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At the heart of general practice since 1960

Why changes to NIC rules will be a relief for GPs

With the possibility of bioterrorist attack very much in the news, Dr Ewan Gerrard advises on what you should do if the worst comes to the worst

GPs know they are the frontline of medicine and the NHS in Britain. The worrying possibility in the 21st century is that they may also find themselves in the frontline against any bioterrorist attack. For most doctors, their training didn't include the deliberate release of chemical, biological, radiological or nuclear agents, so there is a need to improve their awareness of the problem and how they might become involved.

In fact, much of the background information will be known to GPs, and it is only the way this needs to be gathered together with a little additional information on the possible threats and responses that is new.

What are the threats?

Since 9/11 we have all become aware of the potential global threat of terrorism. Potentially more worrying to GPs were the November 2001 incidents in USA of anthrax sent in postal packages. Suddenly, it was necessary to contemplate the covert release of bioterrorist agents into the community in a possibly random fashion, capable of causing serious illness that might present to GPs or emergency departments in the first instance. The question then was: How well prepared is the UK to recognise and deal with such a threat?

The answer was 'patchily'. Urgent steps were taken by the Government and Department of Health to remedy this state of affairs, including setting up expert groups to co-ordinate advice on what agents might be anticipated and how to deal with potential casualties.

Coincidentally, the NHS Direct health advice telephone helpline system had expanded to cover the whole of the country by late 2001, and it became clear this offered a readymade method of giving consistent advice in an emergency.

It also offered an unparalleled source of clinical data about callers' symptoms logged in the decision support system that could be developed as surveillance for possible prodromal evidence of a covert release. As the result of the strong collaboration between NHS Direct and the Health Protection Agency (HPA), a weekly bulletin of this daily surveillance work can be viewed on the HPA website Primary Care pages www.hpa.org.uk/cdr/pages/primarycarewr.htm#nhs.

A further collaboration with the authors of the NHS Pathways project, a next-generation clinical decision support system for the NHS, led to the development of special algorithms – known as Emergency Pathways – to enable rapid triage of people who may have been exposed to an agent once a deliberate release incident had been declared. These 'sleeping' Pathways have been completed for all the anticipated agents of deliberate release and placed in readiness on the NHS intranet, to be activated at a moment's notice if the department orders it.

They are regularly reviewed, both for currency of existing Pathways and the possibility of new agents, and can be adapted rapidly in real time during an incident if necessary.

What might you see?

There are two ways GPs could become involved in a bioterrorist incident: first, by being the professional who first suspects a deliberate release and alerts the Health Protection Unit (HPU); second, by becoming co-opted in an incident in their locality. As with so much in clinical medicine, having a high index of suspicion is essential if unusual cases that might be the result of a deliberate release are not to be missed.

The HPA and RCGP have recently sent Clinical Action Cards to all GPs, which may aid in the recognition of unusual illnesses. Even if the patient is clearly seriously ill requiring emergency resuscitation measures as a first priority, GPs mustn't forget to notify fellow health professionals and HPU of their suspicions.

Agents of bioterrorism may be more dangerous than naturally occurring infections or exposures. This is due to 'weaponisation', that is delivering the agent in a way calculated to have maximum impact on the target population. The key action for any GP suspecting an unusual clinical case is to notify the HPU locally. It is essential for GPs to be prepared by ensuring they and their staff know the local contact arrangements for the HPU in- and out-of-hours.

In some circumstances, for example suspected smallpox, it is appropriate to contact the national health protection support numbers (see table). These numbers are for professionals only.

Radiological agents

The threat could be from a covert radioactive source placed in a public area rather than a more overt incident with fallout from the blast of a 'dirty' bomb. Acute radiation effects are only seen at very high doses, and acute radiation sickness is very serious for the patient, who will be extremely ill and deteriorating rapidly.

It is likely a greater number of people may be exposed to considerably lower levels where there will be no obvious symptoms. If there has been exposure, patients may complain of:

•Feeling unwell, with headache and intense fatigue

•Nausea, with or without vomiting

•Diarrhoea

•Reddening of the skin in the exposed areas.

If radiation exposure is suspected, check what has happened to the patient's clothing (it should be removed and double-bagged) and call the HPU immediately. Do not immediately send the patient to hospital as the HPU advice may be to attend a decontamination unit first.

Chemical agents

This group of agents has a long and notorious history – think of the Sarin attack on the Tokyo subway and the gassing of Iraqi Kurds in recent memory. The identification of the precise agent used in an attack may take time, but some symptoms are common and the course of action similar.

GPs are most likely to see the less severely exposed and affected victims, possibly some time after the event.

Nerve agents, mustard gas and phosgene

There are several nerve agents, most only available to legitimate armed forces. Mustard gases and phosgene cause many of the same symptoms:

•Pain in the eyes and blurred vision

•Hypersalivation and runny nose

•Muscular weakness

•Difficulty breathing (leading to cyanosis), coughing

•Sore throat or hoarseness.

If suspected, the patient should be advised to wash thoroughly with soap and water. Clothes may be contaminated and should be removed and washed (or double-bagged) with minimal touching.

Chlorine and cyanide

Depending on how they are delivered, both of these agents affect breathing. Chlorine can produce coughing, salivation and upper airways irritation, and is extremely irritant to the eyes. Cyanide may cause respiratory failure, only treatable with an antidote and ventilation, but at lower doses it can cause headache, dizziness, nausea and tachycardia. Urgent referral to an ED, stating suspected exposure, is essential.

Ricin

Depending on the route of exposure and dose, ricin can cause sudden severe illness with cough, fever, vomiting and diarrhoea.

As symptoms continue to develop over several hours, it is vital that anyone suspected of suffering as a result of exposure has urgent specialist assessment. Suspected ricin victims should be transferred to hospital rapidly and the HPU notified.

Biological agents

The HPA has divided this disparate group of disease-causing agents into two categories according to their potential for serious bioterrorist threat. Category A includes:

•Smallpox

•Anthrax

•Botulism

•Plague

•Tularaemia

•Viral haemorrhagic fevers (Ebola, Lassa fever, Crimea-Congo, etc).

They are characterised by ease of transmission, high mortality rates and potential for serious public health emergency. Further information on all these agents can be found on the HPA Deliberate Release pages www.hpa.org.uk/infections/topics_az/

deliberate_release/menu.htm

There is a serious risk of promoting transmission in these cases. Once a GP suspects a category A infection, immediate steps to quarantine the patient should be taken and the HPU or national HPA contacted for advice.

The category B group of less severe biological threats includes:

•Brucellosis

•Psittacosis

•Q fever

•Glanders and melioidosis (both infections caused by bacteria of the burkholderia family).

While usually less acute and severe at presentation, most of these are potentially fatal if not treated.

The 'worried well'

GPs are only too familiar with dealing with anxious but well patients. In a public health emergency this can rapidly escalate, and dealing with requests for advice gets increasingly difficult.

GPs need to have confidence they can refer all such inquiries to local TV and radio, for general information, and to NHS Direct for specific health advice. NHS Direct will normally be the provider of any large-scale (and often smaller-scale) helplines to handle the public's health concerns about an incident.

Ewan Gerard is national adviser in public health, NHS Direct, and a part-time GP in Littlehampton, West Sussex

Support contact numbers for health professionals

•HPA Colindale (infectious diseases)

0208 200 6868 (24 hrs) England, Wales, NI

•HPA Emergency Response Division

01980 612100 (24 hrs) England, Wales, NI

•CHaPD (Chemicals)

0870 606 4444 England, Wales, NI

•CDSC Wales

02920 521 997 Wales

•CDSC Northern Ireland

02890 263 765 Northern Ireland

•SCIEH

0141 300 1100 Scotland 0141 211 3600 (24 hrs)

•NRPB (radiological hazards)

01235 834 590 (24 hrs) UK

Useful further information

'New Dimension' –

Office of the Deputy

Prime Minister

www.odpm.gov.uk/stellent/

groups/odpm_control/documents/contentservertemplate/odpm_index.hcst?n=3518&l=3

HPA Deliberate Release web pages

www.hpa.org.uk/infections/

topics_az/deliberate_release/

menu.htm

HPA Deliberate Release Guidance for GPs

www.hpa.org.uk/infections/

topics_az/deliberate_release/

Unknown/Unusual_Illness_GP.pdf

HPA Primary Care NHS Direct surveillance bulletins

www.hpa.org.uk/cdr/pages/

primarycarewr.htm#nhs

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