The need to firm up plans for managing mass casualties, or to quickly detect, report, treat and contain any outbreaks of particularly rare and deadly diseases, promises to be a mighty test of the city, state and national public health infrastructure, as an unprecedented level of collaboration and coordination will be required:

• Primary care physicians, as front-line sentinels against a bioterrorism threat, need to know how they can acquire the clinical acumen to detect diseases that few physicians have ever seen, and must be sure that they are hooked in to resources that allow them to receive and report information quickly.

• Hospital emergency departments need to ensure that they have the specialized plans, pharmaceuticals, facilities, equipment and personnel training to manage a type of disaster that is very different from one for which they are normally prepared.

• Municipal health departments need to have the resources and capability to coordinate effective surveillance, reporting and intervention.

• The state Health Department needs to be linked to federal resources when required, and must be able to direct resources and information to all physicians, hospitals and local health departments in the state.

• Federal resources must be available for rapid deployment to localities faced with medical needs beyond what they are normally equipped to handle.

Assessing this labyrinth of preparedness structures in reverse order—from the big picture down to the individual, private practice physician—offers perhaps the clearest context for understanding where practicing physicians fit in and how they can most effectively represent the interests of their patients and their country.

In its literature, the Centers for Disease Control and Prevention (CDC) asserts that a strong and flexible public health infrastructure is the best defense against any disease outbreak, whether naturally or intentionally caused, and has a strategic plan outlining four areas to improve preparedness:

• Reinforce systems of public health surveillance to ensure rapid detection of unusual outbreaks.

• Build epidemiologic capacity to investigate and control health threats from such events.

• Enhance public health laboratory capability to diagnose the illness and identify etiologic agents most likely to be used in bioterrorist events.

• Develop and coordinate communications systems with other government agencies and the general public to disseminate critical information and allay unnecessary fear.

A number of programs are offered by CDC to pursue these goals. CDC’s Epidemic Intelligence Service (EIS), established during the Cold War in response to the threat of biological warfare, trains personnel to respond to outbreaks and other disaster situations to aid state and local officials to identify potential causes and implement solutions. The Pa. Health Department has three permanent staff experts trained in this program, according to a department spokesperson.

CDC also trains Public Health Prevention Service (PHPS) specialists who can provide on-site programmatic support to extend the manpower of state and local public health staff. Such a specialist is assisting the Philadelphia County Health Department to develop response plans against bioterrorism, according to a department spokesperson.

CDC has established the Epidemiologic and Laboratory Capacity (ELC) program to help state and large local health departments to establish sentinel disease detection systems involving local networks of clinicians and health care providers. The Pa. Health Department is hooked into a communication network of reference laboratories around the country that are routinely used by Pa. hospitals.

The Philadelphia County Health Department has established such a program with infectious disease specialists at six teaching hospitals in Philadelphia, instructing them to report abnormal symptom trends.

CDC has also entered into agreements with selected state health departments, in collaboration with local academic, government, and private sector organizations, to establish Emerging Infections Program (EIP) sites that conduct population-based surveillance for selected diseases, as well as for unexplained deaths and severe illnesses in previously healthy people. The Pa. Health Department is not currently part of this program.

To ensure a prompt and coordinated response with state and local health departments, U.S. quarantine stations, health care professionals, the American public, as well as the World Health Organization and ministries of health of other nations in the event of an intentional release of a biological agent, CDC is implementing the national Health Alert Network (HAN). The purpose of HAN is to establish communications, information, distance-learning and an organizational infrastructure linking public health agencies at the local, state and federal levels via continuous, high-speed connection to the Internet, broadcast communications and satellite- and Web-based distance-learning.

Finally, CDC has developed a National Pharmaceutical Stockpile (NPSP) to be able to send critical drugs, antibiotics, medical supplies and equipment to victims of an incident anywhere in the continental U.S. within 12 hours. The system was used for the first time when medical supplies reached New York City within seven hours of deployment following the attack on the World Trade Center.

Last month, Health and Human Services Secretary Tommy Thompson called for a radical expansion of the NPSP as the centerpiece of a broad plan for coping with potentially more devastating attacks than the recent spate of anthrax spores sent through the mail, and requested Congress to allocate enough funding to have 300 million doses of smallpox vaccine ready by late next year, noting that the existing stockpile of 15 million doses could be diluted to effectively inoculate as many as 77 million people if an emergency arose in the interim.

The Department of Health and Human Services’ (HHS) Office of Emergency Preparedness has contracts with several municipalities across the country to develop Metropolitan Medical Response Systems (MMRS), designed to develop medical "strike teams" by organizing, equipping and training groups of local medical, fire, rescue and other emergency management personnel. The goal of these teams, according to HHS literature, is to enhance local planning and response systems’ capability to care for victims of a terrorist incident involving a weapon of mass destruction—nuclear, chemical or biological—by providing: special training to a subset of local emergency personnel; specialized protective, detection, decontamination, communication and medical equipment; special pharmaceuticals and other supplies; enhanced emergency medical transport and emergency room capabilities; epidemiological investigation resources; mental health support; and victim identification and mortuary services.

In addition to these federally-sponsored intervention programs, a number of national and international resources are available online for physicians looking to ramp-up their preparedness knowledge, including the CDC bioterrorism site, the Johns Hopkins Center for Civilian Biodefense, the U.S. Army infectious disease site, the World Health Organization, JAMA bioterrorism articles, and a Consumer Reports resource for the general public. 

The Region 13 MMRS, which began forming two years ago in the Pittsburgh region, has grown to include over 300 individuals representing 87 organizations and 65 hospitals in 13 southwestern Pa. counties, according to David Pipozar, a public health administrator of the Allegheny County Health Department and chair of Region 13’s MMRS Working Group.

Using a $1 million annual federal grant, says Pipozar, 13 counties and the city of Pittsburgh have signed a cooperative agreement to provide mutual aid in the event of any disaster or terrorist attack resulting in mass casualties. Pipozar’s group meets monthly to coordinate activities that could be initiated in an emergency, including setting up sites and volunteers to deliver mass immunizations, organizing mass patient care systems able to provide sustained support to institutions overwhelmed by patient volume, negotiating agreements with major drug distributors for ready access to a cache of pharmaceuticals deliverable to any of the 13 counties within three hours, and linking county behavioral health coordinators to provide counseling services and rumor control lines to reassure the public.

Pipozar says the group is looking to expand its volunteer pool of physicians, nurses, dentists, paramedics and others with special training to between 600 and 800 individuals to be part of a system that could be federally activated to be deployed in waves for a long-term effort, if needed.

Philadelphia County also has an active MMRS, which it hopes to expand into surrounding counties, according to a Philadelphia Health Department spokesperson.

Pennsylvania’s health care community is in the process of mobilizing response plans and a flurry of educational and training efforts to prepare itself for a potential terrorist scenario.

Using a CDC grant, the state Health Department created a new position to coordinate response plans to chemical and biological weapons and, in April, appointed Kumar Nalluswami, M.D., a public health expert, to the post. The department has a notification system in place to alert hospitals, laboratories and county health departments about any emergency developments.

The Pa. Health Department has also established 24-hour laboratory staffing and has asked hospitals across the state to increase their medical surveillance of patients with "unusual" symptoms, as well as those which are also associated with common maladies, such as:

• Mild fever and sore throat, which can be symptoms of an infection related to anthrax.

• Nausea, loss of appetite, vomiting and fever followed by abdominal pain, vomiting of blood and severe diarrhea, which are associated with intestinal anthrax.

• High fever, fatigue and headaches or backaches, which could be smallpox.

• Double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth and muscle weakness, which are signs of botulism.

• Fever, headache, weakness and coughing that produces bloody or watery sputum, which are plague symptoms.

The Pennsylvania Medical Society (PMS) will host a bioterrorism summit on Nov. 27, to be co-sponsored by the American College of Medical Toxicology and attended by officials from organizations involved in emergency health care planning, policy and research. Participants will discuss ways to make existing disaster medicine resources more readily available to health care professionals, to increase the medical community’s awareness of and participation in disease surveillance, and to develop additional protocols to deal effectively with medical consequences if bioterrorism should occur.

The PMS also sent a fax alert to all of its members providing instructions to medical personnel released by the state Health Department on how to handle suspected anthrax situations. For asymptomatic patients without known exposure, the instructions urge physicians to provide reassurance and inform the patient that there is no screening test available to detect anthrax in an asymptomatic person. The instructions indicate that nasal swabs and blood serum tests should not be used for diagnosis and screening, but only to confirm a symptomatic case or as an epidemiologic tool.

For an asymptomatic person with potential exposure, physicians are instructed to contact local law enforcement and local public health authorities immediately, who will then determine if anthrax exposure has occurred. Physicians should immediately report any suspected or presumptive positive cases of anthrax to law enforcement, local and state health departments. Patients are not to be transported to hospitals until decontamination by EMS personnel has occurred, and police or HAZ-MAT personnel will handle transportation of the suspected substance to an appropriate laboratory.

According to CDC-recommended notification procedures, if a local health officer determines that a bioterrorist incident or threat is confirmed or probable, they should immediately contact the FBI and local law enforcement officials. Although the CDC notes that the public health sector has important responsibilities related to bioterrorism detection, response and control of health consequences, it asserts that the public health response will be most effective if the overall response by all sectors—including pre-hospital, hospital, law enforcement and public safety—is coordinated by the FBI.

Specifically, the FBI is notified for one or more clusters of illnesses that remain unexplained after a preliminary investigation; for deliberate chemical, industrial, radiation or nuclear release; or for one or more cases definitively diagnosed with one or more of the following:

• Any case of smallpox or pulmonary anthrax, since such a disease in even one case would strongly indicate the likelihood of bioterrorism.

• Uncommon agent or disease, e.g., Burkholderia mallei or pseudomallei, smallpox, pulmonary anthrax, occurring in a person with no other explanation.

• An illness caused by a microorganism with markedly atypical features, e.g., features suggesting that the microorganism was genetically altered.

• An illness due to aerosol or food or water sabotage, as opposed to a usual transmission route.

To disseminate information of this kind and to develop ongoing educational initiatives, the PMS is working with the state Health Department to organize day-long educational programs with invited experts to speak on emergency public health preparedness, as well as shorter programs to be offered at local medical societies and hospitals, says PMS Director of Educational and Scientific Affairs Jeff Greenawalt.

The Philadelphia County Medical Society (PCMS) hosted the first meeting last month of the Southeastern Pennsylvania Bioterrorism Preparedness Working Group, chaired by the Philadelphia County Health Department and attended by representatives of surrounding county health departments, as well as the Pennsylvania and New Jersey health departments, according to PCMS President Harris R. Clearfield, M.D. The group plans to meet again in November and is developing plans to identify and share preparedness protocols and to organize a communication network, says Clearfield.

Physicians who are not a member of state or county medical societies are being brought into the information loop through their hospital staff affiliations. The Hospital & Healthsystem Association of Pennsylvania (HAP) is urging its members to disseminate to all medical staff members CDC and state Health Department alerts related to bioterrorism, says HAP’s Vice President for Integrated Delivery Systems Cheri Rinehart.

HAP is faxing and e-mailing useful sources of information to all Emergency Department heads in the state and has also developed a disaster preparedness section on its website for HAP members, listing all relevant health alerts, a disaster readiness checklist and federal and state funding sources, says Rinehart.

HAP is also convening meetings with the Pennsylvania Emergency Management Agency (PEMA), the PMS, the state Health Department, emergency physicians and other players involved in statewide disaster planning to ensure that the resources that Pa. hospitals require are in place, that the expectations of hospitals are clear and that preparedness efforts are well-coordinated, Rinehart notes.

Although preparedness needs vary from hospital to hospital, she says, all are re-evaluating their disaster plans, brushing off their "Y2K" assessments, looking at their medical equipment and pharmacy supplies, assessing their physical plant security needs and their communication systems for coordination with other agencies. Faced with budget crises, Rinehart notes, many hospitals have gone to "just in time" inventories to keep costs down, and will now need to reconfigure inventory need projections, given the new threat environment and patient surge potential.

Given that three out of four Pa. hospitals were unable to meet their operating expenses with patient revenue before Sept. 11, Rinehart adds, HAP’s legislative staff has been working with state and federal legislators in search of funding to help Pa.’s hospitals beef up their inventory and training resources.

Some of Pa.’s rural hospitals had slow systems for Internet access a few years ago, but have spent time and resources installing equipment upgrades for Y2K and are no longer significantly behind the capabilities of urban institutions, according to Rinehart. The state’s emergency Internet, fax and telecommunications system is coordinated through 16 EMS council regions across the state, and some institutions are looking more closely at ways to interface with the CDC’s national Health Alert Network (HAN), she adds.

The Joint Commission on Accreditation of Healthcare Organization this January enacted new emergency standards for institutions that rebuild their hospital emergency departments, including having certain decontamination capabilities, hazardous material traps in showers and reverse-flow ventilation that circulates air directly outside, notes Frederick V. Peterson, MPH, director of constituent services of the Hospital Council of Western Pennsylvania (HCWP). Most hospitals in the 30 western Pa. counties meet these requirements and most have undergone training and have protective gear for disaster management, he says. The EMS will not bring highly contaminated patients to the ER, he adds, but will set up decontamination units at a remote site, and most patients suspected to have been exposed to bioterrorism agents would be cultured outside of hospitals.

Peterson notes that HCWP has been given federal grant money, through the Region 13 MMRS, for training senior-level hospital staff, chief nursing officers, hospital engineers and chairs of hospital disaster committees to bring them up to speed on current disaster preparedness requirements.

The surveillance capability of Philadelphia’s health care system was put to the test during the Republican National Convention last year. The Philadelphia Co. Health Department held a CDC-sponsored training workshop bringing together physicians, hospital staff, police and firefighters for a mock epidemic scenario, says Matthew Levison, M.D., professor of Medicine and Public Health, and an infectious disease specialist at the Medical College of Pennsylvania. Several Philadelphia hospitals also reported to the Health Department groups of symptoms of their actual patients that would suggest a disease caused by a biological weapon. Reporting of these symptom groups was done before the convention to develop a baseline, and after the convention to compare symptom frequency with that baseline, Levison explains. That reporting has again been activated by the Health Department with six teaching hospitals in the city, he says.

"Hopefully, we’ll be ready. The question is, how extreme it will be," says Fred Harchelroad, M.D., chair of Allegheny General Hospital’s Department of Emergency Medicine, who says that his facility is equipped to handle 100 to 200 patients, but would be overwhelmed by several thousand. Chemical threats, he says, are easier to diagnose because of rapidly occurring symptoms after exposure, but they can easily overwhelm the system with large numbers of patients presenting in a short time. Conversely, he notes, biological threats are more difficult to diagnose because of relatively benign early symptoms, but the gradual increase in number of patients would give hospitals more time to ramp-up their resources to meet the threat. "We have contingency plans for various toxins," he adds, alluding to Region 13 MMRS infrastructure and its contracts with pharmaceutical distributors to make quickly available antidotes and anti-microbial agents.

"Physicians are re-educating themselves about these diseases they haven’t seen since their medical school textbooks," says Thomas Campbell, M.D., chair of Western Pennsylvania Hospital’s Department of Emergency Medicine and chair of the hospital’s disaster committee, who points to a number of training venues he has seen, including day-long PEMA sessions, local EMS sessions, teleconferenced hospital grand rounds, webcasts and websites. "In emergency departments," he says, "there’s been a renewed pride in our ability to do a public health service."

"We physicians need to reassure the public, and that comes down to rapport with the patient," says Carl Chudnofsky, M.D., chair of Albert Einstein Medical Center’s Department of Emergency Medicine, who urges physicians to show "worried well" patients the literature demonstrating that the right thing to do is not to prescribe Cipro or antibiotics, or to perform nasal swabs or blood cultures, when there are no symptoms or evidence of exposure to a bioterrorism agent.

"Since influenza and other respiratory viruses are going to be far more likely than bioterrorism agents, physicians should consider the expanded use of viral diagnostic tests. They’re not foolproof, but they are an option to pin down a diagnosis and avoid the unnecessary use of antibiotics," suggests P.J. Brennan, M.D., the University of Pennsylvania Health System’s Chief of Healthcare Quality and Patient Safety, and an infectious disease physician at the Hospital of the University of Pennsylvania. Although few have actually seen patients with anthrax, smallpox or plague, he adds, "Most physicians are familiar with the characteristics of a case of influenza."

Brennan acknowledges that physicians have to maintain an increased level of alertness to the possibility of bioterrorism pathogens and must be informed enough to recognize the cutaneous manifestations of these diseases, their radiographic appearance and their clinical course, while also remembering to take detailed patient histories, which are especially important when assessing likelihood of exposure to the agents.

Levison adds that physicians should react based upon suspicion. "To wait for confirmation of any contagious disease is a mistake," he says, as the need to isolate such a patient is urgent. He warns that surgical masks do not prevent inhaling aerosol-sized pathogen particles, and notes that Class N-95 masks with filters, of the type used with TB patients, are needed for dealing with patients suspected of exposure to communicable pathogens of bioterrorism.