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Bioterrorism:. Are Physician Assistants Prepared to Diagnose and Treat?. Mark Bostic Spring 2006 PAS 646. Objectives. 1) Talk about PA preparedness 2) Talk about bioterroristic diseases. What is bioterrorism?.

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Are Physician Assistants Prepared to Diagnose and Treat?

Mark Bostic

Spring 2006

PAS 646

  • 1) Talk about PA preparedness
  • 2) Talk about bioterroristic diseases
what is bioterrorism
What is bioterrorism?
  • Form of terrorism in which biological agents are used to inflict harm and/or fear upon a population.

physician assistant training
Physician Assistant Training
  • Medical school model
  • Consistent with physician training
  • Bioterrorism?
bioterrorism training
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
physician assistant preparedness
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
cdc top six bioterroristic agents
CDC top six bioterroristic agents
  • Anthrax
  • Smallpox
  • Plague
  • Viral hemorrhagic fevers
  • Botulism
  • Tularemia
  • Bacillus anthracis
    • Spore-forming bacterium
  • Livestock, meat products, wool sorters
  • Inhalational, cutaneous, gastrointestinal
  • Often misdiagnosed as influenza
inhalational anthrax
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
diagnosis inhalational anthrax
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
cutaneous anthrax
Cutaneous anthrax
  • Most prevalent form of infection
  • Skin barrier must be compromised
  • Replication and toxin release
    • May take up to 14 days
diagnosis cutaneous anthrax
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”
treatment anthrax
Treatment: anthrax
  • Combination of:
    • Ciprofloxacin (Cipro ®)
    • Doxycycline (Vibramycin ®)
  • Combination varies depending upon:
    • Adult, child, immunocompromised
  • Amoxicillin for pregnant females
smallpox variola
Smallpox (Variola)
  • DNA virus
  • Transmitted in droplet form
  • Respiratory tract mucosa
  • 12-14 day incubation period
  • Often misdiagnosed as varicella
diagnosis smallpox
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”

treatment smallpox
Treatment: smallpox
  • No cure
  • Tx is supportive
  • Vaccination available = Vaccinia
  • Yersinia pestis
    • Gram negative, pleomorphic coccobacillus
    • Infects by fleas carried by rodents
  • Bubonic, septicemic, pneumonic
diagnosis bubonic and pneumonic plague
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

diagnosis septicemic plague
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
treatment plague
Treatment: plague
  • Streptomycin (1st line)
  • Gentamicin (2nd line)
  • Tetracylines such as chloramphenicol
viral hemorrhagic fevers
Viral hemorrhagic fevers
  • RNA viruses:
    • Arenavirus, bunyavirus, filovirus, flavivirus
  • Infection via vectors:
    • Mosquitoes, ticks, cats, rabbits, people
  • History should include travel to tropical regions
diagnosis vhf
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
viral hemorrhagic fevers1
Viral hemorrhagic fevers

treatment vhf
Treatment: VHF
  • No FDA approved drugs
  • Ribavirin may be effective
  • Supportive treatment of shock:
    • Hydration, blood transfusions, etc.
  • 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
diagnosis botulism
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
treatment botulism cont
Treatment: botulism (cont.)
  • Equine botulinum antiserum
  • Antibiotic therapy experimental
    • Metronidazole
    • PCN
  • Supportive: ventilation and tube feeding
  • 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
diagnosis tularemia
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

treatment tularemia
Treatment: tularemia
  • Ciprofloxacin or doxycycline (early)
  • Streptomycin or gentamicin (late)
  • No vaccine
  • Written plan in every health care facility
  • Notify local health care officer for suspected or confirmed cases
  • 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.
  • 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
  • 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
  • Karwa, M. (2005). “Bioterrorism: Preparing for the impossible or the improbable.” Critical Care Medicine 33(1 Suppl): S75-95.
  • 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
  • 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
  • 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.
  • 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
  • 2002pres/20020131b.html.