STATEMENT OF JOHN G. BARTLETT, M.D

Transcription

1 Summary STATEMENT OF JOHN G. BARTLETT, M.D. PRESIDENT, INFECTIOUS DISEASES SOCIETY OF AMERICA BEFORE THE SUBCOMMITTEE ON PUBLIC HEALTH COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS UNITED STATES SENATE ON BIOTERRORISM: OUR FRONT LINE RESPONSE EVALUATING U.S. PUBLIC HEALTH AND MEDICAL READINESS March 25, 1999 The Infectious Diseases Society of America (IDSA) is a professional society comprised largely of physicians trained in infectious diseases, including 3,000 clinicians; most of the rest conduct research in various areas of public health or research on microbial agents. All of these activities are highly relevant to bioterrorism due to infectious agents such as anthrax, smallpox, tularemia, plague and Ebola virus. IDSA believes that the most conspicuous deficit in prior planning for bioterrorism is the lack of emphasis on the critical role of civilian expertise. In the event of an anthrax attack, be it small or large scale, the first responders will not be civil servants or military personnel; they will be clinicians. A person with inhalation anthrax goes to a physician in an office, emergency room or hospital. It is this health care system that is responsible for diagnosis, treatment and prophylaxis using antibiotics or vaccines. Infectious disease trained physicians play a potentially vital role because their expertise is in the recognition, diagnosis and management of diseases caused by microbes. However, other components of the health care system are also important players emergency room physicians, infection control personnel, microbiologists and primary care providers. The state of Maryland has approximately 250 physicians with training and career commitments to infectious diseases, about 400 emergency room physicians and some 10,000 primary care physicians. These physicians, coupled with other hospital personnel, are critical assets to the three to five public health authorities charged with orchestrating disaster response, but they are not aware of their potential roles in responding to bioterrorism--they don t know them, they ve not been specifically trained for them, and there is little in the current budget to address this need. To be prepared for a bioterrorism attack, sufficient resources and qualified personnel must be available across the country. Federal solutions include block grants to states and localities, changing Medicare conditions of participation and support of organizations such as medical specialty societies to help train the civilian workforce.

2 Complete Statement Mr. Chairman and members of the Subcommittee, I am John Bartlett, M.D., Professor of Medicine and Chief of the Division of Infectious Diseases, John Hopkins University School of Medicine. I am the current President of the Infectious Diseases Society of America (IDSA), a professional society comprised largely of physicians trained in infectious diseases. Our physician members include clinicians, researchers and epidemiologists. Our members research expertise is principally in the areas of public health or microbial agents. Activities of IDSA and its members are highly relevant to bioterrorism, due to our familiarity with infectious agents such as anthrax, smallpox, tularemia, plague and the Ebola virus. We study them, we diagnose them and we treat patients who suffer from them. Mr. Chairman, the President s budget includes substantial new expenditures for bioterrorism and proposes expanded responsibilities for the National Institute for Allergy and Infectious Diseases (NIAID), the Centers for Disease Control (CDC), and the Food and Drug Administration (FDA) for bioterrorism related programs. This is reassuring and appropriate, but it appears that virtually all of the proposed funds will be allocated to governmental agencies. While federal, state and local agencies obviously play a critical role in the nation s preparedness for bioterrorism, the civilian side of this equation has not received the attention it needs. Let me expand on this concern. Much of the planning and, indeed, the public perception of bioterrorism is based on an explosion or chemical attack. For both, the first responders are public servants: policemen, fireman and paramedics. The event is dramatic; it is patently obvious, and, usually, self-contained. The events of bioterrorism with microbial agents will play out in a far different scenario. The first responders here will be within the private sector: emergency room physicians, infectious disease physicians, and intensivists -- primarily medical providers. In the event of an anthrax spray, for example, the initial cases will present as influenza and be seen in private physicians offices, public clinics, and hospital emergency rooms. In most cases the initial diagnosis will be a viral illness, and patients who call physicians will be urged to take aspirin and rest. With smallpox, the most likely diagnosis will be chickenpox, or possibly a dermatological condition. The initial diagnosis of either anthrax or smallpox will not be made in a state public health laboratory or at the CDC. Specimens will be sent to hospital pathology and microbiology laboratories. It is important to recognize that there are virtually no physicians who have ever seen a case of anthrax or a case of smallpox. In both examples, it is thus reasonable to expect substantial delays in recognition and pursuit of a coordinated response. I have picked the examples of anthrax and smallpox simply because they are regarded as the top two prospects based on knowledge of bioterrorist resources. It is important for the committee to appreciate that these two infectious agents present completely different types of challenges: Anthrax causes an illness that looks like flu, followed by shock and death. The mortality rate is about 95% without treatment and about 80% with treatment. According to a report from the Congressional Office of Technology Assessment, a 100-pound release of anthrax spores from a Piper cub over Washington could result in a mortality substantially

3 higher than the nuclear bomb on Hiroshima. It would, in essence, be a medical disaster in size and scope unlike anything ever seen. However, it is critical to understand that most of this devastation could be easily averted through rapid implementation of a prevention program using antibiotics. To be effective, antibiotics would have to be deployed within a few days to several hundred thousand persons. This would require action by virtually every facet of the health care system, but primary care physicians, nurses, and other health professionals would represent the mainstay of the response. For patients who acquire anthrax or have suspected anthrax, there would have to be access to substantial bed capacity. The orchestration of patient flow, implementation of hospital policies for admission, and distribution of prophylactic antibiotics to essential health care workers would be orchestrated largely by infection control departments in hospitals and infectious disease specialists on the hospital staff. There clearly would be an important role for governmental agencies such as state health departments, the CDC, and the U.S. Army Research Institute for Infectious Diseases (USAMRIID) in confirming the initial diagnosis and guiding an orchestrated response to the disaster. However, the major health care and workforce resources would be from the civilian sector. Smallpox is completely different because, unlike anthrax, it is highly contagious. This disease was eliminated from the globe in 1976 under the leadership of D.A. Henderson. Thus, no one has seen a case in 23 years. Smallpox vaccinations have been discontinued so that nearly all persons on earth are now susceptible to the disease. The mortality rate is estimated at about 30%. Most of us in the infectious disease community believe that a single case of smallpox in 1999 would terrify the health care system because of the possibility of a global epidemic. An effective response would require hospitalization of all patients in negative pressure rooms, vaccination of thousands of exposed or potentially exposed persons, and the probable need for quarantine. Please remember that there are very few nurses--certainly none under the age of 55--who know the specialized techniques required for smallpox vaccination. Mr. Chairman, health care professionals working in the private sector represent the response workforce to a bioterrorism attack. Yet, they are painfully unprepared. They are also hard to reach. The reason is that we are all very busy, trying to deal with myriad changes in health care, a mandate to see patients at 15-minute intervals, and an unprecedented medical information blast. To the average physician, bioterrorism is a very low probability event, and, to be frank, the possibility of gaining most physicians attention for 30 minutes on this subject is also a low probability event. Let me illustrate the problem by walking through the sequence of events that might occur in the event of an anthrax spray over Baltimore. I presented a hypothetical patient with inhalation anthrax to Johns Hopkins Hospital s emergency room at 6:00 a.m. on February 23, The emergency room reported that it was then on blue alert, which meant that all 38 beds were occupied, there were 40 patients waiting to be seen in the waiting room, and the hospital was filled to capacity. The blue alert also meant that all emergency rooms in Baltimore were filled so that all new cases faced a long waiting time. The emergency room physician noted that the symptoms I described suggested flu and, if clinically stable, all such patients were simply sent home (as they should be). There were no available beds, but this is not uncommon in the era of managed care, which has resulted in tight restrictions on medical resources. (Maryland has many

4 unoccupied hospital beds, but hospital staffing has been downsized for efficiency, and it would be difficult to mobilize an adequate number of beds to accommodate a large epidemic, at least at the time I made the inquiry.) I then showed the on-call radiologist an x-ray with typical changes of inhalation anthrax. He reported that he would not think of anthrax in such situations because he had never seen a case and didn t know what x-ray changes were to be expected. I then inquired in the laboratory about the possibility of recognizing Bacillusanthraxis, the cause of anthrax, which would be found in blood cultures of patients. The physician in charge noted that this organism has never been detected in his 25 years at Hopkins, and would undoubtedly be discarded as a contaminant relatively early in the identification process. However, he did note that if two or three blood cultures yielded this contaminant, the laboratory would then proceed to full identification. But please note that at least two days would be required to grow the organism before it could be identified. Once identified, he would call the infection control physician and me as chief of infectious diseases. I then called the state health department and got a recorded message. My call was returned three days later. I also called the Hopkins hospital administrator who is in charge of hospital disasters. He said he thought there was a person on call for such emergencies at the state health department but didn t know the number nor how to get it. The point of this presentation is to simply walk the committee through a scenario that is likely to be played out with this type of bioterrorism, in part to illustrate the sharp differences compared to an explosion, and to illustrate the critical role of multiple first responders representing diverse health professionals who are relatively poorly prepared. Solutions to this problem are not necessarily easy, but critically important if we can expect to be responsive to bioterrorism with microbial agents. A part of the solution is clear: there must be substantial and immediate attention to the critical role of the civilian health care sector in the planning process and in the allocation of resources. Are sufficient resources and qualified health professionals available across the country to respond to bioterrorism? Today, the answer is no. Mr. Chairman, Maryland has 16,000 physicians, including 262 members of the IDSA and 400 emergency physicians, as well as thousands of nurses. They are your first responders, but probably less than one percent have ever thought about how to respond to a bioterrorism incident. There are 60 hospitals, each with an infection control department; there are 13,400 acute hospital beds, 30,800 nursing home beds, 829 ICU beds, 165 negative pressure rooms and probably over 1,000 clinics. But we are not aware of a single hospital, HMO or other medical group that has a disaster plan tailored to the specific demands of a bioterrorism attack with agents such as anthrax or smallpox. What types of intervention might be anticipated? What types of activities might be envisioned? Physicians identify with peers and professional societies. This applies especially to infection control practitioners, infectious disease specialists and emergency room physicians; each of these has thought leaders, journals, regular meetings, and relevant expertise. It is important that funds are made available to help professional societies develop and disseminate needed educational materials. The possible format for some of these activities is illustrated by the organization I represent, the Infectious Diseases Society of America. Bioterrorism was the subject of

5 two plenary sessions at our annual meeting, we have included bioterrorism in relevant practice guidelines, updated information is provided in our member newsletter, and we have established a bioterrorism committee within the Society. Members include 5,000 infectious disease specialists who are likely to be involved in the detection of and planning for this type of attack. Similar activities should be encouraged in other relevant societies. Communication systems that are likely to reach health care professionals need to be diverse and must include a variety of mechanisms including national meetings, websites, and journal articles. This is the way health care professionals get information. The intent of these publications is to heighten awareness and provide appropriate direction for application of skills that are idiosyncratic to the disciplines. The communication between federal, state, and local health departments will be critical in efforts to obtain and disseminate information. There are 35 federal agencies alone involved and clearly delineated authority and responsibilities are essential. The Johns Hopkins Center represents an important resource, in part because of the credibility of the institution and the extraordinary qualifications of its leader, Dr. D.A. Henderson, and the team he has built. This group has provided a broad menu of educational activities. These include the first National Conference on Bioterrorism, which was attended by about 1,000 and represented the first time there was extensive discussions on the subject between representatives of academic, public health, federal agencies and the private sector. The Center has also been responsible for over 100 presentations to diverse groups representing government, health care professionals, and others. These presentations will be the road maps to be used in the event of bioterrorism involving the targeted microbes. The Center has produced a series of consensus statements that provide guidance for managing the major agents of biologic warfare. The Center has a website and will have a newsletter that serves as a network to diverse providers throughout the country. The Center is working with multiple professional associations like the IDSA to accomplish these goals. There need to be tabletop demonstrations and extensive regional planing. This is taking place by USAMRIID as well as by state and city health departments, including the Maryland State Health Department. One problem is that these activities have often failed to attract the civilian first responder I have described; for example, I have not encountered a physician in my discipline who is aware of any of these sessions despite the fact that the infectious disease expert is likely to play an important role in bioterrorism involving microbes. Bioterrorism should be included in relevant fellowship training programs and medical school curricula just as other social issues are. One method to assure this gets done is to include relevant questions on certifying exams and to require authorities such as the residency review committees to mandate exposure to bioterrorism response as a criterion for approval.

6 Hospitals need disaster plans that address these issues and they need to be tailored to the idiosyncrasies of individual facilities. Again, this can be implemented by requirements for JCAHO approval. Mr. Chairman, my point is relatively straightforward. The civilian health care workers represent an important--in fact probably the most important--component of the response to bioterrorist attacks using a microbial agent. It is critical that any plans to combat such attacks give appropriate attention to the civilian sector of the public-private partnership necessary to respond effectively Insuring awareness and support of civilian health workers requires greater efforts by state and local governments, professional societies and hospital consortia--but there is a role for the federal government as well. Let me suggest three possible actions by Congress. First, building on experience with health planning activities and preventive health services, legislation should establish a federal state partnership under which block grants are made to state and local health authorities for assisting in planning and education of the private sector to be prepared for antibioterrorism activities. It is unlikely that there will be a receptive audience in the civilian sector unless the requirements for time and resources are accompanied by a carrot or a stick--or both. Second, Congress should revise Medicare Conditions of Participation to insure appropriate infection control activities related to bioterrorism at virtually all hospitals in the country. And, of course, support for medical specialty societies such as ours for targeted educational activities and the Johns Hopkins Center for Civilian Biodefense Studies would be most welcome and used in the national interest. IDSA would be pleased to develop these proposals in greater detail, if you wish. Thank you for your interest and leadership in this critical national issue. I shall be pleased to respond to questions.