Preparing Physicians for Recognizing and Responding to ...

Preparing Physicians for Recognizing and Responding to Bioterrorism: A

Needs-based Approach

Stephen C. Alder, Ph.D.

Melissa Vellinga

October 20, 2004

Countering Bioterrorism 2004

Preparedness through Partnerships

Presentation Overview

Bioterrorism Recognition and ResponseI. What is expected of physicians?

II. How do physicians perceive their own role?

III. Training physicians: What is needed and wanted?

IV. Are we over-reacting?

V. Creating balance in BT preparedness

VI. Developing training for physicians

VII. Summary

BIOTERRORISMWhat are Physicians

Expected to Do?

What the CDC Recommends Physicians Do

• Have basic information about clinical manifestations of infections caused by the select agents of bioterrorism

• Know how to diagnose these conditions

• Know when and how to report confirmed or suspected conditions of importance to local public health and law enforcement officials

• Able to obtain necessary information from patients suspected to have conditions caused by bioterrorism for further investigation

Bioterrorism Preparedness and ResponseJulie L. Gerberding, MD, MPH; James M. Hughes, MD; Jeffrey P, Koplan, MD, MPH

Role Physicians See for Themselves

• Primary Care Physicians– Link to emergency response/public health

infrastructure– Calm persons who are well but worried– Prevent secondary

exposures

Role Physicians See for Themselves

• Emergency Medicine Physicians– Identify index case– Provide primary medical

response– Care for affected

patients

Role Physicians See for Themselves

• Infectious Disease Physicians– Alert health department– Provide expertise to medical community– Act as a regional resource

Role Physicians See for Themselves

• Dermatology and Radiology Physicians– Aid in diagnosis– Identify specific signs of tularemia, smallpox,

and anthrax– Support response efforts

of other physicians

How Should Training be Provided to

Physicians?

Principles of Adult Learning

• Adults are motivated to learn as they experience needs and interests that learning will satisfy

• Adults are motivated to learn when they need the education to effectively cope with real-life situations

• Adult orientation to learning is life centered – it deals more with their actual experience than with theoretical considerations

• Experience is the richest source for adult learning

Knowles, Holton, Swanson, 1998

Principles of Adult Learning

• Adults have a deep need to be self-directed in the learning process

• Individual differences in learning among adults increases with age

• Adults are motivated to engage in education that will enable them to perform tasks or deal with problems with which they will be confronted in everyday life

Knowles, Holton, Swanson, 1998

What Primary Care Physicians Want

• Information about disease surveillance and response that is applicable to both ongoing health concerns and potential bioterrorism events

• To be taught by a physician with expertise in bioterrorism recognition and response

• Hands-on oriented training that includes use of reference materials

What Emergency Medicine Physicians Want

• Ongoing education for identification of and initial response to diseases for specific bioterrorism agents

• To be taught by someone with specific training in bioterrorism who is sensitive to the role of emergency medicine physicians

• Quick reference materials, web-based training, disaster drills and exercises

What Infectious Disease Physicians Want

• The latest training on BT agents and other newly emerging infectious diseases

• Improve channels by which they can interact with the medical and public health community

• To be taught by someone with expertise in BT and emerging infectious disease

• Ongoing updates of the latest information regarding BT

What Dermatology and Radiology Physicians Want

• Better capacity to provide consultation to physicians with patients that may be victims of a bioterrorism event

• To be taught by experts in BT and BT recognition within their specialty

• Grand rounds, general presentations on BT at existing meetings

Needs Assessment Summary• The medical community feels a need to be prepared to

recognize and respond to bioterrorism events.

• The needs assessment conducted among Utah physicians provided insights into their perceived training needs and preferred methods of learning.

• Physicians have many competing demands on their time and a tailored educational offering can increase the intended audience’s acceptance and learning.

Are We Over-reacting?

“The public health community should acknowledge the substantial harm that bioterrorism preparedness has already caused and develop mechanisms to increase our public health resources and to allocate them to address the world’s real health needs”

Cohen HW, Gould RM, Sidel VW. The Pitfalls of Bioterrorism Preparedness: the Anthrax and Smallpox Experiences. American Journal of Public Health. 2004;94:1667-1670.

CDC’s View

• CDC's Health Alert Network has upgraded the capacity of state and local health agencies to detect and communicate different health threats—including bioterrorism, emerging infectious diseases, chronic diseases, and environmental hazards. This means that we reap the benefits of these investments every day, not just in the event of a bioterrorist attack.

CDC Programs in Brief: Bioterrorism and Public Health Preparedness http://www.cdc.gov/programs/bt.htm

CDC’s View

• … these [BT preparedness] measures strengthen the existing public health system while preparing for bioterrorism, infectious disease outbreaks, and other public health threats and emergencies.

CDC Programs in Brief: Bioterrorism and Public Health Preparedness http://www.cdc.gov/programs/bt.htm

“Terrorism presents many new challenges to the nation’s public health infrastructure. ……It is urgent that we now change and reinvest in our public health system to establish and maintain a strong disease-defense system- nationwide, competent, and modern.”

Levy BS, Sidel VW. Terrorism and Public Health: A Balanced Approach to Strengthening Systems and Protecting People. Oxford University Press; New York: 2003.

All-Hazards Preparedness

• The all-hazard preparedness concept is simple in that how you prepare for one disaster or emergency situation is the same for any other disaster

• Preparedness can be achieved through thoughtful planning before a disaster

Federal Emergency Management Agency (FEMA) All-Hazards Preparedness http://www.fema.gov/preparedness/hazards_prepare.shtm

Developing Bioterrorism Training Programs

Example: Developing Training for Primary Care Physicians

Example: How to Develop a Program

• Develop Learning Objectives– Use Information from needs assessment on

physicians’ perceived strengths and weaknesses

– Combine with role identified by the CDC

• Look at physician’s learning preferences

• Design training to meet learning objectives

• Evaluate training based on learning objectives

Review of Results from the Utah-based Needs Assessment

Primary Care Physicians:Current Strengths in Preparation

• Ongoing contact with patients within the local population

• Ability to watch for possible effects of bioterrorism event if alerted

• Ability to detect unusual disease patterns in the population

• Ability to link into hierarchy of medical specialists

Primary Care Physicians:Current Weaknesses in Preparation

• Inadequately prepared to recognize diseases caused by bioterrorism agents

• Inadequately prepared to treat diseases caused by all possible bioterrorism agents

• Time constraints and ongoing priorities do not allow for substantial bioterrorism focus

CDC Recommendations for Physician’s Role

• Have basic information about infections caused by BT agents

• Know how to diagnose these conditions

• Know when and how to report these conditions

• Be able to obtain all necessary information from the patient for further investigation

Learning Objectives

1. Physicians able to identify indications of a BT event

2. Physicians familiar with general signs and symptoms of diseases caused by class A BT agents

3. Link this preparation to their ability to identify disease outbreaks from non-BT sources

Primary Care Physicians:Preferred Methods to Learn

– Training on use of reference materials– Short ongoing monthly training with

accompanying reference materials– Hands-on oriented training– Incorporation of training into existing activities,

such as regular meetings, CME activities and professional meetings

Example: Reference guide for recognition and response to

bioterrorism

Examples of short presentations that can be

made at regularly scheduled meetings for Primary Care

Physicians

What would you look for as indication of unusual disease

occurrence?

What would specifically indicate a BT event?

Let’s check your responses

Indications of Intentional Release of a Biologic Agent

– An unusual temporal or geographic clustering of illness

– Patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak

– An unusual age distribution for common diseases

– a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin.

CDC MMWR 50(41);893-7

Key Indicators of a BT Event • Sudden increase in severity or incidence

of illness

• Appearance of unusual (non-endemic) illness or syndrome in your community

• Geographic and/or temporal pattern of illness

• Occurrence of vector-borne disease where there is no vector

UCLA Center for Public Health and Disasters, Bioterrorism: Are you prepared slideshow presentation

Key Indicators of a BT Event

• Cluster of sick or dead animals

• Atypical seasonality

• Unusual expression of endemic disease

• Multi drug-resistant pathogens

UCLA Center for Public Health and Disasters, Bioterrorism: Are you prepared slideshow presentation

Example of training resources from CDC for small group

presentations to enable Primary Care physicians to recognize

signs and symptoms of diseases caused by class A BT agents

(learning objective 2)

Bioterrorism Agents – PlagueLesson 2

Clinical Presentation

Objectives

• Identify distinctions between – Bubonic Plague– Pneumonic Plague– Septicemic Plague

Other Plague Presentations

• Pharyngeal Plague– Uncommon– Resembles tonsillitis with

peritonsillar abcess– Cervical lymphadenopathy

• Plague Meningitis– Most common in children– Usually end result of ineffective treatment of

other forms– Symptoms mimic other forms of acute plague

Infection Control

• Large numbers of plague bacilli

• Respiratory droplet spread in close direct contact

• Respiratory droplet precautions with suspect cases

• Contact public health

Plague Review QuestionsLesson 2, Question 1

• Gary, Indiana hospital

• 12 month old from Gary

• Acute onset fever, malaise, body aches x 2 days

• Extremely tender lymph node under arm, 2 inches

• Exhibiting neurologic symptoms

Suspect plague meningitis. First step?

Plague Review QuestionsLesson 2, Question 1

What is your first step?

A. Call local health department

B. Rule out other diseases

C. Place in isolation

Example of training resources from UCLA for small group

presentations to enable Primary Care physicians to

recognize signs and symptoms of diseases caused

by class A BT agents (learning objective 2)

UCLA Center for Public Health and Disasters

Bioterrorism Training for PhysiciansUpdated March 2003

Over 1700 Downloads Since Going Online October 2001

Available at: http://www.ph.ucla.edu/cphdr/bioterrorism

Biological TerrorismIntentional or threatened use of viruses,

bacteria, fungi or toxins from living organisms

to produce death or disease in humans,

animals or plants

Evaluation of Possible Inhalation Anthrax

• History of exposure or risk + Symptoms:WBC (bandemia), Blood culture – highest yieldCXR – wide mediastinum, effusion, or infiltrate

Consider CT if CXR normal

• If results abnormal or pt. seriously ill:

Multi-drug treatment• If results normal and pt mildly ill:

Observe and initiate single-drug prophylaxis

Botulism

Source:

Clostridium botulinum

neurotoxin

• Types A, B, E, and F

• Most potent toxin known– Lethal dose 1 ng/kg– 100,000 times more toxic than sarin

Case 1 - Dyspnea, Hypotension

• Patient admitted to ICU:– Fluids, Intubation, Ceftriaxone, Vanco., Gent.

• Later the same day a similar patient presents– Also a stock trader in the same building

• Both patients deteriorate and die the next day

Websites for training materials

• http://www.bt.cdc.gov/training/index.asp

• http://www.cphd.ucla.edu/

• http://www.ama-assn.org/ama/pub/category/6215.html

Evaluation• Many presentations have review questions at the end to assess knowledge of training participants

• Evaluation should assess whether learning objectives have been met

• Evaluation should also serve as a mini needs assessment to help identify directions for future training

Summary1. Physicians need to be prepared to play a vital role in the recognition

and response to bioterrorism

2. Physicians see themselves as having distinct roles depending on their specialty

3. Learning objectives can be developed by utilizing the identified role of targeted physicians and data obtained from needs assessment activities

4. Efficiency of resources may be gained by utilizing an all-hazards approach to preparedness

5. Resources are available for training physicians to recognize and respond to bioterrorism

6. Evaluation can serve to assess training activities and inform future training directions

Acknowledgements

• Co-authors: – Jamie D. Clark, MSPH

– George L. White Jr., PhD, MSPH

– Sharon Talboys, MPH

– Susan Mottice, PhD

• The Utah Department of Health

• The Center for Disease Control & Prevention

• Physician participants in needs assessment

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