Are We Prepared?

Medical Community, Public Health Agencies Ramping Up for Bioterrorism Response

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Public Health Feature -- January 2002

By  Ken Ortolon
Senior editor

Jet airliners crashing into the World Trade Center and the Pentagon. Anthrax-tainted letters arriving through the U.S. mail in the offices of television network news anchors and national political leaders.

Before Sept. 11, 2001, these scenarios would have struck most Americans as being more appropriate to fiction than to reality. But all that has changed. The Sept. 11 terrorist attacks on New York and Washington, D.C., and the deaths of four people on the East Coast who apparently came into contact with letters laced with anthrax spores have opened the eyes of the nation to just how vulnerable America is to terrorist attack, including bioterrorism.

While Texas has not been a target of terrorist attacks yet, Texans have not gone unaffected by these tragic events. In the days following the news that anthrax-tainted letters had been mailed to U.S. Senate Majority Leader Tom Daschle (D-S.D.), NBC News anchor Tom Brokaw, and others, hazardous materials teams in Austin and elsewhere were called out numerous times to deal with odd-looking envelopes or suspicious white powder.

Fortunately, all of those instances turned out to be false alarms. But they have raised the question among health care professionals and public health officials: Is Texas prepared to deal with a bioterrorist incident?

The answer appears to be a qualified "yes."

Measuring Our Preparedness

"The state of Texas is prepared. We should be better prepared," said Texas Commissioner of Health Eduardo Sanchez, MD. "I think that is the simple fact. It's safe to say that we've got the tools, we've got the people, and we've got the knowledge to take care of a bioterrorist attack. But if we had several events happening simultaneously, we might be stretched."

On the local level, preparedness varies from city to city, says Gayle Harris, director of the Texas Medical Association's Public Health Department.

"A number of cities have been working on emergency preparedness for biological and chemical terrorist acts for a number of years through development of their emergency disaster plans," Ms. Harris said.

She says Austin, Houston, and Dallas are among the cities that have been most active in preparing for terrorism. More than two years ago, Austin officials conducted disaster drills that included emergency medical services, public health officials, police and fire departments, and all local hospitals.

Despite those efforts, and efforts of groups like TMA, which held three workshops on bioterrorism for physicians in 1999, Texas is not adequately prepared for a large-scale bioterrorist incident, and neither is the nation, says Houston cardiologist S. Ward Casscells III, MD.

"It's no secret that we're not fully prepared," Dr. Casscells, the John Edward Tyson Distinguished Professor of Medicine and vice president for biotechnology for The University of Texas-Houston Health Science Center, told the Governor's Task Force on Homeland Security during a public hearing held in Houston on Nov. 8. That task force was created by Gov. Rick Perry in October following the Sept. 11 terrorist attacks. "The American Medical Association, the American Society of Public Health, the Centers for Disease Control, three federal task forces in 12 months have all reported that we're not ready to defend against bioterrorism or chemical terrorism," Dr. Casscells said. "One telling statistic is that nationwide only 3 percent of first responders -- that's EMTs and paramedics -- have had bioterrorism training in the last five years."

Additionally, Dr. Casscells told the task force that only 20 percent of hospitals nationwide had counterterrorism plans in place as of early October.

Houston, however, is in much better shape, he says. Some 80 percent of first responders in Houston have had bioterrorism training, while the Texas Medical Center, Memorial Hermann Hospital, and UT-Houston Health Science Center all have counterterrorism plans in place.

Even so, Dr. Casscells says Texas faces several shortcomings in both prevention and response to bioterror. First, few Texas physicians have ever seen cases of anthrax, botulism, plague, or smallpox, which are among the most likely biological agents to be employed in a terrorist incident.

Second, hospitals lack what he called the "surge capacity" to handle mass casualties resulting from such an attack. Because of cost pressures from profit-driven managed care plans, hospitals have closed whole sections and cut staff. That means many cities may not have adequate hospital beds or nursing staff to handle an incident that resulted in hundreds or thousands of casualties.

"If there is a large event, we could not get a handle on it," Dr. Casscells said.

Ramping Up

Realizing that much work is needed before Texas could fully respond to a large-scale bioterror incident, a wide range of public health agencies and medical organizations are working now to increase the preparedness of physicians, hospitals, and the public health infrastructure.

Even before the anthrax scare surfaced, the Texas Department of Health (TDH) issued a Sept. 11 alert urging physicians to maintain a "heightened index of suspicion for unusual events including possible bioterrorism."

TMA also took swift action, e-mailing the TDH alerts on bioterrorism and anthrax to approximately 8,600 Texas physicians involved in direct patient care. TMA also created a bioterrorism bibliography on its Web site to provide vital information from TDH, the U.S. Centers for Disease Control and Prevention, and other sources for both physicians and patients.

In October, TMA President Tom B. Hancher, MD, of Columbus, appointed a Task Force on Bioterrorism to help prepare Texas physicians to meet any bioterrorism threat.

"This past week's news stories prove that Texas physicians must be ready to recognize, diagnose, and treat numerous unfamiliar biological and chemical agents," Dr. Hancher said in announcing the task force on Oct. 16. "It is our association's public duty to educate and prepare physicians for the kind of attack we all pray we'll never have to face."

Dr. Hancher named University of North Texas Health Science Center President Ronald R. Blanck, DO, to chair the task force. Dr. Blanck, former surgeon general of the U.S. Army, said physicians "clearly must be in the forefront" in dealing with bioterrorism.

"Texas is fortunate to have all the expertise necessary, and then some, to provide physicians with the information they need to counsel patients, be part of efforts to prepare, and of course be aware of the possible presence of these diseases," Dr. Blanck said.

The mission of the TMA task force is to enhance awareness, increase knowledge, and tighten the network of communications among physicians, other health care professionals, and medical and nonmedical organizations.

Manning the Front Lines

Dr. Hancher says his goal is to make sure Texas physicians can recognize and treat the most likely bioterrorism threats. And, he has promised Governor Perry that TMA will assist in mobilizing physician volunteers if certain cities or regions should need additional physician manpower to treat victims of a bioterrorist attack.

"As physicians and physician associations, we are the front line of defense," Dr. Hancher told the task force members. "It has been said we're the eyes, ears, and the stethoscopes to meet these challenges, and I think that's absolutely true."

At the task force's first meeting on Nov. 7, Dr. Blanck said he has three priorities for the group. First is the production of "readable, usable, brief, to-the-point" educational materials for physicians and patients. At the meeting, the task force initiated the drafting of treatment protocols on anthrax, smallpox, botulism, and plague that will be limited to two pages to ensure that physicians are more likely to read and follow them. The group also is drafting one-page informational handouts for patients on each of those four diseases.

Dr. Blanck's second priority is improving the interface between public health officials and practicing physicians. And his third priority, he said, is making sure physicians do whatever possible to support enhancement of the state's public health infrastructure.

"If there is a bright spot in all of this, it is the increased emphasis on public health," he said.

Closing the Gaps

That emphasis arose quickly, particularly from the Texas Legislature. In September, state Sen. Mike Moncrief (D-Fort Worth), chair of the Senate Health and Human Services Committee, asked TDH for an assessment of needs to ensure the department was ready to respond to a bioterrorist threat. On Oct. 19, TDH submitted a six-point plan designed to close the gaps in its readiness.

Sharilyn Stanley, MD, TDH associate commissioner for disease control and prevention, says the plan, which would cost some $12 million for the first biennium to implement, is designed to increase the speed at which TDH can react to a bioterrorist event.

"I would say that we're fully capable of responding," Dr. Stanley said. "Where the gaps exist are in areas that would speed our response. If you look at the overall plan, we're asking for things that would speed our ability to be aware that something is going on and to be able to diagnose in our laboratories exactly what agent is involved, then enhance our ability to communicate that back out to local public health officials and the local communities to coordinate a response."

Dr. Sanchez says the No. 1 priority in the plan is the creation of "early response teams" that would be located in all eight of the state's public health regions. These teams would consist of an epidemiologist, a public health nurse, and a public health technician who would focus on active, rather than passive, disease surveillance.

"Right now, our whole disease detection system is very much reliant on physicians having a high index of suspicion and reporting things," Dr. Stanley said. "We know that physicians are very busy. They have lots of priorities in their offices, and reporting communicable diseases does not happen to the level we would like."

The early response teams would do one-on-one education with hospitals, laboratories, and physicians to improve communicable disease reporting, as well as carry out active disease surveillance by reviewing hospital discharge data and patient records in physician offices.

Other provisions of the TDH proposal include:

  • Upgrading equipment and training at public health laboratories in Houston, Dallas, El Paso, San Antonio, Lubbock, Harlingen, and possibly Fort Worth to speed diagnose of anthrax and other biological agents.
  • Enhancing TDH's electronic data collection and disease surveillance capabilities. Currently, 50 percent of infectious disease reports are received through regular mail.
  • Beefing up the Health Alert Network, a telecommunications link that facilitates electronic communication between TDH and local health departments.
  • Creating an Office of State Epidemiologist. Current state epidemiologist Dennis Perotta, PhD, also serves as chief of the TDH Bureau of Epidemiology, which is responsible for the state cancer registry, birth defects registry, injury registry, and numerous other programs. That, Dr. Stanley says, makes it difficult for him to focus adequate attention on disease surveillance.
  • Enhancing TDH laboratory capacity to detect and respond to chemical terrorism.

The Governor's Task Force on Homeland Security, at the recommendation of its Work Group on Health Issues and Bioterrorism, has endorsed the plan, and Governor Perry has asked state Health and Human Services Commissioner Don Gilbert to scrub his agency budgets in an attempt to find funding to carry it out.

Dr. Sanchez says TDH is moving forward with the plan "to the extent possible" while the funding issue is being looked at. If money cannot be found in the current budget, some of the proposals may have to wait for the legislature to reconvene in 2003.

Getting Into the Act

Meanwhile, numerous other organizations also are looking at bioterrorism preparedness. Like TMA, the Texas Hospital Association (THA) has worked closely with the homeland security task force and has disseminated information from TDH, CDC, and other sources to its member hospitals, says Jon Hilsabeck, THA senior vice president.

"Probably the biggest need right now is information and training," Mr. Hilsabeck said, "and that's what we're trying to help them with and provide."

County medical societies across the state also have been working to bring their members up to speed. For example, the Dallas County Medical Society sponsored a symposium on biological and chemical terror for some 250 physicians in October and devoted the entire November issue of its Dallas Medical Journal to bioterrorism.

The Travis County Medical Society also held a symposium on weapons of mass destruction in November that attracted some 250 physicians, emergency medical services personnel, and other health care professionals.

And, numerous medical schools also are looking at the issue, including UT Medical Branch at Galveston, Texas Tech University Health Sciences Center, and The Texas A&M University System Health Science Center.

Patty Patterson, MD, vice president for rural and community health at Texas Tech and chair of TMA's Council on Public Health, says Tech is attacking bioterrorism on two fronts. First is the education of physicians on its faculty "to make sure our doctors plug into the right spot when they see something," she said. Second, the Texas Tech University System has created a task force on antiterrorism and public security that involves the medical school faculty and engineers, lawyers, and others from Tech's general academic faculty.

"We're doing everything to be as prepared as we can be," Dr. Patterson said. "We need general education and awareness and then to be able to move in whatever direction should something happen."

With so many organizations working on bioterrorism, the challenge may be to ensure that everyone is working from the same playbook. Texas Board of Health member Amanullah Khan, MD, who chairs the Work Group on Health Issues and Bioterrorism for the governor's task force, says that group feels strongly that there be a clear chain of command.

"We found that there was a great deal of need for coordination because many groups are independently working on bioterrorism, such as the Texas Hospital Association and the Texas Medical Association," Dr. Khan said in presenting the work group's recommendations to the full task force.

Organization and coordination of all activities to prevent, detect, and manage an incident are vital, he said. "It has to be part of a coordinated plan that is integrated into all of our emergency preparedness," he said.

Sen. Florence Shapiro (R-Plano), vice chair of the work group, echoed those sentiments. "I think the most impressive thing for us was that so many entities are doing so many things that were very, very good," she said. "That was something we were very pleased about. But with all these entities looking at so many different and varied opportunities we want to make sure that there is a seamless process by which all of these entities can be communicating with one another and make absolutely sure that we, as citizens, are the beneficiaries of that seamless system."

Dr. Khan has teamed up with fellow governor's task force member and former Commissioner of Health Robert Bernstein, MD, to convene a coordinating council of health agencies and associations. The coordinating council's first meeting in November involved representatives of TMA, the Texas Osteopathic Medical Association, the Texas Nurses Association, THA, Texas A&M, UT-Houston, the Texas Pharmacy Association, the Texas Association of Local Health Officials, and the National Association of Social Workers. The groups agreed to collaborate with Dr. Sanchez and the health department to develop a coordinated, detailed plan that takes every community in Texas to the next level of preparedness. During this process, TMA's task force will work to keep the issues of physician and public health leadership front and center, particularly in terms of ensuring that Texas physicians who serve as local health authorities know what to do if and when a terrorist event comes to our state.

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

TMA Advantage

Bioterrorism Toolkit Available From TMA

The Texas Medical Association is working to prepare physicians to be the frontline defense against bioterrorism in Texas through the distribution of a bioterrorism toolkit.

The kit includes:

  • Clinical protocols on recognition and evaluation of biological agents in patients, including anthrax, botulism, plague, and smallpox; 
  • Patient education messages and resources;
  • Profiles and addresses of online resources via TMA's Bioterrorism Resource Center; and
  • TMA's Task Force on Bioterrorism goals and activities.

The bioterrorism toolkit is being distributed to all TMA member physicians as a supplement to the January issue of Texas Medicine . For additional information on bioterrorism, check out TMA's Bioterrorism Resource Center.

 

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