Preparing for and responding to bioterrorist attacks: The role of disease management initiatives

Components of disease management that are applicable to the development of services for bioterrorism preparedness and response include collaborative practice models, population identification processes, reporting/feedback loops, process and outcome measurements, patient self-management education, and evidence-based practice guidelines. This management system should be flexible and applicable to all possible diseases associated with bioterrorism, while including specific management recommendations for each disease. There are many gaps in the US's ability to respond to a bioterrorist attack that can only be filled by collaborative research among disciplines involved with bioterrorism preparedness; namely, basic, clinical, and behavioral sciences, public health, and law. Laboratory scientists will need to develop new and improved diagnostic tests, treatments, and protective measures. Behavioral science will have to treat many victims, both the sick and the 'worried well'. While some states have adequate laws in place to facilitate public health authorities' efforts to isolate sick patients and quarantine those exposed, many states do not, and their laws will require modification. Public health agencies must develop and evaluate information technologies and decision support systems for the early detection of a bioterrorist attack, for the tracking of victims who will require prophylactic treatment, and to assist physicians with diagnosis and treatment. Public health and hospitals must also prepare for the treatment of large numbers of patients by increasing surge capacity. Finally, one of the most notable deficiencies in response to recent bioterrorism events has been the inability of public health to provide timely and accurate information. Effective communication is a fundamental element of all aspects of an effective response to emergencies. Before a bioterrorist attack, the nation's preparedness efforts should be evaluated through tabletop and full-scale exercises that are preceded by extensive professional and community education. The US Army Medical Research Institute of Infectious Diseases has identified six primary agents that may be potentially used in bioterrorism: Bacillus anthracis, variola virus, Yersinia pestis, Francisella tularensis, botulinum toxin, and the hemorrhagic fever viruses. These six were identified on the basis of the following criteria: availability of the agent, ease of production, lethality, infectivity, and stability. Disease management requires an understanding of exposure mechanisms and dose response because the route of exposure and the dose will impact on the way a disease presents. In addition to disease management strategies for bioterrorism in general, this article briefly reviews specific diagnosis, treatment, and infection control recommendations for the six primary bioterrorism diseases agents.