Bioterrorism: Field Guide to Disease Identification and Initial Patient Management

Abstract

By Dag K. J. E. von Lubitz, 189 pp, with illus, Boca Raton, Fla, CRC Press, 2004.Crude efforts to use biologic agents in wartime have been reliably documented since the Middle Ages, when armies used gruesome weapons, such as contagion-contaminated corpses, typically directing them against civilian populations rather than opposing forces. In the 20th century, more sophisticated attempts were made in both European and Asian conflicts, again with the stationary civilian sector the principal target. Bioterrorism was a covert military strategy throughout the cold war, and both the United States and the Union of Soviet Socialist Republics developed programs capable of liquidating armies and also causing widespread casualties in civic populations. Although these tactics were seriously contemplated, either moral dogma or the practical realities of containment restrained contemporary military superpowers from using them. Bioterrorism instigated by radical political groups and warring rogue governments surfaced repeatedly in recent years, and although well publicized, the medical community showed limited enthusiasm for preparing for mass biologic disaster until the terrorist strikes on September 11, 2001. That catastrophe was immediately followed by letters containing anthrax spores mailed anonymously to governmental and media offices; the fatalities that followed starkly demonstrated the entire nation's vulnerability to bioterrorism, and America took a crash course to plan for a repeat event.The Centers for Disease Control and Prevention along with national and regional medical organizations spearheaded training programs for emergency responders, physicians, hospitals, and public health laboratories to handle the most likely agents in a biologic attack. The customized materials disseminated to hospital laboratories have generally been, in my opinion, focused and practical. This body of information, however, is in a constant state of revision and refinement; the value of the Internet for immediate access to current data cannot be overemphasized, and the Internet's immediacy cannot be matched by conventional printed references.This book was written as a general guide for hospital and health care personnel who lack Internet availability and computer expertise; concrete applications are limited in part because the target audience is so broad and the material covered is less than encyclopedic. The overview of major pathogens and biotoxins is standard information, organized as simplified outlines of pathogenesis, clinical presentation, differential diagnosis, laboratory identification, and treatment for each agent. A table listing common infectious syndromes (influenza, gastroenteritis, and chickenpox) and the bioterror infections that can mimic these natural diseases is useful; however, the accompanying fold-out grid diagram that catalogues specific clinical signs and symptoms associated with each pathogen is awkward and impractical. Specifically lacking are illustrations of mucocutaneous lesions; radiographic findings; photomicrographs of Gram, methylene blue, Wayson, and sliver stains of specific organisms; and colony morphologic findings of bacterial agents on standard laboratory media. Such basic pictorial aids are mandatory for the initial characterization of these unfamiliar infections.Another limitation that again highlights the rapid evolution of technology and the almost immediate obsolescence of printed references is the incomplete information about rapid enzyme immunoassays and molecular methods, such as polymerase chain reaction for specific and safe confirmation of suspicious specimens referred from community hospital laboratories. The Laboratory Response Network, which links grassroots hospitals to regional and national centers, is also not mentioned. Timely bioterrorism information is readily available through the Web sites of the Centers for Disease Control and Prevention, public health laboratories, and professional societies (including the College of American Pathologists), many of which e-mail alerts of new developments directly to hospital personnel. Most US hospitals provide Internet access to take advantage of these valuable resources, and most laboratory personnel are sufficiently skilled with computers to navigate these sites and maintain proficiency. Facilities that lack Internet capabilities need to recognize that this limitation cannot be overcome by buying yet another textbook. This book is interesting reading but does not have the focus, detail, or timely material to be a serious reference for clinical or laboratory medicine.