In the multivariate model, having received training in bioterrorism preparedness (OR 3.9 [95%CI 2.4–6.3]) and knowing how to obtain information in the event of a bioterrorist attack (OR 6.4 [95%CI 3.9–10.6]) were significantly associated with physicians’ knowing what to do in the event of an attack (Table 4). These factors were also significantly associated with physicians’ ability to recognize signs and symptoms of a bioterrorism-related illness and knowledge of how to report a bioterrorist attack. Believing that bioterrorism was a real threat to their communities was also significantly associated with a physician’s ability to recognize signs and symptoms of a bioterrorism-related illness (OR 1.9 [95%CI 1.2–2.9]). Physicians’ preparedness was not associated with age, gender, geographic location, or residence in a rural, urban, or suburban area.
TABLE 1
Comparison of survey respondents and non-respondents
| % Respondents (n=614) | % Non-respondents (n=362) | P value | ||
|---|---|---|---|---|
| Mean age (SD) | 45 (9.6) | 44 (9.6) | .70 | |
| Age categories | <40 | 32 | 33 | .57 |
| 40–50 | 43 | 45 | ||
| >50 | 26 | 23 | ||
| Gender | Male | 70 | 76 | .07 |
| Medical training | MD degree | 90 | 91 | .53 |
| International | ||||
| Medical Graduate | 17 | 14 | .30 | |
| Board status | Board certified | 86 | 82 | .09 |
| Mean years since certification (SD) | 12 (7.9) | 11 (7.6) | .56 | |
| Geographic setting | Northeast | 14 | ||
| Midwest | 27 | |||
| South | 38 | |||
| West | 21 | |||
| Rural | 35 | |||
| Suburban | 37 | |||
| Urban | 29 | |||
| Population | <25,000 | 36 | ||
| 25,000–350,000 | 41 | |||
| 350,000 | 24 |
TABLE 2
Physicians’ responses to selected survey items
| Strongly agree or agree (%) | Neutral (%) | Strongly disagree or disagree (%) | ||
|---|---|---|---|---|
| Risk assessment | ||||
| “A bioterrorist attack is a real threat...” | in the United States | 95 | 3 | 2 |
| in my local community | 39 | 34 | 27 | |
| Preparedness | ||||
| “Could respond effectively to a bioterrorist attack” | United States | |||
| health care system | 27 | 32 | 42 | |
| My local medical community | 19 | 34 | 47 | |
| My local hospital | 21 | 33 | 46 | |
| “Know what to do as a doctor in the event of a suspected bioterrorist attack.” | 26 | 25 | 49 | |
| “Could respond effectively to a natural disaster” | My local medical community | 62 | 21 | 17 |
| My local hospital | 66 | 19 | 14 | |
| Self | 65 | 20 | 15 | |
| “Could respond effectively to an infectious disease outbreak “ | My local medical community | 60 | 27 | 14 |
| My local hospital | 60 | 25 | 15 | |
| Self | 66 | 22 | 12 | |
| Capabilities in bioterrorism response | ||||
| “Know where to call to report suspected attack” | 57 | 13 | 30 | |
| “Would recognize signs and symptoms” | 24 | 36 | 40 | |
| “Know how to get information about attack” | 56 | 17 | 27 | |
| “Know how to get clinical information about bioterrorism” | 54 | 18 | 28 | |
| Received prior training in bioterrorism preparedness | “Yes” 18 | “No” 82 | ||
| Current knowledge of management of bioterroristrelated illness | “Excellent or Very good” 5 | “Poor” 38 | ||
TABLE 3
Biologic agents physicians consider most likely to be used in a bioterrorist attack
| Agent | Survey respondents (%) |
|---|---|
| Anthrax | 96 |
| Smallpox | 82 |
| Plague | 28 |
| Botulism | 22 |
| Ebola | 16 |
| Nerve gas | 14 |
| Tularemia | 11 |
| Escherichia coli | 7 |
| Salmonella | 5 |
| Influenza virus | 4 |
TABLE 4
Predictors of preparedness in 3 areas of responsibility
| Knowing what to do as a doctor | Recognizing signs and symptoms | Knowing whom to contact | ||||
|---|---|---|---|---|---|---|
| Factor | OR* | 95% CI | OR* | 95% CI | OR* | 95% CI |
| Age <40 | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Age 40–50 | 1.1 | 0.6–1.7 | 1.0 | 0.6–1.7 | .9 | 0.6–1.4 |
| Age >50 | 1.9 | 1.1–3.3 | 1.8 | 1.0–3.2 | 1.3 | 0.8–2.1 |
| Female | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Male | 1.9 | 1.0–2.6 | 1.6 | 0.9–2.6 | .8 | 0.5–1.2 |
| Believe bioterrorist attack is real threat | ||||||
| in community | 1.3 | 0.9–2.0 | 1.9 | 1.2–2.9 | 1.4 | 1.0–2.1 |
| Know how to get info in suspected bio attack | 6.4 | 3.9–10.6 | 6.2 | 3.7–10.5 | 6.3 | 4.3–9.1 |
| Had prior bioterrorism preparedness training | 3.9 | 2.4–6.3 | 2.9 | 1.8–4.7 | 3.3 | 1.9–5.9 |
| Live in urban area | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Live in rural area | 1.2 | 0.7–1.9 | 1.1 | 0.7–1.9 | 1.2 | 0.7–1.9 |
| Live in suburban area | 1.1 | 0.7–1.9 | 1.0 | 0.6–1.6 | 1.0 | 0.6–1.6 |
| * Adjusted for other factors in table. OR=odds ratio. CI=confidence interval. | ||||||
Discussion
Only one quarter of family physicians in this national survey felt prepared to respond to a bioterrorist event. The majority of respondents did not feel confident in diagnosing or managing a bioterrorism-related illness, and fewer than 60% reported knowing how to report a bioterrorist event or obtain information about such an event. In addition, only one quarter of physicians were confident that local or national health care systems could respond effectively to a bioterrorist attack.
Those physicians who had received bioterrorism preparedness training were more likely to report having the skills and knowledge to respond to a bioterrorist attack. Knowing how to get information in the event of a suspected attack was the greatest predictor of being able to diagnose and report cases. Although we did not assess the nature of the training or test physicians’ actual preparedness, these data suggest that training may improve physicians’ abilities to diagnose and treat victims of bioterrorism. Finally, there are no published validated measures of bioterrorism preparedness, and there are few data to demonstrate the effectiveness of particular training interventions.21
Physicians felt more comfortable responding to other types of public health emergencies, such as natural disasters or infectious disease outbreaks. This may be due in part to their personal experiences in dealing with these events, or may reflect the formalized training in public health response that is part of medical school curricula. The reporting and response skills physicians would use in dealing with the public health system during a bioterrorist event are similar to the ones they use during natural disasters and infectious disease outbreaks. However, further emphasis should be placed on the importance of information-gathering and pre-incident intelligence for physicians.4
Because the survey instrument did not define bioterrorism, we relied on the respondents’ personal definitions of bioterrorism. While the timing of the survey coincided with national media attention on the recent anthrax cases, we did not detect a high level of knowledge or confidence in dealing with bioterrorism. In fact, despite the timing, we believe the results are valid and may reflect all physicians’ heightened awareness of the threat of bioterrorism and especially their limitations in dealing with it. Physicians clearly acknowledge the need for more training in bioterrorism response.
Primary care physicians have an important role in the public health response to bioterrorism. The results of this study indicate physicians should be trained in how to identify and manage illnesses caused by biologic weapons, how to obtain information about bioterrorism quickly, and how to activate the public health system in the event of a suspected attack. As the public health infrastructure is improved through increased funding, it should integrate training for front-line primary care physicians in detection, surveillance, and response activities.22 The AAFP has already begun to promote web-based training resources for practicing physicians (www.aafp.org/btresponse). Further study is warranted to test educational interventions designed to improve physicians’ preparedness for bioterrorism and their interactions with the public health sector.