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Countering Bioterror:
Spotlight on Public Health

by Alicia P. Gregory

One of the most important byproducts of last October's anthrax-by-mail attacks is an increased emphasis on public health.

Illustration from bioterrorism cover"We've had a progressive erosion in the funding for the public health system over the last several years," says Douglas Scutchfield, director of the Kentucky School of Public Health. With new funds totaling $15 million from the federal government, Kentucky will hire 15 new epidemiologists (a.k.a. disease detectives), assess how well its 123 hospitals are prepared to deal with bioterrorism, and upgrade animal laboratories in Lexington and Hopkinsville.

Part of this effort will involve table-top exercises, which Scutchfield and Martin Evans, medical director of hospital infection control at the UK Chandler Medical Center, say is the most effective way to train first responders for an outbreak. "A table-top exercise is a drill of an actual event," Scutchfield says. "It brings the relevant stakeholders together to demonstrate how the system would work in the event of an emergency and allows them to 'debug' their bioterrorism plans."

Photo of Douglas Scutchfield and Martin EvansDouglas Scutchfield (left) and Martin Evans are developing bioterrorism drills for first responders: hospital and health department personnel, EMS, police, and firefighters.

Unlike chemical or nuclear attacks where the first people on the scene will most likely be police, firefighters, EMS or FBI, the first responder to bioterrorism will probably be a doctor in an ER. "Identification is going to be very difficult because many of these diseases present with very common symptoms—fever, cough, diarrhea, rash—things we see all the time," Evans says.

"Most of us physicians have never seen a case of anthrax, much less smallpox," says Scutchfield. "We need to raise the level of knowledge about potential bioterrorism agents and how to recognize them, what to do, who you contact next, and how quickly."

Scutchfield and Evans envision rolling into a local hospital with a table-top exercise that would involve diagnosing and communicating information about specific bugs. "We'd involve all the agencies that are going to be mobilized in response to bioterrorism—the police chief, fire chief, health department director, mayor's office, EMS, and hospital personnel," Scutchfield says, adding that the Colorado public health department has already tried this.

"They had a mock smallpox outbreak, and it got to the point where the police and fire departments didn't answer their telephones because the system was overrun. That exercise illustrated that the cops couldn't communicate with the fire department, and neither of them could communicate with the public health department, without a specific communications plan involving cell phones and two-way radios. These exercises allow you to identify those kinds of issues in advance so you know how you're going to deal with them in the event of an actual emergency."

Hospital Readiness
Evans, who leads the Bioterrorism Preparedness Task Force at UK, says this readiness effort is much larger than the University of Kentucky Hospital. "We gathered infectious-disease doctors and infection-control personnel from hospitals all over Lexington, and one of the very first things we had to decide was what we were going to use to treat anthrax," Evans says.

While no anthrax cases were ever confirmed in Lexington, Evans says it was important to choose which drug all local hospitals would give out. Ciprofloxacin, the drug talked about most as the anthrax scare spread, is very costly—$500 wholesale for a 60-day dose (120 tablets). Doxycycline, which comes as a generic—and subsequent tests have proven can be as effective as Cipro—is about $6. "We didn't want to confuse the public by having disparity among the hospitals, where UK was giving the 'cheap' stuff and Central Baptist was giving the 'good' stuff. So we all decided to use Doxy."

Evans is working to prepare for bioterror scenarios in order to protect patients that come into the UK hospital, as well as UK's doctors, nurses and staff. "I don't anticipate major infection-spread problems with non-transmissible agents like anthrax and tularemia," Evans says. "The threat there is that somebody will expose others to the agent by coming in like Pig Pen, the character in the Peanuts comic strip, in a cloud of dust. Someone who suspects they've encountered those agents can simply put their clothes in a bag, shower down and put on fresh clothes before coming to the hospital.

"Pneumonic plague is a concern. You can cough out the bacteria and transmit it to other people, but it's fairly easy to give medications to protect health-care workers and isolate individuals because it's not the kind of thing that's carried by airflow patterns from room to room or floor to floor."

Smallpox, on the other hand, has the ability to spread through a hospital via air ducts. "You'd need to put those patients in negative-pressure airflow rooms—we have quite a few right now for tuberculosis patients," Evans says. "The air comes from the hallways into the rooms and then is exhausted to the outside, generally from the roof. That's sufficient for TB because the bacteria are diluted by the huge quantities of air outside. But the CDC doesn't really feel the same about smallpox. They'd like us to have HEPA filters on the exhaust." These filters are expensive, and Evans says a better care alternative for smallpox patients would be designating and equipping one hospital to handle all smallpox cases in the region.

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