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
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 ...