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The U.S. Postal Service anthrax attacks demonstrated that while diagnosing an index case of a BCN event is difficult, knowledgeable and vigilant clinicians can and do play vital roles in lessening the extent and severity of such attacks. Increased clinical vigilance results in earlier recognition and earlier intervention. Likewise, more vigilant public health efforts facilitate preventive interventions (e.g., antibiotic prophylaxis) and environmental decontamination. This in turn protects exposed workers and prevents further exposures. The clinical and public health experiences gained from the anthrax attacks serve as a valuable frame of reference for anticipating the clinical and public health needs generated by any future BCN attacks.

Certainly, an acute BCN event will activate immediately the machinery of the nation’s public health infrastructure and alert clinicians to evaluate all patients in a different way. With index cases of bioterrorism, the challenges are much greater: clinicians need to recognize BCN exposure even when it is subtle and unheralded, as with the early cases of anthrax.

Clinicians need to be able to take an appropriate history and conduct a targeted physical examination not only to ensure an index case does not get missed following a BCN event, but also to evaluate all patients with a syndrome consistent with BCN exposure following a recognized attack. A second element of clinicians’ responsibilities relates to infection control. Early and strict adherence to established infection control practices is essential to protecting health care workers and first responders, medical and ancillary staff, and secondary contacts, and to limit the spread of an epidemic. Finally, in addition to their bedside skills and awareness of infection control practices, clinicians must also be prepared to engage with both the public health and legal systems when responding to any real or potential BCN event. This chapter provides guidance to clinicians in the three essential responsibilities of clinical diagnosis, infection control, and public health intervention.

Of Note...

Hijackers in Florida

It is believed that one of the September 11 hijackers was seen by a Florida physician for what was initially diagnosed as a skin infection but was later (during the September 11 attack investigations) diagnosed as cutaneous anthrax. In the doctor’s defense, such a diagnosis would have been extraordinarily rare, particularly when the United States had not yet recognized the dangers to come. Nonetheless, a proper diagnosis initially may have altered history—serving to highlight the importance of properly trained and vigilant clinicians.

Clinical vigilance in today’s geopolitical climate has become a requirement for clinicians. Barring a sentinel terrorist event that changes the clinical approach radically, BCN possibilities should be ever present, albeit hovering low and distant on differential diagnoses of appropriate clinical pictures. Such a practice is rife with challenges, particularly because the signs and symptoms of the biological and chemical agents are typically nonspecific, especially early on. This is particularly true in an unrecognized attack as the first cases will likely ...

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