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Internists are well-positioned to play significant roles in recognizing and responding to epidemics, outbreaks, and bioterrorist attacks. They see large numbers of patients with various health problems and may be the patients’ only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. Therefore, Internists must understand early warning signs of different bioterrorist and infectious agents, proper reporting channels and measures, various ways that they can assist the public health response, and roles of different local, state, and federal agencies. In addition, it is important to understand effects of a public health disaster on clinic operations and relevant legal consequences.
During the past half decade, well-publicized events, including the anthrax mail attacks,1 Hurricane Katrina,2 and severe acute respiratory syndrome (SARS)3,4 have reminded us that epidemics, disease outbreaks, bioterrorist attacks, and natural disasters can occur. Although there is debate over when and how they may happen, there is little question that such events could have significant and far-reaching health, social, and economic consequences. Moreover, smaller outbreaks, such as influenza and West Nile Virus,5 occur with greater regularity. Internists can play vital roles in identifying, responding to, and containing bioterrorist attacks and disease outbreaks if they understand their role in these events.
Internists may be among the first to recognize clues that a problem is occurring, especially as initial signs and symptoms may be subtle or mimic common disorders, prompting victims to contact their primary care physicians, rather than go to emergency departments.6 Furthermore, Internists’ broad range of medical knowledge, experience, and skills make them uniquely qualified to diagnose and treat a variety of potential health problems. Internists are also well-positioned to work with various health care personnel and services during a disaster. Therefore, Internists must understand early warning signs of bioterrorist and infectious agents, proper reporting channels and measures, and ways that they can help contain and treat the consequences of epidemics, outbreaks, and attacks.
During its initial stages, an attack, epidemic, or outbreak may not be obvious. Depending on the agent and its mode of transmission, the population density, and the population’s access to health care, it can be days or even weeks before anyone can recognize the problem. As the early response may be crucial in containing the problem and minimizing resultant morbidity and mortality, efforts have been made to develop biosurveillance systems to detect outbreaks and attacks.7–9 These systems collect pertinent data (e.g., pharmacy drug sales, emergency department visit chief complaints, and air samples) and search for irregularities that suggest a problem is occurring. However, these systems are by no means foolproof because they only look for a finite set of clues, do not cover every part of the United States, and may provide equivocal information. Moreover, there could be delays between the point that biosurveillance systems detect suspicious patterns and when the public health system responds. Therefore, Internists might be the first to become aware of a problem and pivotal in initiating the public health response.
Internists see large numbers of patients with various health problems and may be the patients’ only interaction with the medical community for symptoms resulting from infectious diseases and injuries from radiation, chemicals, and/or burns. So they could be the first to report attacks or outbreaks and initiate public health response. Indeed, there are examples of “astute” clinicians being the first to recognize epidemic or bioterrorist attacks (e.g., the 1999 New York City West Nile outbreak,5 the 2001 anthrax attack cases,10,11 and the 2003 SARS epidemic in Vietnam12).
In some cases, bioterrorist and infectious agents cause distinctive signs and symptoms.13,14 For example, of the 10 inhalational anthrax cases in the 2001 attacks, all had fever, chills, lethargy, and chest x-ray abnormalities. Seven had mediastinal widening, and 8 had pleural effusions. All but 1 had elevated liver transaminases. A combination of these findings is highly suspicious for inhalational anthrax, especially in a young, otherwise healthy patient and/or when a patient initially experiences nonspecific influenza-like symptoms followed first by a brief period of apparent recovery, and then, by an abrupt resurgence of more severe symptoms.15 However, in a majority of cases, early symptoms are vague and readily mistaken for more common upper respiratory infections (e.g., influenza, plague, tularemia, and staphylococcal enterotoxin B) or viral gastroenteritis (e.g., hepatitis A, cryptosporidium, and salmonella).
Therefore, in addition to looking for specific symptoms, Internists should remain vigilant about general trends and patient flow in their clinics.16 Any of the following may be the only sign that an attack or outbreak has occurred17,18:
An Internist’s index of suspicion should be even higher when bioterrorism or epidemic alerts are issued.
Internists must be prepared to address a wide range of physical, psychological, and social consequences of public health disasters. Patients may be injured by either a public health disaster or the ensuing mass panic. In addition, Internists may have to function as emergency physicians when emergency departments are overcrowded or unavailable. Specifically, Internists must be prepared to:
Figure 1 illustrates the public health chain of command. Internists suspecting an attack or epidemic should immediately inform the local or state health department and contain any possible threat in their clinics, especially if the agent is contagious. Providing information to wrong people (especially news media) may cause mass terror and delay the public health system’s response. Therefore, Internists must remain calm, understand how their words can be misunderstood and misconstrued, follow instructions from appropriate health, military and law enforcement officials, and allow properly trained public health officials to deal with the media.
Local authorities are responsible for the initial response to any public health emergency with appropriate state agencies providing additional support when necessary. Depending on the nature and magnitude of the problem, local or state authorities may choose to involve federal agencies. Unlike naturally occurring disease outbreaks, bioterrorist attacks are criminal acts and require intervention of law enforcement agencies.45
When there is a risk of contagious disease transmission across state lines or state efforts are deemed inadequate, the federal government assumes authority. The President makes executive decisions. The CDC administers federal quarantine actions. Implementation of order could involve the Department of Defense or the Federal Emergency Management Agency (FEMA). For travelers seeking to enter the United States, the CDC has the authority to enact quarantine. In areas where the CDC’s Division of Global Migration and Quarantine personnel are not stationed, the Immigration and Naturalization Service and the United States Customs Service personnel are trained to identify travelers with potential epidemic.
It is essential that health care professionals adequately protect themselves. They are needed to care for both victims of an outbreak/attack and “regular” patients and can inadvertently spread communicable agents rather quickly, especially to vulnerable members of the population.46,47 One study examined clinicians’ knowledge regarding proper infection control practices during a bioterrorist event and found numerous deficiencies.48
Standard precautions should be exercised for all situations. Internists should wash their hands frequently and be careful when handling body tissues and fluids. Certain diseases require additional precautions (Table 1). Contaminated clothing should be removed promptly and placed in sealed plastic bags. Soap and warm water can wash off most noncontagious agents.49,50 Bleach is needed for chemical decontamination. Any health care worker who receives a needle stick from a potentially bacteremic anthrax-infected patient should receive prophylactic antibiotics.
Although the words quarantine and isolation have been erroneously used interchangeably, quarantine means the separation and confinement of currently healthy people who may have been exposed to a contagious disease, while isolation refers to the separation and confinement of people known or suspected to be infected with the contagious disease. When an infectious disease is confined to a specific locale, the authority to order quarantines usually rests with local or state public health officials. When the event spreads across jurisdictional boundaries within the state, such authority usually is relinquished to the state. There is great variability in quarantine regulations from state to state.51
Clinic patient volume can increase significantly from ill patients and concerned healthy patients (the “worried well”). This “worried well” phenomenon was seen after the 2001 Anthrax attacks.52,53 Internists will have to offer reassurance to the “worried well,” relay appropriate disease information, and direct them to the right public health agencies and relevant websites (e.g., Fig. 1 and websites listed in “Treatment and Prophylaxis”) for information and mass prophylaxis (if needed).54 Clinics should minimize potentially contagious patients’ contact with health care workers and other patients by either temporal segregation (clustering potentially contagious patients later in the day) or spatial segregation (shunting potentially contagious patients towards specific rooms). Therefore, clinic schedulers and telephone operators should be aware of the signs and symptoms that suggest a patient is contagious.55
Proper triaging is necessary. Minor issues and complaints may have to wait, but urgent problems must be addressed. The clinic will not operate with normal efficiency. Health care workers may become ill or be absent. Running additional tests, notifying authorities, taking on and off personal protective equipment, rearranging the clinic, and decontaminating rooms will cause operational delays.
Clinics that routinely run at peak capacity could become overwhelmed, especially if the clinic staff themselves become ill. Every clinic should have clearly established contingency plans and build an extra capacity that can handle unexpected surges in patients.56 Specifically clinics will need:
Anytime medical treatment is administered, legal concerns come into play. Public health disasters are no exception. In a mass casualty setting, the ability to mount an adequate response may be hindered by the myriad of rules and regulations that govern the everyday practice of medicine. Laws vary from state to state, so Internists should be aware of their state’s specific regulations. Unfortunately, many states have not yet adequately addressed or clarified medico-legal issues and regulations in public health disasters.45 Some of these include:
As Internists could play a vital role in epidemics, disease outbreaks, or bioterrorist attacks, they must be knowledgeable, equipped, and prepared. In an emergency, potential legal and administrative barriers should be eased. Clinics should have appropriate contingency plans. Although the risk of large-scale attacks and epidemics seems low, the risk of smaller epidemics and local public health emergencies is much higher. Preparing for large events will help prepare for such smaller events.
Potential Financial Conflicts of Interest None disclosed.