Screening for Inhalational Anthrax Due to Bioterrorism: Evaluating Proposed Screening Protocols

Abstract

Eleven known cases of bioterrorism-related inhalational anthrax (IA) were treated in the United States during 2001. We retrospectively compared 2 methods that have been proposed to screen for IA. The 2 screening protocols for IA were applied to the emergency department charts of patients who presented with possible signs or symptoms of IA at Inova Fairfax Hospital (Falls Church, Virginia) from 20 October 2001 through 3 November 2001. The Mayer criteria would have screened 4 patients (0.4%; 95% CI, 0.1%-0.9%) and generated charges of 1900 dollars. If 29 patients (2.6%; 95% CI, 1.7%-3.7%) with >or=5 symptoms (but without fever and tachycardia) were screened, charges were 13,325 dollars. The Hupert criteria would have screened 273 patients (24%; 95% CI, 22%-27%) and generated charges of 126,025 dollars. In this outbreak of bioterrorism-related IA, applying the Mayer criteria would have identified both patients with IA and would have generated fewer charges than applying the Hupert criteria.

Biowarfare and Bioterrorism

“…7,11,12,19,52 of anthrax, the Mayer criteria 55 would have screened only 4 patients (cost $1900 USD), whereas the Hupert criteria 54 would have screened 273 patients ($126,025 USD). 56 Although it is rare with cutaneous anthrax, any case of anthrax has the potential to develop hemorrhagic meningitis. Therefore, any evidence to suggest meningitis should prompt appropriate investigations such as neuroimaging and a lumbar puncture.…”

Computer‐aided diagnosis with potential application to rapid detection of disease outbreaks

“…Another surveillance strategy is the screening for a rare disease, such as inhalational anthrax, SARS pneumonia, avian influenza, or smallpox, among common, clinically similar cases, such as bacterial pneumonia, dengue, and chickenpox, respectively [33][34][35][36], but these strategies presuppose prior information to focus the diagnostic algorithms. CADDY does not presuppose any prior knowledge of the diagnosis, and in its current edition does not offer algorithms for narrowing the differential diagnoses, although these could be added in later editions.…”

Use of Sentinel Laboratories by Clinicians to Evaluate Potential Bioterrorism and Emerging Infections

“…Even in the midst of a known special pathogen epidemic (e.g., severe acute respiratory syndrome [SARS]), endemic diseases that share similar manifestations (e.g., human influenza or pneumococcal pneumonia) will continue to occur. For respiratory syndromes (figure 1) that initially mimic community-acquired pneumonia or influenza-like illness, epidemiologic clues (e.g., occupational and travel histories) have been critical in identifying inhalational anthrax, SARS, and avian influenza [18]. Acute or generalized febrile vesicular (or pustular) eruptions cause great concern because of the possibility that they may be smallpox or monkeypox (figure 2).…”

“…In the first cluster of anthrax attacks, several cases of cutaneous disease were not recognized until other confirmed cases were reported [26,27]. Similarly, early symptoms of inhalational disease (fever, malaise, and myalgias) are hard to distinguish from influenza-like illness and community-acquired pneumonia [18,28]. However, within a few days, patients' conditions rapidly deteriorate, with development of severe dyspnea, hypoxemia, widened mediastinum, and hemorrhagic pleural effusions evident on chest radiographs.…”