Shortly after the terrorist attacks on Sept. 11, officials at the Mid-Atlantic Kaiser Permanente Medical Group reviewed and began updating their bioterrorism response plan.
Within a month, they had put the plan into action. Then two of their enrollees in suburban Washington, D.C., contracted and died from inhalation anthrax. Within hours after realizing it was dealing with anthrax, the group identified 200 other enrollees who worked at the same mail processing facility, contacted them and began treating them for possible exposure.
The Kaiser medical group--along with health plans, medical societies and physicians nationwide--is figuring out how to prepare for the threat of bioterrorism.
But physicians also face juggling the demands of an increasingly worried population with those of their regular patients.
"The doctors, especially, are going to have to make some decisions such as triaging," says Bill Monning, chair of the AMA's Organized Medical Staff Section. "If you have a list of people who come back every six months . . . for blood pressure, those people obviously can be delayed. There's no reason to believe that we don't have the capacities to take care of patients" affected by bioterrorist attacks.
The key, he says, is being prepared and knowing how to respond.
It was preparation that allowed Kaiser physicians to diagnose anthrax cases even though the two patients didn't know each other and didn't have classic anthrax symptoms, says Adrian Long, M.D., medical director and president of the mid-Atlantic group.
The medical group developed a four-page set of guidelines for those staffing the medical advice hotline for enrollees, says Susan Whyte Simon, media relations director for the group.
In addition to following guidelines set by the Centers for Disease Control and Prevention, Kaiser added guidelines for physicians telling them that they should see patients who were concerned they had contracted anthrax. Kaiser officials told physicians to follow the CDC guidelines, notify law enforcement if necessary and use their medical judgment.
On Oct. 19, the first patient walked into one of the medical centers without an appointment. He told the physician he wasn't feeling well, and the physician thought something was suspicious. So he sent the patient to the emergency room, Whyte Simon says. The infectious disease specialist ultimately diagnosed him with anthrax.
On Oct. 21, a second patient went to an urgent care center complaining of a headache. Physicians learned he worked at the Brentwood, Md., mail facility where the first patient also worked. The same infectious disease specialist was on-call and suspected anthrax, Whyte Simon says.
That's when the medical group implemented another part of its disaster response plan. Group officials combed their databanks to determine which enrollees were employed at the facility and could have been exposed.
"We also became aware that there were private companies that had contracted for sorting of mail that had gone through the facility," Long says, adding that they then identified who those enrollees were. "It was a joint effort by the Permanente physicians working with the health department. We've learned from them. They've learned from us."
One advantage of the Kaiser model is that group officials can quickly communicate via e-mail and voice mail with the more than 800 physicians in the system, as well as with the nurses who staff the enrollee-question line, Long says. He says they are also developing guidelines for other potential threats such as smallpox.
Halfway across the country, HealthPartners Health System in St. Paul, Minn., has developed a way to track patient symptoms and identify clusters of potential bioterrorism-induced illnesses.
The HealthPartners Research Foundation received a grant from the Minnesota Department of Health to develop a surveillance system, says James Nordin, M.D., clinical investigator and pediatrician at HealthPartners.
The group established a system that tracks diagnostic codes and ZIP codes to see if there is a cluster of people with symptoms similar to those for anthrax exposure. Each night, information is sent to the MDH. It is stripped of any patient identifiers and includes only ZIP code, diagnostic code and age.
Ninety percent of diagnostic and symptom codes are entered into the integrated group's system within 48 hours, he says.
"It will get more complicated as the flu season starts," Nordin says. However, bioterrorism doesn't have the same pattern as influenza, he says. "Influenza makes young and old people sick, not (people) in the 20-to-50-year age range."
The data can also be looked at geographically, which could be useful in situations such as smallpox outbreaks, Nordin says.
The project began in July, but the Sept. 11 attacks caused researchers to speed up their work, Nordin says.
The number of people wanting information--and not wanting to rely on just the nightly news for updates--has skyrocketed. That demand led AMA officials to post articles from the Journal of the American Medical Association about bioterrorism, treatment and other issues on their Web site, says Timothy Flaherty, M.D., chair of the AMA Board of Trustees. "We've had such an enormous number of hits, we've had to expand our bandwidth," he says.
The group has also launched a massive media campaign to educate the public about inappropriate antibiotic use, he says. Educating the public and trying to calm fears will be as important as developing a disaster response plan, Flaherty says.
The AMA's Monning says that since the September attacks, national organizations have assessed their disaster response plans. What's lacking, he says, is coordination between various levels.
"We need national leadership to make the decision. Then that decision needs to filter down to every community hospital in the country," he says. "It's really a preparedness issue. There are a lot of other issues that need to be done on a community-wide basis.
"The two components that are going to be essential are educating primary care doctors so they can recognize symptoms in their offices and having a response plan at a local level."
At the basic level of community preparedness is ensuring that physicians and other healthcare workers are able to care for their families at the same time they're caring for the sick.
What medical directors and other healthcare officials need to do is assure healthcare workers that their families will be taken care of, Monning says. That could mean determining whether their immediate families should be vaccinated against any of the current or potential agents the workers are treating, he says.
To try to increase the awareness and coordination at the national and local levels, government agencies have been working with the American Association of Health Plans since the Sept. 11 attacks, says Susan Pisano, the association's spokesperson. When it became clear that the anthrax cases weren't isolated, HHS and the CDC held briefings for association officials, she says. That information has been passed along to plans on the local levels, she says.
Plans have also begun a push to get enrollees their flu shots, Pisano says, since the initial symptoms of anthrax mimic those of the flu.
Officials at Blue Cross and Blue Shield of Vermont have asked nurse reviewers to check hospitals in their networks to see if there are any patterns developing, says Bob Griffin, M.D., medical director of Blue Cross and Blue Shield of Vermont.
"We're encouraging our local, state providers in the network to use the public health system," he says. They're also steeling their staffs for the possibility of diseases other than anthrax.