General treatment principles for victims of bioterrorism should be understood by the practitioner. Specific therapies for individual Class A agents are listed in Table 9-2. From a population perspective, morbidity and mortality are primarily minimized by preventing exposure and providing prophylaxis and immunization as appropriate, and then by treating the infected, symptomatic patients. Treatment may involve specific pharmaceuticals or general supportive care. Depending on the agent involved, prophylaxis or immunization of the hospital staff may be warranted. Prophylaxis, immunization, or treatment may be indicated even without obvious signs of disease or definitive information about exposure. This makes the practitioner heavily reliant on the public health sector to stratify patient risk based on exposure and to provide evidence-based prophylaxis and treatment. With specific agents (e.g., anthrax), large community-based efforts have been developed with federal support related to the dispensing of postexposure prophylaxis (i.e., Medical Counter Measures).20
One of the critical issues in providing treatment to victims of bioterrorism is the development of adequate medical surge.18 This issue is complicated by current healthcare industry practices that minimize staff, maintain just-in-time inventory, and limit hospital bed capacity. Medical surge capacity is developed by first maximizing individual healthcare facility capacity and capabilities (through an effective emergency operations plan) and then by coordinating regional resources to address and match patient needs to available resources. The development of emergency healthcare coalitions is supported by federal funding through the national Hospital Preparedness Program, in part to achieve this surge requirement through information dissemination and effective mutual aid. State and federal assistance should also be included in planning but not relied upon for at least the first 48 hours.
Federal agencies distinguish medical surge capacity from surge capability, which similarly can pose challenges.18 Medical surge capability refers to the ability to manage patients requiring unusual or very specialized medical evaluation and care. It is intuitively obvious, for example, that even one patient presenting with signs and symptoms of smallpox would present highly unusual challenges affecting any hospital's continuity of operations.
Infection control guidelines for the diagnosed or suspected agent should be put into practice. This is essential to protect clinicians, hospital staff, visitors, and other patients. It is also critical in maintaining the ability of the hospital to continue its regular medical commitment to the community. The Association for Professionals in Infection Control and Epidemiology has published guidelines for hospital infection control in response to a bioterrorist event.21 Most agents of concern require only standard precautions (gloves, mucous membrane protection when potential for splashing exists, and a gown when the potential exists for soiling), but meticulous attention to detail is required. The more troubling agents are those that are contagious through airborne or droplet transmission. Disease containment for a case of pneumonic plague requires droplet protection and patient isolation. Smallpox requires airborne and contact precautions and, therefore, full patient isolation. If a contagious disease is spreading within the community, procedures must be instituted to screen everyone entering the healthcare facility (e.g., staff, patients, visitors, delivery personnel) for active disease. This screening should ideally take place in an appropriately established "facility" before entering or immediately upon entry into the hospital building.
Isolation of large numbers of infectious patients may be necessary. Current hospital configurations often prohibit large-scale containment of patients in official isolation rooms, but entire wings could be adapted (using fire doors and manipulation of ventilation/air pressure within hospital smoke compartments) to serve as isolation wards. Plans to provide adequate separation from other, noninfected patients, to designate and train specific staff to care for these patients, and to furnish proper personal protective equipment should be developed in the emergency operations plan annex.
Another important initial consideration for ED personnel is whether patient decontamination is indicated. Decontamination is a consideration only if a patient presents shortly after acute exposure to a substance suspected or confirmed as a biologic agent, in contrast to the presentation of the patient who has already developed symptoms of an infectious disease. If a realistic concern exists, simply disrobing the patient and showering with soap and warm water should be adequate decontamination, but this must be accomplished in a controlled environment before patient entry into the healthcare facility. Clothing and personal belongings should be secured to assist with the public health and law enforcement investigations. Decontamination agents, such as diluted bleach, should be avoided, due to their potential for harm and the lack of demonstrated clinical or protective efficacy.22,23
Just-in-time inventory practices may limit the amount of vaccine, antibiotics, and other pharmaceuticals and supplies available. Vendors for emergency back-up supplies and equipment are commonly shared by multiple institutions, each counting the vendor's back-up cache as their own. Having a community-wide mutual aid system between all the hospitals promotes appropriate sharing of critical supplies, equipment, and staff during an emergency. If prescriptions are being written for antibiotics, the local pharmacies' on-hand supply should be considered (an issue during the anthrax incident in 2001). Writing short-course prescriptions with procedures to provide completion of the medication regimen may be indicated until adequate supplies are available, but this strategy should be implemented on a region-wide basis to not place an individual practitioner's patients at increased risk. Integration of Strategic National Stockpile supplies into a medical community has specific requirements that are available for review through the Centers for Disease Control and Prevention and requires specific planning by the community emergency management and public health agencies.18
In unusual and very threatening situations such as bioterrorism, addressing the requirements of each patient encountered and maximizing efficiency can markedly facilitate the overall processing of victims. For those patients who are potentially exposed but not physically ill, the patient interaction may require sophisticated explanations as to why the individual is or is not receiving a particular therapy. Preprinted instructions (indicating category of risk stratification and why the patient was placed in that category) can increase efficiency and be helpful for patients being treated and released. These instructions should clearly indicate how the disease is transmitted, measures that prevent spread, and early signs and symptoms of disease with appropriate steps if they should occur. Appropriate follow-up should be established (in a large-scale incident, this may not be with a primary care physician but through a public health venue). It is important to note any change in the epidemiology of the incident (e.g., a new site tests positive for the agent) or if new information becomes available on the etiologic agent itself (e.g., antibiotic resistance patterns). Patients may need to be rapidly re-contacted to change therapy. Proper record keeping and organization of charts based on assigned risk category can assist with this process. Entering all patients into a reliable long-term surveillance database should be a task for the public health agency, but hospitals and EDs could facilitate this process.
For agents of concern that have an available vaccine, such as anthrax and smallpox, in a preincident setting, recommendations are to withhold vaccination for the general public.23,24 Anthrax vaccination requires a series of five injections followed by yearly updates. A 2003 initiative to vaccinate healthcare workers and willing civilians against smallpox was discontinued after only a minority of the target cohort actually accepted vaccinations. The risk of potential life-threatening side effects, such as generalized vaccinia and potential cardiac sequelae, complicates the recommendations for smallpox vaccination in the absence of known disease.25
Therapeutics recommended for some bioterrorism agents are normally not approved for children or for pregnant or lactating women. In many situations, these recommendations are relaxed (e.g., Emergency Use Authorization) when the risk of infection and its consequences exceeds the risks of the medication or vaccine. In addition, some unique treatments (e.g., ciprofloxacin for anthrax prophylaxis in children) have received U.S. Food and Drug Administration approval.