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Bioterrorism:
Are Physician Assistants Prepared to Diagnose and Treat?
Mark Bostic
Spring 2006
PAS 646
Objectives
1) Talk about PA preparedness
2) Talk about bioterroristic diseases
What is bioterrorism?
Form of terrorism in which biological agents are used to inflict harm and/or fear upon a population.
http://www.fbi.gov/anthrax/images.htm#1
Physician Assistant Training
Medical school model Consistent with physician training Bioterrorism?
Bioterrorism Training
Physician Assistant Programs’ Websites– No training specified
Accreditation Review Commission on Physician Assistant Programs (ARC-PA)– No training mandated
Liaison Committee on Medical Education (LCME)– No training mandated
Physician Assistant Preparedness
Studies lacking for PA’s Physician preparedness
– HHS Agency for Healthcare Research and Quality (AHRQ) survey indicates physicians unprepared
n=614 physicians, 18% trained, 93% expressed interest
– Johns Hopkins University study indicates physicians unprepared
n=2407 physicians, pretest 46.8%, posttest 79% Chickenpox vs. smallpox, botulism vs. Guillain-Barre
CDC top six bioterroristic agents
Anthrax Smallpox Plague Viral hemorrhagic fevers Botulism Tularemia
Anthrax
Bacillus anthracis– Spore-forming bacterium
Livestock, meat products, wool sorters Inhalational, cutaneous, gastrointestinal Often misdiagnosed as influenza
Inhalational anthrax
Most deadly Incubation period Replication and toxin release Phase I: nonspecific constitutional symptoms
– Mild fever, malaise, myalgia, nonproductive cough, emesis, chest/abdominal pain
Phase II: more severe– Higher fever, chest/neck edema, mediastinal
widening, dyspnea, cyanosis, meningoencephalitis, shock
Diagnosis: inhalational anthrax
Chest x-ray and chest CT– Mediastinal widening, pleural effusion, consolidation
Blood smear and gram stain/culture– Large bacilli– Left shift
Cerebrospinal Fluid– Purulence, decr. glucose, incr. protein, elevated
pressure, blood
Inhalational anthrax
www.cdc.gov
Cutaneous anthrax
Most prevalent form of infection Skin barrier must be compromised Replication and toxin release
– May take up to 14 days
Diagnosis: cutaneous anthrax
1) pruritic papule or pustule surrounded by smaller vesicles
2) mild fever and malaise 3) papule enlarges to a circular lesion
surrounded by edema– Ruptures and necroses– Characteristic “Black Eschar”
Cutaneous anthrax
www.cdc.gov
Treatment: anthrax
Combination of:– Ciprofloxacin (Cipro ®)– Doxycycline (Vibramycin ®)
Combination varies depending upon:– Adult, child, immunocompromised
Amoxicillin for pregnant females
Smallpox (Variola)
DNA virus Transmitted in droplet form Respiratory tract mucosa 12-14 day incubation period Often misdiagnosed as varicella
Diagnosis: smallpox
Rapid onset of nonspecific sx’s– Fever, HA, malaise, chills, myalgia, anorexia, N/V,
diarrhea, abdominal pain, delirium, convulsions Papules surrounded by rash a few days later Centrifugal distribution Papules pustules crusted lesion Simultaneous staging of lesions Not “dewdrops on a rose petal”
Smallpox
www.cdc.gov
Treatment: smallpox
No cure Tx is supportive Vaccination available = Vaccinia
Plague
Yersinia pestis– Gram negative, pleomorphic coccobacillus– Infects by fleas carried by rodents
Bubonic, septicemic, pneumonic
Diagnosis: bubonic and pneumonic plague
Onset of nonspecific sx’s in 2 to 6 days– Fever, chills, weakness, malaise, myalgia, lethargy chest pain, dyspnea, watery/bloody expectorated
sputum– Tender buboes (swollen lymph nodes)– 2 to 4 days later, lung exhibits necrosis, infiltration,
hemorrhaging, effusion, abscesses Chest x-ray Hypotension, respiratory distress, pulmonary
edema = death in 24 hours
Plague
www.cdc.gov
Diagnosis: septicemic plague
Fever, chills, prostration, N/V, abdominal pain Purpura and DIC hypotension, shock, and
death Blood cultures (all types of plague)
– Prior to tx with antibiotics Gram stain & culture (all types of plague)
– Prior to tx with antibiotics Sputum sample
Treatment: plague
Streptomycin (1st line) Gentamicin (2nd line) Tetracylines such as chloramphenicol
Viral hemorrhagic fevers
RNA viruses:– Arenavirus, bunyavirus, filovirus, flavivirus
Infection via vectors:– Mosquitoes, ticks, cats, rabbits, people
History should include travel to tropical regions
Diagnosis: VHF
Onset of nonspecific symptoms:– Fever, HA, myalgia/arthralgia, N/V, diarrhea– Possible bradycardia, tachycardia, liver necrosis,
delirium, confusion, coma Hallmark: generalized systemic coagulopathy
with profuse bleeding– Petechiae, ecchymoses, epistaxis, hematemesis– Bleeding from gingiva, vagina, any puncture sites
Definitive: immunoglobulin Antibody to specific virus
Viral hemorrhagic fevers
http://www.gata.edu.tr/dahilibilimler/infeksiyon/resimler/VIRAL_HEMORRHAGIC_FEVER/__VIRAL_HEMORRHAGIC_FEVERS_2.JPG
Treatment: VHF
No FDA approved drugs Ribavirin may be effective Supportive treatment of shock:
– Hydration, blood transfusions, etc.
Botulism
Spore-forming anaerobic bacterium Clostridium botulinum
Toxin is most lethal of all toxins– 100,000x sarin gas– 15,000x nerve gas
Iraq: enough to kill every human 3 times Bacterium or toxin may be aerosolized, placed
in food supplies Blocks ACh release
Diagnosis: botulism
Descending paralysis Ptosis, diplopia, blurred vision, and dilated,
sluggish pupils Difficulty speaking, chewing, swallowing Paralytic asphyxiation or flaccid airway collapse Culture serum, stool, gastric contents, suspected
food
Treatment: botulism (cont.)
Equine botulinum antiserum Antibiotic therapy experimental
– Metronidazole– PCN
Supportive: ventilation and tube feeding
Tularemia
Nonmotile, aerobic gram negative coccobacillus Francisella tularensis– 2 subspecies: biovar tularensis & biovar palaeartica
Bite of tick, mosquito, handling infected carcass
Aerosolization possible Incubates, then moves to LN and multiplies Pathology at all sites where bacillus spreads
Diagnosis: tularemia
Site of inoculation: papule-pustule-ulcer pattern Eye: ulceration of conjunctiva with LAD Oral: tonsillitis or pharyngitis with cervical LAD Lungs: bronchiolitis, pneumonitis,
pleuropneumonitis with LAD Fever, abdominal pain, diarrhea, emesis IF, GS&C
Tularemia
http://phil.cdc.gov/Phil/details.asp
http://www.logicalimages.com/resourcesBTAgentsTularemia.htm
Treatment: tularemia
Ciprofloxacin or doxycycline (early) Streptomycin or gentamicin (late) No vaccine
Reporting
Written plan in every health care facility Notify local health care officer for suspected or
confirmed cases
Conclusion
Data suggest that physicians are unprepared to diagnose and manage diseases of a bioterroristic cause.
Studies need to be performed to determine whether or not PA’s are prepared.
Thank you for your attention!
References
ARC-PA (2005). “Accreditation standards for physician assistant education.” Section B(1-7): 11-13. CDC (2005). “Agents, diseases, and other threats.” Cited on World Wide Web 1 December 2005 at
http://www.bt.cdc.gov/agent/. Cosgrove, S. E., T. M. Perl, X. Song, S. D. Sisson (2005). “Ability of physicians to diagnose and manage
illness due to category A bioterrorism agents.” Archives of Internal Medicine 165(17): 2002-2006. Endy, T. P., S. J. Thomas, J. V. Lawler (2005). “History of U.S. Military Contributions To The Study of Viral
Hemorragic Fevers.” Military Medicine 170(4): 77-91. Goad, J. A., J. Nguyen (2003). “Hemorrhagic Fever Viruses.” Top Emerg Med 25(1): 66-72. Hickner, J., F. M. Chen (2002). “Survey on Eve of Anthrax Attacks Showed Need for Bioterrorism Training.”
Press release 5 September 2002. Agency for Healthcare Research and Quality, Rockville, MD. Cited on World Wide Web on 22 December 2005 at http://www.ahrq.gov/news/press/pr2002/anthraxpr.htm
Karwa, M. (2005). “Bioterrorism: Preparing for the impossible or the improbable.” Critical Care Medicine 33(1
Suppl): S75-95.
References
LCME (2004). “Functions and structure of a medical school.” Section II(A): 2. Leger, M. M., R. McNellis, R. Davis, L. Larson, R. Muma, T. Quigley, S. Toth (2001). “Biological and chemical
terrorism: Are we clinicians ready?” American academy of physician assistants. Cited on world wide web 3 January 2005 at http://www.aapa.org/
clinissues/BTtext.htm. Lohenry, K. (2004). “Anthrax exposure – stay alert, act swiftly” Journal of the American Academy of Physician
Assistants 17(8): 29-33. NPR online, (2005). “History of Biological Warfare.” Cited on World Wide Web 21 November 2005 at
http://www.npr.org/news/specials/response/anthrax/features/2001/ oct/011018.bioterrorism.history.html. O’Brien, K., M. Higdon, J. Halverson (2003). “Recognition and Management of Bioterrorism Infections.”
American Family Physician 67(9): 1927-34. Straight, T. M., A. A. Lazarus, C. F. Decker (2002). “Defending Against Viruses in Biowarfare.” Postgraduate
Medicine 112(2): 75-80.
References
Varkey, P., G. Poland, F. Cockerill, T. Smith, P. Hagen (2002). “Confronting Bioterrorism: Physicians on the Front Line.” Mayo Clinic Proceedings 77(7): 661-72.
United States Department of Health and Human Services (2002). “HHS announces $1.1 billion in funding to
states for bioterrorism preparedness.” HHS press release 31 January 2002. Cited on World Wide Web 30 December 2005 at http://www.hhs.gov/news/press/
2002pres/20020131b.html.