Physicians are on the front lines in the effort to combat bioterrorism. By watching for highly unusual and unexplained illnesses and reporting them to the appropriate authorities, physicians serve as the early warning system against an attack involving biological or chemical agents.

Remain vigilant
The physician’s role in early detection of an outbreak is extremely important, since our nation’s public health system cannot respond until it is aware that a biological or chemical attack has occurred.

Questioning the severity of symptoms in patients and reporting suspicious disease clusters to public health agencies is more crucial than ever. Physicians should not hesitate to alert their local or state department of health when they strongly suspect bioterrorism is involved. They should report anything highly unusual without worrying whether it is a false alarm.

If necessary, the health department will help coordinate an investigation and contact the appropriate federal authorities.

Of course, physicians should contact public health agencies only after attempting to rule out bioterrorism as the cause of an illness. When patients have specific and persistent symptoms that cannot be attributed to other causes, contacting the appropriate public health agency is warranted.

However, physicians should not perform nasal swabs. These tests, which are conducted to determine the extent of a patient’s exposure, must be performed by epidemiologists.

Patients who call a physician’s office because they fear they have come in contact with a dangerous substance should be told to call the police or fire department. Hazardous material teams trained and equipped to contain such substances will respond in those situations.

Educate patients
Equally important is the dialogue between physician and patient. Anxious patients look to their physicians for reassurance when the public health is threatened, and it is important for physicians to share relevant facts and appropriate warnings. To help calm patients’ fears and keep them safe, physicians should advise patients of the following:

• The Centers for Disease Control and Prevention (CDC) has ample supplies of antibiotics and vaccines that can be rushed to affected populations within hours. Patients should also trust their doctors and should never attempt to diagnose and/or medicate themselves.
• It is impossible for patients to anticipate and obtain all of the various and specific medications that may be needed in the event of an attack. Patients should not attempt to stockpile antibiotics.
• Stockpiling antibiotics as a precaution is dangerous for several reasons:
• It diminishes existing supplies that may be needed in an emergency.
• Antibiotics may do more harm than good if patients don’t know when to start taking them, when to stop or what illness they might have.
• Indiscriminate use of antibiotics creates resistant bacteria.
• There are side effects that may result in serious complications for some patients. Also, some antibiotics (such as Cipro) were not developed for use in children.

Do Internet research
There are several sites on the Internet with current, reliable information on bioterrorism. Physicians may want to visit the following:

www.jama.ama-assn.org
Journal of the American Medical Association (JAMA)
There are many useful articles on bioterrorism at this website, including articles that address anthrax, botulinum toxin, plague, smallpox and tularemia. Descriptions of symptoms and infection control procedures are provided.

www.bt.cdc.gov
Centers for Disease Control and Prevention
The Public Health Emergency Preparedness & Response section of the CDC’s website features a plethora of information on bioterrorism, including health alerts, advisories and updates, video/satellite broadcasts and answers to frequently asked questions.

www.hopkins-biodefense.org
Johns Hopkins University Center for Civilian Biodefense Studies
This website includes information for clinicians on anthrax, as well as concise diagnostic criteria and treatment guidelines for anthrax, botulism, smallpox and plague.

www.acponline.org/bioterro/
American College of Physicians—American Society of Internal Medicine
There is a wealth of bioterrorism information on this site, including what an inhalation anthrax chest X-ray looks like.

Conclusion
While physicians can’t prevent bioterrorist attacks, they are essential to early detection. As part of a large network of experts with specific roles in protecting the public welfare, physicians must balance the importance of that responsibility with the risk of jumping to conclusions. After September 11, the threat is no longer hypothetical. Physicians must strive to keep their patients calm and informed while keeping their own eyes and ears open to the specter of a potential outbreak.