With the majority of the Indian country population using Indian Health Service facilities throughout the nation, is IHS prepared for the possibility of bioterrorism?
Would it be able to correctly diagnose and contain an outbreak of anthrax in the vast spaces of the Navajo Nation or in Pine Ridge or Rosebud, S.D.?
Do IHS employees have the knowledge and stores of medicines needed if bioterrorism strikes Indian country?
They are questions Native Americans are beginning to ask following the death of one man in Florida from anthrax and a co-worker found who tested positive for the disease.
A ripple of fear has gone through an already jittery American public with the possibility of bioterrorism. When Bob Stevens, photography editor for the Sun, died from anthrax, the case was initially believed to be isolated, contracted through natural causes.
In the days since his death, however, a second employee was confirmed to have the disease and a third employee was retested. Stevens’ keyboard at his office in the American Media Inc. building was found to have trace amounts of the anthrax bacteria on it and a broad program of testing and antibiotic treatment was begun involving anyone who visited the building since Aug. 1.
Reports that the anthrax spores found at the American Media building could have come from a laboratory in Iowa, manufactured in the 1950s during the peak of the Cold War, added an even stranger twist. Whether the anthrax came from the Iowa lab cannot be confirmed without further testing.
Yet the question remains: ‘Could terrorists once again be using something made by Americans against them like they did on Sept.11?’
For Indian country health care workers closely following the Florida investigation, knowing why isn’t as important as knowing what to do if the dreaded disease shows up among local clinic populations.
Initially a spokesman for IHS in Oklahoma said the area director’s office had just begun to probe the idea of getting field clinics up to speed on the symptoms of anthrax and reacquainting them with reporting procedures for suspected cases. A spokesman at Oklahoma City’s IHS said he wasn’t even sure what the symptoms of anthrax were.
But at IHS headquarters in Rockville, Md., Craig Vanderwagen, from the director’s office of Clinical and Prevention Services, explained that IHS is indeed ready at the top level for any such incident involving bioterrorism. Vanderwagen, acting chief medical officer for the IHS, detailed the standing policy in place to deal with the threat of bioterrorism in Indian country.
Vanderwagen said he could understand fears American Indian people may have about being left out on their own in the event of bioterrorism.
‘You can’t blame them. They have been left out in the past when it comes to health care.’ But Vanderwagen wanted to assure Indian country that IHS is ready with emergency services during a possible bioterrorism attack.
‘We operate within the National Emergency Response Plan,’ Vanderwagen said. ‘We, like most other providers of care, work closely with the CDC (Center for Disease Control) on issues like this. And of course where there is the possibility of criminal intent, of course the FBI would be right in the middle of that.’
Describing what was going on in Florida, he said it was what IHS would also be doing in a similar situation.
‘First of all, you have to have a high index of suspicion that you are dealing with anthrax. The more common forms are skin or gastrointestinal presentations of the disease. There have been less than 20 cases recorded in the past century of the respiratory type, so the more common presentation is going to be skin and digestive related.
‘The infection affects the digestive system as opposed to the heart or the kidneys or that kind of thing. It is going to affect the gut generally, because the route of entry is going to be oral, people are going to eat it.
‘For a lot of our Indian people, they are at relatively high risk for anthrax relative to the rest of the U.S. population because of where they live. That’s out in the country where these spores are. Most of the time these spores inhabit the dirt all around us. Fortunately, they aren’t terribly infectious, people just don’t get anthrax that often.’
The most important point in treating anthrax is to make sure medical personnel in clinics are looking for it, he said.
‘They have to have a fairly high level of suspicion. They have to be thinking about anthrax,’ Vanderwagen said. ‘You recall we had that hantavirus outbreak ? it took us about three our four weeks to figure it out because we weren’t’ thinking about it. I mean, they just didn’t have hantavirus on their minds. They weren’t thinking about that as a possible cause. They were thinking about flu as a possible at the time.
‘Now every doc and nurse out there is thinking about anthrax so we believe that our people, no less than other providers, are thinking about anthrax, and that is half the battle, because if you think about it, you are going to do the tests to see if you are dealing with anthrax or not.’
Vanderwagen used the employees at the American Media building as an example of heightened awareness among health care workers nationwide, saying testing of a second man for anthrax in Florida occurred because of the heightened state of awareness, in other words, they were thinking anthrax.
As part of the National Emergency Response team, Vanderwagen said he and other IHS employees have attended daily briefings since Sept. 11 and are keeping on top of possible health threats to the American public.
‘Our people need to have that heightened awareness and if they think they might be dealing with anthrax, they need to take the cultures and have the testing done.
‘Once we have identified a case of anthrax, there is a whole process for emergency response that unfolds based on that,’ Vanderwagen said. ‘There are eight regional teams who have primary responsibility for bioterrorism events.
‘Included are the right kinds of medical experts and epidemiological experts and so on. Included in those teams are the pharmaceuticals that are needed to treat a large number of people who may be exposed during a biological event.’
‘ ? let’s say for example we have people in Denver or Albuquerque, cities that are really out in Indian country. Albuquerque is in my mind, really an Indian town. In an event like that, first the providers would be reporting it, then a team much like we had in Lantana (Fla.) would be sent.
‘First a team of epidemiologists ? would look at every hospital case in the county that even looked like, smelled like, might be, could be, possibly is, anthrax to see if ? other active cases of anthrax in the community ? had not been identified yet.
‘That is how they found this guy Saturday. Here was a guy who had worked in the building and had symptoms.
If a single case of anthrax was identified, an epidemiologist team go in and begin ‘examining any illness in the community, anyone who had been hospitalized, anybody who had symptoms that seemed at all like anthrax to see if we had a widespread event or not,’ Vanderwagen said.
If a number of cases were identified, the remainder of the team would be deployed to the community, similar to what is now going on in Florida.
Vanderwagen said pharmaceuticals from the national stockpile would accompany the team, ‘hundreds of thousands of doses of drugs as needed to a community to try to treat those who appear to have been exposed’ and can be treated.
IHS, ‘no less than any other community would have the advantage of that whole emergency process once we pulled the lever on it and said we have a case of anthrax here,’ he said. ‘That immediately unfolds a cascade of events.’
Vanderwagen said that Indian country could expect the same full complement of emergency teams as any other part of the country, if anthrax or other bioterrorism agents are suspected. ‘They can respond to a number of biological events.’
American Indian people shouldn’t be surprised that such policies are in place, he said. Following the attack on the World Trade Center, 30 IHS medical personnel worked at Ground Zero to assist in emergency medical care.
IHS personnel have had training in mock terrorism over the years and are familiar with what they have to do should such a situation arise. ‘We are some of their best responders,’ he said. ‘We are in the business of primary care and in the case of something like this World Trade Center thing, that is exactly what is needed, people with those kinds of skills. When they need firefighters where do they go? They call for the Indian firefighter! ‘
Vanderwagen said he was somewhat concerned that the Oklahoma City spokesman didn’t have information readily available, but said information was available on issues regarding bioterrorism.
‘They are at this point, reading everything they can find,’ Vanderwagen said. ‘We would generally advise them to read the CDC Web page for up-to-date information on these infectious diseases. We have conducted bioterrorism training for our chief medical officers and our clinical directors at least twice in the last year and a half. They have been given the basic overview and as providers they need to begin looking at Web available materials, beyond that the CDC has it all in place.’
The office that calls out the teams is housed in a building next to Vanderwagen’s office and has held daily briefings since the World Trade Center attack.
‘I have been over there twice a day to get briefings about their status. As of this afternoon, no, I had not discussed with the director sending advice to the chief medical officers. There is not much to advise them on other than to be counseling their medical staff to be conscious of the symptoms and to reacquaint themselves with those symptoms.’
If cases of anthrax were found within the American Indian population, Vanderwagen said IHS has plenty of the drug Cipro, which is used in the early stages of the disease. ‘Our clinics have plenty of it because it is used to treat bladder infections and ear infections.’
Should residents of Indian country be concerned about the possibility of bioterrorism?
‘Well, it is our view that we are not a very likely target in reservation environments. I think that Indian people who live in urban settings are probably at greater risk. For instance, in New York, the Urban Indian Center and health program is only 10 blocks from Ground Zero. I think many of our Indian people who live in urban environments may be at some higher risk just because that is where these events are being targeted.
‘I think Indian people have a greater risk that afflict us on a day-to-day basis than we have from this kind of an event. That doesn’t mean that they shouldn’t be conscious of the fact that those things are out there and may be happening and that they should be alert to unusual, sudden disease that doesn’t fit something they have been aware of in the past.
‘Of course anthrax shows up as flu symptoms. The problem for the average patient is, ‘Do I have the flu or what?’ There may be some screening of patients, but like I said, where Indian people live there is a high incident of anthrax spores in nature.’
So far vaccines for anthrax have not been recommended for any population other than the military, Vanderwagen said.
Other experts warn the general population to not begin taking the drug Cipro without the instructions of health care providers.
‘Risks like this will continue to be contained in small areas like the one in Florida,’ Vanderwagen said. ‘We are not recommending that people seek vaccination at this point.’
