Quick Primer for Clinicians on Detecting Public Health Emergencies

Every physician needs to be attuned to general features of public health emergencies, know how to report them, and where to get more information when the need arises, for we are all now on the front lines for potential major medical events--whether perpetrated by mosquitoes, defective water/sewage systems, natural disasters, collisions, terrorists, or other calamities.

You may want to keep copies of this with other reference material in your offices and emergency departments for future use, especially if phone and power lines are disrupted. Early detection and reporting are critical to minimizing impact through astute teamwork by public health and private sector professionals.

Bioterrorist attacks are likely to present as acute outbreaks of unusual syndromes, perhaps out-of-season, or in a new geographic area, or among widely-scattered people who may have been on the same plane or subway station hours or days before. Early recognition is a challenge, given the non-specific prodromal presentations and unfamiliarity of most physicians with these rare or non-endemic diseases.

Unusual disease manifestations and/or clusters should be reported to the state and county/city health departments. For telephone numbers of your city or county health department, check your local phone directory. If possible, contact your local health department for a prompt response. They also know how to access the various state offices.

I. General Features to Note:

Atypical host characteristics (e.g., young [<50], immunologically intact/ no underlying illnesses, no recent international travel or other exposure to potential source of infection) and
Serious, unexpected, acute illness (e.g., abrupt onset, prostration, cardiovascular collapse, respiratory distress, obtundation / change in mental status, disseminated intravascular coagulation) or
Multiple similarly presenting cases (especially if geographically associated or closely clustered in time)
Increases in common syndromes occurring out-of-season (e.g., influenza-like illness in the summer)

II. Syndromes:
(To be reported only if occurring in otherwise-healthy persons – see I.A. above - or of unknown etiology or on Reportable Disease List – see References below)

Acute Severe Pneumonia or Respiratory Distress – especially with:
1. Hemoptysis
2. Cyanosis
3. Shock
4. Widening of the mediastinum
5. Pleural effusions, maybe hemorrhagic
Encephalopathy
1. Acute confusion / obtundation / ataxia
2. Seizures
3. Focal neurologic deficits
4. Fever
Neuromuscular Presentations
1. Acute onset
2. Muscle weakness
3. Cranial nerve palsies (especially pupillary abnormalities)
4. Descending flaccid paralysis
5. Early respiratory distress, speaking & swallowing difficulties
Otherwise Unexplained Rash with Fever – especially if associated with:
1. Synchronous and centripetal papules progressing to pustules
2. Petechiae
3. Ecchymoses
Fever with Mucous Membrane Bleeding
Unexplained Acute Icteric Syndromes
Massive Diarrhea with Dehydration and Collapse

III. The Specific Disorders
included by the New York Academy of Medicine (NYAM) Ad Hoc Committee in assembling the presenting syndromes listed in II above were:

Anthrax
Brucellosis
Plague
Q Fever
Tularemia
Smallpox
Viral Encephalitides
Viral Hemorrhagic Fever
Botulism
Staphylococcal Enterotoxin B
Organophosphate Agents
Other Potential Toxins

This material, a work-in-progress, was originally developed by The Medical Society of the State of New York in on-going collaboration with officials from the New York City Department of Health, the New York State Department of Health, the United States Department of Defense, The New York Academy of Medicine, the National Medical Veterans Society, and the American Medical Association, with special appreciation for the New York Academy of Medicine’s "Clinical Syndromes in Bioterrorism."

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Quick Primer for Clinicians on Detecting Public Health Emergencies

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