The Official Newsletter of the California Poison Control System
Volume 1, Number 2.
June 2002

The Anthrax Outbreak of 2001,
Lessons Learned in California

Also in this issue:
Clinicians and Bioterrorism:
How to Integrate into the Response System

It has been more than six months since the last case of human anthrax attributed to the release of B. anthracis spore contaminated letters in the eastern United States. Although California experienced no cases of anthrax connected with this outbreak, the emergency response, public health and community health care systems were stressed while responding to public concern over the events. This putative bioterrorist event allowed California to test many aspects of its bioterrorism response plan and illustrated how catastrophic health events within California would fit in to our Standardized Emergency Management System (SEMS). It is appropriate at this point in time to reflect on some lessons learned from this event.

  1. Public health and emergency response systems can be stressed even with a relatively geographically constrained event. Although no cases of human anthrax occurred in California (an unrelated outbreak in cattle occurred in Santa Clara county during this time) the resources of the California Department of Health Services(DHS), The California Emergency Services Authority (EMSA), The Governors Office of Emergency Services (OES), as well as local health and emergency response agencies were consumed by coordinating California's response to the epidemic. It is fair to say that had a case occurred within the state or been imported into the state the response demands would have been significantly higher. The lack of cases with California was an important epidemiologic tool that allowed emergency response organizations to appropriately conduct risk assessments on thousands of "white powder" cases and hundreds of persons who presented to health care facilities concerned that they may have symptoms of anthrax. This was an opportunity for California to gauge the resources that will be required to respond to, and coordinate the State's response to future disease outbreaks.

  2. Information is hard to coordinate and disseminate. The information flow early in this anthrax outbreak was scant, incomplete and often contradictory. Even though California was about as geographically distant as a state could be from this event, health professionals needed real time details that were not reported in the media so as to make the best recommendations to state leaders as to the appropriate response and relative priorities to California in protecting its citizens and workers. Because of the multitude of disciplines responsible for portions of the bioterrorism response, as well as the need for the security of some information related to the investigation of the event it became obvious that one single direction communication system was insufficient to meet the varied needs of the health community. The development of secure, redundant, asynchronous, real time communication networks has been fostered by these events. Development of health specific communication networks, such as the health alert network (HAN) will facilitate communication at the Federal, State and Local levels.

  3. Health providers need accurate timely information on these subjects. The needs of health providers for accurate information was identified early in the event. Health providers play a vital role in early detection of additional cases, medical treatment of infected persons, as well as sources of trusted information to their patients. The need for rapid, accurate, practical information in a format suited to a needs of a diverse clinical audiences was illuminated by this incident. This has led to new communication links between practicing local clinicians and their public health departments, showcased the power of the internet, as well as enhanced distance learning techniques in the rapid communication of clinical information to multiple providers of care.

  4. Fear responds to truth. The importance of health officials who were able to communicate with, and be respectful of, the information needs of the public were illustrated in this anthrax outbreak. The need for the general public to perform a "personal risk assessment" illustrated that truthful information will be central in reducing fear and panic.

The solutions suggested by these lessons are currently being implemented at local, regional, and state levels. Although devastating in both personal and economic terms, this anthrax incident has improved the ability of California to respond to future incidents of bioterrorism.

Clinicians and Bioterrorism:
How to Integrate into the
Response System

Among the most common questions I received from clinicians in the days after the first reports of human anthrax surfaced in Florida and Washington was: "How can I prepare to diagnose, treat and educate my patients on these diseases?" Recognizing that we are all busy clinicians and have limited time available to digest reams of technical and clinical information we need rapid and easily available information. Most of us are not infectious disease experts and, despite the media perception to the contrary, events of this time are sufficiently rare that little is gained by making every clinician in the United States a complete bioterrorism expert. My suggestions for all clinicians who are willing to devote approximately 60 minutes to bioterrorism preparation:

  1. Become educated - review basic disease information and epidemiologic principles. Often lost in the rush of obtain factual information is the fact that most clinicians have completed postgraduate training that included basic microbiology, infectious disease and epidemiology. What is required often is a "dusting off" of this knowledge coupled with selected clinical information regarding the agents that represent a threat or lend themselves to bioterrorism use. Of all the excellent websites available I prefer the Centers for Disease Control Website located at . This website has clinical monographs on all of the human threat agents as well as useful epidemiologic links. In addition, information relevant to current disease outbreaks will either be posted here or linkages provided. The articles prepared by the Johns Hopkins group, published in the Journal of the American Medical Association are excellent tools for all clinicians, regardless of discipline, for rapidly summarizing the needed clinical information on a particular agent.

  2. Be clinically suspicious of unusual diseases and presentations. Irrespective of our clinical setting, attention to unusual diseases and presentations are the most important means for early "active" surveillance. Take this opportunity to determine the contact methods for communication with local public health authorities and develop a relationship with them. It is not necessary that a suspicion of bioterrorism exist prior to contacting public health, indeed a potential secondary benefit of heightened awareness of potential bioterrorism is the earlier recognition and reporting of the "routine" public health outbreaks of natural disease and food borne illnesses.

  3. Educate your patients on the issues. All of us are educators of our patients. They look to us for factual truth and health information customized to their unique situations. Whether reassuring our patients that they don't have anthrax or that having ciprofloxacin in the house is unnecessary, individual clinicians play a key role in community education and community health information dissemination in the event of a disease outbreak.

  4. Tell the truth and be flexible. It's ok to say "I don't know". Our patients generally appreciate and respond to factual information and have proven their ability to do a risk assessment once in possession to factual information. Accept the fact that information will change in the course of a disease and that decisions often need to be made on the basis of incomplete information. As additional information becomes available recommendations may need to be revised. It is not a marker of flawed information, rather it is a consequence of a dynamically changing event.

  5. Understand your role in the community response system. We all practice within a larger group, health system, community, or region. Take this opportunity to understand how your local health system integrates into the area, region and state emergency plans. All groups should have designated emergency planners who can assist with identifying the appropriate contacts and describing the response systems. It is best to meet and become familiar with them now rather than in the midst of a disease outbreak.

Consultation assistance

Consultation with a specialist in poison information or with a medical toxicologist can be obtained free of charge by calling the California Poison Control System at 1-800-411-8080.

This issue of CALL US... was written by R. Steven Tharratt, MD, MPVM.

CALL US... is published by the California Poison Control System. Editorial Board: Executive Director, Stuart E. Heard, PharmD; CPCS Medical Directors Timothy E. Albertson, MD, Richard Clark, MD, Richard Geller, MD, Kent R. Olson, MD; CPCS Managing Directors Judith Alsop, PharmD, Thomas E. Kearney, PharmD, Anthony Manoguerra, PharmD. Managing Editor: Susan Kim, PharmD

The California Poison Control System is operated by the School of Pharmacy, University of California, San Francisco.


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