Anthrax attacks highlight holes in US public health system

United States health officials now think that the anthrax attacks that killed 5 people were likely the work of an individual, not a state-sponsored terrorist plot, but the experience of coping with these attacks has left even Secretary of Health Tommy Thompson describing the nation's public health system as "in tatters".The relatively small bioterrorist attack exposed weaknesses in the American public health system that suggest the nation would be hard-put to recover from assault with a more dangerous organism such as smallpox or plague, or from an attack on a chemical or nuclear facility.The public health system has suffered decades of budget cuts, privatization and forced economic competition. The anthrax cases revealed an almost complete breakdown at local and state levels in the ability to detect and respond to large-scale disease outbreaks or threats, whether launched by man or nature. Although Thompson initially defended the government's ability to respond to biowarfare, he told USA Today on 21 November that the federal government will need to spend $300 million per year for the next 5 years to bring state and local public health systems up to reasonable standards. Physicians and ordinary citizens naturally looked to the nation's top health and investigative agencies for aid and guidance, but the federal Department of Health and Human Services (HHS), the Centers for Disease Prevention and Control (CDC) and the Federal Bureau of Investigation (FBI) contributed to public panic and may have cost lives by their failure to grasp the scientific complexities involved.Thompson — who made his mark as a governor willing to drastically slash welfare roles in his state — took the lead in dispensing information in the immediate aftermath of the anthrax attacks, but much of that information was wrong. On 30 September he insisted on the CBS television show 60 Minutes that the federal government has "7,000 medical personnel ready to go" and was "prepared to take care of any contingency, any consequence, that develops for any kind of bioterrorism attack." By 3 October he was backing away from that stout assertion and conceding at a Senate hearing on bioterrorism that the US is not fully prepared to respond to a biowarfare attack. By 21 November he was describing the system as a mess.Emblematic of Thompson's steep climb up the learning curve was his 3 October assertation that if a smallpox outbreak should occur, people in the affected area could simply be treated with antibiotics. Since smallpox is caused by the viruses Variola major and Variola minor, antibiotics would not help, a rudimentary concept many would have hoped the Secretary of Health might know.On 4 October he suggested that the first anthrax case — photo editor Robert Stevens — was contracted in the course of Stevens' leisure-time activities as an outdoorsman. He described it as an "isolated case" with "no evidence of terrorism." Nobody from HHS had bothered to talk to Larry Bush — chief of staff at Atlantis Medical Center in Atlantis, Florida who treated Stevens — before making this public statement, which Bush promptly characterized as "ridiculous." Bush argued that this was the first case of inhalation anthrax in 23 years in the state of Florida, a state famed for its' outdoors-oriented lifestyle, and that the US government wasted valuable time by initially downplaying the possibility of bioterrorism.Bush's full report on Steven's case will appear in 29 November New England Journal of Medicine but was released on the journal's website on 8 November due to its public health importance. He pointed out that "When dispersed in the air as 1 to 5 μm particles, Bacillus anthracis endospores may pose a risk even over large geographic distances," a point established following the accidental release of endospores in Sverdlovsk, Russia, in 1979 and which may have saved lives in the US had it been remembered by federal health authorities.The first anthrax patient was hospitalized on 2 October. The 19 October issue of CDC's Morbidity and Mortality Weekly Report (MMWR) finally provided guidelines for health-care providers for recognizing illness possibly associated with biowarfare. The 1November MMWR advised physicians who suspect a patient might have inhalation anthrax to determine whether flu-like symptoms have been present for 2 to 5 days and if so to order up a white blood cell count, chest radiograph, blood cultures, and CT scan if the radiograph is abnormal. Antibiotics were recommended only if any of the tests come back positive or the patient looked pretty ill. This approach was disputed by CDC's own experts in a telephone briefing held that day. Virginia Caine, from the Division of Infectious Diseases at Indiana University School of Medicine, said that since the time from onset of symptoms to death from inhalation anthrax can be as short as 3 days, physicians should "go ahead and treat – don't wait," should treat with multiple antibiotics, and should make sure that patients continue antibiotics for the full 60-day period spores can lie dormant in the lungs.For two decades both the major American political parties have treated any excess capacity in the health care system as waste and the nation's public health infrastructure as an unnecessary frill. Nearly 40 million Americans have no reliable access to health care because they lack health insurance. This includes a high proportion of service workers and custodial personnel who would probably be among the first exposed to a contagious biowarfare agent.Janet Williams of West Virginia University reported at the American College of Physicians annual meeting in October 2001 that 26 of 30 US hospitals contacted at random said they could handle a maximum of 15 victims of a biowarfare attack, and 22 were completely unequipped to treat victims of a chemical or nuclear attack. Charles Treser at the University of Seattle had previously reported that fewer than 20%of 186 hospitals surveyed had plans for dealing with biological or chemical attacks and only two-thirds had enough antibiotics on hand to treat 50 victims of anthrax exposure. The American Hospital Association thinks that major urban hospitals should be prepared for 1,000 additional patients in the event of a large-scale bioterrorist attack, and rural hospitals should be ready for 200 more patients. The anticipated $11 billion price tag would pay for building up supplies, acquiring decontamination equipment, providing protective clothing, installing air conditioning that prevents the spread of airborne contagion from high-risk patients and upgrading communications systems.The local and state public health departments that surround these hospitals are understaffed, underfunded, and poorly equipped to respond to emergencies. Ten percent do not even have access to e-mail. Last year the federal government spent less than $50 million, spread among all 50 states, on this front-line public health infrastructure.More than 140 counties in the US do not even have health departments, and the average county department shrank from 72 to 67 employees from 1997 to 2000, according to the National Association of County and City Health Officials (NACCHO). One result is that many local health departments are essentially shut down on evenings and weekends, with nobody available to receive and act on reports of suspicious events that might suggest disease outbreaks or intentional release of a biologic agent. Rex Archer — head of NACCHO's committee on bioterrorism and emergency preparedness — estimates that about 15,000 more people are needed in local health departments to achieve reasonable preparedness.A bill proposed by the US Senate would give $3.2 billion in emergency spending this year to help state and local health departments. This would include $1.5 billion to state and local public health agencies to be spread among the 50 states, $1.15 billion to beef up federal stockpiles of vaccines, antibiotics, and medical supplies, $400 million to improve security of food supplies, and only $400 million for grants to hospitals that join local public health agencies to develop preparedness plans.As expected, the Bush Administration has balked at the price tag and instead asked Congress for $1.5 billion, mostly to stockpile antibiotics and vaccines.For a series of 10 comprehensive reviews discussing the impact of the World Trade Center attack and the subsequent bioterrorist threat on front line medical professionals in New York, logon and register at:The Critical Care Forumhttp://ccforum.com/login

Anthrax attacks highlight holes in US public health system

The bioterrorist activity in the United States has identified significant gaps in the supposed seamless and coherent response to major public health emergencies.

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