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
–

Accreditation Review Commission on
Physician Assistant Programs (ARC-PA)
–

No training specified
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
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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
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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
–
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Blood smear and gram stain/culture
–
–
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Mediastinal widening, pleural effusion, consolidation
Large bacilli
Left shift
Cerebrospinal Fluid
–
Purulence, decr. glucose, incr. protein, elevated
pressure, blood
Inhalational anthrax
www.cdc.gov
Cutaneous anthrax
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
Most prevalent form of infection
Skin barrier must be compromised
Replication and toxin release
–
May take up to 14 days
Diagnosis: cutaneous anthrax
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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
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Combination of:
–
–
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Combination varies depending upon:
–
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Ciprofloxacin (Cipro ®)
Doxycycline (Vibramycin ®)
Adult, child, immunocompromised
Amoxicillin for pregnant females
Smallpox (Variola)
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DNA virus
Transmitted in droplet form
Respiratory tract mucosa
12-14 day incubation period
Often misdiagnosed as varicella
Diagnosis: smallpox
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Rapid onset of nonspecific sx’s
–
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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
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No cure
Tx is supportive
Vaccination available = Vaccinia
Plague
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Yersinia pestis
–
–
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Gram negative, pleomorphic coccobacillus
Infects by fleas carried by rodents
Bubonic, septicemic, pneumonic
Diagnosis: bubonic and pneumonic
plague
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Onset of nonspecific sx’s in 2 to 6 days
–
–
–
–
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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
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Fever, chills, prostration, N/V, abdominal pain
Purpura and DIC  hypotension, shock, and
death
Blood cultures (all types of plague)
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Gram stain & culture (all types of plague)
–
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Prior to tx with antibiotics
Prior to tx with antibiotics
Sputum sample
Treatment: plague
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Streptomycin (1st line)
Gentamicin (2nd line)
Tetracylines such as chloramphenicol
Viral hemorrhagic fevers
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RNA viruses:
–
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Infection via vectors:
–
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Arenavirus, bunyavirus, filovirus, flavivirus
Mosquitoes, ticks, cats, rabbits, people
History should include travel to tropical regions
Diagnosis: VHF
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Onset of nonspecific symptoms:
–
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Hallmark: generalized systemic coagulopathy
with profuse bleeding
–
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Fever, HA, myalgia/arthralgia, N/V, diarrhea
Possible bradycardia, tachycardia, liver necrosis,
delirium, confusion, coma
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
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No FDA approved drugs
Ribavirin may be effective
Supportive treatment of shock:
–
Hydration, blood transfusions, etc.
Botulism
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Spore-forming anaerobic bacterium Clostridium
botulinum
Toxin is most lethal of all toxins
–
–
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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
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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.)
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Equine botulinum antiserum
Antibiotic therapy experimental
–
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Metronidazole
PCN
Supportive: ventilation and tube feeding
Tularemia
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Nonmotile, aerobic gram negative
coccobacillus Francisella tularensis
–
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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
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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://www.logicalimages.com/resourcesBTAgentsTularemia.htm
http://phil.cdc.gov/Phil/details.asp
Treatment: tularemia
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Ciprofloxacin or doxycycline (early)
Streptomycin or gentamicin (late)
No vaccine
Reporting
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Written plan in every health care facility
Notify local health care officer for suspected or
confirmed cases
Conclusion
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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.
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CDC (2005). “Agents, diseases, and other threats.” Cited on World Wide Web 1 December 2005 at
http://www.bt.cdc.gov/agent/.
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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.
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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.

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Goad, J. A., J. Nguyen (2003). “Hemorrhagic Fever Viruses.” Top Emerg Med 25(1): 66-72.

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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
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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.
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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.
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Lohenry, K. (2004). “Anthrax exposure – stay alert, act swiftly” Journal of the American Academy of Physician
Assistants 17(8): 29-33.
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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.
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O’Brien, K., M. Higdon, J. Halverson (2003). “Recognition and Management of Bioterrorism Infections.”
American Family Physician 67(9): 1927-34.
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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.
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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.