Physician Jim Augustine is vice chair of
clinical operations for emergency medicine.
A firefighter and EMT for 20 years, he is a
medical adviser to the Atlanta Fire Depart-
ment. He has written hospital and com- munity major incident plans in a variety
of settings.

by Nicki Pesik

n recent months, we have been bombarded with questions about potential threats from contagious agents: What is bioterrorism? How do biological agents spread? Can we protect ourselves? Do we have enough antibiotics and vaccines? How real is the threat?

Bioterrorism is simply defined as the use of bacteria, viruses, or toxins that can incapacitate or cause the death of large numbers of people. Some of the biological agents suitable as biological weapons, according to the Centers for Disease Control and Prevention (CDC), include smallpox, anthrax, pneumonic plague, botulinum toxin, and tularemia because of their ability to cause high mortality and to have a major impact on public health.

These agents would most likely be spread through the air, exposing or infecting thousands of people. Unfortunately, persons exposed would not realize it until 2-14 days later, when symptoms first appear. Furthermore, we can't predict when and where such agents might be used, so personal use of a gas mask or respirator is impractical. Unlike patients exposed to chemical agents, those exposed to biological agents don't require decontamination because their exposure could have been days or weeks before coming to the hospital.

The recent anthrax cases illustrate that these agents can be used to deliberately infect people. Most patients were infected or exposed during the handling or processing of letters contaminated with anthrax. However, we still believe that the general public remains at low risk for exposure.

As physicians, we should strive to educate our patients and staff on the signs and symptoms of anthrax. Most of all we must provide reassurance to our patients. It is especially important to explain the appropriate use of diagnostic tests and antibiotics for anthrax.

For instance, nasal swabs should be used as an epidemiologic tool, not for decision-making regarding the diagnosis, treatment, or prophylaxis for an individual patient. Antibiotics are indicated when a credible exposure has occurred, as determined by law enforcement and public health officials. The inappropriate use of antibiotics may lead to more common bacteria becoming resistant and thereby lessen the future utility of the antibiotics. Emory Healthcare physicians are closely working with public health departments and the CDC to offer the most up-to-date testing and treatment protocols.

The simple truth, though, is that few doctors in this country have ever seen a case of smallpox or anthrax. Many experts believe that emergency departments and primary care clinics will be the first to see these patients and raise concern about the possibility of a man-made epidemic. Because prompt recognition of the clinical signs of these diseases may help limit an outbreak and mitigate its effects, education is key to making clinicians more aware of these unusual cases. That's why the Emory department of emergency medicine is educating its physicians, nurses, and staff in this area.

Compassionate care and protection of our patients and staff is of the utmost priority. The CDC, Department of Defense, and other medical working groups have established guidelines and recommendations for prevention, treatment, and infection control. It's important to understand that only a few of the likely bioterrorism agents are contagious, such as smallpox, pneumonic plague, and viral hemorrhagic fever (VHF) viruses like Ebola. Anthrax is not contagious, and patients with anthrax pose no risk to hospital personnel.

Antibiotics are available to treat both anthrax and pneumonic plague, but there are no specific antiviral agents to treat smallpox or VHF. Smallpox vaccine is recommended if you are exposed to a person infected with smallpox. However, there are only some 15 million doses of smallpox vaccine in the nation. Under current CDC guidelines, the vaccine now is given only to those who work with the smallpox virus.

We do not recommend mass vaccination of the public and health care community for several reasons. In addition to the vaccine supply being very limited, the vaccine is associated with uncommon but potentially serious adverse side effects, including death. Currently, the benefits of vaccination do not outweigh these risks.

The threat of biological agents being used as potential weapons is small, but real. All of us are much more likely to be involved in a car accident than to be a victim of bioterrorism. Nevertheless, the threat cannot be dismissed.

by James Augustine

t no time since the early days of the Cold War has America had to review every facet of its major incident preparedness, as it has done since September 11. Before then, most communities in America already had plans for and experience in dealing with the man-made and natural emergencies that might threaten their citizens. Every day, fire, EMS, law enforcement responders, and hospital personnel handled emergencies and cared for victims.

The American emergency system was created to prepare for most perceived major threats. The earliest American disaster preparedness efforts followed the attack on Pearl Harbor. Then the Cold War raised the specter of a nuclear winter, and Americans built and stocked personal shelters. When nuclear power plants were built, nearby communities prepared for accidental radiation release. The latest versions of disaster planning have prepared us for catastrophic earthquakes in California, major hurricanes in the Sunbelt, and casualties from the Persian Gulf War. Today, within 24 hours of activation, mobile response teams can travel the globe to provide disaster services.

The only plan not tested extensively before last fall was the response to biological agents. That changed with a second wave of unprecedented terrorism that began October 17 with a letter laced with anthrax spores and opened in Senate Majority Leader Tom Daschle's office. It marked the beginning of a new kind of war here, one on bioterrorism.

The attacks raised concerns in the Emory community that the Clifton corridor could be a terrorist target, so preparation has taken a new level of priority and cooperation. The reasons are obvious. Our neighbor, CDC, is the global leader in the study of major illness outbreaks, prevention, and treatment. Emory Healthcare and the Rollins School of Public Health are nationally recognized for medical care and prevention.

The CDC sits both physically and operationally within the Emory community, so it made sense for the university, the CDC, and the county to develop coordinated detailed response plans for major emergencies, including bioterrorism. The region's significant emergency plans for the 1996 Olympics were fine-tuned after local pipe bomb explosions and the West Nile virus outbreak last summer. As a result, Atlanta and Georgia are among the better-prepared cities and states to deal with natural or man-made disasters. The region has plans for dealing with major incidents that routinely include traffic accidents, severe storms, and fires. Preparation for chemical exposures and protection from infectious diseases are routine EMS and emergency department operations.

Frankly, those emergency response plans were given a hard test on September 11. Since then, plans have been updated, and the CDC has heightened its already tight security. We believe that the release of biological agents from such a secure environment is extremely unlikely. Extensive measures have been in place to prevent such an occurrence, and in the event of an explosion, most experts believe that all biological agents would be inactivated. Still, the university has an evacuation plan that designates our satellite campuses on Clairmont and Briarcliff as collection points for students, staff, and relief services should the need arise.

Emory Healthcare is focused on improving its response through assessment of current inventories of supplies and pharmaceuticals, practical disaster drills, and review of current disaster plans. The system's disaster plan covers all departments, including emergency, public safety, laboratory, infection control, human resources, nursing, food services, and administration. Emory University Hospital on campus and Crawford Long Hospital in midtown regularly participate in city-wide disaster-relief exercises - much like fire drills but bigger and more complicated - with other hospitals in the metro area. Grady Hospital, staffed by Emory physicians, already is known throughout the region for superb Level 1 trauma service.

Major strides have been made to improve the public health response as well. An expanded laboratory network offers quick and accurate diagnoses. The National Pharmaceutical Stockpile will augment medical supplies, antibiotics, and vaccines of local and state governments. (A federal mandate can release the stockpile, but a "push package" will be available anywhere in the nation within 12 hours of the decision to release these assets.)

From the Director  /  Letters

Of mice and men

Lives on the line

Our GRA connection

Moving Forward  /  Noteworthy

On point: Perspectives on bioterrorism

Coming to a helipad near you

In addition, the Health Alert Network (HAN) now links public health departments across the country. This telecommunications network provides Emory Healthcare information that can guide clinical management during a bioterrorism event. Programs to improve surveillance systems are also being developed. The emergency department is actively involved in developing both passive and active surveillance systems to quickly identify unusual disease outbreaks.

Because it is impossible to foresee every contingency, planning to respond to a natural or technical disaster must be an ongoing and continuous process. It began long before the tragic events of September 11 and will continue indefinitely.

For more information on bioterrorism, see www.cdc.gov or www.nbc-med.org.