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SECTION
1
Purpose of Physician Readiness Guide for Acts of Water Terrorism
Section One Online CME Credit - Max. 3.0 Credit Hours
How
Real is the Terrorist Threat to U.S. Water Supplies and Public
Health?
Until recently in the United States, contamination of water reserves and
public drinking water systems with biological, chemical or radiologic agents
generally resulted from natural, industrial or unintentional man-made accidents. Unfortunately,
recent terrorist activity in the U.S. has forced the medical community, public
health agencies and water utilities to consider the possibility of intentional
contamination of U.S. water supplies as part of an organized effort to disrupt
and damage important elements of our national infrastructure (1-3).
In the past, protection of potable water supplies from intentional nuclear,
biological or chemical (NBC) contamination was a concern for the military
tasked with protecting troops from known and potential NBC weapons exposure
in the field (4-6). Now there
is growing concern that chemical, biological, and radiological weapons may
be used against the U.S. civilian population with water as one possible vehicle
of transmission or mode of dispersal of these weaponized agents (1,
2, 7, 8).
In
his 2002 State of the Union Address, President Bush noted that
captured Al Qaeda documents included detailed maps of several U.S.
municipal public drinking water systems (9).
Apprehension regarding a terrorist assault on drinking water systems
has also
been reinforced
by news reports and recent arrests of suspects charged with threatening
to contaminate municipal water supplies in the U.S. (3,10-13).
In addition, as part of their 2002 congressional report, the National
Research Council of the National Academy of Sciences concluded
that water supply system contamination and disruption should be
considered a possible terrorist threat in the U.S. (14).
As a result of these reports, there continues to be concern that
water may
represent a potential target for terrorist assaults and that deliberate
contamination of water is a potential public health threat. No
matter how minor the contamination event or short-term the disruption
to the delivery of safe drinking water, the psychological, medical,
and potential public health impact on the U.S. population could
be significant.
Most
recently on February 7, 2003, the National Terrorism Threat Level
was increased to a “high risk” threat level based upon
information received and analyzed by the federal intelligence community
(15). Subsequent to this heightened alert, the
Centers for Disease Control and Prevention (CDC) and the Environmental
Protection Agency
(EPA) issued the following Water Advisory in Response to
the High Threat Level (16).
This
is an official
CDC
Health Advisory
Distributed
via Health Alert Network
February 07, 2003, 20:56 EDT (8:56 PM EDT)
CDCHAN-000113-03-02-07-ADV-N
CDC
and EPA Water Advisory in Response to High Threat Level
Today, the Department of Homeland Security upgraded the Homeland Security
Advisory System from yellow level (elevated risk of terrorist attack)
to orange level (high risk of terrorist attack).
While
there are no data to indicate that water has been specifically
targeted, our nation's water infrastructure
remains at risk to terrorist attacks, or acts intended
to substantially disrupt the ability of a water system
to provide a reliable supply of water. Therefore, public
health agencies and water utilities are encouraged to
continue to work together, keep each other informed of
any unusual activities, and confirm the proper operation
of notification channels in emergency response plans.
Public
health agencies should immediately notify local water utilities
and the state's drinking water administrator in the event
of an unusual number of cases of gastrointestinal illnesses
or other indications of illness that may suggest water
contamination by a biological, chemical or radiological
agent.
Water
utilities should immediately notify public health agencies
24/7 emergency operations number, and the state's drinking
water administrator in the event of specific threats received
at a water facility, customer complaints in water quality,
or if circumstances lead the utility to believe that the
water has been or will be contaminated with a biological,
chemical or radiological agent.
The
Centers for Disease Control and Prevention (CDC) and the
U.S. Environmental Protection Agency (EPA) issue this advisory
jointly.
Categories
of Health Alert messages:
Health Alert: conveys the highest level
of importance; warrants immediate action or attention.
Health Advisory: provides important
information for a specific incident or situation;
may not require immediate action.
Health Update: provides updated
information regarding an incident or situation; unlikely
to require immediate action.
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Overt
and covert acts of terrorism involving weapons of mass destruction
(WMD) pose an intimidating public health threat and a significant
challenge to our healthcare infrastructure as was demonstrated
following the intentional release of Bacillus anthracis spores
through the U.S. postal system in 2001 (17).
Although significant progress has been made to improve the preparedness
skills of the
medical and public health community in the U.S., the majority
of healthcare providers still have limited clinical experience
with the recognition
and management of the type of biological, chemical
and radiologic agents that terrorists may use to threaten the
U.S. civilian population (18).
Most public health and law enforcement authorities consider a successful
attack using weapons
of mass destruction in the U.S. “simply a matter of time” (19).
Therefore, we can no longer assume that such an attack will never
happen (20) and
we must be prepared for the significant responsibilities that we
will face as healthcare providers in the event of a terrorist
assault.
Clinical and Diagnostic Challenges Resulting from the Threat of Water Terrorism:
As healthcare providers, it is not realistic to believe that we can prevent
the first cases of illness or injury resulting from a WMD attack but we may
play a critical role in minimizing the impact of such an event by practicing
medicine with an increased index of suspicion that such an attack may occur
in our community (19, 21). Even if the probability of occurrence remains
low, the public health consequences of a successful covert or overt attack
would be serious (22). With prompt diagnosis and proper management
including preventive and therapeutic measures, prepared healthcare professionals
may be the difference between a controlled response to a terrorist incident
versus a public health crisis (23).
Therefore,
early detection and rapid response to biological, chemical or radiologic
terrorist assaults on the nation's infrastructure including U.S.
water supplies are critical elements to any effective terrorism
response strategy. This is particularly important when addressing
the possibility of water contamination resulting from the current
threat of terrorism. In this scenario, early detection
is paramount in order to decrease the public health impact
of a contamination event as well as the secondary disruption to
water distribution and the psychological impact of the public’s
lack of confidence in water safety and quality (1).
Recognizing
and treating waterborne disease and the health effects of acute
and chronic exposure to water contamination is a diagnostic dilemma
for the majority of practicing physicians in the United States
- even in the best of circumstances - let alone in an emergency
situation resulting from waterborne exposure to weapons of mass
destruction. Health care practitioners face many challenges
when attempting to accurately diagnose and appropriately manage
and treat waterborne disease and the sequelae of exposure to waterborne
contaminants resulting from WMD exposure. These significant
challenges include but are not limited to the following scenarios:
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Prompt
identification of a terrorist assault on water supplies may
be confounded by difficulties in early diagnosis. Many
WMD-related diseases present with vague, non-specific symptoms
in the early phase of illness and may be difficult to differentiate
from naturally occurring disease or typical symptoms associated
with chemical or radiologic exposure from known sources (24).
In addition, the signs and symptoms of waterborne disease and
the health effects of water contamination are often non-specific
and mimic more common medical conditions and disorders unrelated
to water contaminant exposure (25).
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Many
WMD agents display a significantly different clinical picture
when the route of exposure is ingestion presenting an additional
diagnostic challenge to medical practitioners faced with addressing
an intentional waterborne contamination event. Using
food and water supplies as a mode of dispersion for WMD (21,
24) may confound diagnosis, delay treatment and impede protective
public health measures if clinical assessments are restricted
to evaluation of inhalation and cutaneous routes of exposure
alone (6, 19, 26).
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The
level of suspicion and diligence of healthcare providers will
need to remain very high since future terrorist attacks on our
civilian population may not follow an expected pattern of attack
with respect to water. A
small outbreak of WMD-related disease or cluster of toxic exposure
may portend warning of a more large scale attack. Water systems
in small rural communities may represent “testing grounds” for
larger scale attacks on metropolitan municipal systems. This
potential scenario reinforces the integration of terrorism
into the daily differential diagnosis of every physician in
practice
in the U.S. no matter how small or large the community (27,
28).
-
Healthcare
providers will be challenged to obtain accurate exposure histories
from symptomatic patients who may have been exposed to WMD
agents through multiple exposure pathways including waterborne
exposure. The
majority of biological, chemical and radiologic agents that
may be used during an intentional contamination of water supplies
are not unique to water. Most of the WMD agents may be distributed
through multiple routes of exposure and may result from other
sources of WMD dispersal in addition to the waterborne route.
Moreover, public drinking water may represent only one source
of waterborne exposure with deliberate contamination of recreational
waters, swimming pools or even bottled water (6)
also presenting a possible target of terrorist activity.
-
Water-related
disease resulting from intentional contamination with biological,
chemical or radiologic agents may present as benign symptoms
or self-limited illness in a healthy patient population while
the same waterborne exposure in a vulnerable patient population
may result in significant morbidity and mortality. The
impact of a terrorist attack depends upon not only the type
of agent used or method and efficiency of dispersal but also
upon
the type of population exposed and their level of immunity
or vulnerability (6, 29).
Individual vulnerability to weaponized compounds including
waterborne agents may vary widely and differences
in host susceptibility factors may complicate recognition of
an intentional water contamination event. Unfortunately, these
sensitive populations will experience the most drastic health
outcomes from any biological, chemical or radiologic contamination
event resulting from a terrorist assault on water supplies.
Physicians and Healthcare Providers as “Front-line Responders” to
Acts of Water Terrorism:
Early recognition and detection of WMD-related illness and injury by healthcare
providers is obviously critical to any effective anti-terrorism preparedness
strategy for the United States. Physicians and other healthcare
practitioners continue to play a critical role as “front-line responders” particularly
since the first casualties of covert terrorist activity are likely to be
identified by the medical community heralding the initial indication of
an attack (28, 30). Healthcare practitioners
provide the “early
detection system” for possible exposure to WMD since humans continue
to remain the most sensitive and often the only “detector” of
a WMD attack on our population (30-32). Prompt disease
recognition, appropriate treatment and conscientious case reporting by
all physicians - no matter
what their clinical specialty – represent key components to successfully
combating a terrorist attack on the U.S. population and effectively protecting
the nation’s public health (17, 33,
34).
Practicing
healthcare providers are likely to be the first to observe unusual
illness patterns and must understand their critical role as "front-line
responders" in detecting water-related disease resulting from
biological, chemical or radiological terrorism as well. Although
detection methods for recognizing intentional contamination of
a water supply are improving (3), the
most likely initial indication that a water contamination event
has occurred in a community
will be a change in disease trends and illness patterns. This
probable scenario would potentially involve a community-wide waterborne
disease outbreak or a cluster of water-related cases of chemical
or radiologic toxicity in the general population. Therefore, practicing
healthcare providers are likely to be the first to observe unusual
illness patterns and injury from water-related disease
resulting from biological, chemical or radiological terrorism (25).
Early recognition, accurate diagnosis, and conscientious reporting
by community healthcare providers of suspected waterborne disease
cases will be essential to maintaining water security and safety.
Inaccurate
assessment of the incidence of water-related disease resulting
from WMD exposure may limit the successful implementation of water
quality treatment and public health protection strategies in an
affected community. As in any type of anti-terrorism preparedness
(35, 36), a coordinated
and effective response to acts of water terrorism will depend upon
cooperation among a multidisciplinary
team of healthcare providers, public health and water utility practitioners,
law enforcement professionals and community leaders in order to
mitigate the potential impact of an intentional contamination event.
Healthcare providers will need to embrace their critically important
role as active participants in this public health challenge in
order to protect their patients and their community. Emergency
preparedness response plans addressing acts of water terrorism
must include healthcare practitioners as critical stakeholders
and essential members.
In addition, as a result of heightened public awareness regarding the potential
for additional terrorist activity, physicians and other healthcare providers
will be required to play a leading role in risk communication with the public,
if an act of waterborne terrorism occurs in the U.S. Healthcare providers
are among the most trusted sources of information for the general public
regarding drinking water quality and safety in the U.S. (25) and community
residents will immediately turn to their healthcare providers for advice
regarding the safety of their drinking water during an intentional contamination
event. Medical and public health practitioners will be faced with
providing credible and timely risk communication and public notification
of a suspected water contamination event in light of the potential for significant
concern in the general population resulting from such an event.
Physician Readiness and Education as One Defense for Acts of Waterborne
Terrorism:
The education of healthcare providers, public health officials and first
responders will play a crucial role in the prompt
recognition, treatment, and prevention of the medical consequences of weapons
of mass
destruction
exposure (36,
37). Healthcare providers must become familiar with not only the clinical
presentation, diagnosis, management and prevention of WMD-related disease
in their patients but also the appropriate mechanisms for communicating
with law enforcement agencies, public utilities, the media and the concerned
public
(38, 39). Military physicians
have routinely received training in the management of biological, chemical
and radiologic disasters but now the civilian medical
community must develop similar skills in order to respond to potential
terrorist activity against the U.S. population (39,
40).
Specialized
training for healthcare providers and access to targeted information
by the medical community will be essential to any effective response
to acts of water terrorism for several reasons:
-
The
illness and injury resulting from civilian exposure to weapons
of mass destruction agents would not be part of any healthcare
provider’s routine clinical practice experience (36, 41,
42). A terrorist assault on water supplies may potentially involve
use of weaponized and "exotic" or unusual biological
or chemical agents.
-
The
majority of practicing physicians in the U.S. have received no
formalized training in the recognition and evaluation of waterborne
disease or in the management of the short and long-term health
effects of water contamination (25).
-
Most
practicing physicians and healthcare providers are poorly prepared
to detect water-related disease resulting from intentional biological,
chemical or radiologic contamination and may not be adequately
trained to respond appropriately to a terrorist assault on water
(25).
In
order to effectively develop and implement anti-terrorism strategies
and disaster preparedness planning in the United States, this critical
knowledge gap of the medical community must be addressed. Educational
tools for healthcare providers and preparedness training for the
medical community are key elements to any anti-terrorism strategy
that promises to protect water supplies and prevent waterborne
disease in the general public resulting from intentional contamination (25).
Objectives of this Physician Readiness Guide for Acts of Water Terrorism:
The results of a recent national survey of approximately 1000 family physicians
revealed that the greatest predictor of being able to respond to
bioterrorism was “knowing how to get information in the event of a
suspected attack,” including clinical information (43).
The need for immediate access to specialized information and reference materials
by the medical community is particularly important when addressing the recognition
and management of acts of water terrorism since the consequences of intentional
contamination of drinking water could have serious public health consequences.
In addition, the initial medical response required to address this type of
terrorist activity would be an inherently local or regional challenge for
healthcare systems and medical providers until external resources could become
available. According to the American Medical Association, local medical responders
including healthcare providers will potentially need to function unassisted
for 6 to 8 hours until outside resources arrive in response to a terrorist
attack (40).
Therefore,
clinicians will need to have immediate access to
constantly updated information in order to respond to the medical
and public health needs of their community (42)
subsequent to any act of water terrorism. The primary purpose
of this Physician Readiness for Acts of Water Terrorism guide is
to address this
critical need for streamlined access to resources that will help
guide them through the recognition, management and prevention of
water-related disease resulting from intentional acts of water
terrorism.
The
changing nature of the terrorist threat that includes the continuing
emergence of exotic and weaponized agents as well as new modes
of dispersal requires specific attention to current and consistently
up-to-date reference information. This physician on-line readiness
guide has been developed in order to provide access to clinically
relevant and updated information in a format that offers easy access
to practicing physicians in a clinical setting. This web-based
program has been peer-reviewed by medical, public health and military
specialists and has been developed and referenced with peer-reviewed
journal articles. The on-line readiness guide provides the following
educational components to healthcare practitioners and public health
specialists faced with addressing the evaluation and management
of water-related disease resulting from terrorist activity:
Physician
Readiness for Acts of Water Terrorism
Educational Components
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- Review
of the threat of water terrorism in the United States including
water as a vehicle for transmission of biological, chemical and
radiologic agents.
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- Discussion
of accurate exposure history-taking techniques and assessment
of multiple exposure pathways and contaminant sources as part
of a clinical evaluation to accurately diagnose water-related
disease possibly resulting from intentional contamination of
water reserves.
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- Presentation
of clinical resources addressing the accurate diagnosis, appropriate
medical management, recommended laboratory evaluation, and prevention
guidelines for biological, chemical and radiologic compounds
that may be used as waterborne agents.
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- Specific precautionary
guidelines for susceptible populations at increased risk for
morbidity and mortality resulting from intentional chemical,
biological and radiologic contamination of water supplies.
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- Use of epidemiologic
clues and syndromic surveillance techniques to detect waterborne
terrorism.
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- Access to
case reporting mechanisms and surveillance requirements for notification
of suspected outbreaks or cluster of disease resulting from a
potential terrorist water contamination event.
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- Discussion
of effective risk communication strategies and public affairs
procedures for discussing health risks associated with intentional
water contamination.
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Clinician On-Line
Resources Guide and Targeted Search Engine Tools:
In addition to the educational resources developed and described above, this
physician readiness guide also provides access to a wealth of information
available through use of targeted search engines and Internet-based references
and resources. We have dedicated an entire section of this physician readiness
guide to the informational resources posted by various governmental, academic,
military and specialty medical organizations addressing physician preparedness.
This dedicated section of the readiness guide acts as a "central
access point" for comprehensive anti-terrorism preparedness
resources for medical and public health practitioners. (For
more information refer to Section
7 - Clinician On-Line Resources Guide and Targeted Search Engine Tools).
There is a wealth of general and detailed information
available on the Internet regarding various aspects of physician
preparedness for all forms of terrorism that serve as valuable
tools for evaluating water-related disease and water contaminant
exposure from terrorist activity. This posted information
includes a full spectrum of resources from clinical practice
guidelines to patient fact sheets to appropriate case reporting
procedures. However, locating this information is often difficult
for most health care practitioners, particularly in an emergency
situation. In order to facilitate easy access to reliable
web-based information for the busy practicing clinician,
we have organized and categorized this specialized information
in a manner that incorporates: 1) ease of access for healthcare
practitioners and 2) technology support for the physician
end-user at every feasible opportunity.
Accessing
terrorism preparedness information using general Internet search
engines and broad search terms is often inefficient, time consuming
and impractical for most practicing healthcare providers. During
the development of this educational program, we reviewed hundreds
of terrorism preparedness websites hosted by a large pool of medical,
governmental, private, academic and professional organizations.
We have organized these valuable Internet resources for targeted
use by healthcare providers in the following manner:
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We
have summarized over 100 terrorism preparedness websites that
we believe provide both reliable and accessible information
to healthcare providers faced with addressing various aspects
of terrorism preparedness and the recognition, management,
and prevention of water-related disease.
-
We
have developed several technology tools to assist the physician
end-user of this readiness guide including a series of targeted
search engines allowing quick and easy access to valuable information
available on the Internet searchable by key word.
Free
Access to this Physician Readiness for Acts of Water Terrorism
Guide:
We trust that this Physician Readiness for Acts of Water Terrorism on-line
guide will serve as a valuable resource tool in your clinical practice when
faced with the possible threat of water terrorism in your community. Access
to this on-line resource is provided to healthcare practitioners at no cost
as a result of funding provided by the Environmental Protection Agency and
the Arnot Ogden Medical Center.
Continuing Medical Education (CME) Offering for Physician On-Line Readiness Guide:
The American College of Preventive Medicine (ACPM) and Dr. Patricia L. Meinhardt, a representative of ACPM, have developed a Continuing Medical Education (CME) module of this Physician On-Line Readiness Guide. Healthcare practitioners face many clinical challenges when attempting to accurately diagnose and appropriately manage and treat waterborne disease resulting from water terrorism. This Continuing Medical Education (CME) online resource is intended to provide healthcare professionals with an educational experience that intends to: 1) improve their diagnostic acumen in the recognition, treatment, and prevention of waterborne disease and the health effects of water terrorism; 2) increase their working knowledge of tools such as epidemiologic indicators and syndromic surveillance to enhance detection and diagnosis of water terrorism; and 3) improve their risk communication skills and outreach strategies when providing information to their patients regarding water quality and safety during and after an intentional water contamination event.
The American College of Preventive Medicine (ACPM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME credits for physicians participating in this continuing medical educational activity. Through ACPM, Category 1 credits toward the American Medical Association (AMA) Physician's Recognition Award (PRA) are offered. ACPM will award a Continuing Medical Education (CME) Certificate to physicians (MDs, DOs) completing this educational activity and a Certificate of Participation to non-physicians participating in this continuing education.
This CME online course is organized into ten sections representing the core curriculum the Physician Preparedness for Acts of Water Terrorism online readiness guide. The ACPM designates this educational activity for a maximum of 22.5 hours in Category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in this educational activity. CME credit can be earned for the entire course OR for individual sections of Physician Preparedness for Acts of Water Terrorism: A Physician Online Readiness Guide.
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