accountability Act permits disclosure of health information without individual consent for public health purposes and for national defense and security.13
Early detection of an unusual disease occurrence is critical to a strong preparedness and response plan. In particular, surveillance of multiple sources of data is more meaningful for early warning to detect bioterrorism, raising a more profound urgency to use electronic health data. One of the key data sources associated with the Enhanced Health Surveillance System is the County of San Diego EMS Quality Assurance Network that has been operational since 1993. This provides real-time, live data for every patient transported to a hospital by paramedics in San Diego County and real-time, live hospital resource data. The Quality Assurance Network is the only system of its kind in the country and collaborates with every hospital in the county to manage and use patientspecific information securely.
The Community Epidemiology Division has strong partnerships with the medical and laboratory communities on whom they rely as critical reporting sources of legally notifiable diseases and unusual disease events, including the deliberate release of agents. Syndromic surveillance of prediagnostic data is used to monitor seasonal trends and trigger clinical testing and increased surveillance while providing an early warning system.
Additional sources of data are the border infectious disease surveillance program that conducts active surveillance of fever/rash syndromes, hepatitis and West Nile virus, and the County Veterinarian Office. Veterinarians play a key role in the recognition and immediate reporting of known or suspected cases of plague and West Nile, for example.
Laboratory Facilities. The San Diego County Public Health Laboratory is a Biosafety Level 2 laboratory with Level 3 capabilities to analyze agents such as anthrax, plague, tularemia, and brucellosis. The laboratory analyzes specimens from human, animal, and environmental sources (including food and water) for microorganisms of public health significance. Further expertise for micro-organism identification is available from the California Department of Health Services' Microbial Disease Laboratory and Viral and Rickettsial Disease Laboratory in Berkeley. Specimens and isolates can also be referred to the CDC (a Biosafety Level 4 laboratory), especially if biological terrorism agents are suspected.
The Community Epidemiology Division formed an internal Rapid Response Team comprised of epidemiologists, public health nurses, public health microbiologists, physicians, environmental health specialists, and communicable disease investigators to enhance the capacity to address critical public health concerns. Qualified investigators are available 24 hours a day/7 days a week/365 days a year to respond to large and/or significant communicable disease occurrences, including acts of bioterrorism. Several public health professionals have been specially trained and incorporated into the County Hazardous Incident Response Team and the metropolitan medical strike team to assist in the rapid assessment and early mitigation of an event.
A key element to a systematic response is strong centralized command and control. Command and control procedures include coordinating local, federal, and state assets. Rapid expansion of the local health care system, involving triage and treatment of large numbers of patients, alternate treatment facilities, increased staffing, plans for volunteers, isolation and quarantine issues, effective access of large quantities of pharmaceutical and medical supplies, and dissemination of information to the public may be needed.
As in other communities, San Diego County's planning and response efforts depend on the public as capable allies in the response to disaster. Because of the multiethnic and multicultural characteristics of San Diego County, planning includes identification of vulnerable populations, multhingual materials, and culturally relevant messages. Strategies to communicate plans for responding to bioterrorism have included newspaper articles, town meetings, routine interaction with the media, and outreach to key decision makers in the community.
Although the federal and state governmental authorities have plans for responding to suspected or confirmed bioterrorism, the most critical element [in the management of bioterrorism] is a well-coordinated local response. This article describes the response plan of a large urban community that is ethnically diverse, located on an international border, and includes a large military complex. An existing surveillance system has been enhanced by the local public health agency so that the responsibilities of physicians are clearly delineated. The key responsibility of the frontline physician is timely reporting of suspected bioterrorism to public health authorities using a 24 hours a day/7 days a week/365 days a year system. After making a report, local public health officials assume the responsibility for notifying law enforcement, medical response teams, state health authorities, or the CDC.
In the event of terrorism, pediatric health professionals, like all physicians, are expected to report potential bioterrorism events promptly and to develop protocols for response in their practice settings. These protocols should include contact information for the local public health agency, appropriate diagnostic procedures, specific precautions to be implemented, use of protective equipment, and appropriate treatment guidelines.
Pediatric health professionals are well positioned to meet the developmental^ appropriate healthcare needs of infants, children, and adolescents. Pediatric health professionals must also be prepared to respond to the fears of children and their worried parents/caregivers in an effective manner, without disrupting ongoing patient care.
1. Broad WJ, Johnston D. Report linking anthrax and hijackers is investigated. New York Times. March 23, 2002:A9.
2. Heylighen F. Occam's Razor. Principia Cybernetica Web. Brussels: Principia Cybernetica; July 7, 1997. Available at: http:/ /pespmcl.vub.ac.be/OCCAMRAZ.html.
3. Centers for Disease Control and Prevention. Smallpox vaccination overview. Available at: http://www.bt.cdc.gov/ agent / smallpox / vaccination / facts.asp.
4. Atkinson WA, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 7th ed. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention; 2002:243.
5. Centers for Disease Control and Prevention. Pneumocystis pneumonia - Los Angeles. MMWR Morb Mortal WkIy Rep. 1981;30:250-252.
6. Federal Emergency Management Agency and American Red Cross. Your Family Disaster Plan. Washington, DC: Federal Emergency Management Agency. FEMA L-191; ARC 4466.
7. Federal Emergency Management Agency and American Red Cross. Your Family Disaster Supplies Kit. Washington, DC: Federal Emergency Management Agency; March 1992; FEMA L-189; ARC 4463.
8. American Academy of Pediatrics. California Chapter 3: Bioterrorism update for pediatricians [online posting]; October 1, 2001. Available at: http:/ /www. aapca3.org / bioterror_update.htm.
9. Kortepeter M, Christopher G, Cieslak T, et al., eds. USAMRIID's Medical Management of Biological Casualties Handbook. 4th ed. Fort Derrick, MD: US Army Medical Research Institute of Infectious Diseases; February 2001. Available at: http:/ /www.usamriid.army.mil /education / bluebook.html.
10. Chemical-biological terrorism and its impact on children: a subject review. American Academy of Pediatrics. Committee on Environmental Health and Committee on Infectious Diseases. Pediatrics. 2000;105(3 Pt l):662-670. Available at: http:/ /www.aap.org /policy /re9959.html. Accessed December 9, 2002.
11. Nathanson CE, Lampell J. Solving our border crossing problem in an era of terrorism [briefing paper]. Forum Fronterizo. December 2001. Available at: http://www.sandiegodialogue.org/pdfs /decl3_bp.pdf. Accessed January 8, 2003.
12. State Department of Health Services. California Code of Regulations. Title 17, Chapter 4, Subchapter 1, Article 1, Section 2500. Reporting to the Local Health Authority [online]. Available at: http:/ / www.calregs.com /cgibin/ om_isapi.dll?clientID=178832&infob ase=ccr&softpage=Browse_Frame_Pg42.
13. Gostin LO. National health information privacy: regulations under the Health Insurance Portability and Accountability Act. JAMA. 200135:3015-3021.
Actions Expected of Physicians
Consideration for Home Preparedness