October 19, 2001

Fear factor of bioterrorism

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A particulate respirator mask can easily filter out Anthrax endospores. (illustration by Dominic Doyle)

Fear factor of bioterrorism

When a Greyhound bus crashed on Oct. 3, Emergency Department and Trauma Unit staff took extra precautions when a rumor began floating into the hospital that biological agents were involved in the crashing of the bus.

Shortly after a Florida man died from inhalation anthrax and some of his former co-workers tested positive, several people presented to the Vanderbilt Emergency Department with flu-like symptoms and said they thought they had anthrax.

As it turned out, biological agents have not been part of any incident. But they illustrate the aim of terrorism—to strike fear in hearts and minds like a match to kindling. And health care workers, who are going to be at the front lines of this “new war,” are at risk of being exposed not only to deadly bugs sent with evil intent, but to the collateral damage of these weapons—terror, fear and hysteria.

“Unfortunately, terrorists can be very good at creating terror, namely fear,” said Dr. Paul Ragan, associate professor of Psychiatry. “What’s insidious about chemical or biological warfare is that it involves agents that are unseen,” Ragan said. “What do we do when we can’t see what hurts you?”

Last year, Dr. William Schaffner, chair of Preventive Medicine, co-authored a New England Journal of Medicine case report about “epidemic hysteria,” or “mass psychogenic illness” that took place in Warren County High School in 1989. After one teacher reported smelling gas and came down with an amalgam of vague symptoms, 161 students and staff were taken to the local hospital with similar complaints. State and federal officials spent days investigating the school, but found no possible biohazard.

“The human mind can be very inventive,” Schaffner said. And that happened without the context of terrorism Americans have witnessed since Sept. 11.

Health care workers also face the power of suggestion.

“How many health care workers have begun to itch when present with a patient who has lice? They didn’t itch before. They’re not likely to get lice,” he said. “If we do that with lice, imagine our response with anthrax.”

The first step health care workers can take to prevent hysteria, said Dr. Corey Slovis, chairman of Emergency Medicine, is to become educated.

“As the major medical resource for this region, we do have the risk of people with a fear of exposure to biologic weapon rushing to our Emergency Department in a case of mass hysteria, people with a fear of exposure to biological weapons,” Slovis said. “The single best agent to prevent hysteria is knowledge. That’s what we need to do for ourselves and for the general public, so we all respond in a sane and rational manner.”

Knowing what to expect and what to do in different circumstances is the first line of defense.

“Our hospital staff at Vanderbilt is going to be as well-educated about these diseases as possible,” Slovis said. “We have a large number of faculty in both the medical school and the nursing school with the abilities to make sure our staff are so well educated that any emotional response based on lack of knowledge is minimized.”

Fears are normal, Ragan said. “But we can quiet those fears with hard knowledge.”

And some people, including those with compromised immune systems or people with hypochondriasis or other mental health problems, have more reason to be fearful, Ragan said.

“We have to interpret the symptoms not from our point of view, but from the patients’ points of view,” he said. “Not everybody is losing sleep over terrorist attacks, but one-third of the thousands of respondents to a recent survey are. Being dismissive or demeaning to patients is not helpful and may intensify their symptoms. Do whatever re-evaluation is reasonable and provide mature, not patronizing reassurance.”

Weeding out bad information also is key. Building a personal stash of antibiotics, or self-administering medication when it is not medically necessary, only plays into the hysteria and increases the chances of resistant organisms. State health officials are working with federal officials to provide more antibiotics to rural areas, Schaffner said, and Vanderbilt has increased its “just in time” inventory of appropriate antibiotics.

Another measure is vigilance. Health care workers should stay informed with information from the Centers for Disease Control and Prevention and other legitimate sources, Slovis said.

Also, Schaffner said, everyone should be alert and participate in controlling hysteria. “It’s our job to provide information and resources so that we can take care of events as they occur,” he said. And if Vanderbilt should receive victims of bioterrorism, he reassures us, “barrier precautions are exceedingly effective. We can deal with these patients in a professional manner without being in fear of infection.”

Slovis said, “Terrorists work by causing terror. They usually fail when people respond rationally.” n