Medical Computing Today's
Bioterrorism Web Resources for Physicians
Selected, annotated links to clinical resources, government news and other rapidly updated information
Updated: April 6, 2001
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has placed online a collection of Anthrax articles, the most recent from last November on the anthrax toxin. (For background, see Bacillus Anthracis and Anthrax from the Department of Bacteriology at the University of Wisconsin -- Madison).
CDC's bimonthly Emerging Infectious Diseases includes a list of scholarly Bioterrorism-related Articles. Of interest to this nation's recent debate is Modeling Potential Responses to Smallpox as a Bioterrorist Weapon.
The following are generally recognized as the most authoritative of the longstanding online bioterrorism resources:
Official Government: Over the past nine months, the CDC Public Health Emergency Preparedness and Response has evolved into the US government's major online resource on bioterrorism. It maintains official public health messages and press releases on Anthrax and more recently Smallpox, now accessible off their own pages. A relatively new section for Lab and Health Professionals is probably the best first stop on online resource for physicians. The home page has a news link, and in-depth list of resources on Anthrax, Smallpox, and other biological, chemical, and radiologic agents. Each lists resources (usually journal articles) in descending chronological order, which is important as many are unfortunately dated.
MMWR Information about Anthrax and BioTerrorism, a well-maintained listing of all current and past articles, is one of the best Web resources for physicians on the subject. Each week has an update, and many contain interim public health guidelines. Their October 19's Recognition of Illness Associated with Intentional Release of Biological Agent is especially timely. Department of Health and Human Services (DHH) Biological Incidents maintains a list of press releases and speeches, and clinical information from the CDC and other federal agencies. National Immunization Program: Smallpox has sections for the public, and healthcare professionals, and includes a link to the January 2002 Interim Smallpox Response Plan and Guidelines in Word and PDF formats. The Response Plan describes the concept of ring vaccination; "Any vaccination strategy for containing a smallpox outbreak should utilize the ring vaccination concept. This includes isolation of confirmed and suspected smallpox cases with tracing, vaccination, and close surveillance of contacts to these cases as well as vaccination of the household contacts of the contacts."
To assist physicians with the current anthrax outbreak, most local and state health departments have online information for physicians.
Anthrax updates from relevant local and state health departments include Florida, Washington, D.C., New Jersey, and New York City.
Medical Associations: The American College of Emergency Physicians (ACEP) has a nice annotated list of Bioterriorism.
See too the home page of the American College of Physicians--American Society of Internal Medicine (ACS-ASIM) for updates, and their Bioterrorism Resource Center for thoughtful group of links to medical and mental health resources, among others. In particular, check out the interactive decision support algorithms listed under each infectious disease. American Academy of Family Physicians Respond has another excellent collection of thoughtful links, particularly of MMWR articles and educational resources. Both groups offer online discussions, but for members only. Other resources for all physicians: the American College of Surgeons' Unconventional Civilian Disasters: What Every Surgeon Should Know and the American Academy of Pediatrics' Children, Bioterrorism, and Disaster.
Other well-maintained update resources from medical organizations include the home page from APIC, and AMA Terrorism Disaster Preparedness and Medical Response, the latter marred by its overly promotional "Taking The Lead" headline.
Journals: See the New England Journal of Medicine (NEJM)'s Special Notice: Information on Anthrax and other Biological Threats for links to relevant articles, in particular Recognition and Management of Anthrax -- an update, from its November 29, 2001 issue. Unfortunately, this collection has not been updated in 2002. But elsewhere on the site, NEJM early release articles on smallpox from the April 25, 2002 issue, were placed online in late March. Note that their 1999 review article on Anthrax is a classic reference on the subject. JAMA bioterrorism articles is an extensive and better maintained listing.
Johns Hopkin's Published Materials includes Confronting Biological Weapons, an ongoing series of articles from Clinical Infectious Diseases. The most recent article in the series, Bioterrorism and the people: How to vaccinate a city against panic, doesn't mention smallpox specifically but is obviously applicable to our national debate.
Clinical References: Clinical updates from trusted medical texts are a wonderful Web resource. AccessMedicine Bioterrorism Watch provides free access to pertinent chapters in Harrison's Principles of Internal Medicine, along with a very nice list of links.
UpToDate's excellent The information in the electronic clinical database UpToDate on Pathogenesis and epidemiology of Anthrax, and Clinical features and treatment of Anthrax is authoritative and readable, as is typical for UpToDate. For a practical approach, see Identifying and managing casualties of biological terrorism, specifically Tables 2C and 2D. (Fortunately, the CDC provides physicians with their suggested workup -- look at Figures 2 and 3 for clinical evaluations for persons with possible inhalational, and cutaneous, anthrax, respectively, from their MMWR November 2nd update.)
A pdf file from a trusted drug reference, The Medical Letter Postexposure Anthrax Prophylaxis is current as of October 29, 2001 -- but note that the CDC is evaluating its postexposure antibiotic prophylaxis protocol specific to our current situation.
EMedicine's Chemical, Biological, Radiological, Nuclear and Explosives section includes information on individual agents, protective equipment, and ER evaluation. This huge, imperfectly edited online resource has some emergency physicians questioning the accuracy of its content, although I don't believe that criticism applies to this section.
Projects: ER One is a federally-funded project in Washington Hospital Center to plan and design an "all risks ready" ED with the capacity to handle large numbers of injured patients in the event of biological and chemical emergencies. For the public, their well-designed Web site is primarily a collection of excellent resources, including links to journal articles on bioterrorism (see home page's right navigation panel), a Smartsearch engine to various online sites (see home page's left navigation panel), a ten Powerpoint presentation of various emergency scenarios as handled by an "all risks ready" ED, and a wonderful group of links on related topics.
As described on its Web page, a group of emergency medicine informaticians propose The Frontiers of Medicine Project ,
"a collaborative effort of emergency medicine, public health, informatics, and other agencies and institutions to develop non-proprietary, standardized methods for reporting emergency department patient data. The Project conceptualizes the rapid deployment of a non-proprietary, vendor-neutral, standards-based regional public health information infrastructure. This infrastructure, composed of inter-linked regional public health networks, could be used as a surveillance and "early warning" system to potentially detect chemical and biological terrorism." The Project intends to become fully integrated with the CDC's National Electronic Disease Surveillance System. Also freely available online is a recent Annuals of Emergency Medicine article on the Frontiers of Medicine project.
Multimedia: The University of North Carolina's School of Public Health provides easy access to dozens of Bioterrorism On-demand webcasts. The vast majority are from the CDC, who uses UNC as its online home, but the School includes several of its lectures as well. Unfortunately, I was unable to establish a connection using this wonderful resource; I hope that's not a universal experience. The US Army Medical Research and Material Command's Biological and Chemical Warfare and Terrorism: Medical Issues and Response is a freely available archived webcast from a presentation given late last year. Registration is required.
Continuing Medical Education: ACP-ASIM has made available Medical Aspects of Biological Terrorism from its popular self-education program, MKSAP XII. It's a good general background, with information presented by clinical case, questions-and-answers, and key points. The More Extensive Info sections under The University of Alabama at Binghamton (UAB) Emerging Infections and Potential Bioterrorist Agents provide concise narratives on anthrax and smallpox, among others. One hour of CME is freely available; not surprising, since UAB has one of the best online CME sites for physicians. Cyberounds' What every practicioner must know about bioterrorism is a basic article just posted online in March.
Slide Shows: ER World Bioterrorism Educational Resources, is courtesy of the San Diego County Medical Society and normally available only to SDCMS physicians; kudos to Mel Ochs, M.D. for making the resource available. Check out both the SDCMS' Primer and the set of accompanying slides, freely offered in a variety of formats. Saint Louis University School of Public Health's Powerpoint Presentation on general bioterriorism and specific biological agents are available in both Powerpoint and Adobe.
Daily News: Medical NBC Online Information Server links to bioterrorism-related news articles from major media and Internet resources, though it hasn't been updated in a few months. Fans of The New York Times will appreciate ACP-ASIM's search for NYTimes articles on anthrax over the past week.
Handhelds: ACP-ASIM PDA Portal on Bioterrorism uses ObserverExpress. Pepid is offering its Nuclear, Biological, and Chemical Weapons to those who cough up a name and email address. It's both generous and good promotion for this handheld clinical database, but I always find important errors in Pepid cards and these are no exception. For example, under Anthrax, airborne precautions isn't required.
Online Discussions: In response to some physicians' frustration with unsatisfying answers from the CDC, last year the ACEP hosted a bulletin board with physician questions for the CDC. The board is still online but is presently quiescent. CDC Provides Q&A for Emergency Physicians summarizes the information exchange.
Additional Resources Regarding our nation's state of prepareness, scare yourself by reading A Plague on your City: Observations from TOPOFF from the February 2001 issue of Clinical Infectious Diseases. From the article: "The United States Congress directed the Department of Justice to conduct an exercise engaging key personnel in the management of mock chemical, biological, or cyberterrorist attacks. The resulting exercise was called "TOPOFF," named for its engagement of top officials of the United States government...on May 17 (2000)...An aerosol of plague (Y. pestis) bacilli is released covertly at the Denver Performing Arts Center..." At least anthrax isn't contagious.
See PubMed search of bioterrorism for abstracts of new articles from medical journals, and The Terrorism Portal, a categorization site by VerticalPortals.com, for a general Web resource.
Physicians can find Emergency Contacts, and identify and contact the beginning collection of academic, specialty, and local exemplar Centers for Public Health Preparedness, also from the CDC. The Agency of Healthcare Research and Quality (AHRQ) bioterrorism projects and networks are listed in this year old press release.
I will update this list as improved resources and information becomes available. Please email me with suggested links.
Disclosure: The author of this list wrote three chapters unrelated to bioterrorism for eMedicine, one of the Web resources mentioned above.
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