Mark Bostic

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.