bioterrorism: are physician assistants prepared to diagnose and treat? mark bostic spring 2006 pas...
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Bioterrorism:
Are Physician Assistants Prepared to Diagnose and Treat?
Mark Bostic
Spring 2006
PAS 646
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Objectives
1) Talk about PA preparedness
2) Talk about bioterroristic diseases
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What is bioterrorism?
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
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Physician Assistant Training
Medical school model Consistent with physician training Bioterrorism?
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Bioterrorism Training
Physician Assistant Programs’ Websites– No training specified
Accreditation Review Commission on Physician Assistant Programs (ARC-PA)– No training mandated
Liaison Committee on Medical Education (LCME)– No training mandated
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Physician Assistant Preparedness
Studies lacking for PA’s Physician preparedness
– HHS Agency for Healthcare Research and Quality (AHRQ) survey indicates physicians unprepared
n=614 physicians, 18% trained, 93% expressed interest
– Johns Hopkins University study indicates physicians unprepared
n=2407 physicians, pretest 46.8%, posttest 79% Chickenpox vs. smallpox, botulism vs. Guillain-Barre
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CDC top six bioterroristic agents
Anthrax Smallpox Plague Viral hemorrhagic fevers Botulism Tularemia
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Anthrax
Bacillus anthracis– Spore-forming bacterium
Livestock, meat products, wool sorters Inhalational, cutaneous, gastrointestinal Often misdiagnosed as influenza
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Inhalational anthrax
Most deadly Incubation period Replication and toxin release Phase I: nonspecific constitutional symptoms
– 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
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Diagnosis: inhalational anthrax
Chest x-ray and chest CT– Mediastinal widening, pleural effusion, consolidation
Blood smear and gram stain/culture– Large bacilli– Left shift
Cerebrospinal Fluid– Purulence, decr. glucose, incr. protein, elevated
pressure, blood
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Inhalational anthrax
www.cdc.gov
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Cutaneous anthrax
Most prevalent form of infection Skin barrier must be compromised Replication and toxin release
– May take up to 14 days
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Diagnosis: cutaneous anthrax
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”
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Cutaneous anthrax
www.cdc.gov
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Treatment: anthrax
Combination of:– Ciprofloxacin (Cipro ®)– Doxycycline (Vibramycin ®)
Combination varies depending upon:– Adult, child, immunocompromised
Amoxicillin for pregnant females
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Smallpox (Variola)
DNA virus Transmitted in droplet form Respiratory tract mucosa 12-14 day incubation period Often misdiagnosed as varicella
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Diagnosis: smallpox
Rapid onset of nonspecific sx’s– 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”
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Smallpox
www.cdc.gov
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Treatment: smallpox
No cure Tx is supportive Vaccination available = Vaccinia
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Plague
Yersinia pestis– Gram negative, pleomorphic coccobacillus– Infects by fleas carried by rodents
Bubonic, septicemic, pneumonic
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Diagnosis: bubonic and pneumonic plague
Onset of nonspecific sx’s in 2 to 6 days– 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
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Plague
www.cdc.gov
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Diagnosis: septicemic plague
Fever, chills, prostration, N/V, abdominal pain Purpura and DIC hypotension, shock, and
death Blood cultures (all types of plague)
– Prior to tx with antibiotics Gram stain & culture (all types of plague)
– Prior to tx with antibiotics Sputum sample
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Treatment: plague
Streptomycin (1st line) Gentamicin (2nd line) Tetracylines such as chloramphenicol
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Viral hemorrhagic fevers
RNA viruses:– Arenavirus, bunyavirus, filovirus, flavivirus
Infection via vectors:– Mosquitoes, ticks, cats, rabbits, people
History should include travel to tropical regions
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Diagnosis: VHF
Onset of nonspecific symptoms:– Fever, HA, myalgia/arthralgia, N/V, diarrhea– Possible bradycardia, tachycardia, liver necrosis,
delirium, confusion, coma Hallmark: generalized systemic coagulopathy
with profuse bleeding– Petechiae, ecchymoses, epistaxis, hematemesis– Bleeding from gingiva, vagina, any puncture sites
Definitive: immunoglobulin Antibody to specific virus
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Viral hemorrhagic fevers
http://www.gata.edu.tr/dahilibilimler/infeksiyon/resimler/VIRAL_HEMORRHAGIC_FEVER/__VIRAL_HEMORRHAGIC_FEVERS_2.JPG
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Treatment: VHF
No FDA approved drugs Ribavirin may be effective Supportive treatment of shock:
– Hydration, blood transfusions, etc.
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Botulism
Spore-forming anaerobic bacterium Clostridium botulinum
Toxin is most lethal of all toxins– 100,000x sarin gas– 15,000x nerve gas
Iraq: enough to kill every human 3 times Bacterium or toxin may be aerosolized, placed
in food supplies Blocks ACh release
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Diagnosis: botulism
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
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Treatment: botulism (cont.)
Equine botulinum antiserum Antibiotic therapy experimental
– Metronidazole– PCN
Supportive: ventilation and tube feeding
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Tularemia
Nonmotile, aerobic gram negative coccobacillus Francisella tularensis– 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
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Diagnosis: tularemia
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
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Tularemia
http://phil.cdc.gov/Phil/details.asp
http://www.logicalimages.com/resourcesBTAgentsTularemia.htm
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Treatment: tularemia
Ciprofloxacin or doxycycline (early) Streptomycin or gentamicin (late) No vaccine
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Reporting
Written plan in every health care facility Notify local health care officer for suspected or
confirmed cases
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Conclusion
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.
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Thank you for your attention!
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References
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/pr2002/anthraxpr.htm
Karwa, M. (2005). “Bioterrorism: Preparing for the impossible or the improbable.” Critical Care Medicine 33(1
Suppl): S75-95.
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References
LCME (2004). “Functions and structure of a medical school.” Section II(A): 2. Leger, M. M., R. McNellis, 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.
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References
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/
2002pres/20020131b.html.