Bioterrorism Are Physician Assistants Prepared to Diagnose and

Bioterrorism: Are Physician Assistants Prepared to Diagnose and Treat? Mark Bostic Spring 2006 PAS 646

Objectives l 1) Talk about PA preparedness l 2) Talk about bioterroristic diseases

What is bioterrorism? l 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 l l l Medical school model Consistent with physician training Bioterrorism?

Bioterrorism Training l Physician Assistant Programs’ Websites – l Accreditation Review Commission on Physician Assistant Programs (ARC-PA) – l No training specified No training mandated Liaison Committee on Medical Education (LCME) – No training mandated

Physician Assistant Preparedness l l Studies lacking for PA’s Physician preparedness – HHS Agency for Healthcare Research and Quality (AHRQ) survey indicates physicians unprepared l – n=614 physicians, 18% trained, 93% expressed interest Johns Hopkins University study indicates physicians unprepared l l n=2407 physicians, pretest 46. 8%, posttest 79% Chickenpox vs. smallpox, botulism vs. Guillain-Barre

CDC top six bioterroristic agents l l l Anthrax Smallpox Plague Viral hemorrhagic fevers Botulism Tularemia

Anthrax l Bacillus anthracis – l l l Spore-forming bacterium Livestock, meat products, wool sorters Inhalational, cutaneous, gastrointestinal Often misdiagnosed as influenza

Inhalational anthrax l l Most deadly Incubation period Replication and toxin release Phase I: nonspecific constitutional symptoms – l 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 l Chest x-ray and chest CT – l Blood smear and gram stain/culture – – l 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 l l l Most prevalent form of infection Skin barrier must be compromised Replication and toxin release – May take up to 14 days

Diagnosis: cutaneous anthrax l l l 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 l Combination of: – – l Combination varies depending upon: – l Ciprofloxacin (Cipro ®) Doxycycline (Vibramycin ®) Adult, child, immunocompromised Amoxicillin for pregnant females

Smallpox (Variola) l l l DNA virus Transmitted in droplet form Respiratory tract mucosa 12 -14 day incubation period Often misdiagnosed as varicella

Diagnosis: smallpox l Rapid onset of nonspecific sx’s – l l l 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 l l l No cure Tx is supportive Vaccination available = Vaccinia

Plague l Yersinia pestis – – l Gram negative, pleomorphic coccobacillus Infects by fleas carried by rodents Bubonic, septicemic, pneumonic

Diagnosis: bubonic and pneumonic plague l Onset of nonspecific sx’s in 2 to 6 days – – l l 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 l l l Fever, chills, prostration, N/V, abdominal pain Purpura and DIC hypotension, shock, and death Blood cultures (all types of plague) – l Gram stain & culture (all types of plague) – l Prior to tx with antibiotics Sputum sample

Treatment: plague l l l Streptomycin (1 st line) Gentamicin (2 nd line) Tetracylines such as chloramphenicol

Viral hemorrhagic fevers l RNA viruses: – l Infection via vectors: – l Arenavirus, bunyavirus, filovirus, flavivirus Mosquitoes, ticks, cats, rabbits, people History should include travel to tropical regions

Diagnosis: VHF l Onset of nonspecific symptoms: – – l Hallmark: generalized systemic coagulopathy with profuse bleeding – – l 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 l l l No FDA approved drugs Ribavirin may be effective Supportive treatment of shock: – Hydration, blood transfusions, etc.

Botulism l l Spore-forming anaerobic bacterium Clostridium botulinum Toxin is most lethal of all toxins – – l l l 100, 000 x sarin gas 15, 000 x 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 l l l 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. ) l l Equine botulinum antiserum Antibiotic therapy experimental – – l Metronidazole PCN Supportive: ventilation and tube feeding

Tularemia l Nonmotile, aerobic gram negative coccobacillus Francisella tularensis – l l 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 l l l 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/resources. BTAgents. Tularemia. htm http: //phil. cdc. gov/Phil/details. asp

Treatment: tularemia l l l Ciprofloxacin or doxycycline (early) Streptomycin or gentamicin (late) No vaccine

Reporting l l Written plan in every health care facility Notify local health care officer for suspected or confirmed cases

Conclusion l l 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.

l Thank you for your attention!

References l l l l 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/pr 2002/anthraxpr. htm Karwa, M. (2005). “Bioterrorism: Preparing for the impossible or the improbable. ” Critical Care Medicine 33(1 Suppl): S 75 -95.

References l l l l LCME (2004). “Functions and structure of a medical school. ” Section II(A): 2. Leger, M. M. , R. Mc. Nellis, 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 l l 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/ 2002 pres/20020131 b. html.